Pub Date : 2024-11-01DOI: 10.1016/j.jmig.2024.09.123
A Matthaeus , S Dudhat , G Janik
Study Objective
Novel laparoscopic approach to management of arteriovenous (AV) malformation that preserves fertility.
Design
Case study.
Setting
Reproductive surgery program within reproductive medicine clinic and OR equipped for minimally invasive surgery.
Patients or Participants
One patient with AV malformation and three failed uterine artery embolizations (UAE).
Interventions
Laparoscopy and hysteroscopy with ultrasound guidance used to remove AV malformation and uterine reconstruction in patient with previously failed UAE x3.
Measurements and Main Results
Resolution of menorrhagia and three successful pregnancies delivered by C-section at 37 weeks.
Conclusion
Laparoscopic resection of AV malformation with ultrasound guidance is an effective management for AV malformation in patients desiring future pregnancy.
{"title":"Fertility-Preserving Laparoscopic Surgery for Uterine Arteriovenous Malformation After Failed Uterine Artery Embolization","authors":"A Matthaeus , S Dudhat , G Janik","doi":"10.1016/j.jmig.2024.09.123","DOIUrl":"10.1016/j.jmig.2024.09.123","url":null,"abstract":"<div><h3>Study Objective</h3><div>Novel laparoscopic approach to management of arteriovenous (AV) malformation that preserves fertility.</div></div><div><h3>Design</h3><div>Case study.</div></div><div><h3>Setting</h3><div>Reproductive surgery program within reproductive medicine clinic and OR equipped for minimally invasive surgery.</div></div><div><h3>Patients or Participants</h3><div>One patient with AV malformation and three failed uterine artery embolizations (UAE).</div></div><div><h3>Interventions</h3><div>Laparoscopy and hysteroscopy with ultrasound guidance used to remove AV malformation and uterine reconstruction in patient with previously failed UAE x3.</div></div><div><h3>Measurements and Main Results</h3><div>Resolution of menorrhagia and three successful pregnancies delivered by C-section at 37 weeks.</div></div><div><h3>Conclusion</h3><div>Laparoscopic resection of AV malformation with ultrasound guidance is an effective management for AV malformation in patients desiring future pregnancy.</div></div>","PeriodicalId":16397,"journal":{"name":"Journal of minimally invasive gynecology","volume":"31 11","pages":"Page S30"},"PeriodicalIF":3.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142658070","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.2024.09.054
E Wolverton , E Qiao , SB Kaiser , C Gould , JM Wong
Study Objective
This surgical tutorial demonstrates an efficient and reproducible technique for use of intra-ureteral indocyanine green (ICG) dye at the time of ureteral catheter placement to aid in intraoperative ureteral visualization.
Design
Narrated instructional surgical video.
Setting
Academic tertiary care hospital.
Patients or Participants
Two patients undergoing complex robotic gynecologic surgery with anticipated severe pelvic anatomic distortion or adhesive disease.
Interventions
Stepwise demonstration of surgical technique and considerations during ureteral catheter placement with injection of ICG dye at the time of complex pelvic surgery.
Measurements and Main Results
This video describes 1) operative set-up, 2) surgical techniques and considerations during ureteral catheter placement and intra-ureteral ICG dye injection, and 3) demonstration of near infra-red (NIR) visualization of ICG dye intraoperatively.
Conclusion
Although the overall risk of lower urinary tract injury during pelvic surgery is low, complex gynecologic surgery with distorted pelvic anatomy or significant adhesive disease poses an increased risk for ureteral obscurement and injury. Use of intra-ureteral ICG dye is a safe and replicable method of ureteral visualization with the potential to improve the safety of complex minimally invasive pelvic surgery. This instructional video tutorial provides surgeons with a reproducible technique for intra-ureteral ICG dye use at the time of pelvic surgery.
