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Gynecology

Find all the surgical interventions, lectures, experts opinions, debates, webinars and operative techniques per specialty.


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Laparoscopic rectal shaving for rectocervical endometriotic nodule
This is the case of a 32-year-old G0P0 woman presenting with severe dysmenorrhea, severe dyspareunia, and constipation. Pelvic examination showed a normal vagina, a fixed uterus, and mobile adnexae. Transvaginal ultrasonography (TvUSG) showed that the uterus and both ovaries were normal. A left parasalpingeal endometrioma (15mm), an obliterated Douglas pouch, as well as rectocervical and infiltrated rectal nodules (18mm and 0.6mm respectively) were also evidenced. Since bilateral ovaries were fixed to the pelvic sidewall, the operative strategy included bilateral ureterolysis and dissection of the hypogastric nerve and the pararectal fossa. Finally, the rectocervical nodule was mobilized by performing cervical and rectal shaving. The rectum was controlled by means of a methylene blue test. The final pathology was endometriosis.
H Altuntaş
Surgical intervention
6 months ago
2988 views
479 likes
0 comments
06:58
Laparoscopic rectal shaving for rectocervical endometriotic nodule
This is the case of a 32-year-old G0P0 woman presenting with severe dysmenorrhea, severe dyspareunia, and constipation. Pelvic examination showed a normal vagina, a fixed uterus, and mobile adnexae. Transvaginal ultrasonography (TvUSG) showed that the uterus and both ovaries were normal. A left parasalpingeal endometrioma (15mm), an obliterated Douglas pouch, as well as rectocervical and infiltrated rectal nodules (18mm and 0.6mm respectively) were also evidenced. Since bilateral ovaries were fixed to the pelvic sidewall, the operative strategy included bilateral ureterolysis and dissection of the hypogastric nerve and the pararectal fossa. Finally, the rectocervical nodule was mobilized by performing cervical and rectal shaving. The rectum was controlled by means of a methylene blue test. The final pathology was endometriosis.
Laparoscopic complete parametrectomy associated with upper vaginectomy and bilateral pelvic lymphadenectomy
This video shows a reproducible approach to complete parametrectomy in a patient who had had a hysterectomy. The procedure begins with adhesiolysis and dissection of the lateral pelvic spaces in order to identify and isolate the parametrium. The paravesical fossa is then dissected medially and laterally using the umbilical artery as a landmark. The surgeon identifies the uterine artery and parametrium by following the umbilical artery. Using the uterine artery as a landmark of the parametrium, dissection is continued posteriorly developing the pararectal spaces in order to isolate the posterior part of the parametrium. The ureter is dissected towards the ureteral channel and unroofed. The procedure is carried on with the complete isolation of the ureter in its anterior aspect between the parametrium and the bladder. The bladder pillar is then transected at the level of the bladder. The rectal pillar is transected at the level of the rectum, paying attention to isolate the inferior hypogastric nerve. The parametrium is then cut at the level of the hypogastric vessel. The vagina is cut with ultrasonic scissors using a cap of RUMI II as a guide, and the specimen is extracted vaginally. The surgeon performs a bilateral lymphadenectomy. In this step, the obturator nerve is dissected to prevent injuries at the medial aspect of the obturator artery. The vagina is closed with continued stitches vaginally using an extracorporeal knotting technique.
H Camuzcuoglu, B Sezgin
Surgical intervention
6 months ago
2796 views
444 likes
0 comments
11:55
Laparoscopic complete parametrectomy associated with upper vaginectomy and bilateral pelvic lymphadenectomy
This video shows a reproducible approach to complete parametrectomy in a patient who had had a hysterectomy. The procedure begins with adhesiolysis and dissection of the lateral pelvic spaces in order to identify and isolate the parametrium. The paravesical fossa is then dissected medially and laterally using the umbilical artery as a landmark. The surgeon identifies the uterine artery and parametrium by following the umbilical artery. Using the uterine artery as a landmark of the parametrium, dissection is continued posteriorly developing the pararectal spaces in order to isolate the posterior part of the parametrium. The ureter is dissected towards the ureteral channel and unroofed. The procedure is carried on with the complete isolation of the ureter in its anterior aspect between the parametrium and the bladder. The bladder pillar is then transected at the level of the bladder. The rectal pillar is transected at the level of the rectum, paying attention to isolate the inferior hypogastric nerve. The parametrium is then cut at the level of the hypogastric vessel. The vagina is cut with ultrasonic scissors using a cap of RUMI II as a guide, and the specimen is extracted vaginally. The surgeon performs a bilateral lymphadenectomy. In this step, the obturator nerve is dissected to prevent injuries at the medial aspect of the obturator artery. The vagina is closed with continued stitches vaginally using an extracorporeal knotting technique.
Use of visual cues in hysteroscopic management of Asherman's syndrome
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.
Suy Naval, R Naval, Sud Naval, A Padmawar
Surgical intervention
6 months ago
1783 views
383 likes
0 comments
06:01
Use of visual cues in hysteroscopic management of Asherman's syndrome
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.
Laparoscopy for peritonitis of gynecological origin, how far can we go?
This video shows the second and final laparoscopic treatment of a generalized peritonitis. The case is that of a 38-year-old woman who was initially managed with a first laparoscopy for peritonitis due to a pyosalpinx with left salpingectomy, adhesiolysis, and lavage. In the postoperative course, despite medical treatment, she continues to complain of a persistent severe biologic inflammatory syndrome (multidrug-resistant Bacteroides fragilis). At day 8, a second laparoscopy was decided upon, with suction, lavage, collapse, and lavage of residual pockets, adhesiolysis of bowel and both ovaries and remnant tube, and drainage. The patient recovered quickly.
JB Dubuisson
Surgical intervention
9 months ago
3283 views
573 likes
0 comments
08:01
Laparoscopy for peritonitis of gynecological origin, how far can we go?
This video shows the second and final laparoscopic treatment of a generalized peritonitis. The case is that of a 38-year-old woman who was initially managed with a first laparoscopy for peritonitis due to a pyosalpinx with left salpingectomy, adhesiolysis, and lavage. In the postoperative course, despite medical treatment, she continues to complain of a persistent severe biologic inflammatory syndrome (multidrug-resistant Bacteroides fragilis). At day 8, a second laparoscopy was decided upon, with suction, lavage, collapse, and lavage of residual pockets, adhesiolysis of bowel and both ovaries and remnant tube, and drainage. The patient recovered quickly.
Laparoscopic anatomy of the pelvic floor involved in laparoscopic surgery for pelvic organ prolapse (POP) and urinary incontinence
In this key lecture, Professor Jean-Bernard Dubuisson delineates the laparoscopic pelvic floor anatomy involved in surgical procedures for the management of pelvic organ prolapse (POP) and urinary incontinence. Traditional anatomy considers three levels: pelvic and perineal muscles, ligaments, and the space between all fascias covering the organs. Visceral ligaments occupy an anteroposterior axis (pubovesical ligaments, bladder pillars, and uterosacral ligaments) and a transverse axis (lateral bladder ligaments, cardinal ligaments, paracervix and rectal pillars). The four attachment sites which may be used by the surgeon for fascia and pelvic organ attachment in POP surgery are discussed-- Cooper’s ligament, white line, ischial spine, and sacral promontory. Approximately 90 laparoscopic anatomy pictures are presented in this authoritative lecture. The dissection planes and the different pelvic spaces used for surgery are explained, insisting on the main vessels, nerves, plexus, ureters which are obstacles to bear in mind and to avoid.
JB Dubuisson
Lecture
10 months ago
3304 views
598 likes
0 comments
24:09
Laparoscopic anatomy of the pelvic floor involved in laparoscopic surgery for pelvic organ prolapse (POP) and urinary incontinence
In this key lecture, Professor Jean-Bernard Dubuisson delineates the laparoscopic pelvic floor anatomy involved in surgical procedures for the management of pelvic organ prolapse (POP) and urinary incontinence. Traditional anatomy considers three levels: pelvic and perineal muscles, ligaments, and the space between all fascias covering the organs. Visceral ligaments occupy an anteroposterior axis (pubovesical ligaments, bladder pillars, and uterosacral ligaments) and a transverse axis (lateral bladder ligaments, cardinal ligaments, paracervix and rectal pillars). The four attachment sites which may be used by the surgeon for fascia and pelvic organ attachment in POP surgery are discussed-- Cooper’s ligament, white line, ischial spine, and sacral promontory. Approximately 90 laparoscopic anatomy pictures are presented in this authoritative lecture. The dissection planes and the different pelvic spaces used for surgery are explained, insisting on the main vessels, nerves, plexus, ureters which are obstacles to bear in mind and to avoid.
Complete cytoreductive surgery (CRS) and HIPEC using a minimally invasive approach with NOTES extraction for peritoneal carcinomatosis from primary ovarian cancer
This is the case of a 60-year old woman who sought medical advice for constipation and increased abdominal perimeter in October 2016. The abdominal CT-scan suggested a peritoneal carcinomatosis of ovarian origin along with an ascites.
