Pub Date : 2024-11-01DOI: 10.1016/j.jmig.2024.09.083
RJ Schneyer, K Hamilton, ML Barker, MT Siedhoff
Study Objective
To describe cervical endometriosis, a rare manifestation of endometriosis, to present an unusual case of cystic endometriosis involving the cervix, and to demonstrate strategies for tackling the obliterated posterior cul de sac.
Design
Educational video highlighting surgical techniques.
Setting
Academic medical center.
Patients or Participants
We present a case of a patient undergoing surgical management of deeply infiltrating endometriosis of the posterior cul de sac, including a cervical endometrioma.
Interventions
Laparoscopic excision of endometriosis, including resection of the cervical endometrioma, utilizing 3mm accessory ports.
Measurements and Main Results
We describe the etiology, presentation, and diagnosis of cervical endometriosis and review the deep and superficial subtypes of this condition. We review strategies for approaching the obliterated posterior cul de sac, including: 1) Optimizing exposure with mobilization of the sigmoid colon and ovarian retraction, 2) minimizing bleeding with uterine artery ligation and vasopressin injection, and 3) dissecting out the ureter to prevent injury. We demonstrate excision of a large rectovaginal nodule that required rectal shaving and a 3cm colpotomy to completely excise the lesion. Finally, we demonstrate excision of the cervical endometrioma utilizing ultrasonic energy.
Conclusion
Cervical endometriosis is rare manifestation of endometriosis that may require surgical management in symptomatic patients. This condition may arise from extension of deeply infiltrating endometriosis involving the posterior compartment. This video highlights strategies for approaching the obliterated posterior cul de sac and demonstrates the excision of an unusual cervical endometrioma. Additionally, this video demonstrates the feasibility of utilizing 3mm accessory ports in cases of advanced endometriosis.
{"title":"Laparoscopic Excision of a Cervical Endometrioma","authors":"RJ Schneyer, K Hamilton, ML Barker, MT Siedhoff","doi":"10.1016/j.jmig.2024.09.083","DOIUrl":"10.1016/j.jmig.2024.09.083","url":null,"abstract":"<div><h3>Study Objective</h3><div>To describe cervical endometriosis, a rare manifestation of endometriosis, to present an unusual case of cystic endometriosis involving the cervix, and to demonstrate strategies for tackling the obliterated posterior cul de sac.</div></div><div><h3>Design</h3><div>Educational video highlighting surgical techniques.</div></div><div><h3>Setting</h3><div>Academic medical center.</div></div><div><h3>Patients or Participants</h3><div>We present a case of a patient undergoing surgical management of deeply infiltrating endometriosis of the posterior cul de sac, including a cervical endometrioma.</div></div><div><h3>Interventions</h3><div>Laparoscopic excision of endometriosis, including resection of the cervical endometrioma, utilizing 3mm accessory ports.</div></div><div><h3>Measurements and Main Results</h3><div>We describe the etiology, presentation, and diagnosis of cervical endometriosis and review the deep and superficial subtypes of this condition. We review strategies for approaching the obliterated posterior cul de sac, including: 1) Optimizing exposure with mobilization of the sigmoid colon and ovarian retraction, 2) minimizing bleeding with uterine artery ligation and vasopressin injection, and 3) dissecting out the ureter to prevent injury. We demonstrate excision of a large rectovaginal nodule that required rectal shaving and a 3cm colpotomy to completely excise the lesion. Finally, we demonstrate excision of the cervical endometrioma utilizing ultrasonic energy.</div></div><div><h3>Conclusion</h3><div>Cervical endometriosis is rare manifestation of endometriosis that may require surgical management in symptomatic patients. This condition may arise from extension of deeply infiltrating endometriosis involving the posterior compartment. This video highlights strategies for approaching the obliterated posterior cul de sac and demonstrates the excision of an unusual cervical endometrioma. Additionally, this video demonstrates the feasibility of utilizing 3mm accessory ports in cases of advanced endometriosis.</div></div>","PeriodicalId":16397,"journal":{"name":"Journal of minimally invasive gynecology","volume":"31 11","pages":"Page S18"},"PeriodicalIF":3.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142658466","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1016/j.jmig.2024.09.140
SF Hojabri , J Dada , C McCaffrey , E Miazga
Study Objective
This video explores three laparoscopic techniques for superficial endometriosis resection—hydro dissection with a suction irrigator, excision with monopolar scissors, and laparoscopic laser excision. This video provides a comprehensive stepwise approach to the three resection techniques, as well as explores the benefits and drawbacks of each. Considerations include lesion characteristics, surgeon proficiency, instrument availability, and cost. These techniques enhance surgical options for superficial endometriosis, promoting a tailored approach to superficial endometriosis resection and optimized patient care.
Design
Video.
Setting
Operating Room.
Patients or Participants
One Patient.