{"title":"Intra-Ureteral Indocyanine Green (ICG) Dye Use During Complex Pelvic Surgery: A Surgical Tutorial and Guide","authors":"E Wolverton , E Qiao , SB Kaiser , C Gould , JM Wong","doi":"10.1016/j.jmig.2024.09.054","DOIUrl":"10.1016/j.jmig.2024.09.054","url":null,"abstract":"<div><h3>Study Objective</h3><div>This surgical tutorial demonstrates an efficient and reproducible technique for use of intra-ureteral indocyanine green (ICG) dye at the time of ureteral catheter placement to aid in intraoperative ureteral visualization.</div></div><div><h3>Design</h3><div>Narrated instructional surgical video.</div></div><div><h3>Setting</h3><div>Academic tertiary care hospital.</div></div><div><h3>Patients or Participants</h3><div>Two patients undergoing complex robotic gynecologic surgery with anticipated severe pelvic anatomic distortion or adhesive disease.</div></div><div><h3>Interventions</h3><div>Stepwise demonstration of surgical technique and considerations during ureteral catheter placement with injection of ICG dye at the time of complex pelvic surgery.</div></div><div><h3>Measurements and Main Results</h3><div>This video describes 1) operative set-up, 2) surgical techniques and considerations during ureteral catheter placement and intra-ureteral ICG dye injection, and 3) demonstration of near infra-red (NIR) visualization of ICG dye intraoperatively.</div></div><div><h3>Conclusion</h3><div>Although the overall risk of lower urinary tract injury during pelvic surgery is low, complex gynecologic surgery with distorted pelvic anatomy or significant adhesive disease poses an increased risk for ureteral obscurement and injury. Use of intra-ureteral ICG dye is a safe and replicable method of ureteral visualization with the potential to improve the safety of complex minimally invasive pelvic surgery. This instructional video tutorial provides surgeons with a reproducible technique for intra-ureteral ICG dye use at the time of pelvic surgery.</div></div>","PeriodicalId":16397,"journal":{"name":"Journal of minimally invasive gynecology","volume":"31 11","pages":"Page S12"},"PeriodicalIF":3.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142658056","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.2024.09.093
B Bhagavath , H Huddleston , MH Emanuel , AB Hooker , CA Salazar , C Martin , D Sobti , J Kumar , MG Munro
Study Objective
Adverse pregnancy outcomes following intrauterine lysis of adhesions have been reported. The objective was to perform a meta-analysis of published research to quantify the risk.
Design
Systematic review.
Setting
International, multi-institutional collaboration.
Patients or Participants
Using search terms including intrauterine adhesions, surgery, and clinical outcomes, Cochrane, Embase and PubMed databases were systematically searched without any date limits. Very few randomized controlled trials were found pertaining to this assessment and hence meta-analysis could not be performed. Therefore, observational studies were included to perform a systematic review.
Interventions
Hysteroscopic adhesiolysis.
Measurements and Main Results
2214 abstracts were identified and 418 assessed for eligibility. 235 studies were found to be eligible and 18 were eventually included in the analysis. Preterm delivery rate was 17%. Placental abnormalities included 11% placenta acreta spectrum disorders and 3% previa. Antepartum hemorrhage occurred in 3% and Peripartum hemorrhage in 10%. Hysterectomy was performed in 4%.
Conclusion
Hysteroscopic lysis was adhesions is associated with adverse events during subsequent pregnancies. High quality studies are needed to better assess the impact of intrauterine adhesiolysis on pregnancy outcomes.
{"title":"Adverse Pregnancy Outcomes Following Intrauterine Adhesiolysis - A Systematic Review","authors":"B Bhagavath , H Huddleston , MH Emanuel , AB Hooker , CA Salazar , C Martin , D Sobti , J Kumar , MG Munro","doi":"10.1016/j.jmig.2024.09.093","DOIUrl":"10.1016/j.jmig.2024.09.093","url":null,"abstract":"<div><h3>Study Objective</h3><div>Adverse pregnancy outcomes following intrauterine lysis of adhesions have been reported. The objective was to perform a meta-analysis of published research to quantify the risk.</div></div><div><h3>Design</h3><div>Systematic review.</div></div><div><h3>Setting</h3><div>International, multi-institutional collaboration.</div></div><div><h3>Patients or Participants</h3><div>Using search terms including intrauterine adhesions, surgery, and clinical outcomes, Cochrane, Embase and PubMed databases were systematically searched without any date limits. Very few randomized controlled trials were found pertaining to this assessment and hence meta-analysis could not be performed. Therefore, observational studies were included to perform a systematic review.</div></div><div><h3>Interventions</h3><div>Hysteroscopic adhesiolysis.</div></div><div><h3>Measurements and Main Results</h3><div>2214 abstracts were identified and 418 assessed for eligibility. 235 studies were found to be eligible and 18 were eventually included in the analysis. Preterm delivery rate was 17%. Placental abnormalities included 11% placenta acreta spectrum disorders and 3% previa. Antepartum hemorrhage occurred in 3% and Peripartum hemorrhage in 10%. Hysterectomy was performed in 4%.</div></div><div><h3>Conclusion</h3><div>Hysteroscopic lysis was adhesions is associated with adverse events during subsequent pregnancies. High quality studies are needed to better assess the impact of intrauterine adhesiolysis on pregnancy outcomes.</div></div>","PeriodicalId":16397,"journal":{"name":"Journal of minimally invasive gynecology","volume":"31 11","pages":"Pages S20-S21"},"PeriodicalIF":3.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142658440","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.2024.09.078
S Parikh, V Brown, RS Barbaresso, RP Pasic
Study Objective
To demonstrate the utility of preoperative sonographic evaluation for deep infiltrating endometriosis (DIE) and correlate ultrasound and intraoperative findings through a clinical scenario.
Design
A stepwise demonstration and comparison of ultrasound and intraoperative evaluation of DIE with narrated video footage.
