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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
3 years ago
5528 views
297 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.
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
2 years ago
6300 views
401 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.
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
2 years ago
2744 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.
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
2 years ago
2762 views
91 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.
Laparoscopic oophorectomy for solid ovarian mass
We present the case of a 28-year-old woman with no relevant previous surgical or medical history. The patient was addressed for the removal of a right ovarian mass. She presented with dysmenorrhea and occasional dyspareunia. There were no other symptoms. Her physical examination showed a right adnexal mass to the vaginal touch. Preoperative work-up included a pelvic ultrasound, which showed a tumor apparently originating from the right ovary, of solid homogeneous appearance. MRI confirmed the presence of the solid mass, measuring approximately 6cm. No other pathological findings were present in the rest of the abdominal cavity. Tumor markers were negative. The patient had not completed childbearing and desired a conservative surgical approach. The different aspects of the surgical management were explained, including the possibility of performing an oophorectomy if no healthy ovarian tissue could be identified.
A Wattiez, C Redondo Guisasola, M Puga, R Fernandes, J Alves
Surgical intervention
6 years ago
5374 views
83 likes
0 comments
08:33
Laparoscopic oophorectomy for solid ovarian mass
We present the case of a 28-year-old woman with no relevant previous surgical or medical history. The patient was addressed for the removal of a right ovarian mass. She presented with dysmenorrhea and occasional dyspareunia. There were no other symptoms. Her physical examination showed a right adnexal mass to the vaginal touch. Preoperative work-up included a pelvic ultrasound, which showed a tumor apparently originating from the right ovary, of solid homogeneous appearance. MRI confirmed the presence of the solid mass, measuring approximately 6cm. No other pathological findings were present in the rest of the abdominal cavity. Tumor markers were negative. The patient had not completed childbearing and desired a conservative surgical approach. The different aspects of the surgical management were explained, including the possibility of performing an oophorectomy if no healthy ovarian tissue could be identified.
Laparoscopic oophoropexy
This is the case of a 25-year-old woman with a previous history of right ovarian torsion that necessitates removal of that ovary. The patient expressed concern regarding fertility and possible torsion of the left ovary in the future.
During laparoscopy, an elongated utero-ovarian ligament was noticed. Decision was made to proceed with oophoropexy to decrease the chance of ovarian torsion in the future.
The video demonstrates the back load technique of the needle introduced through the 5mm port incision to achieve optimal cosmetic results.
The needle was passed through the left utero-ovarian ligament. Plication started from the ovarian end towards the uterine end. Extracorporeal knot was tied.
Interceed™ was used to minimize the risk of subsequent adhesions.
M Milad, N Latif, I Moy
Surgical intervention
7 years ago
7770 views
204 likes
0 comments
03:05
Laparoscopic oophoropexy
This is the case of a 25-year-old woman with a previous history of right ovarian torsion that necessitates removal of that ovary. The patient expressed concern regarding fertility and possible torsion of the left ovary in the future.
During laparoscopy, an elongated utero-ovarian ligament was noticed. Decision was made to proceed with oophoropexy to decrease the chance of ovarian torsion in the future.
The video demonstrates the back load technique of the needle introduced through the 5mm port incision to achieve optimal cosmetic results.
The needle was passed through the left utero-ovarian ligament. Plication started from the ovarian end towards the uterine end. Extracorporeal knot was tied.
Interceed™ was used to minimize the risk of subsequent adhesions.
Transumbilical single incision laparoscopic left ovariectomy
Background: Transumbilical single incision laparoscopy has been reported to be a feasible and safe procedure to treat gynecologic diseases. This video presents a left ovariectomy performed in a patient with a symptomatic giant ovarian cyst.

Clinical case: A 56-year-old female with a body mass index of 20.5 kg/m2, was consulted for abdominal pain localized in the left iliac fossa. Preoperative work-up showed a left ovarian cyst of 12cm in diameter. The cyst appeared to be round, with smooth walls, homogenic liquid, and without intracystic proliferations. The procedure was performed using an 11mm reusable port for a 10mm, 30-degree standard length scope, and curved reusable instruments according to Dapri (Karl Storz Endoskope). The specimen was extracted through the umbilicus in a custom-made plastic bag.

Results: No conversion to open surgery nor additional ports were necessary. The laparoscopy lasted 37 minutes and the final umbilical incision length was 15mm. Pathological data revealed a serous cystadenoma. The patient was discharged on postoperative day 1. At 7-month follow-up, no late complications were found and the patient was asymptomatic.

Conclusions: Transumbilical single incision laparoscopy is beneficial for gynecologic diseases and this technique allow for a final scar of minimal size. The cost of the procedure is similar to that of multi-port laparoscopy.
G Dapri, M Degueldre
Surgical intervention
6 years ago
2928 views
33 likes
0 comments
03:46
Transumbilical single incision laparoscopic left ovariectomy
Background: Transumbilical single incision laparoscopy has been reported to be a feasible and safe procedure to treat gynecologic diseases. This video presents a left ovariectomy performed in a patient with a symptomatic giant ovarian cyst.