Interventions
Systematic surgical approach for 3 different techniques for resection of endometriosis.
Measurements and Main Results
We demonstrated 3 different techniques for resection of endometriosis in this video.
Conclusion
In conclusion, these three techniques offer valuable options for resecting superficial endometriosis. The choice of technique may depend on the location and characteristics of the lesion and underlying tissue, surface area of desire tissue resection, availability, and cost of instruments, as well as the surgeon's training, experience, and preference.
{"title":"Resection of Superficial Endometriosis: Three Laparoscopic Techniques","authors":"SF Hojabri , J Dada , C McCaffrey , E Miazga","doi":"10.1016/j.jmig.2024.09.140","DOIUrl":"10.1016/j.jmig.2024.09.140","url":null,"abstract":"<div><h3>Study Objective</h3><div>This video explores three laparoscopic techniques for superficial endometriosis resection—hydro dissection with a suction irrigator, excision with monopolar scissors, and laparoscopic laser excision. This video provides a comprehensive stepwise approach to the three resection techniques, as well as explores the benefits and drawbacks of each. Considerations include lesion characteristics, surgeon proficiency, instrument availability, and cost. These techniques enhance surgical options for superficial endometriosis, promoting a tailored approach to superficial endometriosis resection and optimized patient care.</div></div><div><h3>Design</h3><div>Video.</div></div><div><h3>Setting</h3><div>Operating Room.</div></div><div><h3>Patients or Participants</h3><div>One Patient.</div></div><div><h3>Interventions</h3><div>Systematic surgical approach for 3 different techniques for resection of endometriosis.</div></div><div><h3>Measurements and Main Results</h3><div>We demonstrated 3 different techniques for resection of endometriosis in this video.</div></div><div><h3>Conclusion</h3><div>In conclusion, these three techniques offer valuable options for resecting superficial endometriosis. The choice of technique may depend on the location and characteristics of the lesion and underlying tissue, surface area of desire tissue resection, availability, and cost of instruments, as well as the surgeon's training, experience, and preference.</div></div>","PeriodicalId":16397,"journal":{"name":"Journal of minimally invasive gynecology","volume":"31 11","pages":"Page S36"},"PeriodicalIF":3.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142658014","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1016/j.jmig.2024.09.047
L Kowalski , M Buchman , H Bian , A Newmark , DE Luciano , A Ulrich
Study Objective
To compare patient pain perception with extension of the umbilical versus suprapubic laparoscopic port site at the time of tissue morcellation.
Design
Prospective cohort study.
Setting
Academic hospital.
Patients or Participants
Women undergoing surgery with anticipated manual morcellation for tissue extraction by minimally invasive gynecologists between October 2022 and February 2024. Sixty-four patients were enrolled, thirteen were excluded, twenty-seven were included in the suprapubic site morcellation group and twenty-three in the umbilical site morcellation group.
Interventions
Patients were assigned to suprapubic or umbilical port site extension for morcellation based on surgeon preference, specimen size and location, and patient characteristics. Patient pain perception at 24 hours and 2 weeks post-operatively was obtained through a survey with a ten-point visual analog pain scale. Number of narcotics was recorded.
Measurements and Main Results
The difference in worst pain score at 24 hours and 2 weeks post-operatively was not statistically significant between groups. Mean worst pain scores at 24 hours post-operative were 7.37 ± 2.42 and 7.3 ±1.74 for the suprapubic and umbilical group respectively (p=0.528). Mean worst pain scores 2 weeks post-operative were 5.78 ± 2.83 and 4.87 ± 2.47 for the suprapubic and umbilical group respectively (p=0.244). The number of post-operative narcotics used at 24 hours was not statistically different, but at 2 weeks was 4.8 ± 4.5 and 2.3 ± 2.6 in the suprapubic and umbilical group respectively (p=0.037) and was statistically different. Mean patient satisfaction with post-operative pain was not different between groups. There were no statistical differences in length of hospital stay, post-operative complications, or post-operative hernia.
Conclusion
Our study demonstrates that there was no difference in patient reported post-operative pain between extension of the umbilical versus the suprapubic port site, but there was a statistical difference in narcotic usage with umbilical morcellation being associated with less narcotic requirement 2 weeks after surgery.