The PET-scan did not show any other lesions. CA125 levels were high (1265 U/mL). The biopsy was positive and immunohistochemistry (IHC) showed a high-grade ovarian peritoneal serous carcinoma (CK7: (+), CK20: (-), WTI: (+), P53: (+), PAX8: (+), CA125: (+), RE: (+)). The diagnosis of a FIGO stage IIIc peritoneal carcinomatosis of ovarian origin was established. The patient was treated with neoadjuvant chemotherapy (Carboplatin-Paclitaxel- Bevacizumab, 4 cycles).
The patient showed a favorable clinical response with ascites disappearance. The radiological imaging also showed the disappearance of peritoneal implants. Only a 3cm right parauterine mass persisted and a biochemical response was noted with CA125 decrease (32 U/mL). A radical cytoreductive surgery is decided upon using a minimally invasive intraperitoneal hyperthermia chemotherapy. A complete cytoreduction (CC0) was performed after tumor load determination with a Peritoneal Cancer Index (PCI) of 4. It showed a greater pelvic affectation and a minimal involvement of the greater omentum. We performed a hysterectomy, a double adnexectomy, and a bilateral pelvic and parietal peritonectomy. Complete omentectomy with a gastro-omental arcade preservation, round ligament resection, bilateral iliac lymphadenectomy, and appendectomy were performed. The surgical specimens were extracted through the vagina. The patient underwent an intraoperative hyperthermic intraperitoneal chemotherapy (42ºC) with Paclitaxel (60mg/m2). Postoperative outcomes were uneventful.
A Arjona-Sánchez, S Rufian Pena, D Garcilazo Arismendi, A Cosano Alvarez, A Moreno Navas, JM Sanchez Hidalgo, FJ Briceño Delgado
Surgical intervention
1 year ago
4663 views
393 likes
0 comments
32:37
Complete cytoreductive surgery (CRS) and HIPEC using a minimally invasive approach with NOTES extraction for peritoneal carcinomatosis from primary ovarian cancer
This is the case of a 60-year old woman who sought medical advice for constipation and increased abdominal perimeter in October 2016. The abdominal CT-scan suggested a peritoneal carcinomatosis of ovarian origin along with an ascites.
The PET-scan did not show any other lesions. CA125 levels were high (1265 U/mL). The biopsy was positive and immunohistochemistry (IHC) showed a high-grade ovarian peritoneal serous carcinoma (CK7: (+), CK20: (-), WTI: (+), P53: (+), PAX8: (+), CA125: (+), RE: (+)). The diagnosis of a FIGO stage IIIc peritoneal carcinomatosis of ovarian origin was established. The patient was treated with neoadjuvant chemotherapy (Carboplatin-Paclitaxel- Bevacizumab, 4 cycles).
The patient showed a favorable clinical response with ascites disappearance. The radiological imaging also showed the disappearance of peritoneal implants. Only a 3cm right parauterine mass persisted and a biochemical response was noted with CA125 decrease (32 U/mL). A radical cytoreductive surgery is decided upon using a minimally invasive intraperitoneal hyperthermia chemotherapy. A complete cytoreduction (CC0) was performed after tumor load determination with a Peritoneal Cancer Index (PCI) of 4. It showed a greater pelvic affectation and a minimal involvement of the greater omentum. We performed a hysterectomy, a double adnexectomy, and a bilateral pelvic and parietal peritonectomy. Complete omentectomy with a gastro-omental arcade preservation, round ligament resection, bilateral iliac lymphadenectomy, and appendectomy were performed. The surgical specimens were extracted through the vagina. The patient underwent an intraoperative hyperthermic intraperitoneal chemotherapy (42ºC) with Paclitaxel (60mg/m2). Postoperative outcomes were uneventful.
Hysteroscopic treatment of a symptomatic isthmocele in a bicorporeal uterus
Clinical case: We report the case of a primigravida 36-year-old woman, with a unicervical bicorporeal uterus type. An isthmocele was diagnosed within a context of postmenstrual abnormal uterine bleeding and secondary infertility arising after C-section. The hydrosonography evidenced a moderate scar defect, the myometrium next to the "niche" measuring 3mm. Because of the symptomatology and the failure of multiple embryo transfer procedures, an operative hysteroscopy was performed. The patient was able to become pregnant spontaneously and give birth to a healthy child via C-section.

Conclusion: A minimally invasive procedure using a hysteroscopic resection of the fibrotic scar tissue is to be considered first, given the existence of an isthmocele in a symptomatic and/or infertile woman, even in the case of a uterine malformation. It is an effective and safe treatment option. However, it has to be considered only if the residual myometrium measures more than 3mm next to the defect.

Key words:
Hysteroscopic resection, isthmocele, cesarean section, bicorporeal uterus.
J Dubuisson
Surgical intervention
1 year ago
3715 views
306 likes
1 comment
05:12
Hysteroscopic treatment of a symptomatic isthmocele in a bicorporeal uterus
Clinical case: We report the case of a primigravida 36-year-old woman, with a unicervical bicorporeal uterus type. An isthmocele was diagnosed within a context of postmenstrual abnormal uterine bleeding and secondary infertility arising after C-section. The hydrosonography evidenced a moderate scar defect, the myometrium next to the "niche" measuring 3mm. Because of the symptomatology and the failure of multiple embryo transfer procedures, an operative hysteroscopy was performed. The patient was able to become pregnant spontaneously and give birth to a healthy child via C-section.

Conclusion: A minimally invasive procedure using a hysteroscopic resection of the fibrotic scar tissue is to be considered first, given the existence of an isthmocele in a symptomatic and/or infertile woman, even in the case of a uterine malformation. It is an effective and safe treatment option. However, it has to be considered only if the residual myometrium measures more than 3mm next to the defect.

Key words:
Hysteroscopic resection, isthmocele, cesarean section, bicorporeal uterus.
Laparoscopic uterovaginal anastomoses for cervical agenesis
Cervical agenesis occurs in one in 80,000 to 100,000 births. According to the American Fertility Society, cervical agenesis should be classified as a type 1b Müllerian anomaly. According to the ESHRE/ESGE classification, it is classified in class C4 category.
This is the case of a 16 year-old female patient with primary amenorrhea and episodes of cyclical lower abdominal pain for one year. After complete examination and investigations, diagnosis of isolated cervical agenesis with hematometra and left ovarian chocolate cyst was established. Laparoscopic uterovaginal anastomoses were performed using an innovative technique and an appropriate management of endometriosis. A hysteroscopy was later performed and showed anastomotic patency. As a result, the patient has been experiencing spontaneous regular menstruation for nine months.
Suy Naval, R Naval, Sud Naval, A Padmawar
Surgical intervention
1 year ago
1728 views
176 likes
0 comments
07:49
Laparoscopic uterovaginal anastomoses for cervical agenesis
Cervical agenesis occurs in one in 80,000 to 100,000 births. According to the American Fertility Society, cervical agenesis should be classified as a type 1b Müllerian anomaly. According to the ESHRE/ESGE classification, it is classified in class C4 category.
This is the case of a 16 year-old female patient with primary amenorrhea and episodes of cyclical lower abdominal pain for one year. After complete examination and investigations, diagnosis of isolated cervical agenesis with hematometra and left ovarian chocolate cyst was established. Laparoscopic uterovaginal anastomoses were performed using an innovative technique and an appropriate management of endometriosis. A hysteroscopy was later performed and showed anastomotic patency. As a result, the patient has been experiencing spontaneous regular menstruation for nine months.
Colorectal resection in deep endometriosis: multidisciplinary laparoscopic approach (colorectal and gynecologic surgical teams)
In this video, we present the clinical case of a 42-year-old woman with deep pelvic endometriosis with rectal infiltration. After hormone therapy, the patient was operated on due to chronic pain. A laparoscopic approach was performed by a multidisciplinary team including colorectal and gynecologic surgeons having a wide experience in this field.
A CT-scan, MRI, and colonoscopy were performed before the surgery showing a deep infiltrating endometriosis with anterior rectal bowel involvement in the images and normal colorectal mucosa in the endoscopy.
Under general anesthesia, the laparoscopic approach was performed with 4 trocars. Deep infiltrating endometriosis (DIE) required a hysterectomy and rectal resection to clean all the pelvic space. An end-to-end colorectal anastomosis was performed and the extraction of the specimen (uterus and rectum) was carried out transvaginally. The patient was discharged on postoperative day 4 without complications.
JF Noguera, MD, PhD, J Gilabert-Estelles, J Aguirrezabalaga, B López, J Dolz
Surgical intervention
1 year ago
2518 views
297 likes
0 comments
09:55
Colorectal resection in deep endometriosis: multidisciplinary laparoscopic approach (colorectal and gynecologic surgical teams)
In this video, we present the clinical case of a 42-year-old woman with deep pelvic endometriosis with rectal infiltration. After hormone therapy, the patient was operated on due to chronic pain. A laparoscopic approach was performed by a multidisciplinary team including colorectal and gynecologic surgeons having a wide experience in this field.
A CT-scan, MRI, and colonoscopy were performed before the surgery showing a deep infiltrating endometriosis with anterior rectal bowel involvement in the images and normal colorectal mucosa in the endoscopy.
Under general anesthesia, the laparoscopic approach was performed with 4 trocars. Deep infiltrating endometriosis (DIE) required a hysterectomy and rectal resection to clean all the pelvic space. An end-to-end colorectal anastomosis was performed and the extraction of the specimen (uterus and rectum) was carried out transvaginally. The patient was discharged on postoperative day 4 without complications.
