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Gynecology

Find all the surgical interventions, lectures, experts opinions, debates, webinars and operative techniques per specialty.
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
1 year ago
4527 views
451 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
1 year ago
2995 views
386 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.
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, S Wegener, I Streuli
Surgical intervention
1 year ago
4672 views
312 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
1919 views
178 likes
1 comment
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.
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
2 years ago
1398 views
131 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
2 years ago
1373 views
123 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.
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
3 years ago
2813 views
174 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
3330 views
131 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.
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
8851 views
308 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.
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
4 years ago
2093 views
83 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
4 years ago
1138 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
4 years ago
1525 views
62 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
4 years ago
2040 views
100 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
4 years ago
2688 views
115 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.
Vascular anomalies found by retroperitoneal laparoscopic para-aortic lymphadenectomy
The retroperitoneum is an area of great interest in gynecologic oncology. The knowledge of the anatomy and potential vascular anomalies, which can be found, can help prevent complications.
The retroperitoneal vascular anomalies are often asymptomatic. Their prevalence ranges between 2.4 and 30% according to the published literature.
Its diagnosis includes imaging techniques or it can be made during surgery.
Although the presence of these variations may go unnoticed, different potential complications can be devastating (e.g., hemorrhage, loss of organs or even death).
In this video, the authors demonstrate some variations of retroperitoneal vessels diagnosed during the practice of retroperitoneal laparoscopic para-aortic lymphadenectomy performed in gynecologic cancer patients (advanced cervical cancer, endometrial carcinoma, and ovarian cancer in early stages).
In our case series of 60 procedures performed during 2011, 2012, and 2013, vascular anatomical anomalies are 33.33% (20 cases) and all of them were diagnosed during surgery.
First, the anomaly of the renal vascular territory (arterial or venous) was the most frequent, followed by anomalies which affect gonadal vessels, and finally by great vessel anomalies.
H Di Fiore, MC González Álvarez, R Sanz Baro, C Redondo Guisasola, JE García Villayzan
Surgical intervention
4 years ago
2022 views
59 likes
0 comments
13:28
Vascular anomalies found by retroperitoneal laparoscopic para-aortic lymphadenectomy
The retroperitoneum is an area of great interest in gynecologic oncology. The knowledge of the anatomy and potential vascular anomalies, which can be found, can help prevent complications.
The retroperitoneal vascular anomalies are often asymptomatic. Their prevalence ranges between 2.4 and 30% according to the published literature.
Its diagnosis includes imaging techniques or it can be made during surgery.
Although the presence of these variations may go unnoticed, different potential complications can be devastating (e.g., hemorrhage, loss of organs or even death).
In this video, the authors demonstrate some variations of retroperitoneal vessels diagnosed during the practice of retroperitoneal laparoscopic para-aortic lymphadenectomy performed in gynecologic cancer patients (advanced cervical cancer, endometrial carcinoma, and ovarian cancer in early stages).
In our case series of 60 procedures performed during 2011, 2012, and 2013, vascular anatomical anomalies are 33.33% (20 cases) and all of them were diagnosed during surgery.
First, the anomaly of the renal vascular territory (arterial or venous) was the most frequent, followed by anomalies which affect gonadal vessels, and finally by great vessel anomalies.
Laparoscopic type C radical hysterectomy and pelvic lymphadenectomy for cervical cancer
This video shows a standardized and reproducible approach to radical hysterectomy. The procedure begins with the dissection of the lateral pelvic spaces in order to identify and isolate the paracervix. After coagulation and division of the round ligament, the surgeon performs a T-shape incision until the psoas muscles to expose the field for the ilio-obturator lymphadenectomy. The paravesical fossa is then dissected in its medial and lateral aspect using the umbilical artery as a landmark. Following the umbilical artery in a ventral to dorsal direction, the surgeon identifies the uterine artery and the paracervix. Using the uterine artery as a landmark of the paracervix, dissection is continued posteriorly developing the Latzko and Okabayashi spaces in order to isolate the paracervix. Once the spaces have been developed, the lymphadenectomy is performed separating the external iliac vessels from the psoas muscle to reach the obturator fossa. During this step, the obturator nerve is identified to avoid injuries and to mark the caudal limit of the lymphadenectomy.