Setting
A tertiary, academic hospital with an experienced endometriosis sonographer and high-volume MIGS specialist.
Patients or Participants
A 25-year-old presented with chronic pelvic pain and history of endometriosis after failing multiple medical therapies.
Interventions
DIE occurs in 4-37% of patients with endometriosis. Ultrasound is recommended as a first-line imaging for evaluation and has high sensitivity and specificity for DIE. At our institution, same day preoperative ultrasound is performed for patients based on the IDEA group consensus on the systematic approach to sonographic evaluation of endometriosis. This evaluation includes a basic assessment of the uterus and adnexa, soft markers such as sliding sign, and the anterior and posterior compartments of the pelvis.
Measurements and Main Results
In this patient, ultrasound illustrated an immobile uterus with a 3 cm right ovarian endometrioma and two hypoechoic lesions in the posterior cul-du-sac, indicating adhesive disease and advanced-stage endometriosis. The patient had a laparoscopic resection of endometriosis, right ovarian cystectomy, bilateral ureterolysis, adhesiolysis and enterolysis, rectal shaving, and an appendectomy. Sonographic results correlated accurately with intraoperative findings, and the pathology was consistent with endometriosis.
Conclusion
Ultrasound is imperative for assessing patients with suspected or confirmed advanced-stage endometriosis. A structured pelvic ultrasound should be completed in a manner that assesses for uterine and adnexal mobility and endometriosis lesions or nodules in the anterior and/or posterior compartments of the pelvis. This type of evaluation allows for appropriate surgical planning and counseling, especially for advanced laparoscopic procedures. However, there needs to be more specialized sonographic training to improve the accuracy of preoperative sonographic evaluation of endometriosis.
研究目的通过一个临床场景展示深部浸润性子宫内膜异位症（DIE）术前超声评估的实用性，并将超声和术中发现关联起来.设计通过解说视频录像逐步展示和比较 DIE 的超声和术中评估.患者或参与者一名25岁的患者，因慢性盆腔疼痛和子宫内膜异位症病史而就诊，经多种药物治疗无效。超声波被推荐为评估的一线影像学检查，对 DIE 具有很高的敏感性和特异性。在我院，根据 IDEA 小组就子宫内膜异位症超声评估的系统方法达成的共识，对患者进行当天的术前超声检查。在该患者中，超声显示子宫不能移动，右侧卵巢有一个3厘米长的子宫内膜异位瘤，后骶骨有两个低回声病灶，提示粘连性疾病和晚期子宫内膜异位症。患者接受了腹腔镜子宫内膜异位症切除术、右卵巢囊肿切除术、双侧输尿管溶解术、粘连溶解术和肠溶解术、直肠剃除术以及阑尾切除术。超声检查结果与术中发现准确相关，病理结果与子宫内膜异位症一致。在完成结构化盆腔超声检查时，应评估子宫和附件的活动度以及盆腔前部和/或后部的子宫内膜异位症病灶或结节。通过这种评估，可以制定适当的手术计划并提供咨询，尤其是对于先进的腹腔镜手术而言。不过，还需要进行更专业的声学培训，以提高子宫内膜异位症术前声学评估的准确性。
{"title":"Preoperative Sonographic Evaluation of Deep Infiltrating Endometriosis","authors":"S Parikh, V Brown, RS Barbaresso, RP Pasic","doi":"10.1016/j.jmig.2024.09.078","DOIUrl":"10.1016/j.jmig.2024.09.078","url":null,"abstract":"<div><h3>Study Objective</h3><div>To demonstrate the utility of preoperative sonographic evaluation for deep infiltrating endometriosis (DIE) and correlate ultrasound and intraoperative findings through a clinical scenario.</div></div><div><h3>Design</h3><div>A stepwise demonstration and comparison of ultrasound and intraoperative evaluation of DIE with narrated video footage.</div></div><div><h3>Setting</h3><div>A tertiary, academic hospital with an experienced endometriosis sonographer and high-volume MIGS specialist.</div></div><div><h3>Patients or Participants</h3><div>A 25-year-old presented with chronic pelvic pain and history of endometriosis after failing multiple medical therapies.</div></div><div><h3>Interventions</h3><div>DIE occurs in 4-37% of patients with endometriosis. Ultrasound is recommended as a first-line imaging for evaluation and has high sensitivity and specificity for DIE. At our institution, same day preoperative ultrasound is performed for patients based on the IDEA group consensus on the systematic approach to sonographic evaluation of endometriosis. This evaluation includes a basic assessment of the uterus and adnexa, soft markers such as sliding sign, and the anterior and posterior compartments of the pelvis.