Role of laparoscopy in treating ovarian cancer
Borderline ovarian tumors (BOTs) represent about 10 to 20% of all ovarian malignancies and differ from invasive ovarian cancers (IOCs) by many characters. The standard management of BOT is peritoneal washing cytology, hysterectomy, bilateral salpingo-oophorectomy, omentectomy, complete peritoneal resection of macroscopic lesions; in case of mucinous BOTs, appendectomy should be performed. Because BOTs are often diagnosed at an earlier stage, in younger women and have a better prognosis and a higher survival rate than IOCs, fertility-sparing surgery is one of the options to preserve a childbearing capacity. However, conservative surgery is still controversial.
So far, postoperative chemotherapy, radiotherapy, and hormone therapy are not recommended. BOTs are characteristically difficult to diagnose using preoperative radiological methods, exhibit inconsistencies in expression of tumor markers, and are often inaccurately identified using frozen sections. In these slides, Dr. Marco Puga will discuss the controversial issues of BOTs and will present the management of BOTs.
M Puga
Lecture
1 year ago
2425 views
167 likes
0 comments
31:15
Role of laparoscopy in treating ovarian cancer
Borderline ovarian tumors (BOTs) represent about 10 to 20% of all ovarian malignancies and differ from invasive ovarian cancers (IOCs) by many characters. The standard management of BOT is peritoneal washing cytology, hysterectomy, bilateral salpingo-oophorectomy, omentectomy, complete peritoneal resection of macroscopic lesions; in case of mucinous BOTs, appendectomy should be performed. Because BOTs are often diagnosed at an earlier stage, in younger women and have a better prognosis and a higher survival rate than IOCs, fertility-sparing surgery is one of the options to preserve a childbearing capacity. However, conservative surgery is still controversial.
So far, postoperative chemotherapy, radiotherapy, and hormone therapy are not recommended. BOTs are characteristically difficult to diagnose using preoperative radiological methods, exhibit inconsistencies in expression of tumor markers, and are often inaccurately identified using frozen sections. In these slides, Dr. Marco Puga will discuss the controversial issues of BOTs and will present the management of BOTs.
Laparoscopic resection of endometriotic fibrotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels and adherent to the mid-sigmoid colon
Deep endometriosis is one of the most complex and risky surgeries. Its laparoscopic management requires a systematic approach, a good anatomical knowledge, and a high level of surgical competency.
This is the case of a 37-year-old lady presenting with a complex deep pelvic endometriosis. She had a long history of severe dysmenorrhea, colicky abdominal pain, back pain, and constipation. Imaging studies (MR) showed a large fibrotic endometriotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels, nerves, and adherent to a 4cm segment of the mid-sigmoid colon.
This patient has a complicated past history of left ureter ligation during a caesarean section (in 2011), which resulted in a left-sided nephrectomy in 2012. She got a pneumothorax complication, lung drainage, right-side thoracotomy in 2013, and finally a total pleurectomy in 2014.
A Wattiez, R Nasir, I Argay
Surgical intervention
1 year ago
4593 views
310 likes
0 comments
42:42
Laparoscopic resection of endometriotic fibrotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels and adherent to the mid-sigmoid colon
Deep endometriosis is one of the most complex and risky surgeries. Its laparoscopic management requires a systematic approach, a good anatomical knowledge, and a high level of surgical competency.
This is the case of a 37-year-old lady presenting with a complex deep pelvic endometriosis. She had a long history of severe dysmenorrhea, colicky abdominal pain, back pain, and constipation. Imaging studies (MR) showed a large fibrotic endometriotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels, nerves, and adherent to a 4cm segment of the mid-sigmoid colon.
This patient has a complicated past history of left ureter ligation during a caesarean section (in 2011), which resulted in a left-sided nephrectomy in 2012. She got a pneumothorax complication, lung drainage, right-side thoracotomy in 2013, and finally a total pleurectomy in 2014.
Sentinel node technique in uterine cancers (update of April 2012 lecture)
Endometrial cancer is the most common gynecologic malignancy. In the majority of patients, the disease will present at an early stage, without metastasis, and with an excellent prognosis.
Total hysterectomy and bilateral salpingo-oophorectomy with or without a lymph node dissection is the standard method in the management of endometrial cancer. Although the rate of metastasis in patients with early stage endometrial cancer is low, the standard of treatment still includes a complete or selective pelvic and para-aortic lymphadenectomy for staging, resulting in detrimental side-effects, including lower extremity lymphedema. SLN mapping is based on the concept that lymph node metastasis is the result of an orderly process, that is, the lymph drains in a specific pattern away from the tumor, and therefore if the SLN, or first node, is negative for metastasis, then the nodes after the SLN should also be negative. Among gynecological cancers, a variety of methods have been described to detect a sentinel node in situ including colored dyes and radioisotopes, the latter requiring a specialized gamma detection probe. In this key presentation, Dr. Querleu will talk about the SNL technique in uterine cancers.
D Querleu
Lecture
1 year ago
1235 views
128 likes
0 comments
34:36
Sentinel node technique in uterine cancers (update of April 2012 lecture)
Endometrial cancer is the most common gynecologic malignancy. In the majority of patients, the disease will present at an early stage, without metastasis, and with an excellent prognosis.
Total hysterectomy and bilateral salpingo-oophorectomy with or without a lymph node dissection is the standard method in the management of endometrial cancer. Although the rate of metastasis in patients with early stage endometrial cancer is low, the standard of treatment still includes a complete or selective pelvic and para-aortic lymphadenectomy for staging, resulting in detrimental side-effects, including lower extremity lymphedema. SLN mapping is based on the concept that lymph node metastasis is the result of an orderly process, that is, the lymph drains in a specific pattern away from the tumor, and therefore if the SLN, or first node, is negative for metastasis, then the nodes after the SLN should also be negative. Among gynecological cancers, a variety of methods have been described to detect a sentinel node in situ including colored dyes and radioisotopes, the latter requiring a specialized gamma detection probe. In this key presentation, Dr. Querleu will talk about the SNL technique in uterine cancers.
Role of para-aortic staging lymphadenectomy in advanced cervical cancer (update of September 2014 lecture)
Pelvic and para-aortic lymph node evaluation is a major component of the surgical staging procedure for several gynecologic malignancies. Cervical cancer is clinically staged, but assessment of pelvic and para-aortic lymph nodes is performed with lymphadenectomy and/or imaging. The surgical and oncologic goals of lymph node dissection are to define the extent of disease, and thereby, to guide further treatment. Lymphadenectomy may also have a therapeutic goal in conditions in which removing nodes harboring metastatic disease improves survival. The role of para-aortic lymph node dissection for women diagnosed with LACC had been described in these slides.
F Kridelka
Lecture
1 year ago
1227 views
122 likes
1 comment
27:54
Role of para-aortic staging lymphadenectomy in advanced cervical cancer (update of September 2014 lecture)
Pelvic and para-aortic lymph node evaluation is a major component of the surgical staging procedure for several gynecologic malignancies. Cervical cancer is clinically staged, but assessment of pelvic and para-aortic lymph nodes is performed with lymphadenectomy and/or imaging. The surgical and oncologic goals of lymph node dissection are to define the extent of disease, and thereby, to guide further treatment. Lymphadenectomy may also have a therapeutic goal in conditions in which removing nodes harboring metastatic disease improves survival. The role of para-aortic lymph node dissection for women diagnosed with LACC had been described in these slides.
Endometrial cancer surgical indications
The surgical management of endometrial cancer has been markedly changed by minimally invasive techniques. After three decades of laparoscopy, robotic surgery has built upon and expanded the population of patients able to benefit from minimally invasive techniques. Updates in the field of laparoscopy continue, including single site surgery. The emergence and rapid uptake of robotics continues to produce favorable outcomes while simultaneously expanding minimal access surgery to the obese and elderly populations. Sentinel lymph node detection and single port surgery are expanding areas which will continue to push the role of minimally invasive surgery (MIS) in endometrial cancer. In this key lecture, Dr. Querleu will discuss the role of MIS in the management of endometrial cancer.
D Querleu
Lecture
1 year ago
1239 views
101 likes
0 comments
29:34
Endometrial cancer surgical indications
The surgical management of endometrial cancer has been markedly changed by minimally invasive techniques. After three decades of laparoscopy, robotic surgery has built upon and expanded the population of patients able to benefit from minimally invasive techniques. Updates in the field of laparoscopy continue, including single site surgery. The emergence and rapid uptake of robotics continues to produce favorable outcomes while simultaneously expanding minimal access surgery to the obese and elderly populations. Sentinel lymph node detection and single port surgery are expanding areas which will continue to push the role of minimally invasive surgery (MIS) in endometrial cancer. In this key lecture, Dr. Querleu will discuss the role of MIS in the management of endometrial cancer.