The procedure is carried on with the isolation of the ureter in its anterior aspect between the paracervix and the bladder. To do so, the bladder pillar is identified and the dissection is pursued between its medial and lateral aspect developing the so-called space of Yabuki. 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 paracervix is then cut at the level of the hypogastric vessel and the ureter is unroofed.
The vagina is cut with monopolar energy using a vaginal valve as a guide and the specimen is extracted vaginally.
The vagina is closed with three stitches using an extracorporeal knotting technique.
G Centini, K Afors, J Castellano, C Meza Paul, R Murtada, A Wattiez
Surgical intervention
4 years ago
10440 views
344 likes
1 comment
07:20
Laparoscopic type C radical hysterectomy and pelvic lymphadenectomy for cervical cancer
This video shows a standardized and reproducible approach to radical hysterectomy. The procedure begins with the dissection of the lateral pelvic spaces in order to identify and isolate the paracervix. After coagulation and division of the round ligament, the surgeon performs a T-shape incision until the psoas muscles to expose the field for the ilio-obturator lymphadenectomy. The paravesical fossa is then dissected in its medial and lateral aspect using the umbilical artery as a landmark. Following the umbilical artery in a ventral to dorsal direction, the surgeon identifies the uterine artery and the paracervix. Using the uterine artery as a landmark of the paracervix, dissection is continued posteriorly developing the Latzko and Okabayashi spaces in order to isolate the paracervix. Once the spaces have been developed, the lymphadenectomy is performed separating the external iliac vessels from the psoas muscle to reach the obturator fossa. During this step, the obturator nerve is identified to avoid injuries and to mark the caudal limit of the lymphadenectomy.
The procedure is carried on with the isolation of the ureter in its anterior aspect between the paracervix and the bladder. To do so, the bladder pillar is identified and the dissection is pursued between its medial and lateral aspect developing the so-called space of Yabuki. 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 paracervix is then cut at the level of the hypogastric vessel and the ureter is unroofed.
The vagina is cut with monopolar energy using a vaginal valve as a guide and the specimen is extracted vaginally.
The vagina is closed with three stitches using an extracorporeal knotting technique.
Laparoscopic management of a cavitated non-communicating rudimentary uterine horn of a unicornuate uterus: a case report
Introduction: A unicornuate uterus with a cavitated non-communicating rudimentary uterine horn is one of the most uncommon uterine anomalies of the female genital tract. It has an estimated frequency of 1 in 100,000 among the fertile female population. This anomaly results from the abnormal maturation of one Müllerian duct with the normal development of the contralateral one.
Case: This video describes the laparoscopic diagnosis and management of a unicornuate uterus with a left cavitated non-communicating rudimentary uterine horn in a 27-year old woman who presented with lower abdominal pain and severe dysmenorrhea. She was submitted to a preoperative imaging study with a MRI, a uro-CT and a CT-scan of the vertebral column. There were no concomitant urinary anomalies and the sagittal CT-scan revealed abnormalities in the development of the terminal portion of the column. A laparoscopic removal of this cavitated non-communicating uterine horn was performed without any complication in the postoperative period.
Conclusion: Operative laparoscopy proved to be a successful approach in the treatment of this congenital Müllerian anomaly.
H Ferreira Carvalho
Surgical intervention
4 years ago
1742 views
55 likes
0 comments
05:13
Laparoscopic management of a cavitated non-communicating rudimentary uterine horn of a unicornuate uterus: a case report
Introduction: A unicornuate uterus with a cavitated non-communicating rudimentary uterine horn is one of the most uncommon uterine anomalies of the female genital tract. It has an estimated frequency of 1 in 100,000 among the fertile female population. This anomaly results from the abnormal maturation of one Müllerian duct with the normal development of the contralateral one.