</div></div><div><h3>Measurements and Main Results</h3><div>In this patient, ultrasound illustrated an immobile uterus with a 3 cm right ovarian endometrioma and two hypoechoic lesions in the posterior cul-du-sac, indicating adhesive disease and advanced-stage endometriosis. The patient had a laparoscopic resection of endometriosis, right ovarian cystectomy, bilateral ureterolysis, adhesiolysis and enterolysis, rectal shaving, and an appendectomy. Sonographic results correlated accurately with intraoperative findings, and the pathology was consistent with endometriosis.</div></div><div><h3>Conclusion</h3><div>Ultrasound is imperative for assessing patients with suspected or confirmed advanced-stage endometriosis. A structured pelvic ultrasound should be completed in a manner that assesses for uterine and adnexal mobility and endometriosis lesions or nodules in the anterior and/or posterior compartments of the pelvis. This type of evaluation allows for appropriate surgical planning and counseling, especially for advanced laparoscopic procedures. However, there needs to be more specialized sonographic training to improve the accuracy of preoperative sonographic evaluation of endometriosis.</div></div>","PeriodicalId":16397,"journal":{"name":"Journal of minimally invasive gynecology","volume":"31 11","pages":"Pages S16-S17"},"PeriodicalIF":3.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142658004","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.2024.09.132
X Deffieux , A Hackenthal , JL Benifla , I Juhasz-Böess , M Breitbach , O Buchweitz , N Habib , K Hald , B Haj Hamoud , C Huchon , V Lysdal , M Nigelis , M Rudnicki , E Solomayer , FA Taran , H Michelsen-Wahl , R Azziz , V Bagnardi
Study Objective
The LevaLap™ 1.0 (Core Access Surgical Technologies, Atlanta, GA, USA) was designed to promote safer, more stable, and more predictable abdominal access when using the Veress needle for insufflation. Among other benefits, it increases the distance between the access site and retroperitoneal vessels by >5 cm. We report on the first post-marketing clinical study (PMCF) assessing experience with the use of the LevaLap™ 1.0 during gynecologic laparoscopic surgery.
Design
Prospective multicenter study.
Setting
Operating room.
Patients or Participants
Women ≥18 years old. Exclusion criteria: pregnancy, access site surgery in prior 10 days, abdominal hernia, contraindication to Veress needle or laparoscopy use, BMI >30 kg/m2, and inability/unwillingness to provide consent.
Interventions
Use of the LevaLap™ 1.0 to facilitate abdominal access when using the Veress needle for insufflation.
Measurements and Main Results
157 subjects were studied by 9 surgeons, each performing ≥5 cases (5-22 cases/surgeon); mean age: 43.6±14.4 yrs. and mean BMI: 24.8±3.8 kg/m2. Access site was 83.4% trans-umbilical, 15.3% peri-umbilical, 0.6% Palmer's point, and 0.6% other. Using the device, 96.8% (95% CI: 92.7%-99.0%, n=152/157) of patients’ access was successfully achieved at 1st attempt and 99.4% (95% CI: 96.5-100.0, n=156/157) within the first two attempts. One minor device-related AE was reported: a circular redness on the skin at the site of device application, resolving spontaneously the following morning. Surgeons noted easier access in 58%, increased confidence in 68.5%, increased access control in 66.9%, and increased access efficiency in 66.2% of cases.
Conclusion
The results of this PMCF study indicate that the use of the LevaLap™ 1.0 resulted in easier, greater control and greater efficiency during abdominal access using the Veress needle. In 96.8% of patients access was achieved at 1st attempt, and in 99.4% within the first two attempts. The use of the LevaLap™ 1.0 facilitates abdominal access when using the Veress needle for insufflation.