{"title":"Effect of Location of Minilaparotomy for Morcellation at the Time of Myomectomy and Hysterectomy on Postoperative Pain","authors":"L Kowalski , M Buchman , H Bian , A Newmark , DE Luciano , A Ulrich","doi":"10.1016/j.jmig.2024.09.047","DOIUrl":"10.1016/j.jmig.2024.09.047","url":null,"abstract":"<div><h3>Study Objective</h3><div>To compare patient pain perception with extension of the umbilical versus suprapubic laparoscopic port site at the time of tissue morcellation.</div></div><div><h3>Design</h3><div>Prospective cohort study.</div></div><div><h3>Setting</h3><div>Academic hospital.</div></div><div><h3>Patients or Participants</h3><div>Women undergoing surgery with anticipated manual morcellation for tissue extraction by minimally invasive gynecologists between October 2022 and February 2024. Sixty-four patients were enrolled, thirteen were excluded, twenty-seven were included in the suprapubic site morcellation group and twenty-three in the umbilical site morcellation group.</div></div><div><h3>Interventions</h3><div>Patients were assigned to suprapubic or umbilical port site extension for morcellation based on surgeon preference, specimen size and location, and patient characteristics. Patient pain perception at 24 hours and 2 weeks post-operatively was obtained through a survey with a ten-point visual analog pain scale. Number of narcotics was recorded.</div></div><div><h3>Measurements and Main Results</h3><div>The difference in worst pain score at 24 hours and 2 weeks post-operatively was not statistically significant between groups. Mean worst pain scores at 24 hours post-operative were 7.37 ± 2.42 and 7.3 ±1.74 for the suprapubic and umbilical group respectively (p=0.528). Mean worst pain scores 2 weeks post-operative were 5.78 ± 2.83 and 4.87 ± 2.47 for the suprapubic and umbilical group respectively (p=0.244). The number of post-operative narcotics used at 24 hours was not statistically different, but at 2 weeks was 4.8 ± 4.5 and 2.3 ± 2.6 in the suprapubic and umbilical group respectively (p=0.037) and was statistically different. Mean patient satisfaction with post-operative pain was not different between groups. There were no statistical differences in length of hospital stay, post-operative complications, or post-operative hernia.</div></div><div><h3>Conclusion</h3><div>Our study demonstrates that there was no difference in patient reported post-operative pain between extension of the umbilical versus the suprapubic port site, but there was a statistical difference in narcotic usage with umbilical morcellation being associated with less narcotic requirement 2 weeks after surgery.</div></div>","PeriodicalId":16397,"journal":{"name":"Journal of minimally invasive gynecology","volume":"31 11","pages":"Page S14"},"PeriodicalIF":3.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142658063","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1016/j.jmig.2024.09.061
O Dawodu , MN Allen , M Gedeon , JHJ Kim
Study Objective
To demonstrate a minimally invasive surgical approach to disseminated peritoneal leiomyomatosis.
Design
Case report.
Setting
Tertiary medical center.
Patients or Participants
36-year-old G0 with prior myomectomy with use of power morcellator and now disseminated peritoneal leiomyomatosis undergoing fertility sparing management.
Interventions
The patient underwent a successful robot-assisted laparoscopic myomectomy, abdominal wall mass excision, and excision of abdominal and pelvic masses. Key surgical steps illustrated include:
•
Image guided mapping of lesions
•
Port placement for multi-quadrant visualization
•
30° camera supraumbilical
•
Port hopping feature
•
Use of vessel sealer
•
Identification of vital structures
•
Resection of myomas
○
Traction-Countertraction
○
Blunt and sharp dissection
○
External downward pressure for identification of intramuscular masses
•
Repair of fascial defect
•
Abdominal survey - “run the bowel.”
•
Specimen bagging and cold knife morcellation
Measurements and Main Results
Patient was discharged home on the day of surgery with an uncomplicated post-operative course.
Conclusion
Utilization of Da Vinci Xi Robotic Surgical System features and multidisciplinary planning allow strategic surgical approach and adequate visualization of the abdomen and pelvis to resect leiomyomas in unusual locations.