Case: This video describes the laparoscopic diagnosis and management of a unicornuate uterus with a left cavitated non-communicating rudimentary uterine horn in a 27-year old woman who presented with lower abdominal pain and severe dysmenorrhea. She was submitted to a preoperative imaging study with a MRI, a uro-CT and a CT-scan of the vertebral column. There were no concomitant urinary anomalies and the sagittal CT-scan revealed abnormalities in the development of the terminal portion of the column. A laparoscopic removal of this cavitated non-communicating uterine horn was performed without any complication in the postoperative period.
Conclusion: Operative laparoscopy proved to be a successful approach in the treatment of this congenital Müllerian anomaly.
Stepwise radical vaginal trachelectomy: Dargent’s operation
Up to 40% of early cervical cancers are diagnosed in young women who might desire fertility preservation. More than 1,000 cases of Radical Vaginal Trachelectomy (RVT) have been published so far, with over 450 pregnancies achieved. Oncological outcomes of this treatment are totally comparable with the ones obtained with radical hysterectomies for similar size lesions. Additionally, these results are similar or superior when compared to the other routes of trachelectomy.
The procedure is always combined with a laparoscopic pelvic lymphadenectomy to rule out the possibility of lymph node metastases.
This video demonstrates the technique of RVT. Interesting parts of the vaginal steps are shown along with their contemporary laparoscopic views for didactic purposes.
E Leblanc, F Narducci, L Bresson, M Puga
Surgical intervention
4 years ago
2934 views
86 likes
0 comments
09:21
Stepwise radical vaginal trachelectomy: Dargent’s operation
Up to 40% of early cervical cancers are diagnosed in young women who might desire fertility preservation. More than 1,000 cases of Radical Vaginal Trachelectomy (RVT) have been published so far, with over 450 pregnancies achieved. Oncological outcomes of this treatment are totally comparable with the ones obtained with radical hysterectomies for similar size lesions. Additionally, these results are similar or superior when compared to the other routes of trachelectomy.
The procedure is always combined with a laparoscopic pelvic lymphadenectomy to rule out the possibility of lymph node metastases.
This video demonstrates the technique of RVT. Interesting parts of the vaginal steps are shown along with their contemporary laparoscopic views for didactic purposes.
Single port laparoscopy and extraperitoneal para-aortic lymphadenectomy
Background: To report the feasibility and reproducibility of single port extraperitoneal para-aortic lymphadenectomy in locally advanced cervical cancer before chemoradiotherapy. This procedure is used in our institution in patients with negative PET-CT imaging in the para-aortic area to define radiation field limits more accurately.
Methods: Prospective study of patients with stage IB1N+-IVA cervical cancer treated at the Institute Gustave Roussy from January 2011 to January 2013.
Results: There was no conversion to laparotomy or to conventional multiport laparoscopy among our 50 cases. Only one failure occurred after removal of 2 nodes. In this case, we chose to stop the procedure because of the risk of a vascular complication due to the vascular anatomic variation. The median and mean number of lymph nodes removed were 18 [2-47] and 19 respectively. Six (12%) patients had metastatic para-aortic nodes. Radiotherapy fields were extended when para-aortic nodes were involved.
Conclusion: Extraperitoneal staging via a single port left iliac approach is feasible with conventional tools; it is reproducible and safe, and offers a high degree of cosmetic satisfaction.
S Gouy, C Uzan, A Leary, P Morice
Surgical intervention
5 years ago
2423 views
40 likes
0 comments
09:54
Single port laparoscopy and extraperitoneal para-aortic lymphadenectomy
Background: To report the feasibility and reproducibility of single port extraperitoneal para-aortic lymphadenectomy in locally advanced cervical cancer before chemoradiotherapy. This procedure is used in our institution in patients with negative PET-CT imaging in the para-aortic area to define radiation field limits more accurately.
Methods: Prospective study of patients with stage IB1N+-IVA cervical cancer treated at the Institute Gustave Roussy from January 2011 to January 2013.