{"title":"Post-Marketing Experience With the Levalap™ 1.0: Improved Abdominal Access WHEN Using the Veress Needle During Laparoscopic Surgery","authors":"X Deffieux , A Hackenthal , JL Benifla , I Juhasz-Böess , M Breitbach , O Buchweitz , N Habib , K Hald , B Haj Hamoud , C Huchon , V Lysdal , M Nigelis , M Rudnicki , E Solomayer , FA Taran , H Michelsen-Wahl , R Azziz , V Bagnardi","doi":"10.1016/j.jmig.2024.09.132","DOIUrl":"10.1016/j.jmig.2024.09.132","url":null,"abstract":"<div><h3>Study Objective</h3><div>The LevaLap™ 1.0 (Core Access Surgical Technologies, Atlanta, GA, USA) was designed to promote safer, more stable, and more predictable abdominal access when using the Veress needle for insufflation. Among other benefits, it increases the distance between the access site and retroperitoneal vessels by >5 cm. We report on the first post-marketing clinical study (PMCF) assessing experience with the use of the LevaLap™ 1.0 during gynecologic laparoscopic surgery.</div></div><div><h3>Design</h3><div>Prospective multicenter study.</div></div><div><h3>Setting</h3><div>Operating room.</div></div><div><h3>Patients or Participants</h3><div>Women ≥18 years old. <em>Exclusion criteria:</em> pregnancy, access site surgery in prior 10 days, abdominal hernia, contraindication to Veress needle or laparoscopy use, BMI >30 kg/m<sup>2</sup>, and inability/unwillingness to provide consent.</div></div><div><h3>Interventions</h3><div>Use of the LevaLap™ 1.0 to facilitate abdominal access when using the Veress needle for insufflation.</div></div><div><h3>Measurements and Main Results</h3><div>157 subjects were studied by 9 surgeons, each performing ≥5 cases (5-22 cases/surgeon); mean age: 43.6±14.4 yrs. and mean BMI: 24.8±3.8 kg/m<sup>2</sup>. Access site was 83.4% trans-umbilical, 15.3% peri-umbilical, 0.6% Palmer's point, and 0.6% other. Using the device, 96.8% (95% CI: 92.7%-99.0%, n=152/157) of patients’ access was successfully achieved at 1<sup>st</sup> attempt and 99.4% (95% CI: 96.5-100.0, n=156/157) within the first two attempts. One minor device-related AE was reported: a circular redness on the skin at the site of device application, resolving spontaneously the following morning. Surgeons noted easier access in 58%, increased confidence in 68.5%, increased access control in 66.9%, and increased access efficiency in 66.2% of cases.</div></div><div><h3>Conclusion</h3><div>The results of this PMCF study indicate that the use of the LevaLap™ 1.0 resulted in easier, greater control and greater efficiency during abdominal access using the Veress needle. In 96.8% of patients access was achieved at 1<sup>st</sup> attempt, and in 99.4% within the first two attempts. The use of the LevaLap™ 1.0 facilitates abdominal access when using the Veress needle for insufflation.</div></div>","PeriodicalId":16397,"journal":{"name":"Journal of minimally invasive gynecology","volume":"31 11","pages":"Pages S33-S34"},"PeriodicalIF":3.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142658151","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.2024.09.055
SA Freeman , MA McGrattan , M Atri , A Murji
Study Objective
To review the classification and surgical management options for interstitial ectopic pregnancy (IEP) and demonstrate a novel approach to the management of distal IEP, the myometrium-sparing laparoscopic retrograde milking technique.
Design
One patient underwent surgical management of distal IEP using the laparoscopic retrograde milking technique followed by routine salpingectomy. She was seen for routine 6-week postoperative follow-up.
Setting
The patient was positioned in dorsal lithotomy with legs in stirrups and arms tucked. A 10mm 30-degree laparoscope and three 5-mm accessory ports were used.
Patients or Participants
One patient with distal IEP was selected and provided informed consent for video recording of her surgery to be used for educational and research purposes.
Interventions
The laparoscopic retrograde milking technique, an emerging technique for management of distal IEP that avoids myometrial incision, was used to milk the pregnancy into the tubal ampulla. Routine salpingectomy was then performed.
Measurements and Main Results
The patient had an uncomplicated surgery and recovery. Her beta-HCG was followed weekly until negative.
Conclusion
Distal IEPs may be safely and effectively managed with the laparoscopic retrograde milking technique followed by routine salpingectomy. Surgeon skill remains paramount to the surgical management of IEPs due to the risk of intraoperative rupture. Providers performing the milking technique should be prepared to urgently convert the procedure to a cornuostomy or wedge resection and be comfortable with laparoscopic suturing. If myometrial incision can be avoided through use of the milking technique, advantages may include reduced operative time, decreased blood loss, faster recovery, and the possibility of vaginal delivery in subsequent pregnancies by avoiding a myometrial incision, an option typically not recommended after laparoscopic cornuostomy or cornual wedge resection. Although theoretically this technique does not breach the myometrium, patients should be counselled about the lack of evidence regarding risk of uterine rupture during trial of labour after salpingectomy using this technique.