Clinical case: A 56-year-old female with a body mass index of 20.5 kg/m2, was consulted for abdominal pain localized in the left iliac fossa. Preoperative work-up showed a left ovarian cyst of 12cm in diameter. The cyst appeared to be round, with smooth walls, homogenic liquid, and without intracystic proliferations. The procedure was performed using an 11mm reusable port for a 10mm, 30-degree standard length scope, and curved reusable instruments according to Dapri (Karl Storz Endoskope). The specimen was extracted through the umbilicus in a custom-made plastic bag.

Results: No conversion to open surgery nor additional ports were necessary. The laparoscopy lasted 37 minutes and the final umbilical incision length was 15mm. Pathological data revealed a serous cystadenoma. The patient was discharged on postoperative day 1. At 7-month follow-up, no late complications were found and the patient was asymptomatic.

Conclusions: Transumbilical single incision laparoscopy is beneficial for gynecologic diseases and this technique allow for a final scar of minimal size. The cost of the procedure is similar to that of multi-port laparoscopy.
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
1 year ago
4956 views
587 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.
Ovarian tissue cryopreservation
The French law on bioethics dated August 6 2004 now states the possibility for any person to benefit from a gamete or a germinal tissue collection as well as its preservation. Collection and preservation are planned when the patient’s management may induce a fertility alteration or when the patient’s fertility may be prematurely altered. Young girls who have not reached the age of puberty and who are about to undergo high-dose chemotherapy and/or major radiation therapy for cancer, can benefit from a cryopreservation of their ovarian tissue. It will allow to preserve fertility when these patients have a wish for pregnancy. Once collected, preserved ovarian cortical strips are systematically sent for frozen section to the pathology department in order to be processed for cryopreservation. Later on, when these young women have been healed and wish to become pregnant, the thawing of preserved ovarian cortical strips and the orthotopic autograft can take place. We suggest to collect the anterior cortex from both ovaries, which allows to preserve the two remaining ovaries. Another technique, which is performed by other teams, involves a unilateral oophorectomy for ovarian tissue preservation. A bilateral hemicortical sampling on both ovaries is well accepted by patients and their parents. Indeed, the video does not present an oophorectomy, which is considered as a definitive procedure, but a bilateral sampling which leaves two ovaries in place. The ovaries are reduced in size but are anatomically and functionally healthy.
F Becmeur
Surgical intervention
2 years ago
1153 views
56 likes
0 comments
03:05
Ovarian tissue cryopreservation
The French law on bioethics dated August 6 2004 now states the possibility for any person to benefit from a gamete or a germinal tissue collection as well as its preservation. Collection and preservation are planned when the patient’s management may induce a fertility alteration or when the patient’s fertility may be prematurely altered. Young girls who have not reached the age of puberty and who are about to undergo high-dose chemotherapy and/or major radiation therapy for cancer, can benefit from a cryopreservation of their ovarian tissue. It will allow to preserve fertility when these patients have a wish for pregnancy. Once collected, preserved ovarian cortical strips are systematically sent for frozen section to the pathology department in order to be processed for cryopreservation. Later on, when these young women have been healed and wish to become pregnant, the thawing of preserved ovarian cortical strips and the orthotopic autograft can take place. We suggest to collect the anterior cortex from both ovaries, which allows to preserve the two remaining ovaries. Another technique, which is performed by other teams, involves a unilateral oophorectomy for ovarian tissue preservation. A bilateral hemicortical sampling on both ovaries is well accepted by patients and their parents. Indeed, the video does not present an oophorectomy, which is considered as a definitive procedure, but a bilateral sampling which leaves two ovaries in place. The ovaries are reduced in size but are anatomically and functionally healthy.
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
2 years ago
5320 views
312 likes
1 comment
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.
Hybrid NOTES transvaginal cholecystectomy using 2 instruments (2.2mm and 3mm)
A 79-year-old patient presented with symptomatic cholecystolithiasis without signs of cholecystitis. Biochemical parameters were normal. Sonography showed large gallstones, which is a good indication for a transvaginal approach.
As we know, NOTES (natural orifice transluminal endoscopic surgery) is under constant evolution. Last year, hybrid procedures gained more importance. In our surgical department, we perform these procedures as a valid alternative for conventional laparoscopy. We observed that out patients have less pain, faster recovery, and at last almost no scar and are not at risk for incisional hernias.