Results: There was no conversion to laparotomy or to conventional multiport laparoscopy among our 50 cases. Only one failure occurred after removal of 2 nodes. In this case, we chose to stop the procedure because of the risk of a vascular complication due to the vascular anatomic variation. The median and mean number of lymph nodes removed were 18 [2-47] and 19 respectively. Six (12%) patients had metastatic para-aortic nodes. Radiotherapy fields were extended when para-aortic nodes were involved.
Conclusion: Extraperitoneal staging via a single port left iliac approach is feasible with conventional tools; it is reproducible and safe, and offers a high degree of cosmetic satisfaction.
Lumbo-aortic lymphadenectomy: improving exposure with the T’lift™ device
Lymph node dissection in the lumbo-aortic area is a challenging procedure. The main concerns during surgery include the risk of major vascular injury and the potential lesion of other structures such as the ureter or the duodenum. A thorough surgical strategy and adequate exposure are mandatory to reduce the possibility of complications.
During this surgical demonstration, the most important aspects of the strategy are discussed. Special emphasis is put on exposure and the use of the T’lift™ device is shown. This simple technique allows for a fast and safe suspension of the peritoneum, improving the visualization of the operative field.
A Wattiez, M Puga, CY Akladios, C Redondo Guisasola, Al Ussia
Surgical intervention
6 years ago
4246 views
59 likes
0 comments
15:01
Lumbo-aortic lymphadenectomy: improving exposure with the T’lift™ device
Lymph node dissection in the lumbo-aortic area is a challenging procedure. The main concerns during surgery include the risk of major vascular injury and the potential lesion of other structures such as the ureter or the duodenum. A thorough surgical strategy and adequate exposure are mandatory to reduce the possibility of complications.
During this surgical demonstration, the most important aspects of the strategy are discussed. Special emphasis is put on exposure and the use of the T’lift™ device is shown. This simple technique allows for a fast and safe suspension of the peritoneum, improving the visualization of the operative field.
Radical nerve-sparing hysterectomy (type C1)
This video demonstrates a nerve-sparing radical hysterectomy (type C1).
During type C Radical Hysterectomy (RH), the uterus is removed en bloc with its ligaments along with a vaginal margin of 15 to 20mm. The uterosacral ligaments are transected from the level of the rectum and the vesicouterine ligament at the level of the bladder. The ureter is dissected until it enters the bladder. It is mobilized completely to resect the lateral parametrium from the lateral wall.

Radical hysterectomy type C1 implies the preservation of the hypogastric inferior nerve and the bladder branch of the hypogastric plexus during the resection of the parametrium.
During the surgery, the components of the hypogastric plexus are identified: the inferior hypogastric nerve running from the lateral wall of the rectum and the splanchnic nerves from S2-S4. The deep uterine vein is an essential landmark because we can find the first splanchnic nerve underneath it. Consequently, during the resection of the posterior parametrium, the uterosacral ligament can be completely resected while conserving the inferior hypogastric nerve. Division of the lateral parametrium is pursued without including the splanchnic nerves. During the transection of the caudal part of the paracervix and the paracolpium, attention must be paid not to include the vesical branch of the inferior hypogastric plexus that runs parallel to paravaginal vessels.
M Malzoni, A Ruggiero, M Puga
Surgical intervention
6 years ago
8251 views
152 likes
1 comment
20:14
Radical nerve-sparing hysterectomy (type C1)
This video demonstrates a nerve-sparing radical hysterectomy (type C1).
During type C Radical Hysterectomy (RH), the uterus is removed en bloc with its ligaments along with a vaginal margin of 15 to 20mm. The uterosacral ligaments are transected from the level of the rectum and the vesicouterine ligament at the level of the bladder. The ureter is dissected until it enters the bladder. It is mobilized completely to resect the lateral parametrium from the lateral wall.

Radical hysterectomy type C1 implies the preservation of the hypogastric inferior nerve and the bladder branch of the hypogastric plexus during the resection of the parametrium.