{"title":"Robotic Excision of Disseminated Peritoneal Leiomyomas","authors":"O Dawodu , MN Allen , M Gedeon , JHJ Kim","doi":"10.1016/j.jmig.2024.09.061","DOIUrl":"10.1016/j.jmig.2024.09.061","url":null,"abstract":"<div><h3>Study Objective</h3><div>To demonstrate a minimally invasive surgical approach to disseminated peritoneal leiomyomatosis.</div></div><div><h3>Design</h3><div>Case report.</div></div><div><h3>Setting</h3><div>Tertiary medical center.</div></div><div><h3>Patients or Participants</h3><div>36-year-old G0 with prior myomectomy with use of power morcellator and now disseminated peritoneal leiomyomatosis undergoing fertility sparing management.</div></div><div><h3>Interventions</h3><div>The patient underwent a successful robot-assisted laparoscopic myomectomy, abdominal wall mass excision, and excision of abdominal and pelvic masses. Key surgical steps illustrated include:<ul><li><span>•</span><span><div>Image guided mapping of lesions</div></span></li><li><span>•</span><span><div>Port placement for multi-quadrant visualization</div></span></li><li><span>•</span><span><div>30° camera supraumbilical</div></span></li><li><span>•</span><span><div>Port hopping feature</div></span></li><li><span>•</span><span><div>Use of vessel sealer</div></span></li><li><span>•</span><span><div>Identification of vital structures</div></span></li><li><span>•</span><span><div>Resection of myomas</div></span></li><li><span>○</span><span><div>Traction-Countertraction</div></span></li><li><span>○</span><span><div>Blunt and sharp dissection</div></span></li><li><span>○</span><span><div>External downward pressure for identification of intramuscular masses</div></span></li><li><span>•</span><span><div>Repair of fascial defect</div></span></li><li><span>•</span><span><div>Abdominal survey - “run the bowel.”</div></span></li><li><span>•</span><span><div>Specimen bagging and cold knife morcellation</div></span></li></ul></div></div><div><h3>Measurements and Main Results</h3><div>Patient was discharged home on the day of surgery with an uncomplicated post-operative course.</div></div><div><h3>Conclusion</h3><div>Utilization of Da Vinci Xi Robotic Surgical System features and multidisciplinary planning allow strategic surgical approach and adequate visualization of the abdomen and pelvis to resect leiomyomas in unusual locations.</div></div>","PeriodicalId":16397,"journal":{"name":"Journal of minimally invasive gynecology","volume":"31 11","pages":"Page S6"},"PeriodicalIF":3.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142658184","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1016/j.jmig.2024.06.006
{"title":"Retroperitoneal Cystic Endometriosis Incidentally Found at Time of Hysterectomy","authors":"","doi":"10.1016/j.jmig.2024.06.006","DOIUrl":"10.1016/j.jmig.2024.06.006","url":null,"abstract":"","PeriodicalId":16397,"journal":{"name":"Journal of minimally invasive gynecology","volume":"31 11","pages":"Pages 899-901"},"PeriodicalIF":3.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141399704","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1016/j.jmig.2024.06.012
Objective
To reinterpret the surgical anatomy of paracolpium in radical hysterectomy and to explore its implications for the surgery.
Setting
The term “paracolpium” first defined by Fothergill in 1907, is essential in radical hysterectomy. However, several challenges remain unresolved. These include: (1) inconsistent terminology in relation to its defined attributes; (2) the lack of consensus on anatomical landmarks; (3) unclear associations with the cardinal and sacral ligaments; and (4) the critical implications and requirements of paracolpium resection in radical hysterectomy practices.
Participants
A patient in her 60s diagnosed with stage IB2 cervical cancer was enrolled in a clinical trial and assigned to the laparoscopic surgery group. A step-by-step, narrated video demonstration.
Interventions
During the procedure, post-excision of the uterosacral, cardinal, and vesicovaginal ligaments, we identified a ligament-like structure situated between the middle third of the vagina and the pelvic wall. We have termed this structure the “paracolpium ligament.” A detailed anatomical description was performed, outlining its crucial attachments:
• Medial attachment: middle third of the vagina
• Lateral attachment: tendinous arch of the pelvic fascia (TAPF)
To ensure a safe dissection, the paracolpium ligament was exposed by removing anterior and posterior fat tissue. The extent of surgical resection was adapted based on the tumor's location. Extensive resection of the paracolpium ligament was essential when the tumor was localized to one side of the vagina to ensure complete removal of the disease; otherwise, preservation of the ligament was considered feasible.
Conclusion
In this video, we meticulously name and define the “paracolpium ligament,” providing groundbreaking insights into its anatomical and surgical implications in radical hysterectomy. Our findings contribute to a better understanding of surgical anatomy for cervical cancer.
