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Gynecology

Find all the surgical interventions, lectures, experts opinions, debates, webinars and operative techniques per specialty.
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
2790 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
3305 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
8781 views
307 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.
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
2020 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
2645 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.
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
2918 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.
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
2101 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.
Laparoscopic myomectomy: tips 'n tricks
Surgery is the treatment of choice for myomas. Myomectomy has undergone a dramatic evolution over the years. Laparoscopic myomectomy provides a preferable alternative to abdominal myomectomy for women with symptomatic fibroids who desire uterine preservation. It is also an excellent method for women who have infertility primarily related to fibroids. A lot of patients prefer myomectomy over hysterectomy even if they do not desire pregnancy. However, laparoscopic myomectomy is not easy and needs some practice. Together with the basic steps, some tips and tricks are provided to make this technique even more safe and feasible for surgeons. For good results, the use of a few technical tricks provides an optimal solution for all issues.
A Wattiez, P Trompoukis, AM Furtado Lima, J Nassif, B Gabriel
Surgical intervention
8 years ago
9502 views
188 likes
0 comments
08:35
Laparoscopic myomectomy: tips 'n tricks
Surgery is the treatment of choice for myomas. Myomectomy has undergone a dramatic evolution over the years. Laparoscopic myomectomy provides a preferable alternative to abdominal myomectomy for women with symptomatic fibroids who desire uterine preservation. It is also an excellent method for women who have infertility primarily related to fibroids. A lot of patients prefer myomectomy over hysterectomy even if they do not desire pregnancy. However, laparoscopic myomectomy is not easy and needs some practice. Together with the basic steps, some tips and tricks are provided to make this technique even more safe and feasible for surgeons. For good results, the use of a few technical tricks provides an optimal solution for all issues.