During the surgery, the components of the hypogastric plexus are identified: the inferior hypogastric nerve running from the lateral wall of the rectum and the splanchnic nerves from S2-S4. The deep uterine vein is an essential landmark because we can find the first splanchnic nerve underneath it. Consequently, during the resection of the posterior parametrium, the uterosacral ligament can be completely resected while conserving the inferior hypogastric nerve. Division of the lateral parametrium is pursued without including the splanchnic nerves. During the transection of the caudal part of the paracervix and the paracolpium, attention must be paid not to include the vesical branch of the inferior hypogastric plexus that runs parallel to paravaginal vessels.
Total Laparoscopic Hysterectomy (TLH)
Total Laparoscopic Hysterectomy (TLH) is a safe and reproducible technique. However, its use has been limited so far. The most quoted criticisms to this surgery are technical difficulties and concerns about urinary complications.
In the different publications that have demonstrated the feasibility and safety of the procedure, a step by step technique has always been remarked.
It is a very complete lecture that addresses all aspects to achieve good results when performing TLH. Not only Dr. Osorio outlines the 10 key steps of this surgery, but she also presents the preoperative set-up, the instruments required, and the specific considerations related to the ureter and to the management of difficult cases.
F Osorio
Lecture
6 years ago
5385 views
71 likes
0 comments
18:13
Total Laparoscopic Hysterectomy (TLH)
Total Laparoscopic Hysterectomy (TLH) is a safe and reproducible technique. However, its use has been limited so far. The most quoted criticisms to this surgery are technical difficulties and concerns about urinary complications.
In the different publications that have demonstrated the feasibility and safety of the procedure, a step by step technique has always been remarked.
It is a very complete lecture that addresses all aspects to achieve good results when performing TLH. Not only Dr. Osorio outlines the 10 key steps of this surgery, but she also presents the preoperative set-up, the instruments required, and the specific considerations related to the ureter and to the management of difficult cases.
Myomectomy: variations and difficult cases
The aim of this presentation is to demonstrate the rules to avoid difficult situations in laparoscopic myomectomy. Myomectomy is one of the most challenging laparoscopic procedures, and can be time-consuming. Prior to performing a laparoscopic approach, it is always necessary to consider myoma-related factors such as number, location, and size. Regarding the surgeon’s experience, the most frequent problems are related to hemostasis achievement, traction maneuvers to enucleate myoma, and closure of uterine wall defect. Strategy and experience are truly essential to face difficult cases, and alternatives to facilitate the procedure include trocar placement, uterine artery clipping to reduce blood loss, but the most important issue remains appropriate patient selection.
E Zupi
Lecture
6 years ago
2945 views
69 likes
0 comments
15:08
Myomectomy: variations and difficult cases
The aim of this presentation is to demonstrate the rules to avoid difficult situations in laparoscopic myomectomy. Myomectomy is one of the most challenging laparoscopic procedures, and can be time-consuming. Prior to performing a laparoscopic approach, it is always necessary to consider myoma-related factors such as number, location, and size. Regarding the surgeon’s experience, the most frequent problems are related to hemostasis achievement, traction maneuvers to enucleate myoma, and closure of uterine wall defect. Strategy and experience are truly essential to face difficult cases, and alternatives to facilitate the procedure include trocar placement, uterine artery clipping to reduce blood loss, but the most important issue remains appropriate patient selection.
Strategy for laparoscopic total hysterectomy with a big adnexal mass
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.
A Wattiez, C Zacharopoulou, J Albornoz, M Puga, E Faller
Surgical intervention
6 years ago
4677 views
137 likes
0 comments
28:57
Strategy for laparoscopic total hysterectomy with a big adnexal mass
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.
Sentinel node technique in uterine cancers
Standard full pelvic lymph node dissection is a simple operation but with potential complications, such as lymphedema, which can be very disturbing for the patient. Additionally, even full pelvic dissection may miss the so-called “ectopic nodes”. Moreover, if a large number of nodes are sent for pathological exam, the pathologist is unable to perform serial sections and immunohistochemistry (IHC) to all nodes. For that reason, the pathologist could well miss positive nodes.
