Jaime ALBORNOZ

Adequate exposure of the surgical field is a fundamental step in all kinds of surgeries. A good visualization of the operative field simplifies the procedure and provides safety.
In laparoscopy, exposure can be improved using simple methods, such as the organ suspension. The T’lift™ device is a suspension-bracket especially designed for this purpose. Its use is simple and can be applied in multiple situations. During this video, the complete technique of suspension is described. Twelve clinical applications are presented.

Organ suspension using a T-lift™ device is a simple method to enhance exposure in laparoscopic surgery, providing adequate vision and operating space and allowing the assistant to focus on helping the surgeon, thus reducing operative times, without the need for difficult intra-abdominal needle manipulation as well as the risk of bowel and vascular injury associated with that approach.
Several examples of organ suspension with the T-lift™ are demonstrated in this video, including suspension of the ovaries, sigmoid colon or vagina in simple procedures, as well as in more complex procedures, for instance by holding the anterior rectal wall for bowel resection with transanal specimen extraction.

This video demonstrates the case of a 74-year-old woman suffering from pelvic prolapse (hysterocele, cystocele, enterocele). A laparoscopic colposacropexy combined with subtotal hysterectomy and double adnexectomy is performed. This is a complex procedure, which requires a perfect knowledge and understanding of both the pelvic anatomy and of the surgical technique for an adequate repair of defects. The standardized technique is followed, showing the six point technique for the fixation of the mesh.

This video shows a total laparoscopic technique of bowel resection using the vagina to extract the specimen. This technique of Natural Orifice Specimen Extraction (NOSE) seems particularly adapted for women with bowel endometriosis.

Endometriosis of the bladder is mostly due to ademyosis of the isthmus uterinus involving the posterior wall of the bladder. Once the nodule has been detached from the anterior uterine wall, this video shows that a mucosal skinning or shaving of the bladder is possible and quite easy.

In this video, Dr. Olivier Garbin demonstrates the management of total septate uterus in a stepwise fashion. The procedure starts with the vaginal septum, division of the cervix, and continues with hysteroscopic resection of the septum. A previous 3D ultrasound is mandatory to differentiate septate uterus from bicornuate uterus.

Bladder endometriosis is the most common presentation of urinary tract endometriosis and is frequently associated with specific symptoms such as dysuria, hematuria and recurrent urinary tract infections. Although it may be associated with ureteral endometriosis in severe cases, in most cases, it presents as an isolated disease.
The laparoscopic approach for bladder endometriosis nodule excision requires careful dissection of the paravesical spaces and identification of both ureters entering each ureteral tunnel. The shaving technique until healthy tissue is reached should be attempted, but if mucosal invasion is found, complete wall excision should be performed. In some occasions, when the nodule invades the bladder trigone, a double-J catheter may be inserted and left in place for 6 to 8 weeks.
In this video, we present the case of a 23-year-old woman complaining with significant dysuria associated with hematuria, dysmenorrhea, dyspareunia, and chronic pelvic pain. Magnetic resonance imaging described a 5cm nodule located in the bladder dome, and cystoscopy confirmed the diagnosis. The patient was referred to our Endometriosis Centre after diagnostic laparoscopy.

In this key lecture, Dr. Jaime Albornoz provides an overview of urinary tract endometriosis, its diagnosis, and its management.

Several aspects are of utmost relevance to perform Pelvic Lymphadenectomy (PL) and Radical Modified Hysterectomy (RMH).
This film presents a didactical presentation of RMH and PL performed in a 46-year-old woman with stage Ia2 cervical carcinoma. Oncological risks of the surgery, anatomical landmarks, the surgical technique and choice of instruments are discussed. Several tips and tricks are outlined by the surgeon during the different steps of the surgery.

The aim of this lecture is to describe the different techniques available to enter the abdomen safely. Dr. Albornoz stresses that the open entry technique is associated with a significant reduction in failed entry, and that the direct trocar entry technique is currently the faster and safer closed technique. Finally, the author highlights that the way to avoid complications is to understand and always perform the technique which makes the surgeon feel more comfortable.

Endometriosis can affect the bowel in 5-15% of cases and the most common sites are the rectum, the sigmoid colon, the appendix, and the small bowel. Patients may present dysmenorrhea, dyspareunia and chronic pelvic pain, as well as digestive symptoms such as dyschezia, constipation and diarrhea during menstruation. Preoperative work-up includes transanal ultrasound and magnetic resonance imaging, which according to the nodule’s location, can accurately describe the lesions. The laparoscopic approach includes adhesiolysis (shaving), partial thickness wall excision (mucosal skinning), discoid resection, and segmental bowel resection. In this video, we present the case of a 30-year-old patient complaining from severe dysmenorrhea, dyspareunia and dyschezia associated with deep infiltrating endometriosis (DIE) of the sigmoid colon that was treated by means of nodule excision, segmental bowel resection, and transanal specimen extraction.

