Total laparoscopic hysterectomy (TLH) using the LigaSure™ Retractable L-hook Laparoscopic Sealer/Divider

This video shows a myomectomy in which uterine arteries and infundibulopelvic ligaments are clipped temporarily in order to reduce intraoperative blood loss.
In addition, the incision of the uterus used to extract the myoma is not typical as the myoma is partially intramural and partially in the broad ligament. The choice of this incision is driven by the aim of decreasing blood loss, obtaining good ergonomics and anatomical exposure.

This video describes the technique of laparoscopic hysterectomy. The challenge in this case is the presence of a large fibroid uterus and distorted anatomy on the right side, which required a slightly different approach to the division of the right utero-ovarian ligament. Here is also shown the technique of morcellation using the laparoscopic blade.

Up to 40% of early cervical cancers are diagnosed in young women who might desire fertility preservation. More than 1,000 cases of Radical Vaginal Trachelectomy (RVT) have been published so far, with over 450 pregnancies achieved. Oncological outcomes of this treatment are totally comparable with the ones obtained with radical hysterectomies for similar size lesions. Additionally, these results are similar or superior when compared to the other routes of trachelectomy.
The procedure is always combined with a laparoscopic pelvic lymphadenectomy to rule out the possibility of lymph node metastases.
This video demonstrates the technique of RVT. Interesting parts of the vaginal steps are shown along with their contemporary laparoscopic views for didactic purposes.

Hysterectomy when managing a big adnexal mass has always been a challenging situation for laparoscopic surgeons. Complete preoperative assessment, surgical experience and strategy are fundamental to address adnexal pathology laparoscopicallly, both for benign and malignant conditions. Adequate trocar placement, full inspection of the abdominal cavity, comprehensive evaluation of the tumor’s surface, cytology and definition of the nature of the adnexal mass are truly essential. In addition, proper identification of standard anatomical landmarks is fundamental to perform hysterectomy with adnexectomy, which helps to prevent damage to surrounding structures. Final assessment of the vaginal cuff may lead to the diagnosis of pelvic floor disorders that should be repaired during vaginal cuff closure. In this video, we present a case of hysterectomy and adnexectomy by laparoscopy in a 46-year-old patient complaining of abdominal pain secondary to the presence of a 13cm simple adnexal cyst with normal CA 125 values.

The severe form of intrauterine adhesions (IUA) is probably the most difficult pathology to be treated by hysteroscopic surgery. The use of small diameter resectoscopes facilitates faster operations and less endometrial trauma, and is expected to be more efficient for the treatment of IUA. The concomitant use of ultrasound helps the surgeon to identify the ostia and prevents him from perforating the myometrium. The main effort is to identify the endometrial and sub-endometrial cleavage plane without injuring the myometrium. Longer periods of amenorrhea, older aged patients, and repeated surgery attempts to clear adhesions reduce chances of achieving pregnancy. Postoperative Hyalobarrier® anti-adhesive agents reduce the risk of adhesion reformation but do not increase pregnancy rates.

In this lecture, Professor Isaacson explains his technique for total laparoscopic hysterectomy step by step. The lecture begins with an outline of the required instruments to perform the procedure, including advantages and disadvantages of the most frequently used. The author then explains in a very clear and effective way his 7-step procedure to perform a total laparoscopic hysterectomy, including tips and tricks for difficult cases.

This video shows a laparoscopic total hysterectomy and a bilateral pelvic lymphadenectomy for endometrial cancer. The patient is obese with a BMI of 34, which makes the surgical intervention more difficult. Anatomical landmarks are very well shown.

The normal uterine cavity is distorted or obliterated due to severe adhesions in Asherman’s syndrome, which makes surgery difficult to perform. The high-definition vision of the camera can help to identify visual cues and clues during hysteroscopy, which can guide the surgery.
The objective of this video is to demonstrate that the information gathered from various visual cues during hysteroscopy is really helpful to the surgeon.
The video focuses on the use of the following seven visual cues: color of fibrous bands and endometrium which imparts a white spectrum; thread-like texture of fibrotic bands; lacunae and their dilatation in scar tissue; probing and post-probing analysis using scissors (5 French); color and appearance of myometrial fibers which impart a pink spectrum; vascularity differentiation; matching analysis with a normal uterine cavity.
Various techniques described for the management of this condition include fluorescence-guided, ultrasonography-guided, and hysteroscopic adhesiolysis under laparoscopic control, which are expensive procedures. We suggest that the high-definition vision and visual cues during hysteroscopy should be initially used intraoperatively for guidance purposes before using such options. It may be sufficient to achieve the desired result in most cases.

The aim of this presentation is to demonstrate the rules to avoid difficult situations in laparoscopic myomectomy. Myomectomy is one of the most challenging laparoscopic procedures, and can be time-consuming. Prior to performing a laparoscopic approach, it is always necessary to consider myoma-related factors such as number, location, and size. Regarding the surgeon’s experience, the most frequent problems are related to hemostasis achievement, traction maneuvers to enucleate myoma, and closure of uterine wall defect. Strategy and experience are truly essential to face difficult cases, and alternatives to facilitate the procedure include trocar placement, uterine artery clipping to reduce blood loss, but the most important issue remains appropriate patient selection.