On the other hand, the sentinel node technique is able to detect the nodes that are not included in standard pelvic node dissection. It is also able to diagnose micro-metastasis on serial sections.
This technique, which is performed laparoscopically, uses blue dye combined with radio-isotopic identification and mapping, potentially associated with planar lymphoscintigraphy and SPECT-CT. In this way, it is possible to also detect “hot” nodes that are not colored by blue dye. The injection is performed in each quadrant of the cervix, approximately 2mm deep in the stroma.
In the near future, the sentinel node will probably have become the only one to be removed in early cervical cancer as well as in low and intermediate risk endometrial cancer.
D Querleu
Lecture
7 years ago
1631 views
19 likes
0 comments
28:53
Sentinel node technique in uterine cancers
Standard full pelvic lymph node dissection is a simple operation but with potential complications, such as lymphedema, which can be very disturbing for the patient. Additionally, even full pelvic dissection may miss the so-called “ectopic nodes”. Moreover, if a large number of nodes are sent for pathological exam, the pathologist is unable to perform serial sections and immunohistochemistry (IHC) to all nodes. For that reason, the pathologist could well miss positive nodes.
On the other hand, the sentinel node technique is able to detect the nodes that are not included in standard pelvic node dissection. It is also able to diagnose micro-metastasis on serial sections.
This technique, which is performed laparoscopically, uses blue dye combined with radio-isotopic identification and mapping, potentially associated with planar lymphoscintigraphy and SPECT-CT. In this way, it is possible to also detect “hot” nodes that are not colored by blue dye. The injection is performed in each quadrant of the cervix, approximately 2mm deep in the stroma.
In the near future, the sentinel node will probably have become the only one to be removed in early cervical cancer as well as in low and intermediate risk endometrial cancer.
Challenges of uterine fibroids - focus: endoscopic and hysteroscopic enucleation
25 to 30% of women are diagnosed with uterine myomas worldwide. Laparoscopic myomectomy has remarkable advantages for patients with less postoperative pain and shorter recovery time. The fibroid resection technique varies depending on the myoma’s size and position.
Pedunculated fibroids: The myoma’s pedicle is cauterized by means of the bipolar forceps and divided after loop placement.
Subserous and intramural myomas: An incision extended until the pseudo-capsule is made vertically or horizontally at the site of the underlying myoma. The dissection is performed strictly within the pseudo-capsule plane with the help of two pairs of grasping forceps using traction and counter-traction. After myoma enucleation, the uterus is sutured along a seromuscular plane using one or two layers of separate polydioxanon suture (PDS) stitches with extracorporeal or intracorporeal knots. Continuous suction and irrigation is performed to minimize adhesion formation. The myomas are then extracted by morcellation using an electric morcellator; an alternative method is to take it out by colpotomy, or to cut it in case of smaller pieces.
Cervical myomas: These can be easily reached and enucleated transvaginally.
Adenomyosis uteri: In case of dysmenorrhea resulting from well-discernible adenomyotic lesions, a careful resection is recommended by hysteroscopy or laparoscopy.
Adenomatoid tumors: They resemble fibroids with no clear cleavage plane. The exclusion from malignancy is only possible by histology which account for their necessary removal; they can also turn into malignancy.
Submucous myomas: They are located within the uterine cavity; their resection is performed hysteroscopically with the resectoscopic loop in a slicing manner with bipolar or monopolar current. Attention must be paid regarding resection if the distance between the myoma and the uterine serosa is less than 8mm. The laparotomic approach is preferably performed if the myoma is bigger than 20cm in diameter, located at very critical points, suspected of being a sarcoma, or if there are more than 10 fibroids. In any case when surgery is indicated, laparoscopic or hysteroscopic myomectomy is the primary choice according to the location. The results of many international series demonstrate the feasibility of laparoscopic and hysteroscopic myomectomy as a technique leading to a remission of symptoms with a low rate of complications and leading to an increased rate of fertility.