{"title":"A Reinterpretation of Paracolpium in Radical Hysterectomy: New Insights into Its Surgical Implication","authors":"","doi":"10.1016/j.jmig.2024.06.012","DOIUrl":"10.1016/j.jmig.2024.06.012","url":null,"abstract":"<div><h3>Objective</h3><div>To reinterpret the surgical anatomy of paracolpium in radical hysterectomy and to explore its implications for the surgery.</div></div><div><h3>Setting</h3><div>The term “paracolpium” first defined by Fothergill in 1907, is essential in radical hysterectomy. However, several challenges remain unresolved. These include: (1) inconsistent terminology in relation to its defined attributes; (2) the lack of consensus on anatomical landmarks; (3) unclear associations with the cardinal and sacral ligaments; and (4) the critical implications and requirements of paracolpium resection in radical hysterectomy practices.</div></div><div><h3>Participants</h3><div>A patient in her 60s diagnosed with stage IB2 cervical cancer was enrolled in a clinical trial and assigned to the laparoscopic surgery group. A step-by-step, narrated video demonstration.</div></div><div><h3>Interventions</h3><div>During the procedure, post-excision of the uterosacral, cardinal, and vesicovaginal ligaments, we identified a ligament-like structure situated between the middle third of the vagina and the pelvic wall. We have termed this structure the “paracolpium ligament.” A detailed anatomical description was performed, outlining its crucial attachments:</div><div> <!-->• Medial attachment: middle third of the vagina</div><div> <!-->• Lateral attachment: tendinous arch of the pelvic fascia (TAPF)</div><div> <!-->• Cranial attachment: cardinal-uterosacral ligaments confluence</div><div> <!-->• Caudal attachment: pubococcygeus muscle fascia</div><div> <!-->• Dorsal: paravaginal space</div><div> <!-->• Ventral: pararectal space</div><div>To ensure a safe dissection, the paracolpium ligament was exposed by removing anterior and posterior fat tissue. The extent of surgical resection was adapted based on the tumor's location. Extensive resection of the paracolpium ligament was essential when the tumor was localized to one side of the vagina to ensure complete removal of the disease; otherwise, preservation of the ligament was considered feasible.</div></div><div><h3>Conclusion</h3><div>In this video, we meticulously name and define the “paracolpium ligament,” providing groundbreaking insights into its anatomical and surgical implications in radical hysterectomy. Our findings contribute to a better understanding of surgical anatomy for cervical cancer.</div></div>","PeriodicalId":16397,"journal":{"name":"Journal of minimally invasive gynecology","volume":"31 11","pages":"Page 908"},"PeriodicalIF":3.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141468680","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1016/j.jmig.2024.09.046
E Young , E Williams , M Green , D Delvadia
Study Objective
Most published data on the Sonata System® for transcervical radiofrequency ablation (RFA) of uterine fibroids is from the initial clinical trials. We report our initial experience and surgical/medical reintervention rates 18 months post-procedure to examine the utility of RFA as an alternative to hysterectomy.
Design
Single center retrospective chart review.
Setting
One clinical site.
Patients or Participants
All patients who underwent ultrasound-guided RFA for symptomatic fibroids using the Sonata System® at our institution between April 2021 and March 2023 (n=51).
Interventions
A retrospective chart review was conducted on all patients who underwent transcervical RFA of symptomatic fibroids.
Measurements and Main Results
51 patient charts reviewed, with a median of 4 fibroids treated per patient. Patient demographics and operative outcomes were similar to initial trials for the device. Treated fibroids ranged from 1-12cm, considerably larger those in the device clinical trials ranging 1-5cm. There were no device related complications. Cumulative surgical re-intervention rates at 6mo, 12mo, and 18mo postoperatively were calculated using Kaplan Meier analysis and found to be 2%, 7.8%, and 24.3%. Of the nine patients requiring surgical reintervention, four resulted in major gynecologic surgery, hysterectomy or myomectomy. Additionally, 68.6%, 62.7%, and 53.3% of patients maintained a medication free interval through 6mo, 12mo, and 18mo. 85.3% of patients discontinued hormonal therapy immediately postoperatively.
Conclusion
The Sonata System® for RFA can be considered an effective minimally invasive modality to treat symptomatic fibroids for the appropriate patient. We ablated considerably larger fibroids than in the initial trials while maintaining low surgical reintervention rates through 18months, suggesting more patients may be eligible for this treatment than initially described. This review provides insight into practical use of the Sonata System® in the ambulatory setting, to guide patient selection and preoperative counseling. Further studies are warranted to test the system in expanded patient populations, and to understand long-term outcomes and likelihood of true hysterectomy avoidance.