Ureteral endometriosis is rare. Yet, it represents one of the most challenging surgeries in the management of endometriosis. In this video, we present a 25-year-old woman in whom a left ureterolysis, a right ureteral division and anastomosis were performed because of severe endometriosis.

This video shows an original case of laparoscopic broad ligament myomectomy. Prevention of ureteral injury and careful hemostasis are essential to perform this procedure.

This video demonstrates a very particular case of adhesiolysis associated with myomectomy and tubal surgery in a patient who had already had endometriosis surgery with bowel resection. Pain recurrence is in fact due to adhesions as the adnexa are covered by the peritoneum as well as an adhesion between the myoma and the rectal anastomosis. In this case, laparoscopy proves to be very useful to perform adhesiolysis safely and with adequate visual control. Once the anatomy has been restored, a myomectomy and a bilateral fimbrioplasty are performed.

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

Endometriosis is defined as the presence of endometrial-like tissue outside the uterus, which induces a chronic inflammatory reaction.
Deep infiltrating endometriosis nodules extend beyond 5mm beneath the peritoneum and may involve the uterosacral ligaments, vagina, bowel, bladder and ureters. This is the case of a 40-year-old multiparous woman complaining of significant dysmenorrhea, mild dyspareunia, and left inguinal pain.
In this video, we show the dissection of the left parametrium and the resection of an endometriotic nodule that had exerted an extrinsic compression over the obturator nerve.

We present the case of a 36-year-old G3P3 woman. She presents with dysmenorrhea, chronic deep pelvic pain, dyspareunia, dyschezia, and constipation. The rectovaginal exam reveals a relatively fixed retroverted uterus. MRI shows an endometriotic nodule at the level of the torus uterinus that is attached to the anterior wall of the rectosigmoid junction.

Bowel endometriosis is described in 3% to 37% of patients with endometriosis. In 90% of these cases, the rectum, the sigmoid colon or both are involved. It is the most severe form of the disease and its surgical management is complex. Surgery is very challenging and the degree of radical excision should always be counterbalanced with the risk of complications and functional disorders. Four types of surgery can be chosen: superficial excision or shaving, mucosal skinning, discoid excision, and segmental bowel resection. We believe that bowel resection can be avoided in some cases if mucosal skinning is first attempted. This video shows 2 endometriotic lesions of the rectosigmoid junction that were treated by mucosal skinning, hence avoiding an unnecessary segmental resection. The final result was satisfactory and postoperative outcome was uneventful. In 2008, the patient underwent a laparoscopic intervention, which revealed the presence of a deep infiltrating endometriosis and bilateral endometriotic cysts. Bilateral ovarian cystectomy was performed. Postoperative MRI for pelvic pains revealed a persistent lesion of the recto-vaginal septum. The patient then presented with persistent dysmenorrhea (8/10), chronic pelvic pain (8/10), dyschezia (6/10) without dyspareunia or bladder-related symptoms. Clinical examination showed a mobile anteverted uterus without clear evidence of a nodule lesion at the rectovaginal septum neither was it at the level of uterosacral ligaments, but most probably the presence of adhesions between the uterus and the rectosigmoid junction. Despite treatment with GnRH agonist, the patient was referred to the emergency department several times for bouts of intense pain.

This video presents a multiple laparoscopic myomectomy in a 31-year-old patient with chronic pelvic pain and metrorrhagia. Myomectomy starts after intraoperative temporary clipping of the uterine artery and infundibulopelvic vessels. This simple method allows for the prevention of massive bleeding during the excision of the myomas. Once all myomas have been enucleated, they are extracted by morcellation.

We present the case of a 29-year-old nulligest woman. Four years ago, she had a previous surgery with a rectovaginal nodule removed both by laparoscopy and vaginal approach. She has complained of dyspareunia (8/10), dysmenorrhea (8/10), dyschezia (8/10) and infertility over the last 2 years, but she also suffers from bladder dysfunction requiring urinary self-catheterization during her menstrual periods. The laparoscopic exploration revealed a big fibrotic nodule located in the right pelvic sidewall involving the right ureter and the rectum. Right ureter resection and anastomosis were performed. Segmental rectosigmoid resection was followed by transvaginal specimen extraction and a transanal colorectal anastomosis. The intracorporeal laparoscopic technique allows for a limited bowel devascularization and for an appropriate anastomosis with no need for extra abdominal incisions. No complications were noted and the patient had a good clinical evolution.

Laparoscopy is a type of minimally invasive surgery with known advantages over laparotomy: reduced risk of any adverse effect of surgery, reduced pain and fewer days in hospital. Access to the abdominal cavity is the first challenge, as at least 50% of gastrointestinal and major blood vessel complications occur during the first umbilical trocar insertion. For this reason it is fundamental to know the anatomy of the abdominal wall in order to safely place the trocars during laparoscopic surgery.