L Mettler
Lecture
7 years ago
2110 views
26 likes
0 comments
38:04
Challenges of uterine fibroids - focus: endoscopic and hysteroscopic enucleation
25 to 30% of women are diagnosed with uterine myomas worldwide. Laparoscopic myomectomy has remarkable advantages for patients with less postoperative pain and shorter recovery time. The fibroid resection technique varies depending on the myoma’s size and position.
Pedunculated fibroids: The myoma’s pedicle is cauterized by means of the bipolar forceps and divided after loop placement.
Subserous and intramural myomas: An incision extended until the pseudo-capsule is made vertically or horizontally at the site of the underlying myoma. The dissection is performed strictly within the pseudo-capsule plane with the help of two pairs of grasping forceps using traction and counter-traction. After myoma enucleation, the uterus is sutured along a seromuscular plane using one or two layers of separate polydioxanon suture (PDS) stitches with extracorporeal or intracorporeal knots. Continuous suction and irrigation is performed to minimize adhesion formation. The myomas are then extracted by morcellation using an electric morcellator; an alternative method is to take it out by colpotomy, or to cut it in case of smaller pieces.
Cervical myomas: These can be easily reached and enucleated transvaginally.
Adenomyosis uteri: In case of dysmenorrhea resulting from well-discernible adenomyotic lesions, a careful resection is recommended by hysteroscopy or laparoscopy.
Adenomatoid tumors: They resemble fibroids with no clear cleavage plane. The exclusion from malignancy is only possible by histology which account for their necessary removal; they can also turn into malignancy.
Submucous myomas: They are located within the uterine cavity; their resection is performed hysteroscopically with the resectoscopic loop in a slicing manner with bipolar or monopolar current. Attention must be paid regarding resection if the distance between the myoma and the uterine serosa is less than 8mm. The laparotomic approach is preferably performed if the myoma is bigger than 20cm in diameter, located at very critical points, suspected of being a sarcoma, or if there are more than 10 fibroids. In any case when surgery is indicated, laparoscopic or hysteroscopic myomectomy is the primary choice according to the location. The results of many international series demonstrate the feasibility of laparoscopic and hysteroscopic myomectomy as a technique leading to a remission of symptoms with a low rate of complications and leading to an increased rate of fertility.
LSH and LIH tissue conserving solutions for hysterectomy
The objectives of pelvic floor reconstructive surgery are to restore anatomy, optimize function, and reduce morbidity. The anatomic fundamentals comprise normal vaginal axis, fascial attachments, fascial breaks, vascularity and neuromuscular considerations.
Operative alternatives depending on the pelvic floor compartment:
Posterior wall: Enterocele:
Enterocele repair performed vaginally, which is a minimally invasive approach; Mc Call’s culdoplasty; sacrospinous fixation; sacral culpopexy and mesh kits.
Rectocele: posterior colporrhaphy; fascial reconstruction; Zacharin grafting and mesh kits. Abdominal alternatives include enterocele repair, high McCall’s suspension, sacral culdopexy and sacrospinous vault suspension. All of these can be carried out laparoscopically.
Anterior wall: Abdominal approach: open or laparoscopic Burch, paravaginal repair and sling. Vaginal alternative: anterior culdorrhaphy, traditional sling, TVT, TOT, RF sling, etc. Recommendations: the defects should be assessed preoperatively, and at the time of surgery, the objective is to evaluate the pelvis, to isolate the defects, and to repair each defect. The site-specific repair technique includes standard modified lithotomy position, trocar placement to facilitate suturing, repair of posterior defects first; anterior defect repair with paravaginal defects repaired first, followed by Burch sutures, and permanent sutures for all structural repairs. Failure or complications include poor vaginal axis, recurrent enterocele, graft problems, Urinary Stress Incontinence (USI) and sacral radiculopathy.
Conclusions: The objectives of pelvic surgery can be accomplished via laparoscopy. In virtually all studies evaluating the morbidity of laparoscopy versus laparotomy, morbidity was less in the laparoscopic group.