{"title":"Evaluation of Transcervical Ultrasound Guided Radiofrequency Ablation of Symptomatic Uterine Fibroids in a Single Center","authors":"E Young , E Williams , M Green , D Delvadia","doi":"10.1016/j.jmig.2024.09.046","DOIUrl":"10.1016/j.jmig.2024.09.046","url":null,"abstract":"<div><h3>Study Objective</h3><div>Most published data on the Sonata System® for transcervical radiofrequency ablation (RFA) of uterine fibroids is from the initial clinical trials. We report our initial experience and surgical/medical reintervention rates 18 months post-procedure to examine the utility of RFA as an alternative to hysterectomy.</div></div><div><h3>Design</h3><div>Single center retrospective chart review.</div></div><div><h3>Setting</h3><div>One clinical site.</div></div><div><h3>Patients or Participants</h3><div>All patients who underwent ultrasound-guided RFA for symptomatic fibroids using the Sonata System® at our institution between April 2021 and March 2023 (n=51).</div></div><div><h3>Interventions</h3><div>A retrospective chart review was conducted on all patients who underwent transcervical RFA of symptomatic fibroids.</div></div><div><h3>Measurements and Main Results</h3><div>51 patient charts reviewed, with a median of 4 fibroids treated per patient. Patient demographics and operative outcomes were similar to initial trials for the device. Treated fibroids ranged from 1-12cm, considerably larger those in the device clinical trials ranging 1-5cm. There were no device related complications. Cumulative surgical re-intervention rates at 6mo, 12mo, and 18mo postoperatively were calculated using Kaplan Meier analysis and found to be 2%, 7.8%, and 24.3%. Of the nine patients requiring surgical reintervention, four resulted in major gynecologic surgery, hysterectomy or myomectomy. Additionally, 68.6%, 62.7%, and 53.3% of patients maintained a medication free interval through 6mo, 12mo, and 18mo. 85.3% of patients discontinued hormonal therapy immediately postoperatively.</div></div><div><h3>Conclusion</h3><div>The Sonata System® for RFA can be considered an effective minimally invasive modality to treat symptomatic fibroids for the appropriate patient. We ablated considerably larger fibroids than in the initial trials while maintaining low surgical reintervention rates through 18months, suggesting more patients may be eligible for this treatment than initially described. This review provides insight into practical use of the Sonata System® in the ambulatory setting, to guide patient selection and preoperative counseling. Further studies are warranted to test the system in expanded patient populations, and to understand long-term outcomes and likelihood of true hysterectomy avoidance.</div></div>","PeriodicalId":16397,"journal":{"name":"Journal of minimally invasive gynecology","volume":"31 11","pages":"Pages S13-S14"},"PeriodicalIF":3.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142658062","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1016/j.jmig.2024.09.068
NB Luna Ramirez , MS Orlando , NB Barba , E Shippey , E Flores , P Garcia-Filion , R Kho
Study Objective
Abdominal wall endometriosis (AWE), a sequelae of cesarean delivery (CD), has been reported to occur in 0.03%-0.45% in small cohort reports. The true incidence is currently unknown. This study aims to identify the true incidence of AWE and risk factors for its development.
Design
A prospective study to measure the incidence of AWE in patients that underwent primary CD between 2010 and 2023. Cases of primary CD were identified using the national Vizient Clinical Database and followed in time for diagnosis of AWE.
Setting
National database that collects de-identified information from over 500 academic and community hospitals in the US.
Patients or Participants
Cohort of patients that underwent primary CD from 2010-2023 derived from a population-based database. Identified using ICD-codes.
Interventions
None.
Measurements and Main Results
The study cohort has 2,356,503 cases of CD. Median age is [31.0 years (interquartile range: 27, 35)]. AWE was diagnosed in 18,030 (0.8%) of patients and 93% (n=16812) occurred after primary CD. The median time to diagnosis is 2.9 years (1.46, 4.91). The population incidence rate was 1.70/1000 person-years (1.67, 1.72) in women after primary CD. Incidence rates rose with increasing maternal age at primary CD: 18-24 years [0.90/1000 person-years (0.86, 0.95)], 25-29 years [1.48/1000 person-years (1.43, 1.53)], 30-34 years [1.79/1000 person-years (1.75, 1.84)], 35-39 years [2.21/1000 person-years (2.15, 2.27)], and 40 years and older [2.42/1000 years (2.31,2.54)]. Increasing risk with maternal age was statistically significant for a positive linear trend (ptrend<0.001). Risk factor for AWE include private insurance [1.59 (1.54, 1.65)], white [1.73 (1.6, 1.79)], smoking status at CD [2.06 (1.98, 2.15)], and BMI 25-29 kg/m2[2.01 (1.92, 2.10)].
Conclusion
This is the first study to calculate the true incidence of AWE. This study provides greater understanding of the condition and its risk factors.
{"title":"Incidence of Abdominal Wall Endometriosis After Cesarean Delivery","authors":"NB Luna Ramirez , MS Orlando , NB Barba , E Shippey , E Flores , P Garcia-Filion , R Kho","doi":"10.1016/j.jmig.2024.09.068","DOIUrl":"10.1016/j.jmig.2024.09.068","url":null,"abstract":"<div><h3>Study Objective</h3><div>Abdominal wall endometriosis (AWE), a sequelae of cesarean delivery (CD), has been reported to occur in 0.03%-0.45% in small cohort reports. The true incidence is currently unknown. This study aims to identify the true incidence of AWE and risk factors for its development.</div></div><div><h3>Design</h3><div>A prospective study to measure the incidence of AWE in patients that underwent primary CD between 2010 and 2023. Cases of primary CD were identified using the national Vizient Clinical Database and followed in time for diagnosis of AWE.</div></div><div><h3>Setting</h3><div>National database that collects de-identified information from over 500 academic and community hospitals in the US.</div></div><div><h3>Patients or Participants</h3><div>Cohort of patients that underwent primary CD from 2010-2023 derived from a population-based database. Identified using ICD-codes.</div></div><div><h3>Interventions</h3><div>None.</div></div><div><h3>Measurements and Main Results</h3><div>The study cohort has 2,356,503 cases of CD. Median age is [31.0 years (interquartile range: 27, 35)]. AWE was diagnosed in 18,030 (0.8%) of patients and 93% (n=16812) occurred after primary CD. The median time to diagnosis is 2.9 years (1.46, 4.91). The population incidence rate was 1.70/1000 person-years (1.67, 1.72) in women after primary CD. Incidence rates rose with increasing maternal age at primary CD: 18-24 years [0.90/1000 person-years (0.86, 0.95)], 25-29 years [1.48/1000 person-years (1.43, 1.53)], 30-34 years [1.79/1000 person-years (1.75, 1.84)], 35-39 years [2.21/1000 person-years (2.15, 2.27)], and 40 years and older [2.42/1000 years (2.31,2.54)]. Increasing risk with maternal age was statistically significant for a positive linear trend (p<sub>trend</sub><0.001). Risk factor for AWE include private insurance [1.59 (1.54, 1.65)], white [1.73 (1.6, 1.79)], smoking status at CD [2.06 (1.98, 2.15)], and BMI 25-29 kg/m2[2.01 (1.92, 2.10)].</div></div><div><h3>Conclusion</h3><div>This is the first study to calculate the true incidence of AWE. This study provides greater understanding of the condition and its risk factors.</div></div>","PeriodicalId":16397,"journal":{"name":"Journal of minimally invasive gynecology","volume":"31 11","pages":"Page S1"},"PeriodicalIF":3.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142658265","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1016/j.jmig.2024.09.121