{"title":"Laparoscopic Surgical Management of Interstitial Ectopic Pregnancy: The Retrograde Milking Technique","authors":"SA Freeman , MA McGrattan , M Atri , A Murji","doi":"10.1016/j.jmig.2024.09.055","DOIUrl":"10.1016/j.jmig.2024.09.055","url":null,"abstract":"<div><h3>Study Objective</h3><div>To review the classification and surgical management options for interstitial ectopic pregnancy (IEP) and demonstrate a novel approach to the management of distal IEP, the myometrium-sparing laparoscopic retrograde milking technique.</div></div><div><h3>Design</h3><div>One patient underwent surgical management of distal IEP using the laparoscopic retrograde milking technique followed by routine salpingectomy. She was seen for routine 6-week postoperative follow-up.</div></div><div><h3>Setting</h3><div>The patient was positioned in dorsal lithotomy with legs in stirrups and arms tucked. A 10mm 30-degree laparoscope and three 5-mm accessory ports were used.</div></div><div><h3>Patients or Participants</h3><div>One patient with distal IEP was selected and provided informed consent for video recording of her surgery to be used for educational and research purposes.</div></div><div><h3>Interventions</h3><div>The laparoscopic retrograde milking technique, an emerging technique for management of distal IEP that avoids myometrial incision, was used to milk the pregnancy into the tubal ampulla. Routine salpingectomy was then performed.</div></div><div><h3>Measurements and Main Results</h3><div>The patient had an uncomplicated surgery and recovery. Her beta-HCG was followed weekly until negative.</div></div><div><h3>Conclusion</h3><div>Distal IEPs may be safely and effectively managed with the laparoscopic retrograde milking technique followed by routine salpingectomy. Surgeon skill remains paramount to the surgical management of IEPs due to the risk of intraoperative rupture. Providers performing the milking technique should be prepared to urgently convert the procedure to a cornuostomy or wedge resection and be comfortable with laparoscopic suturing. If myometrial incision can be avoided through use of the milking technique, advantages may include reduced operative time, decreased blood loss, faster recovery, and the possibility of vaginal delivery in subsequent pregnancies by avoiding a myometrial incision, an option typically not recommended after laparoscopic cornuostomy or cornual wedge resection. Although theoretically this technique does not breach the myometrium, patients should be counselled about the lack of evidence regarding risk of uterine rupture during trial of labour after salpingectomy using this technique.</div></div>","PeriodicalId":16397,"journal":{"name":"Journal of minimally invasive gynecology","volume":"31 11","pages":"Page S8"},"PeriodicalIF":3.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142658216","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.2024.09.112
P Ting , M Suen
Study Objective
The goal of this video is to demonstrate a surgical teaching video for learners to identify commonly encountered tissue planes during an uncomplicated laparoscopic hysterectomy and to have access to it as a learning resource.
Design
This video will provide learners with repetitive exposure to the same surgical planes, with multiple opportunities to predict the correct dissection site. This surgical teaching will advance the experience of junior trainees outside in the OR in a safe environment, and accelerate their development along the learning curve.
Setting
All videos were acquired during uncomplicated total laparoscopic hysterectomies in the operating room.
Patients or Participants
Patient undergoing uncomplicated total laparoscopic hysterectomies.
Interventions
Totally laparoscopic hysterectomy.
Measurements and Main Results
Three commonly encounter tissue planes from laparoscopic hysterectomy will be shown. The first site is omental or bowel adhesions to the anterior abdominal wall upon entry. Second site is physiological adhesions of the sigmoid colon to the left pelvic side wall. The third side is commonly encountered bladder adhesions to the anterior aspect of the uterus.
Conclusion
A surgical teaching video for learners to identify commonly encountered tissue planes during an uncomplicated laparoscopic hysterectomy and to have access to it as a learning resource.
During the preparation of this work, no AI tool was used for editing, processing, or production of the video.
{"title":"Surgical Educational Video for Identifying Tissue Planes in an Uncomplicated Laparoscopic Hysterectomy","authors":"P Ting , M Suen","doi":"10.1016/j.jmig.2024.09.112","DOIUrl":"10.1016/j.jmig.2024.09.112","url":null,"abstract":"<div><h3>Study Objective</h3><div>The goal of this video is to demonstrate a surgical teaching video for learners to identify commonly encountered tissue planes during an uncomplicated laparoscopic hysterectomy and to have access to it as a learning resource.</div></div><div><h3>Design</h3><div>This video will provide learners with repetitive exposure to the same surgical planes, with multiple opportunities to predict the correct dissection site. This surgical teaching will advance the experience of junior trainees outside in the OR in a safe environment, and accelerate their development along the learning curve.</div></div><div><h3>Setting</h3><div>All videos were acquired during uncomplicated total laparoscopic hysterectomies in the operating room.</div></div><div><h3>Patients or Participants</h3><div>Patient undergoing uncomplicated total laparoscopic hysterectomies.</div></div><div><h3>Interventions</h3><div>Totally laparoscopic hysterectomy.</div></div><div><h3>Measurements and Main Results</h3><div>Three commonly encounter tissue planes from laparoscopic hysterectomy will be shown. The first site is omental or bowel adhesions to the anterior abdominal wall upon entry. Second site is physiological adhesions of the sigmoid colon to the left pelvic side wall. The third side is commonly encountered bladder adhesions to the anterior aspect of the uterus.</div></div><div><h3>Conclusion</h3><div>A surgical teaching video for learners to identify commonly encountered tissue planes during an uncomplicated laparoscopic hysterectomy and to have access to it as a learning resource.</div><div><em>During the preparation of this work, no AI tool was used for editing, processing, or production of the video.</em></div></div>","PeriodicalId":16397,"journal":{"name":"Journal of minimally invasive gynecology","volume":"31 11","pages":"Page S27"},"PeriodicalIF":3.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142658451","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.2024.07.003
Study Objective
To examine racial disparities in route of hysterectomy and perioperative outcomes before and after expansion of high-volume minimally invasive surgeons (>10 minimally invasive hysterectomies [MIHs]/year).
