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

Description of technique, steps and basic precautions for hysteroscopic myomectomy. Also discussion of myoma classification, indication and selection of patients.

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.

We present the case of a 61-year-old woman presenting with a pelvic mass with an utero-adnexal origin diagnosed by ultrasound. The patient complained of transvaginal bleeding, light pelvic pain, and dyschezia. At bimanual examination, Douglas’ pouch is found to be occupied, and the uterus fixed. A contrasted CT-scan reveals no apparent signs of metastasis.
This video demonstrates that performing a complete staging and debulking of advanced cancer cases is safe and feasible in the hands of experienced gynecological surgeons.

For a long time, morcellation of an undiagnosed malignancy, an old and frightening topic, has been a matter of extensive discussions. Clinicians and pathologists still lack instruments to clearly diagnose specific pathologies such as leiomyosarcomas. Minimally invasive surgery brought numerous advantages for the patient. However, morcellation is a key issue for the extraction of a large uterus and myomas. In this video, we present an option for the extraction of myomas. By insufflating a large Endobag®, a virtual abdominal cavity is created, and the mass is morcellated under direct vision. The resistant bag works not only as a protection for the abdominal cavity in case of an undiagnosed malignancy, but also serves to deviate organs from the morcellator.

The role of lymph node staging in high-risk endometrial cancer is a tricky subject as there is no strong evidence supporting it yet. This authoritative lecture provides a good overview of the application of this technique for these specific patients.

25 to 30% of women are diagnosed with uterine myomas worldwide. Laparoscopic myomectomy has remarkable advantages for patients with less postoperative pain and shorter recovery time. The fibroid resection technique varies depending on the myoma’s size and position.
Pedunculated fibroids: The myoma’s pedicle is cauterized by means of the bipolar forceps and divided after loop placement.
Subserous and intramural myomas: An incision extended until the pseudo-capsule is made vertically or horizontally at the site of the underlying myoma. The dissection is performed strictly within the pseudo-capsule plane with the help of two pairs of grasping forceps using traction and counter-traction. After myoma enucleation, the uterus is sutured along a seromuscular plane using one or two layers of separate polydioxanon suture (PDS) stitches with extracorporeal or intracorporeal knots. Continuous suction and irrigation is performed to minimize adhesion formation. The myomas are then extracted by morcellation using an electric morcellator; an alternative method is to take it out by colpotomy, or to cut it in case of smaller pieces.
Cervical myomas: These can be easily reached and enucleated transvaginally.
Adenomyosis uteri: In case of dysmenorrhea resulting from well-discernible adenomyotic lesions, a careful resection is recommended by hysteroscopy or laparoscopy.
Adenomatoid tumors: They resemble fibroids with no clear cleavage plane. The exclusion from malignancy is only possible by histology which account for their necessary removal; they can also turn into malignancy.
Submucous myomas: They are located within the uterine cavity; their resection is performed hysteroscopically with the resectoscopic loop in a slicing manner with bipolar or monopolar current. Attention must be paid regarding resection if the distance between the myoma and the uterine serosa is less than 8mm. The laparotomic approach is preferably performed if the myoma is bigger than 20cm in diameter, located at very critical points, suspected of being a sarcoma, or if there are more than 10 fibroids. In any case when surgery is indicated, laparoscopic or hysteroscopic myomectomy is the primary choice according to the location. The results of many international series demonstrate the feasibility of laparoscopic and hysteroscopic myomectomy as a technique leading to a remission of symptoms with a low rate of complications and leading to an increased rate of fertility.

Introduction: A unicornuate uterus with a cavitated non-communicating rudimentary uterine horn is one of the most uncommon uterine anomalies of the female genital tract. It has an estimated frequency of 1 in 100,000 among the fertile female population. This anomaly results from the abnormal maturation of one Müllerian duct with the normal development of the contralateral one.
Case: This video describes the laparoscopic diagnosis and management of a unicornuate uterus with a left cavitated non-communicating rudimentary uterine horn in a 27-year old woman who presented with lower abdominal pain and severe dysmenorrhea. She was submitted to a preoperative imaging study with a MRI, a uro-CT and a CT-scan of the vertebral column. There were no concomitant urinary anomalies and the sagittal CT-scan revealed abnormalities in the development of the terminal portion of the column. A laparoscopic removal of this cavitated non-communicating uterine horn was performed without any complication in the postoperative period.
Conclusion: Operative laparoscopy proved to be a successful approach in the treatment of this congenital Müllerian anomaly.

Laparoscopic hysterectomy is a common procedure in the gynecological sphere. In order to perform a safe, easy and reproducible surgery, surgeons require adequate training as well as theoretical knowledge. In this key lecture, a perfect approach to the main steps required for a perfect laparoscopic hysterectomy is demonstrated.

We present the case of a 65-year-old patient, diagnosed with uterine fibroids that have increased in volume over the last months. The patient had previously undergone a rectosigmoid resection and an appendectomy due to an adenocarcinoma. This surgery was streamed live worldwide, and it provides a unique opportunity to learn how to assess, diagnose, and treat intraoperative unexpected complications.

This video demonstrates the technique of a total laparoscopic hysterectomy with adnexectomy. Our patient is a 44-year-old lady with Tamoxifen-induced endometrial hyperplasia, which failed to respond to medical treatment.
Umbilical incision is made on the left internal border to give a more aesthetic scar.
Direct entry is performed. The assistant helps to lift the abdomen while the surgeon directs the trocar perpendicularly towards the rectus sheath first, then directs it towards the pelvis. The midline port is inserted: this should be at a slightly higher level than the lateral ports for better ergonomics. The uterine manipulator has a rotating ceramic valve for opening the vagina and a set of rings to maintain the pneumoperitoneum. The procedure is started by coagulating and cutting the round ligament on the left and opening the broad ligament. The broad ligament is opened parallel to the infundibulopelvic ligament for adnexectomy and a window is made over the grey area. The posterior leaf of the broad ligament is opened towards the left uterosacral ligament. The anterior leaf of the broad ligament is opened towards the vagina by dissecting the space and coagulating and cutting the tissues in between. The dissection is continued until the uterine artery is reached. The left infundibulopelvic ligament is coagulated and cut. The same procedure is done on the other side. Bladder dissection is performed with the help of the assistant holding up the bladder and entering the vesicovaginal space. The bladder is dissected away, beyond the valve of the manipulator. The left uterine artery is coagulated and cut. The left uterosacral ligament is coagulated and cut. The right uterine vessels are coagulated and cut followed by the uterosacral ligament. The vagina is now cut against the valve of the manipulator using a monopolar hook. Bleeding points are coagulated with a bipolar forceps. The vagina is sutured in two layers using extracorporeal knots. The procedure is now complete and hemostasis is confirmed. This patient had a favourable postoperative outcome and was discharged on postoperative day 1.