Combining VATS and laparoscopic approach in the resection of ovarian carcinoma metastasis
This is the case of a 64-year-old woman with a history of hysterectomy and left adnexectomy. In 2012, a vaginal ultrasound revealed a right ovarian mass diagnosed as a right ovarian cancer. In December 2012, she underwent a right adnexectomy with pelvic, lumbo-aortic lymphadenectomy and omentectomy. Final pathological staging of the ovarian cystadenocarcinoma was pT3cpN1Mx (IIIC). She completed 6 cycles of adjuvant chemotherapy with carboplatin and paclitaxel. During the follow-up exam, the patient remained symptom-free and presented with a stable perihepatic lesion. In 2015, two new lesions were found on CT-scan: one in the anterior mediastinum (14mm) and another in the abdominal diaphragm in contact with a liver segment VIII (19mm). In addition, CA 125 raised from 19 to 50kU/L. PET-scan only evidenced these two new lesions (SUV= 10). Taking into account the patient’s excellent performance status, long disease-free survival, stability of lesions, with CT-scans performed with a 3-month interval, and the possibility of video-assisted surgery, it was decided to use VATS and laparoscopy to remove the lesions. Final pathological findings showed ovarian cystadenocarcinoma metastases in 2 lesions (R0). The third perihepatic lesion was a cyst. The patient was discharged on postoperative day 4.
F Cabral, JA Pereira, P Calvinho, P Amado, R Maio
Surgical intervention
1 year ago
2620 views
90 likes
0 comments
11:33
Combining VATS and laparoscopic approach in the resection of ovarian carcinoma metastasis
This is the case of a 64-year-old woman with a history of hysterectomy and left adnexectomy. In 2012, a vaginal ultrasound revealed a right ovarian mass diagnosed as a right ovarian cancer. In December 2012, she underwent a right adnexectomy with pelvic, lumbo-aortic lymphadenectomy and omentectomy. Final pathological staging of the ovarian cystadenocarcinoma was pT3cpN1Mx (IIIC). She completed 6 cycles of adjuvant chemotherapy with carboplatin and paclitaxel. During the follow-up exam, the patient remained symptom-free and presented with a stable perihepatic lesion. In 2015, two new lesions were found on CT-scan: one in the anterior mediastinum (14mm) and another in the abdominal diaphragm in contact with a liver segment VIII (19mm). In addition, CA 125 raised from 19 to 50kU/L. PET-scan only evidenced these two new lesions (SUV= 10). Taking into account the patient’s excellent performance status, long disease-free survival, stability of lesions, with CT-scans performed with a 3-month interval, and the possibility of video-assisted surgery, it was decided to use VATS and laparoscopy to remove the lesions. Final pathological findings showed ovarian cystadenocarcinoma metastases in 2 lesions (R0). The third perihepatic lesion was a cyst. The patient was discharged on postoperative day 4.
Sutures transfixing bladder as a complication of laparoscopic burch colposuspension
Laparoscopic Burch colposuspension may be difficult in cases of stress urinary incontinence (SUI) associated with large lateral cystocele. In these cases, complications may occur. However, they are rare.
This video shows the cystoscopic treatment of intravesical adhesions, secondary to sutures transfixing the bladder during the Burch laparoscopic procedure and lateral suspension, without perioperative use of control cystoscopy. An office cystoscopy was performed after the operation, nine months later, because of gradual onset of entirely isolated pelvic pain at the end of urination. It showed intravesical synechia as bilateral pillars. The different steps of the operation are the following:
1) Diagnostic laparoscopy with a good status of the lateral suspension without mesh migration.
2) Operative laparoscopy with opening of Retzius’s space, dissection, adhesiolysis, and division of the non-absorbable sutures of the past colposuspension in order to mobilize the bladder, followed by reperitonization of Retzius’s space.
3) Diagnostic cystoscopy confirming adhesions as bilateral pillars, laterally to the trigone with normal ejaculation of both ureteral ostia.
4) Operative cystoscopy after catheterization of both ureters: division of the pillars with the monopolar electrode without visualization of the Burch sutures, as they probably migrated upward in the first postoperative months.
In the postoperative period, ureteral catheters are removed 48 hours after surgery. Pain resolves completely during urination. Normal kidneys and ureters are observed at ultrasound.
This video clearly demonstrates the advantages related to the routine use of cystoscopy at the end of the laparoscopic Burch procedure, especially in cases of large lateral cystocele.
JB Dubuisson, J Dubuisson, JM Wenger, A Caviezel
Surgical intervention
2 years ago
2132 views
94 likes
0 comments
07:41
Sutures transfixing bladder as a complication of laparoscopic burch colposuspension
Laparoscopic Burch colposuspension may be difficult in cases of stress urinary incontinence (SUI) associated with large lateral cystocele. In these cases, complications may occur. However, they are rare.
This video shows the cystoscopic treatment of intravesical adhesions, secondary to sutures transfixing the bladder during the Burch laparoscopic procedure and lateral suspension, without perioperative use of control cystoscopy. An office cystoscopy was performed after the operation, nine months later, because of gradual onset of entirely isolated pelvic pain at the end of urination. It showed intravesical synechia as bilateral pillars. The different steps of the operation are the following:
1) Diagnostic laparoscopy with a good status of the lateral suspension without mesh migration.
2) Operative laparoscopy with opening of Retzius’s space, dissection, adhesiolysis, and division of the non-absorbable sutures of the past colposuspension in order to mobilize the bladder, followed by reperitonization of Retzius’s space.
3) Diagnostic cystoscopy confirming adhesions as bilateral pillars, laterally to the trigone with normal ejaculation of both ureteral ostia.
4) Operative cystoscopy after catheterization of both ureters: division of the pillars with the monopolar electrode without visualization of the Burch sutures, as they probably migrated upward in the first postoperative months.
In the postoperative period, ureteral catheters are removed 48 hours after surgery. Pain resolves completely during urination. Normal kidneys and ureters are observed at ultrasound.
This video clearly demonstrates the advantages related to the routine use of cystoscopy at the end of the laparoscopic Burch procedure, especially in cases of large lateral cystocele.
Intravesical mini-laparoscopic repair of vesicovaginal fistulas
Vesicovaginal fistulas (VVF) constitute the most common type of genitourinary fistulas. In developed countries, VVF are almost always iatrogenic and frequently a secondary complication of gynecologic surgery. Some minimally invasive techniques have been introduced to decrease morbidity related to standard open procedures for the treatment of VVF. One such procedure is the intravesical mini-laparoscopic approach. The aim of this was to present our initial clinical experience using this technique for transvesical VVF repair. In 2014, we carried out a mini-laparoscopic repair of VVF in two women who did not respond to conservative treatment with a Foley catheter. The procedure was performed transvesically with a 3mm instrument and a 5mm, 30-degree scope. The fistulous tract was dissected and partially excised. The bladder and vaginal wall defects were closed in two layers with two separate running barbed, absorbable 3/0 sutures. Median operative time was approximately 100 minutes, and blood loss was not significant. Patients were discharged from hospital 24 hours after surgery. A Foley catheter was left in place for 14 days. Imaging examinations performed 6 weeks postoperatively revealed no VVF. In patients with simple fistulas, this technique provides a minimally invasive easily reproducible approach with few associated complications.
The advantages of this technique as compared to the conventional laparoscopic approach are described as follows:
- the risk of bleeding is reduced because the size of the incision made is smaller and access to the fistula site is easier and direct without manipulating abdominal structures;
- the length of hospital stay required is significantly shorter with intravesical mini-laparoscopic than laparoscopic surgery conventional approach.
A Llueca, JL Herraiz, M Rodrigo, Y Maazouzi, D Piquer, M Guijarro, A Cañete, J Escrig
Surgical intervention
2 years ago
2920 views
121 likes
1 comment
07:16
Intravesical mini-laparoscopic repair of vesicovaginal fistulas
Vesicovaginal fistulas (VVF) constitute the most common type of genitourinary fistulas. In developed countries, VVF are almost always iatrogenic and frequently a secondary complication of gynecologic surgery. Some minimally invasive techniques have been introduced to decrease morbidity related to standard open procedures for the treatment of VVF. One such procedure is the intravesical mini-laparoscopic approach. The aim of this was to present our initial clinical experience using this technique for transvesical VVF repair. In 2014, we carried out a mini-laparoscopic repair of VVF in two women who did not respond to conservative treatment with a Foley catheter. The procedure was performed transvesically with a 3mm instrument and a 5mm, 30-degree scope. The fistulous tract was dissected and partially excised. The bladder and vaginal wall defects were closed in two layers with two separate running barbed, absorbable 3/0 sutures. Median operative time was approximately 100 minutes, and blood loss was not significant. Patients were discharged from hospital 24 hours after surgery. A Foley catheter was left in place for 14 days. Imaging examinations performed 6 weeks postoperatively revealed no VVF. In patients with simple fistulas, this technique provides a minimally invasive easily reproducible approach with few associated complications.
The advantages of this technique as compared to the conventional laparoscopic approach are described as follows:
- the risk of bleeding is reduced because the size of the incision made is smaller and access to the fistula site is easier and direct without manipulating abdominal structures;
- the length of hospital stay required is significantly shorter with intravesical mini-laparoscopic than laparoscopic surgery conventional approach.
Laparoscopic retroperitoneal access to ovarian cysts fixed by severe pelvic adhesions: a case report
Left cystectomy or left adnexectomy can be difficult in cases of frozen pelvis, with an adnexa entirely covered with the sigmoid colon and stuck to the pelvic sidewall.