Design
Retrospective cohort study.
Setting
Multicenter academic teaching institution.
Patients
All patients who underwent a scheduled hysterectomy for benign indications during 2018 (preintervention) and 2022 (postintervention).
Interventions
Recruitment of fellowship in minimally invasive gynecologic surgery–trained faculty and increased surgical training for academic specialists in obstetrics and gynecology occurred in 2020.
Measurements and Main Results
Patients in the preintervention cohort (n = 171) were older (median age, 45 years vs 43 years; p = .003) whereas patients in the postintervention cohort (n = 234) had a higher burden of comorbidities (26% American Society of Anesthesiologists class III vs 19%; p = .03). Uterine weight was not significantly different between cohorts (p = .328). Between the pre- and postintervention cohorts, high-volume minimally invasive surgeons increased from 27% (n = 4) to 44% (n = 7) of those performing hysterectomies within the division and percentage of hysterectomies performed via minimally invasive route increased (63% vs 82%; p <.001). In the preintervention cohort, Black patients had a lower percentage of hysterectomies performed via minimally invasive route than White patients (Black = 56% MIH vs White = 76% MIH; p = .014). In the postintervention cohort, differences by race were no longer significant (Black = 78% MIH vs White = 87% MIH; p = .127). There was a significant increase (22%) in MIH for Black patients between cohorts (p <.001). After adjusting for age, body mass index, American Society of Anesthesiologists class, previous surgery, and uterine weight, disparities by race were no longer present in the postintervention cohort. Perioperative outcomes including length of stay (p <.001), infection rates (p = .002), and blood loss (p = .01) improved after intervention.
Conclusion
Increasing fellowship in minimally invasive gynecologic surgery–trained gynecologic surgeons and providing more opportunities in robotic/laparoscopic training for academic specialists may improve access to MIH for Black patients and reduce disparities.
研究目的研究高容量微创外科医生（>10 例微创子宫切除术 (MIH)/年）扩张前后，子宫切除术路径和围手术期结果的种族差异：多中心学术教学机构 患者：2018年（干预前）和2022年（干预后）期间所有因良性适应症接受预定子宫切除术的患者：2020年，招募受过妇科微创手术研究员培训的教师，并增加妇产科学术专家的手术培训：干预前队列（n=171）的患者年龄较大（中位年龄为45岁 vs. 43岁，p=0.003），而干预后队列（n=234）的患者合并症较多（26% ASA III级 vs. 19%，p=0.03）。各组间的子宫重量无明显差异（P=0.328）。在干预前和干预后的队列中，该分部内进行子宫切除术的高容量微创外科医生从27%（4人）增加到44%（7人），通过微创途径进行子宫切除术的比例也有所上升（63%对82%，P=0.03）：增加接受过FMIGs培训的妇科外科医生，并为学术专家提供更多的机器人/腹腔镜培训机会，可改善黑人患者接受MIH的机会，并减少差异。
{"title":"High-Volume Surgeons and Reducing Racial Disparities in Route of Hysterectomy","authors":"","doi":"10.1016/j.jmig.2024.07.003","DOIUrl":"10.1016/j.jmig.2024.07.003","url":null,"abstract":"<div><h3>Study Objective</h3><div>To examine racial disparities in route of hysterectomy and perioperative outcomes before and after expansion of high-volume minimally invasive surgeons (>10 minimally invasive hysterectomies [MIHs]/year).</div></div><div><h3>Design</h3><div>Retrospective cohort study.</div></div><div><h3>Setting</h3><div>Multicenter academic teaching institution.</div></div><div><h3>Patients</h3><div>All patients who underwent a scheduled hysterectomy for benign indications during 2018 (preintervention) and 2022 (postintervention).</div></div><div><h3>Interventions</h3><div>Recruitment of fellowship in minimally invasive gynecologic surgery–trained faculty and increased surgical training for academic specialists in obstetrics and gynecology occurred in 2020.</div></div><div><h3>Measurements and Main Results</h3><div>Patients in the preintervention cohort (n = 171) were older (median age, 45 years vs 43 years; p = .003) whereas patients in the postintervention cohort (n = 234) had a higher burden of comorbidities (26% American Society of Anesthesiologists class III vs 19%; p = .03). Uterine weight was not significantly different between cohorts (p = .328). Between the pre- and postintervention cohorts, high-volume minimally invasive surgeons increased from 27% (n = 4) to 44% (n = 7) of those performing hysterectomies within the division and percentage of hysterectomies performed via minimally invasive route increased (63% vs 82%; p <.001). In the preintervention cohort, Black patients had a lower percentage of hysterectomies performed via minimally invasive route than White patients (Black = 56% MIH vs White = 76% MIH; p = .014). In the postintervention cohort, differences by race were no longer significant (Black = 78% MIH vs White = 87% MIH; p = .127). There was a significant increase (22%) in MIH for Black patients between cohorts (p <.001). After adjusting for age, body mass index, American Society of Anesthesiologists class, previous surgery, and uterine weight, disparities by race were no longer present in the postintervention cohort. Perioperative outcomes including length of stay (p <.001), infection rates (p = .002), and blood loss (p = .01) improved after intervention.</div></div><div><h3>Conclusion</h3><div>Increasing fellowship in minimally invasive gynecologic surgery–trained gynecologic surgeons and providing more opportunities in robotic/laparoscopic training for academic specialists may improve access to MIH for Black patients and reduce disparities.</div></div>","PeriodicalId":16397,"journal":{"name":"Journal of minimally invasive gynecology","volume":"31 11","pages":"Pages 911-918"},"PeriodicalIF":3.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141555002","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.2024.07.006
Leslie K. Palacios-Helgeson MD , Ashish Premkumar MD , Jacqueline M.K. Wong MD , Claire H. Gould MD , Megan A. Cahn PhD , Blake C. Osmundsen MD
Study Objective
To investigate the association between race and route of hysterectomy among patients undergoing hysterectomy for abnormal uterine bleeding (AUB) in the absence of uterine myoma disease and excluding malignancy.