With this video, we describe a comfortable 2 instrument technique using a hybrid transvaginal approach. A pneumoperitoneum of 12mmHg is created using a Veress needle at the umbilicus. A 3mm port is placed. A percutaneous clamp is placed with a diameter of 2.2mm. The patient is placed in a Trendelenburg position, and the transvaginal trocar, 12mm in diameter and 15cm in length, is pushed into the posterior fornix. A conventional cholecystectomy is performed with no loss of triangulation. Transvaginal clipping (by means of a large 45cm clip applier) and extraction are performed. Transabdominal scars are closed with a simple bandage and no suturing. The colpotomy is closed using separate Vicryl 2/0 sutures.
The procedure took 30 minutes. In our group, we have a mean operating time of 30 minutes for hybrid transvaginal cholecystectomies.
S Heyman, B Gypen, F van Sprundel, J Valk, L Hendrickx
Surgical intervention
3 years ago
1179 views
44 likes
0 comments
05:08
Hybrid NOTES transvaginal cholecystectomy using 2 instruments (2.2mm and 3mm)
A 79-year-old patient presented with symptomatic cholecystolithiasis without signs of cholecystitis. Biochemical parameters were normal. Sonography showed large gallstones, which is a good indication for a transvaginal approach.
As we know, NOTES (natural orifice transluminal endoscopic surgery) is under constant evolution. Last year, hybrid procedures gained more importance. In our surgical department, we perform these procedures as a valid alternative for conventional laparoscopy. We observed that out patients have less pain, faster recovery, and at last almost no scar and are not at risk for incisional hernias.
With this video, we describe a comfortable 2 instrument technique using a hybrid transvaginal approach. A pneumoperitoneum of 12mmHg is created using a Veress needle at the umbilicus. A 3mm port is placed. A percutaneous clamp is placed with a diameter of 2.2mm. The patient is placed in a Trendelenburg position, and the transvaginal trocar, 12mm in diameter and 15cm in length, is pushed into the posterior fornix. A conventional cholecystectomy is performed with no loss of triangulation. Transvaginal clipping (by means of a large 45cm clip applier) and extraction are performed. Transabdominal scars are closed with a simple bandage and no suturing. The colpotomy is closed using separate Vicryl 2/0 sutures.
The procedure took 30 minutes. In our group, we have a mean operating time of 30 minutes for hybrid transvaginal cholecystectomies.
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
4 years ago
2546 views
96 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.
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
4 years ago
1063 views
32 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.
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
3 years ago
3986 views
162 likes
0 comments
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 ileocaecal and sigmoid resection with transanal natural orifice specimen extraction (NOSE) for endometriosis
In 12 to 30% of endometriosis cases, the disease is located in the bowel. Caecum and small bowel endometriosis are found in only 3.6% and 7% respectively of those cases while the sigmoid colon and the rectum are most commonly affected in 85% of cases. The laparoscopic management of this disease has evolved drastically over the last decade, and even delicate cases such as small bowel endometriosis can be completely managed by laparoscopy. It is key to be locally invasive towards the disease but conservative with regards to organ function preservation. The specimen will be extracted through natural orifices and without any ileostomy. Our patients are commonly young and healthy women who will certainly benefit from a tailored surgery with immediate symptom relief in addition to minimum abdominal scarring can have a significant positive impact on patient’s psychological well-being and subsequent recovery.
In the present case, we present a 36-year old woman who was diagnosed with endometriosis and presented with 3 episodes of bowel pseudo-obstruction and dyschezia, and put under medical treatment. She was found to have multiple endometriotic nodules, with concurrent ileocaecal and rectosigmoid disease, for which a double bowel resection with transanal natural orifice specimen extraction (NOSE) was performed without complications.
A Wattiez, J Leroy, C Meza Paul, K Afors, J Castellano, G Centini, R Fernandes, R Murtada
Surgical intervention
5 years ago
1920 views
46 likes
0 comments
38:15
Laparoscopic ileocaecal and sigmoid resection with transanal natural orifice specimen extraction (NOSE) for endometriosis
In 12 to 30% of endometriosis cases, the disease is located in the bowel. Caecum and small bowel endometriosis are found in only 3.6% and 7% respectively of those cases while the sigmoid colon and the rectum are most commonly affected in 85% of cases. The laparoscopic management of this disease has evolved drastically over the last decade, and even delicate cases such as small bowel endometriosis can be completely managed by laparoscopy. It is key to be locally invasive towards the disease but conservative with regards to organ function preservation. The specimen will be extracted through natural orifices and without any ileostomy. Our patients are commonly young and healthy women who will certainly benefit from a tailored surgery with immediate symptom relief in addition to minimum abdominal scarring can have a significant positive impact on patient’s psychological well-being and subsequent recovery.
In the present case, we present a 36-year old woman who was diagnosed with endometriosis and presented with 3 episodes of bowel pseudo-obstruction and dyschezia, and put under medical treatment. She was found to have multiple endometriotic nodules, with concurrent ileocaecal and rectosigmoid disease, for which a double bowel resection with transanal natural orifice specimen extraction (NOSE) was performed without complications.