MG Leon , J Cervantes , K Schmidt
Study Objective
To describe the classification of cesarean scar pregnancies (CSP). To demonstrate tips and tricks for resection of exogenous CSP with an obliterated anterior cul de sac.
Design
Surgical educational video.
Setting
Procedure performed under general anesthesia with robotic assistance. Patient in dorsal lithotomy position.
Patients or Participants
35 years old gravida 4 para 3 women at 9 weeks and 6 days gestation who presented to the emergency room with vaginal bleeding. Her BHCG was 9,506mIU/mL, she had a history of 3 prior cesarean sections, and a BMI 41.
Interventions
Robotic assisted resection of type IIIA cesarean scar ectopic pregnancy with dissection of obliterated anterior cul de sac and temporary uterine artery occlusion.
Measurements and Main Results
This video demonstrates various strategies to safely navigate these complex cases. Retroperitoneal dissection with a lateral and a medial approach are demonstrated in order to access the uterine artery at its origin for temporary occlusion. A lateral to medial approach to the obliterated cul de sac by starting the dissection in the avascular space anterior to the round ligament is discussed. Lysing filmy adhesions prior to dense scar may assist in safe dissection. Placing a uterine manipulator under laparoscopic guidance may prevent disruption and acute bleeding of the ectopic pregnancy. Identifying the cervical cup anterior to the uterine vessels allows for better dissection around the ectopic pregnancy and decreases the chance of bladder, ectopic, or uterine vessel injury. Most adhesions from prior cesarean sections happen at the lower uterine segment and a tunnel is developed under the dense lower uterine segment adhesions to separate the bladder from the ectopic pregnancy. An angled 30-degree scope may help with adequate visualization for the anterior dissection. Back-filling the bladder is useful to determine the boarders of a safe dissection.
Conclusion
This video demonstrates tips and tricks for successful resection of type IIIA exogenous cesarean scar ectopic pregnancy.
{"title":"Tips and Tricks for Successful Resection of Cesarean Scar Ectopic With an Obliterated Anterior Cul De Sac","authors":"MG Leon , J Cervantes , K Schmidt","doi":"10.1016/j.jmig.2024.09.121","DOIUrl":"10.1016/j.jmig.2024.09.121","url":null,"abstract":"<div><h3>Study Objective</h3><div>To describe the classification of cesarean scar pregnancies (CSP). To demonstrate tips and tricks for resection of exogenous CSP with an obliterated anterior cul de sac.</div></div><div><h3>Design</h3><div>Surgical educational video.</div></div><div><h3>Setting</h3><div>Procedure performed under general anesthesia with robotic assistance. Patient in dorsal lithotomy position.</div></div><div><h3>Patients or Participants</h3><div>35 years old gravida 4 para 3 women at 9 weeks and 6 days gestation who presented to the emergency room with vaginal bleeding. Her BHCG was 9,506mIU/mL, she had a history of 3 prior cesarean sections, and a BMI 41.</div></div><div><h3>Interventions</h3><div>Robotic assisted resection of type IIIA cesarean scar ectopic pregnancy with dissection of obliterated anterior cul de sac and temporary uterine artery occlusion.</div></div><div><h3>Measurements and Main Results</h3><div>This video demonstrates various strategies to safely navigate these complex cases. Retroperitoneal dissection with a lateral and a medial approach are demonstrated in order to access the uterine artery at its origin for temporary occlusion. A lateral to medial approach to the obliterated cul de sac by starting the dissection in the avascular space anterior to the round ligament is discussed. Lysing filmy adhesions prior to dense scar may assist in safe dissection. Placing a uterine manipulator under laparoscopic guidance may prevent disruption and acute bleeding of the ectopic pregnancy. Identifying the cervical cup anterior to the uterine vessels allows for better dissection around the ectopic pregnancy and decreases the chance of bladder, ectopic, or uterine vessel injury. Most adhesions from prior cesarean sections happen at the lower uterine segment and a tunnel is developed under the dense lower uterine segment adhesions to separate the bladder from the ectopic pregnancy. An angled 30-degree scope may help with adequate visualization for the anterior dissection. Back-filling the bladder is useful to determine the boarders of a safe dissection.</div></div><div><h3>Conclusion</h3><div>This video demonstrates tips and tricks for successful resection of type IIIA exogenous cesarean scar ectopic pregnancy.</div></div>","PeriodicalId":16397,"journal":{"name":"Journal of minimally invasive gynecology","volume":"31 11","pages":"Page S29"},"PeriodicalIF":3.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142658072","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1016/j.jmig.2024.09.050
CAZ Mabini , T Tam , S Siddique
Study Objective
To demonstrate the utility of indocyanine green (ICG) as an intraoperative aid in the hysteroscopic-assisted robotic repair of isthmocele in a patient with Asherman's syndrome.