Design
A cross-sectional cohort study utilizing the Healthcare Cost and Utilization Project Nationwide Inpatient Sample and National Ambulatory Surgical databases to compare abdominal to minimally invasive routes of hysterectomy.
Setting
Hospitals and hospital-affiliated ambulatory surgical centers participating in the Healthcare Cost and Utilization Project in 2019.
Patients
A total of 75 838 patients who had undergone hysterectomy for AUB, excluding uterine myoma and malignancy.
Interventions
n/a
Measurements and Main Results
Of the 75 838 hysterectomies performed for AUB in the absence of uterine myomas and malignancy, 10.1% were performed abdominally and 89.9% minimally invasively. After adjusting for confounders, Black patients were 38% more likely to undergo abdominal hysterectomy compared to White patients (OR 1.38, CI 1.12–1.70 p = .002). Black race, thus, is independently associated with open surgery.
Conclusion
Despite excluding uterine myomas as a risk factor for an abdominal route of hysterectomy, Black race remained an independent predictor for abdominal versus minimally invasive hysterectomy, and Black patients were found to undergo a disproportionately higher rate of abdominal hysterectomy compared to White patients.
{"title":"A National Database Study on Racial Disparities in Route of Hysterectomy With a Surrogate Control for Uterine Size: A Proposed Quality Metric for Benign Indications","authors":"Leslie K. Palacios-Helgeson MD , Ashish Premkumar MD , Jacqueline M.K. Wong MD , Claire H. Gould MD , Megan A. Cahn PhD , Blake C. Osmundsen MD","doi":"10.1016/j.jmig.2024.07.006","DOIUrl":"10.1016/j.jmig.2024.07.006","url":null,"abstract":"<div><h3>Study Objective</h3><div>To investigate the association between race and route of hysterectomy among patients undergoing hysterectomy for abnormal uterine bleeding (AUB) in the absence of uterine myoma disease and excluding malignancy.</div></div><div><h3>Design</h3><div>A cross-sectional cohort study utilizing the Healthcare Cost and Utilization Project Nationwide Inpatient Sample and National Ambulatory Surgical databases to compare abdominal to minimally invasive routes of hysterectomy.</div></div><div><h3>Setting</h3><div>Hospitals and hospital-affiliated ambulatory surgical centers participating in the Healthcare Cost and Utilization Project in 2019.</div></div><div><h3>Patients</h3><div>A total of 75 838 patients who had undergone hysterectomy for AUB, excluding uterine myoma and malignancy.</div></div><div><h3>Interventions</h3><div>n/a</div></div><div><h3>Measurements and Main Results</h3><div>Of the 75 838 hysterectomies performed for AUB in the absence of uterine myomas and malignancy, 10.1% were performed abdominally and 89.9% minimally invasively. After adjusting for confounders, Black patients were 38% more likely to undergo abdominal hysterectomy compared to White patients (OR 1.38, CI 1.12–1.70 p = .002). Black race, thus, is independently associated with open surgery.</div></div><div><h3>Conclusion</h3><div>Despite excluding uterine myomas as a risk factor for an abdominal route of hysterectomy, Black race remained an independent predictor for abdominal versus minimally invasive hysterectomy, and Black patients were found to undergo a disproportionately higher rate of abdominal hysterectomy compared to White patients.</div></div>","PeriodicalId":16397,"journal":{"name":"Journal of minimally invasive gynecology","volume":"31 11","pages":"Pages 929-935"},"PeriodicalIF":3.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141603782","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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