This video clearly demonstrates the advantages of the left retroperitoneal access to the adnexa, limiting the risks of injury of the ureter and the perforation of the sigmoid colon. The different steps of the operation are as follows: 1) Lysis of adhesions between the sigmoid colon and the left pelvic sidewall to visualize the tube. 2) Division of adhesions between the sigmoid colon and the uterus to visualize the left ovary. 3) Left retroperitoneal access to the ovary with a longitudinal incision of the peritoneum, laterally. 4) Division of the utero-ovarian pedicle. 5) Retroperitoneal dissection of the ureter to completely release the ovary from the ureter. 6) Lysis of the upper surface of the ovary from the sigmoid colon.
JB Dubuisson, J Dubuisson
Surgical intervention
2 years ago
5085 views
296 likes
0 comments
08:20
Laparoscopic retroperitoneal access to ovarian cysts fixed by severe pelvic adhesions: a case report
Left cystectomy or left adnexectomy can be difficult in cases of frozen pelvis, with an adnexa entirely covered with the sigmoid colon and stuck to the pelvic sidewall.
This video clearly demonstrates the advantages of the left retroperitoneal access to the adnexa, limiting the risks of injury of the ureter and the perforation of the sigmoid colon. The different steps of the operation are as follows: 1) Lysis of adhesions between the sigmoid colon and the left pelvic sidewall to visualize the tube. 2) Division of adhesions between the sigmoid colon and the uterus to visualize the left ovary. 3) Left retroperitoneal access to the ovary with a longitudinal incision of the peritoneum, laterally. 4) Division of the utero-ovarian pedicle. 5) Retroperitoneal dissection of the ureter to completely release the ovary from the ureter. 6) Lysis of the upper surface of the ovary from the sigmoid colon.
Severe complex endometriosis with ascites: laparoscopic management
Frozen pelvis due to endometriosis is one of the most complex and risky situations which surgeons sometimes face. Its laparoscopic management requires a systematic approach, a good anatomical knowledge and a high level of surgical competency. This is a frozen pelvis case secondary to a complicated severe endometriosis in a young nulliparous lady. She had hemorrhagic abdominal ascites secondary to endometriosis, with a sub-occlusive syndrome. Her disease was further complicated with upper abdominal and pelvic fibrosis with a large umbilical endometriotic nodule as well as splenic, omental and sigmoid endometriosis. This video demonstrates the strategy of the laparoscopic management of this condition.
A Wattiez, R Nasir, A Host
Surgical intervention
2 years ago
3550 views
160 likes
1 comment
31:22
Severe complex endometriosis with ascites: laparoscopic management
Frozen pelvis due to endometriosis is one of the most complex and risky situations which surgeons sometimes face. Its laparoscopic management requires a systematic approach, a good anatomical knowledge and a high level of surgical competency. This is a frozen pelvis case secondary to a complicated severe endometriosis in a young nulliparous lady. She had hemorrhagic abdominal ascites secondary to endometriosis, with a sub-occlusive syndrome. Her disease was further complicated with upper abdominal and pelvic fibrosis with a large umbilical endometriotic nodule as well as splenic, omental and sigmoid endometriosis. This video demonstrates the strategy of the laparoscopic management of this condition.
Laparoscopic management of extrauterine leiomyomas
Uterine leiomyomas affect 20 to 30% of women older than 35 years. Extrauterine leiomyomas are rarer, and they present a greater diagnostic challenge. These histologically benign leiomyomas occasionally occur with unusual growth patterns or in unusual locations which make their identification more challenging both clinically and radiologically. Unusual growth patterns may be seen, including benign metastasizing leiomyoma, disseminated peritoneal leiomyomatosis, intravenous leiomyomatosis, parasitic leiomyoma, and retroperitoneal growth. Diffuse peritoneal leiomyomatosis manifests as innumerable peritoneal nodules resembling those in peritoneal carcinomatosis. Parasitic leiomyoma and retroperitoneal leiomyomatosis usually manifest as single or multiple pelvic or retroperitoneal masses. Retroperitoneal growth is yet another unusual growth pattern of leiomyomas. Multiple leiomyomatous masses are usually seen in the pelvic retroperitoneum in women with a concurrent uterine leiomyoma or a history of uterine leiomyoma. Rarely, the extrauterine masses may extend to the upper retroperitoneum, as high as the level of the renal hilum. Occasionally, leiomyomas become adherent to surrounding structures (e.g., broad ligament, omentum, or retroperitoneal connective tissue), develop an auxiliary blood supply, and lose their original attachment to the uterus, hence becoming “parasitic.” We are presenting a case of extrauterine leiomyoma, which was operated for laparoscopic myomectomy for huge cervical leiomyoma 4 years back but was converted to an abdominal myomectomy.
D Limbachiya
Surgical intervention
2 years ago
2642 views
172 likes
0 comments
09:11
Laparoscopic management of extrauterine leiomyomas
Uterine leiomyomas affect 20 to 30% of women older than 35 years. Extrauterine leiomyomas are rarer, and they present a greater diagnostic challenge. These histologically benign leiomyomas occasionally occur with unusual growth patterns or in unusual locations which make their identification more challenging both clinically and radiologically. Unusual growth patterns may be seen, including benign metastasizing leiomyoma, disseminated peritoneal leiomyomatosis, intravenous leiomyomatosis, parasitic leiomyoma, and retroperitoneal growth. Diffuse peritoneal leiomyomatosis manifests as innumerable peritoneal nodules resembling those in peritoneal carcinomatosis. Parasitic leiomyoma and retroperitoneal leiomyomatosis usually manifest as single or multiple pelvic or retroperitoneal masses. Retroperitoneal growth is yet another unusual growth pattern of leiomyomas. Multiple leiomyomatous masses are usually seen in the pelvic retroperitoneum in women with a concurrent uterine leiomyoma or a history of uterine leiomyoma. Rarely, the extrauterine masses may extend to the upper retroperitoneum, as high as the level of the renal hilum. Occasionally, leiomyomas become adherent to surrounding structures (e.g., broad ligament, omentum, or retroperitoneal connective tissue), develop an auxiliary blood supply, and lose their original attachment to the uterus, hence becoming “parasitic.” We are presenting a case of extrauterine leiomyoma, which was operated for laparoscopic myomectomy for huge cervical leiomyoma 4 years back but was converted to an abdominal myomectomy.
In bag morcellation of a uterine fibroid
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.
R Fernandes, A Silva e Silva, JP Carvalho
Surgical intervention
3 years ago
3174 views
130 likes
0 comments
06:37
In bag morcellation of a uterine fibroid
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.
Laparoscopic management of bladder endometriosis
Endometriosis is an enigmatic disorder, which affects women in their reproductive age. Failure of recent clinical trials on non-surgical management of endometriosis confirms the role of surgery as a viable treatment of choice. However, recurrence after surgery is common. Recurrence rate varies according to the surgeon’s skills, instrumentation, surgical techniques, and to the postoperative intervention outcome. In patients with severe endometriosis, lesions usually involve the posterior cul-de-sac, anterior rectum, one or both pelvic sidewalls, involving the ureters, the rectosigmoid, and less commonly the anterior bladder, the appendix, and the small bowel. Ureteral retroperitoneal dissection becomes mandatory in extensive endometriosis due to pelvic anatomical distortion. It also leaves the bowel intact without injuring it as the pseudo-peritoneum is lifted along with the inflamed bowel. Consequently, in the surgical practice of benign pathologies, a proper knowledge of the retroperitoneal anatomy ensures complete clearance in cases of advanced endometriosis and frozen pelvis. Here, we present a very interesting case of bladder endometriosis associated with hematuria during menstruation. Partial cystectomy is the treatment of choice for patients with bladder endometriosis in most cases. Provided surgeons are skilled and lesions require no ureteral reimplantation, operative laparoscopy is a valid alternative to laparotomy for partial cystectomy.
D Limbachiya
Surgical intervention
3 years ago
1917 views
63 likes
0 comments
06:56
Laparoscopic management of bladder endometriosis
Endometriosis is an enigmatic disorder, which affects women in their reproductive age. Failure of recent clinical trials on non-surgical management of endometriosis confirms the role of surgery as a viable treatment of choice. However, recurrence after surgery is common. Recurrence rate varies according to the surgeon’s skills, instrumentation, surgical techniques, and to the postoperative intervention outcome. In patients with severe endometriosis, lesions usually involve the posterior cul-de-sac, anterior rectum, one or both pelvic sidewalls, involving the ureters, the rectosigmoid, and less commonly the anterior bladder, the appendix, and the small bowel. Ureteral retroperitoneal dissection becomes mandatory in extensive endometriosis due to pelvic anatomical distortion. It also leaves the bowel intact without injuring it as the pseudo-peritoneum is lifted along with the inflamed bowel. Consequently, in the surgical practice of benign pathologies, a proper knowledge of the retroperitoneal anatomy ensures complete clearance in cases of advanced endometriosis and frozen pelvis. Here, we present a very interesting case of bladder endometriosis associated with hematuria during menstruation. Partial cystectomy is the treatment of choice for patients with bladder endometriosis in most cases. Provided surgeons are skilled and lesions require no ureteral reimplantation, operative laparoscopy is a valid alternative to laparotomy for partial cystectomy.