Design
Video case review.
Setting
Procedure was performed by a MIGS fellowship-trained surgeon at a community-based hospital.
Patients or Participants
A 43-year-old G7P5032 referral from OBGYN with history of prior endometrial ablation diagnosed with an isthmocele on TVUS in the setting of cyclic postmenstrual bleeding.
Interventions
Use of ICG during a hysteroscopic-assisted robotic repair of an isthmocele.
Measurements and Main Results
ICG was utilized to enhance visualization of the isthmocele when hysteroscopic transillumination and visual palpatory cues are difficult to appreciate due to abnormal uterine anatomy such as Asherman's Syndrome. Two months follow up saline-infused sonography demonstrated significant improvement in residual myometrial thickness (RMT) and lack of fluid collection at site of previously noted isthmocele defect. Patient's post operative course was uncomplicated with complete resolution of symptoms.
Conclusion
ICG is a valuable tool for identifying an isthmocele defect in complex surgical cases where scarring and adhesions obscure normal uterine anatomy and landmarks. Use of ICG is safe and can improve surgical accuracy and outcomes in the management of an isthmocele, particularly in patients with prior uterine surgeries and altered anatomical structures. This technique warrants further investigation in larger prospective studies to assess its impact in patient outcomes.
{"title":"When in Doubt, Green It Out: Use of ICG in the Hysteroscopic-Assisted Robotic Excision of an Isthmocele in a Patient With Asherman's Syndrome","authors":"CAZ Mabini , T Tam , S Siddique","doi":"10.1016/j.jmig.2024.09.050","DOIUrl":"10.1016/j.jmig.2024.09.050","url":null,"abstract":"<div><h3>Study Objective</h3><div>To demonstrate the utility of indocyanine green (ICG) as an intraoperative aid in the hysteroscopic-assisted robotic repair of isthmocele in a patient with Asherman's syndrome.</div></div><div><h3>Design</h3><div>Video case review.</div></div><div><h3>Setting</h3><div>Procedure was performed by a MIGS fellowship-trained surgeon at a community-based hospital.</div></div><div><h3>Patients or Participants</h3><div>A 43-year-old G7P5032 referral from OBGYN with history of prior endometrial ablation diagnosed with an isthmocele on TVUS in the setting of cyclic postmenstrual bleeding.</div></div><div><h3>Interventions</h3><div>Use of ICG during a hysteroscopic-assisted robotic repair of an isthmocele.</div></div><div><h3>Measurements and Main Results</h3><div>ICG was utilized to enhance visualization of the isthmocele when hysteroscopic transillumination and visual palpatory cues are difficult to appreciate due to abnormal uterine anatomy such as Asherman's Syndrome. Two months follow up saline-infused sonography demonstrated significant improvement in residual myometrial thickness (RMT) and lack of fluid collection at site of previously noted isthmocele defect. Patient's post operative course was uncomplicated with complete resolution of symptoms.</div></div><div><h3>Conclusion</h3><div>ICG is a valuable tool for identifying an isthmocele defect in complex surgical cases where scarring and adhesions obscure normal uterine anatomy and landmarks. Use of ICG is safe and can improve surgical accuracy and outcomes in the management of an isthmocele, particularly in patients with prior uterine surgeries and altered anatomical structures. This technique warrants further investigation in larger prospective studies to assess its impact in patient outcomes.</div></div>","PeriodicalId":16397,"journal":{"name":"Journal of minimally invasive gynecology","volume":"31 11","pages":"Pages S10-S11"},"PeriodicalIF":3.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142658142","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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