T Lyons
Lecture
7 years ago
1475 views
7 likes
0 comments
23:12
LSH and LIH tissue conserving solutions for hysterectomy
The objectives of pelvic floor reconstructive surgery are to restore anatomy, optimize function, and reduce morbidity. The anatomic fundamentals comprise normal vaginal axis, fascial attachments, fascial breaks, vascularity and neuromuscular considerations.
Operative alternatives depending on the pelvic floor compartment:
Posterior wall: Enterocele:
Enterocele repair performed vaginally, which is a minimally invasive approach; Mc Call’s culdoplasty; sacrospinous fixation; sacral culpopexy and mesh kits.
Rectocele: posterior colporrhaphy; fascial reconstruction; Zacharin grafting and mesh kits. Abdominal alternatives include enterocele repair, high McCall’s suspension, sacral culdopexy and sacrospinous vault suspension. All of these can be carried out laparoscopically.
Anterior wall: Abdominal approach: open or laparoscopic Burch, paravaginal repair and sling. Vaginal alternative: anterior culdorrhaphy, traditional sling, TVT, TOT, RF sling, etc. Recommendations: the defects should be assessed preoperatively, and at the time of surgery, the objective is to evaluate the pelvis, to isolate the defects, and to repair each defect. The site-specific repair technique includes standard modified lithotomy position, trocar placement to facilitate suturing, repair of posterior defects first; anterior defect repair with paravaginal defects repaired first, followed by Burch sutures, and permanent sutures for all structural repairs. Failure or complications include poor vaginal axis, recurrent enterocele, graft problems, Urinary Stress Incontinence (USI) and sacral radiculopathy.
Conclusions: The objectives of pelvic surgery can be accomplished via laparoscopy. In virtually all studies evaluating the morbidity of laparoscopy versus laparotomy, morbidity was less in the laparoscopic group.
Retroperitoneal laparoscopic para-aortic lymphadenectomy: stage IIB cervical carcinoma
This video demonstrates a retroperitoneal para-aortic lymphadenectomy for stage IIB epidermoid cervical carcinoma. This procedure allows to identify patients who should undergo extended field radiotherapy. The intervention is pursued with the dissection of the lympho-adipose tissue situated in the following anatomical boundaries: ureters and psoas muscles laterally, the iliac artery bifurcation —lower limit— and the left renal vein —superior limit. A diagnostic laparoscopy is first performed to rule out metastasis. A 10mm, 0-degree scope is used. An umbilical Hasson trocar is placed to explore the abdominal cavity. A left McBurney’s incision is then made, and the retroperitoneal space is created digitally. The Hasson trocar is placed with a 10mm balloon through the anterior incision. Two additional ports are placed in the anterior axillary line, a 12mm one and a 5mm one. The 5mm Ligasure™ V device and a grasping forceps are used throughout the whole intervention. At the end of the procedure, the lympho-adipose tissue is extracted using an Endobag through an enlarged peritoneal opening.
H Di Fiore, O Martínez, I Pérez, I Borrego, A Cristóbal
Surgical intervention
7 years ago
867 views
51 likes
0 comments
14:47
Retroperitoneal laparoscopic para-aortic lymphadenectomy: stage IIB cervical carcinoma
This video demonstrates a retroperitoneal para-aortic lymphadenectomy for stage IIB epidermoid cervical carcinoma. This procedure allows to identify patients who should undergo extended field radiotherapy. The intervention is pursued with the dissection of the lympho-adipose tissue situated in the following anatomical boundaries: ureters and psoas muscles laterally, the iliac artery bifurcation —lower limit— and the left renal vein —superior limit. A diagnostic laparoscopy is first performed to rule out metastasis. A 10mm, 0-degree scope is used. An umbilical Hasson trocar is placed to explore the abdominal cavity. A left McBurney’s incision is then made, and the retroperitoneal space is created digitally. The Hasson trocar is placed with a 10mm balloon through the anterior incision. Two additional ports are placed in the anterior axillary line, a 12mm one and a 5mm one. The 5mm Ligasure™ V device and a grasping forceps are used throughout the whole intervention. At the end of the procedure, the lympho-adipose tissue is extracted using an Endobag through an enlarged peritoneal opening.