Strategy for laparoscopic total hysterectomy and bilateral salpingectomy in case of large uterus
This video demonstrates the case of a 46-year-old patient presented with menorrhagia and anemia.
Clinical examination revealed a large mass almost reaching the level of the umbilicus.
The uterus appeared much bigger than usual on MRI, with a large myoma coming out of the pelvis.
It was decided to perform total laparoscopic hysterectomy combined with bilateral salpingectomy.
This video demonstrates the appropriate strategy to safely perform total laparoscopic hysterectomy in case of large uterus, showing the appropriate surgical steps and providing safety tips. The specimen weighed more than 1kg.
A Wattiez, F Asencio, J Faria, I Argay, L Schwartz
Surgical intervention
3 years ago
8348 views
303 likes
0 comments
25:01
Strategy for laparoscopic total hysterectomy and bilateral salpingectomy in case of large uterus
This video demonstrates the case of a 46-year-old patient presented with menorrhagia and anemia.
Clinical examination revealed a large mass almost reaching the level of the umbilicus.
The uterus appeared much bigger than usual on MRI, with a large myoma coming out of the pelvis.
It was decided to perform total laparoscopic hysterectomy combined with bilateral salpingectomy.
This video demonstrates the appropriate strategy to safely perform total laparoscopic hysterectomy in case of large uterus, showing the appropriate surgical steps and providing safety tips. The specimen weighed more than 1kg.
Laparoscopic dissection of sacral promontory for sacrocolpopexy
Objective: To describe the laparoscopic dissection of the sacral promontory during a laparoscopic sacrocolpopexy, with a special focus on anatomical landmarks and surgical traps.
Setting: Department of Gynecology, CMCO, Strasbourg University Hospital, France.
Patients: Women with invalidating genital prolapse
Interventions: Laparoscopic sacrocolpopexy is performed using three operative ports (one midline, suprapubic port and two lateral ports) and a 0-degree umbilical Karl Storz optical port. In order to suture a polypropylene mesh to the anterior vertebral ligament, the promontory area must be dissected. To improve sacral promontory exposure, the rectum is usually suspended to the left anterior abdominal wall by means of T’Lift™ tissue retraction systems. By palpating the area under the aortic bifurcation and the confluence of iliac veins, the sacral promontory is identified. The right ureter is also identified. Using two duck jaw fenestrated forceps, the peritoneum is lifted --retroperitoneal vessels are fixed to the vertebral elements, and widely opened. The promontory is carefully dissected until the anterior vertebral ligament becomes visible. As the presacral space is rich in blood vessels and nerve elements, surgeons are advised to preserve it.
However, the surgical approach to the vertebral ligament is sometimes difficult in obese women, when patients present anatomical variations such as a low iliac venous circulation confluence, a duplicity of middle sacral vessels, periosteal perforators, a winding right common iliac artery, or in the presence of lymph nodes.
Discussion: Laparoscopic sacrocolpopexy complications rates such as bleeding originating from the promontory varying from 0 to 4.7%, which sometimes require conversion to open abdominal sacrocolpopexy. Described by radiologists at almost 3cm from the sacral promontory, the right ureter can also be injured during reperitonization.
Conclusion: Laparoscopic dissection of the promontory requires specific and careful attention to be paid to non-infrequent anatomical variations.
V Gabriele, AJ Carin, K Afors, O Garbin
Surgical intervention
3 years ago
4933 views
224 likes
0 comments
07:24
Laparoscopic dissection of sacral promontory for sacrocolpopexy
Objective: To describe the laparoscopic dissection of the sacral promontory during a laparoscopic sacrocolpopexy, with a special focus on anatomical landmarks and surgical traps.
Setting: Department of Gynecology, CMCO, Strasbourg University Hospital, France.
Patients: Women with invalidating genital prolapse
Interventions: Laparoscopic sacrocolpopexy is performed using three operative ports (one midline, suprapubic port and two lateral ports) and a 0-degree umbilical Karl Storz optical port. In order to suture a polypropylene mesh to the anterior vertebral ligament, the promontory area must be dissected. To improve sacral promontory exposure, the rectum is usually suspended to the left anterior abdominal wall by means of T’Lift™ tissue retraction systems. By palpating the area under the aortic bifurcation and the confluence of iliac veins, the sacral promontory is identified. The right ureter is also identified. Using two duck jaw fenestrated forceps, the peritoneum is lifted --retroperitoneal vessels are fixed to the vertebral elements, and widely opened. The promontory is carefully dissected until the anterior vertebral ligament becomes visible. As the presacral space is rich in blood vessels and nerve elements, surgeons are advised to preserve it.
However, the surgical approach to the vertebral ligament is sometimes difficult in obese women, when patients present anatomical variations such as a low iliac venous circulation confluence, a duplicity of middle sacral vessels, periosteal perforators, a winding right common iliac artery, or in the presence of lymph nodes.
Discussion: Laparoscopic sacrocolpopexy complications rates such as bleeding originating from the promontory varying from 0 to 4.7%, which sometimes require conversion to open abdominal sacrocolpopexy. Described by radiologists at almost 3cm from the sacral promontory, the right ureter can also be injured during reperitonization.
Conclusion: Laparoscopic dissection of the promontory requires specific and careful attention to be paid to non-infrequent anatomical variations.
Laparoscopic treatment of bilateral endometriotic cysts
The different surgical approaches to ovarian endometriosis are the following: ovarian cystectomy, endometrioma fenestration and removal, or a technique combining cystectomy and removal.
In order to perform a cystectomy without damaging the ovary, different steps must be followed, including adhesiolysis between the ovary and the broad ligament, cyst opening at the site of eversion and adhesion. Traction and counter-traction allow to separate the cyst’s wall from the ovarian cortex. As the endometrioma is surrounded by a fibrotic capsule, there is a risk of removing normal ovarian tissue and ovocytes. Blood vessels must be identified and selective coagulation must be performed to prevent destruction of the normal ovarian tissue.
Endometrioma fenestration and removal can be performed with different sources of energy such as bipolar coagulation, carbon dioxide laser and plasma energy. Depending on the size of the endometrioma, the removal technique can be performed in one or three steps. But to avoid 2 laparoscopic procedures, a combined technique of excision and removal of the endometrioma could be offered in cases of large cysts.
Medical treatment is administered preoperatively only in cases of pelvic pain and postoperatively in cases of pelvic pain and if there is no desire for pregnancy.
According to a recent systematic review and meta-analysis, the ovarian reserve, evaluated by the AMH level, is affected by surgery, and even more in cases of bilateral cysts.

To conclude, ovarian endometrioma surgery requires a learning curve to prevent ovarian damage, which can be caused by normal ovarian tissue removal or by a strong coagulation. Repetitive surgery has to be clearly evaluated as it is also responsible for ovarian reserve decrease.
M Nisolle
Lecture
3 years ago
2192 views
93 likes
0 comments
19:00
Laparoscopic treatment of bilateral endometriotic cysts
The different surgical approaches to ovarian endometriosis are the following: ovarian cystectomy, endometrioma fenestration and removal, or a technique combining cystectomy and removal.
In order to perform a cystectomy without damaging the ovary, different steps must be followed, including adhesiolysis between the ovary and the broad ligament, cyst opening at the site of eversion and adhesion. Traction and counter-traction allow to separate the cyst’s wall from the ovarian cortex. As the endometrioma is surrounded by a fibrotic capsule, there is a risk of removing normal ovarian tissue and ovocytes. Blood vessels must be identified and selective coagulation must be performed to prevent destruction of the normal ovarian tissue.
Endometrioma fenestration and removal can be performed with different sources of energy such as bipolar coagulation, carbon dioxide laser and plasma energy. Depending on the size of the endometrioma, the removal technique can be performed in one or three steps. But to avoid 2 laparoscopic procedures, a combined technique of excision and removal of the endometrioma could be offered in cases of large cysts.
Medical treatment is administered preoperatively only in cases of pelvic pain and postoperatively in cases of pelvic pain and if there is no desire for pregnancy.
According to a recent systematic review and meta-analysis, the ovarian reserve, evaluated by the AMH level, is affected by surgery, and even more in cases of bilateral cysts.

To conclude, ovarian endometrioma surgery requires a learning curve to prevent ovarian damage, which can be caused by normal ovarian tissue removal or by a strong coagulation. Repetitive surgery has to be clearly evaluated as it is also responsible for ovarian reserve decrease.
DIE and laparoscopic treatment
Hormone therapy was designed to suppress estrogen synthesis and to reduce the size of ectopic endometrial implants. However, the recurrence of pain after cessation is estimated at 50% and indicates that surgery is required for symptomatic patients.
Conservative surgery is effective in terms of pain reduction if complete excision is obtained, and consequently a preoperative assessment is mandatory to put forward a multidisciplinary approach in specialized centers.
In cases of excision of the nodular lesion by means of mucosal skinning, the resection of uterosacral ligaments and of the posterior vaginal fornix is usually recommended. A comparison between standard and reverse laparoscopic techniques demonstrated a statistically significant lower rate of major postoperative complications by using the reverse technique.
Bowel endometriosis requires bowel resection if the size is estimated to exceed 3cm, to affect 50% of the bowel's diameter or to induce a stenosis. Different techniques could be proposed such as a segmental bowel resection, a discoid resection or a stapled resection.
Concerning the rate of complications, it has been published that mucosal skinning is associated with fewer complications than segmental resection.
Recently, robotic assisted laparoscopy was used for the treatment of advanced stage endometriosis; however, it is associated with an increased operative time and a longer hospital stay.

To conclude, a skilled surgical team is necessary to perform the complete removal of lesions without increasing the risk of complications and to obtain good results in terms of pelvic pain and fertility.
M Nisolle
Lecture
3 years ago
1668 views
75 likes
0 comments
23:49
DIE and laparoscopic treatment
Hormone therapy was designed to suppress estrogen synthesis and to reduce the size of ectopic endometrial implants. However, the recurrence of pain after cessation is estimated at 50% and indicates that surgery is required for symptomatic patients.
Conservative surgery is effective in terms of pain reduction if complete excision is obtained, and consequently a preoperative assessment is mandatory to put forward a multidisciplinary approach in specialized centers.
In cases of excision of the nodular lesion by means of mucosal skinning, the resection of uterosacral ligaments and of the posterior vaginal fornix is usually recommended. A comparison between standard and reverse laparoscopic techniques demonstrated a statistically significant lower rate of major postoperative complications by using the reverse technique.
Bowel endometriosis requires bowel resection if the size is estimated to exceed 3cm, to affect 50% of the bowel's diameter or to induce a stenosis. Different techniques could be proposed such as a segmental bowel resection, a discoid resection or a stapled resection.
Concerning the rate of complications, it has been published that mucosal skinning is associated with fewer complications than segmental resection.
Recently, robotic assisted laparoscopy was used for the treatment of advanced stage endometriosis; however, it is associated with an increased operative time and a longer hospital stay.

To conclude, a skilled surgical team is necessary to perform the complete removal of lesions without increasing the risk of complications and to obtain good results in terms of pelvic pain and fertility.
Modern hysteroscopy for diagnosis and treatment (office hysteroscopy)
Modern technology has brought diagnostic hysteroscopy as a mainstay of modern gynecologic practice. The ambulatory visualization of the uterine cavity has obvious major benefits for the patient and the diagnostic algorithms. However, it has not been generally implemented by the physicians for obvious drawbacks – it is painful, difficult to get good visualization, difficult to organize and to provide significant tissue for histology.
The new TROPHY hysteroscope is especially designed to counteract the abovementioned drawbacks providing physicians most innovative possibilities resulting in an all in one diagnostic procedure and the highest patient comfort. The most specific feature of this hysteroscope is that it can be loaded with accessory sheaths in an active and passive position providing the possibility of enlarging the visual procedure with endometrial sampling or surgical actions for pathological examination of the endometrium and myometrium without removing the instrument. Additionally, one can remove the hysteroscope and use the accessory sheet to introduce the Trophy D&C suction curette or the Endo-myometrial sampler. Histology from endometrium and myometrium is possible without the need of a speculum and even minor interventions such as polyp or myoma resection are possible in a one-stop procedure.
Magnetic Resonant Imaging (MRI) has demonstrated that the uterus can be separated in 3 important functional areas. For this reason, exploration of the uterus in the infertile patient should implement the evaluation of the endometrium, the junctional zone myometrium (JZ), and the outer myometrium.
MRI cannot be implemented as a screening examination but the combination of transvaginal ultrasound and office hysteroscopy provides a complete one-stop diagnostic and eventually therapeutic procedure.
In this way, myometrial disorders, uterine congenital malformations, endometrium pathologies, and the cervical canal pathway can be evaluated easily.
This lecture describes a modern ambulatory one-stop approach, by combining ultrasound, hysteroscopy and endomyometrial tissue sampling for diagnostic and therapeutic purposes. This one-stop approach opens a totally new and advanced dimension to the screening, diagnosis and treatment of uterine pathologies in the infertile patient.
R Campo
Lecture
3 years ago
1895 views
81 likes
0 comments
24:50
Modern hysteroscopy for diagnosis and treatment (office hysteroscopy)
Modern technology has brought diagnostic hysteroscopy as a mainstay of modern gynecologic practice. The ambulatory visualization of the uterine cavity has obvious major benefits for the patient and the diagnostic algorithms. However, it has not been generally implemented by the physicians for obvious drawbacks – it is painful, difficult to get good visualization, difficult to organize and to provide significant tissue for histology.
The new TROPHY hysteroscope is especially designed to counteract the abovementioned drawbacks providing physicians most innovative possibilities resulting in an all in one diagnostic procedure and the highest patient comfort. The most specific feature of this hysteroscope is that it can be loaded with accessory sheaths in an active and passive position providing the possibility of enlarging the visual procedure with endometrial sampling or surgical actions for pathological examination of the endometrium and myometrium without removing the instrument. Additionally, one can remove the hysteroscope and use the accessory sheet to introduce the Trophy D&C suction curette or the Endo-myometrial sampler. Histology from endometrium and myometrium is possible without the need of a speculum and even minor interventions such as polyp or myoma resection are possible in a one-stop procedure.
Magnetic Resonant Imaging (MRI) has demonstrated that the uterus can be separated in 3 important functional areas. For this reason, exploration of the uterus in the infertile patient should implement the evaluation of the endometrium, the junctional zone myometrium (JZ), and the outer myometrium.
MRI cannot be implemented as a screening examination but the combination of transvaginal ultrasound and office hysteroscopy provides a complete one-stop diagnostic and eventually therapeutic procedure.
In this way, myometrial disorders, uterine congenital malformations, endometrium pathologies, and the cervical canal pathway can be evaluated easily.
This lecture describes a modern ambulatory one-stop approach, by combining ultrasound, hysteroscopy and endomyometrial tissue sampling for diagnostic and therapeutic purposes. This one-stop approach opens a totally new and advanced dimension to the screening, diagnosis and treatment of uterine pathologies in the infertile patient.
Prevention and treatment of intrauterine adhesions
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.
V Tanos
Lecture
3 years ago
1040 views
39 likes
0 comments
12:40
Prevention and treatment of intrauterine adhesions
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.
Complications in operative hysteroscopy
Most hysteroscopic surgery complications can be prevented. Education and good training are definitely the most important factors for both novice and experienced surgeons to reduce complications risks. The most frequent complications in hysteroscopic surgery are uterine wall perforation (during dilatation, or during surgery) and uterine or cervical bleeding. Fluid overload can be reduced with the use of a bipolar resectoscope, normal saline being the distending medium. Air embolism is a life-threatening condition and all surgeons should be aware and ready for the adequate treatment. Complications related to anesthesia and especially to patients with concomitant pathologies can also be minimized using office hysteroscopic surgery procedures.
V Tanos
Lecture
3 years ago
1376 views
60 likes
0 comments
17:38
Complications in operative hysteroscopy
Most hysteroscopic surgery complications can be prevented. Education and good training are definitely the most important factors for both novice and experienced surgeons to reduce complications risks. The most frequent complications in hysteroscopic surgery are uterine wall perforation (during dilatation, or during surgery) and uterine or cervical bleeding. Fluid overload can be reduced with the use of a bipolar resectoscope, normal saline being the distending medium. Air embolism is a life-threatening condition and all surgeons should be aware and ready for the adequate treatment. Complications related to anesthesia and especially to patients with concomitant pathologies can also be minimized using office hysteroscopic surgery procedures.
Hysteroscopic myomectomy and ART
Fibroids represent an extremely common benign uterine pathology, the incidence of which increases with age, and approximately 10% of women with infertility problems will present a myoma. The association between uterine myoma and infertility is still controversial. Evidence exists that subserosal myomas do not impair the pregnancy rate in IVF whereas submucous myomas significantly decrease the implantation rate. Unfortunately, the effect of intramural myomas upon reproduction outcomes remains unknown, and until now no adequate diagnostic and therapeutic guidelines have been established.
Magnetic resonance imaging (MRI) imaging has redefined the functional anatomy of the uterus. Contrarily to ultrasound, MRI demonstrates that the non-pregnant myometrium is not a homogeneous smooth muscle mass but consists of two different structural and functional entities. The myometrium adjacent to the endometrium is a different hormone-dependent uterine compartment called junctional zone (JZ) myometrium. It is a functionally important entity in reproduction and it is ontogenetically related to the endometrium. Submucosal fibroids originate from this JZ myometrium and differ from subserosal fibroids as they have less cytogenetic abnormalities, less expression of Sex Steroid Hormone receptors, and they are more responsive to GnRH analog treatment and provide fewer recurrences after surgery.
Despite the lack of randomized studies, the sharp decline in pregnancy rates in case of submucous myoma is quite convincing and it is based on the existing evidence that myomectomy should be performed prior to ART for junctional zone myomas which protrude into the uterine cavity.
We demonstrate the different modern techniques of hysteroscopic myomectomy, the new instrumentation, the tips and tricks, the possible complications and clinical outcome.
R Campo
Lecture
3 years ago
1867 views
97 likes
0 comments
27:15
Hysteroscopic myomectomy and ART
Fibroids represent an extremely common benign uterine pathology, the incidence of which increases with age, and approximately 10% of women with infertility problems will present a myoma. The association between uterine myoma and infertility is still controversial. Evidence exists that subserosal myomas do not impair the pregnancy rate in IVF whereas submucous myomas significantly decrease the implantation rate. Unfortunately, the effect of intramural myomas upon reproduction outcomes remains unknown, and until now no adequate diagnostic and therapeutic guidelines have been established.
Magnetic resonance imaging (MRI) imaging has redefined the functional anatomy of the uterus. Contrarily to ultrasound, MRI demonstrates that the non-pregnant myometrium is not a homogeneous smooth muscle mass but consists of two different structural and functional entities. The myometrium adjacent to the endometrium is a different hormone-dependent uterine compartment called junctional zone (JZ) myometrium. It is a functionally important entity in reproduction and it is ontogenetically related to the endometrium. Submucosal fibroids originate from this JZ myometrium and differ from subserosal fibroids as they have less cytogenetic abnormalities, less expression of Sex Steroid Hormone receptors, and they are more responsive to GnRH analog treatment and provide fewer recurrences after surgery.
Despite the lack of randomized studies, the sharp decline in pregnancy rates in case of submucous myoma is quite convincing and it is based on the existing evidence that myomectomy should be performed prior to ART for junctional zone myomas which protrude into the uterine cavity.
We demonstrate the different modern techniques of hysteroscopic myomectomy, the new instrumentation, the tips and tricks, the possible complications and clinical outcome.
Laparoscopic myomectomy in infertile women
The incidence of fibroids in women of reproductive age is reported to be between 20 and 40% (Verkauf, 1992; American Society for Reproductive Medicine, 2001). Their presence could cause failure to conceive, but no scientific evidence supports improvement after the surgical removal of the fibroid. This was recently highlighted in a review (Donnez and Jadoul, 2002) reporting a pregnancy rate after myomectomy in infertile women varying between 10 and 80%. Reported results in the literature are confusing due to the heterogeneity of the included patients and the different final outcomes. While subserosal and submucosal leiomyomas are likely to originate respectively from the outer myometrium and junctional zone myometrium, intramural fibroids may originate from the outer myometrium as well as from the junctional zone of the myometrium. It is agreed, although not proven, that patients with submucosal and intramural myomas have an impaired reproductive performance. Removal of submucosal myoma will result in a better reproductive performance, which is not obvious after removal of intramural myoma.
Laparoscopic removal has the benefit to have a lower morbidity and a lower risk for postoperative adhesion formation. Benefits and techniques will be discussed.
S Gordts
Lecture
3 years ago
2401 views
114 likes
0 comments
28:01
Laparoscopic myomectomy in infertile women
The incidence of fibroids in women of reproductive age is reported to be between 20 and 40% (Verkauf, 1992; American Society for Reproductive Medicine, 2001). Their presence could cause failure to conceive, but no scientific evidence supports improvement after the surgical removal of the fibroid. This was recently highlighted in a review (Donnez and Jadoul, 2002) reporting a pregnancy rate after myomectomy in infertile women varying between 10 and 80%. Reported results in the literature are confusing due to the heterogeneity of the included patients and the different final outcomes. While subserosal and submucosal leiomyomas are likely to originate respectively from the outer myometrium and junctional zone myometrium, intramural fibroids may originate from the outer myometrium as well as from the junctional zone of the myometrium. It is agreed, although not proven, that patients with submucosal and intramural myomas have an impaired reproductive performance. Removal of submucosal myoma will result in a better reproductive performance, which is not obvious after removal of intramural myoma.
Laparoscopic removal has the benefit to have a lower morbidity and a lower risk for postoperative adhesion formation. Benefits and techniques will be discussed.
Principles of tubal surgery
This presentation focuses on the specific advantages of tubal surgery as compared to assisted reproductive techniques (ART).
Tubal surgery is a valid option in selected cases.
This selection is only possible through endoscopy and a precise knowledge of lesions is necessary. Three kinds of lesions have to be precisely known: pelvic adhesions and tubal lesions, either distal or proximal.
Nowadays, a special focus has to be made on subtle tubal lesions which were underestimated until recently.
Diagnosis and patient selection is a key factor and it is best achieved through transvaginal endoscopy such as fertiloscopy.
Even if today laparoscopy is the gold standard to treat tubal abnormalities, the principles of microsurgery which were defined a long time ago have to be strictly applied if one wants to get a pregnancy rate equivalent or superior to what is expected with in vitro fertilization (IVF).
A Watrelot
Lecture
3 years ago
1582 views
77 likes
0 comments
16:07
Principles of tubal surgery
This presentation focuses on the specific advantages of tubal surgery as compared to assisted reproductive techniques (ART).
Tubal surgery is a valid option in selected cases.
This selection is only possible through endoscopy and a precise knowledge of lesions is necessary. Three kinds of lesions have to be precisely known: pelvic adhesions and tubal lesions, either distal or proximal.
Nowadays, a special focus has to be made on subtle tubal lesions which were underestimated until recently.
Diagnosis and patient selection is a key factor and it is best achieved through transvaginal endoscopy such as fertiloscopy.
Even if today laparoscopy is the gold standard to treat tubal abnormalities, the principles of microsurgery which were defined a long time ago have to be strictly applied if one wants to get a pregnancy rate equivalent or superior to what is expected with in vitro fertilization (IVF).
The indications of transvaginal endoscopy for diagnosis and treatment of infertility
Standard laparoscopy is frequently postponed and omitted in the exploration of the infertile patient. It is a rather invasive and not innocuous procedure. However, direct endoscopic visualization of the pelvis and the uterine cavity is still considered the gold standard and it is preferred over indirect imaging techniques.
The transvaginal single access approach offers the opportunity to explore the uterus and tubo-ovarian organs in an ambulatory “one-stop fertility” clinical setting. Only direct visualization of the pelvis allows for an accurate diagnosis of minimal endometriosis, tubo-ovarian adhesions, sequellae of PID. When indicated, the procedure was completed with a patency test, salpingoscopy and hysteroscopy. In patients without obvious pelvic pathology, transvafinal endoscopy (TVE) can be used as a first-line diagnostic procedure without postponing an early diagnosis and accurate therapy.
Because of the easy access to the fossa ovarica, the preferred implantation site of endometriosis, limited surgical procedures such as adhesiolysis become possible, the same goes for the treatment of ovarian endometrioma, and ovarian drilling. It allows for an accurate and meticulous dissection of peri-ovarian adhesions and hydroflotation is very helpful in the identification of the exact cleavage plane between the different organs. Small scissors, forceps, and a bipolar coagulation probe are used. A meticulous hemostasis is mandatory, as bleeding will disturb visualization in a watery medium. In case of endometriosis, after the endometrioma has been opened, the chocolate fluid is removed and the inner site of the cyst is superfluously rinsed. The bipolar probe is used to fulgurate the inner endometrial layering.
To drill the ovarian capsule, we use a 5 French bipolar needle (Karl Storz, Tuttlingen, Germany). On each ovary, 5 to 10 punctures were created preferentially at the antero-lateral side of the ovary. The 5 French bipolar needle is gently pushed against the ovarian surface and current is activated with an energy output of 70 Watts. The procedure was carried out in the ambulatory patient in a one-day clinical setting.
S Gordts
Lecture
3 years ago
945 views
30 likes
0 comments
30:53
The indications of transvaginal endoscopy for diagnosis and treatment of infertility
Standard laparoscopy is frequently postponed and omitted in the exploration of the infertile patient. It is a rather invasive and not innocuous procedure. However, direct endoscopic visualization of the pelvis and the uterine cavity is still considered the gold standard and it is preferred over indirect imaging techniques.
The transvaginal single access approach offers the opportunity to explore the uterus and tubo-ovarian organs in an ambulatory “one-stop fertility” clinical setting. Only direct visualization of the pelvis allows for an accurate diagnosis of minimal endometriosis, tubo-ovarian adhesions, sequellae of PID. When indicated, the procedure was completed with a patency test, salpingoscopy and hysteroscopy. In patients without obvious pelvic pathology, transvafinal endoscopy (TVE) can be used as a first-line diagnostic procedure without postponing an early diagnosis and accurate therapy.
Because of the easy access to the fossa ovarica, the preferred implantation site of endometriosis, limited surgical procedures such as adhesiolysis become possible, the same goes for the treatment of ovarian endometrioma, and ovarian drilling. It allows for an accurate and meticulous dissection of peri-ovarian adhesions and hydroflotation is very helpful in the identification of the exact cleavage plane between the different organs. Small scissors, forceps, and a bipolar coagulation probe are used. A meticulous hemostasis is mandatory, as bleeding will disturb visualization in a watery medium. In case of endometriosis, after the endometrioma has been opened, the chocolate fluid is removed and the inner site of the cyst is superfluously rinsed. The bipolar probe is used to fulgurate the inner endometrial layering.
To drill the ovarian capsule, we use a 5 French bipolar needle (Karl Storz, Tuttlingen, Germany). On each ovary, 5 to 10 punctures were created preferentially at the antero-lateral side of the ovary. The 5 French bipolar needle is gently pushed against the ovarian surface and current is activated with an energy output of 70 Watts. The procedure was carried out in the ambulatory patient in a one-day clinical setting.