Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S182–S195
Objective: The objective of this surgical teaching video is to break down the
Total Laparoscopic Hysterectomy procedure into seven standard steps.
After viewing this instructional video, participants should be able to
standardize the approach to total laparoscopic hysterectomy in their
patients.
Results: 50 year-old with a fibroid uterus presented for evaluation of
uterovaginal prolapse and stage 2 anterior vaginal wall prolapse. Total
laparoscopic hysterectomy with incorporation of the distal uterosacral
ligaments in the vaginal cuff closure was performed.
VIDEO POSTER: ENDOMETRIOSIS
610
Recurrent Endometriosis after Hysterectomy and Bilateral
Salpingoophorectomy
Carrillo JF, Howard FM. Obstetrics and Gynecology, University of
Rochester School of Medicine & Dentistry, Rochester, New York
It has been suggested that improvement of pain and pain relief after total
hysterectomy and bilateral salpingoophorectomy, can be as high as 85-
90%. Recurrence of endometriosis after hysterectomy and
salpingoophorectomy is an uncommon scenario, only described in case
reports. There are no clear risk factors, but incomplete resection of the
ovaries and endometriosis lesions at the time of hysterectomy, infiltrative
endometriosis and hormonal replacement therapy (HRT) might be
associated. We present a patient who underwent a total laparoscopic
hysterectomy with bilateral salpingoophorectomy, was placed on HRT
and had persistent pelvic pain with bilateral pelvic masses. She had
menopausal hormonal levels. Was taken to the operating room for
removal of masses. We outline the importance of adequate dissection of
bowel, ureters and recognition of the pertinent anatomical structures
before removal of the masses, as well as the rare but not impossible
scenario of persistent endometriosis after a radical surgery for
endometriosis.
611
Laparoscopic Excision of Retroperitoneal Pelvic Mass over Right
Iliac Vessels
Miller J,1 Parsa A,1 Dalman R,2 Nezhat C.1 1Center for Special Minimally
Invasive and Robotic Surgery, Stanford University, Palo Alto, California;
2 controversial especially since the decision to proceed with laparoscopy
Vascular Surgery, Stanford University, Stanford, California
Extragenital endometriosis of the major pelvic vessels has been the subject
of incidental case reports. Endometriosis occurring around large pelvic
vessels has been reported to cause pain, catamenial edema and DVT. This
is a videopresentation of a 49 year old female with history of
endometriosis, who presents with right sided pelvic and lower extremity
pain. Pelvic imaging showed a 4 cm mass overlying the right iliac
vessels. After preoperative consultation with vascular surgery,
laparoscopic excision of retroperitoneal mass was performed.
612
Colorectal Endometriosis: Laparoscopic Surgical Management and
Training
Najjar H, Manley T, Tsaltas J. Gynaecological Endosurgery Unit, Monash
Medical Centre, Southern Health, Bentleigh East, Victoria, Australia
Endometriosis is a common, chronic and oestrogen dependant condition. It
is commonly associated with both infertility and pelvic pain. One of the
most challenging and difficult management issues is severe Deep
Infiltrating endometriosis with bowel disease. Surgical excision of severe
colorectal endometriosis may improve patients’ symptoms and fertility
outcomes. The laparoscopic approach is feasible and safe. It requires
a multidisciplinary team approach and extensive surgical training. The
surgical techniques are detailed in this short video. An outline on the
evolution of training for this surgery will be discussed.
S183
613
Deep Infiltrating Endometriosis: Laparoscopic Resection of Pelvic,
Liver and Diaphragmatic Nodules
Palmer M, Eisenstein D, Sangha R, Abouljoud M, Bruno D. Womens
Health Services, Henry Ford Health System, Detroit, Michigan
This case demonstrates a conservative approach to resection of endometriosis
in a patient with previously diagnosed stage 4 endometriosis. The patient is
a 35 year old patient who desired preservation of fertility. MRI evaluation of
the pelvis and abdomen revealed implants of endometriosis in the liver and
diaphragm. Laparoscopic resection of all visible endometriosis and
restoration of normal anatomy was accomplished. Resection of liver and
diaphragm nodules was attempted laparoscopically but was converted to
an open procedure after discovery that the diaphragm lesions were invasive
through the pleural surface of the diaphragm. The laparoscopic technique
demonstrates a logical approach to dealing with the frozen pelvis and
demonstrates safe and efficient dissection of stage 4 endometriosis with
ectopic implants outside the pelvis.
614
TLH BSO with Bowel Resection for Advanced Endometriosis Using
a ‘‘Dental Floss Dunk’’ Technique
Siedhoff MT, Findley AD, Hobbs KA. Advanced Laparoscopy & Pelvic
Pain, University of North Carolina at Chapel Hill, Chapel Hill, North
Carolina
This case demonstrates a technique for removing a rectal endometriosis nodule
by ‘‘dunking’’ it with suture placed in the jaws of a circular stapler like dental
floss. The surgery also demonstrates opening the avascular spaces of
the pelvis–pararectal, paravesical, vesicovaginal, and rectovaginal–in
a systematic way to ensure safe and complete endometriosis resection.
615
Transvaginal Ultrasound Guided Sclerosis of Endometriomas
Snegovskikh VV, Flores VA, Frishman GN. Obstetrics and Gynecology,
Warren Alpert Medical School of Brown University, Providence, Rhode
Island
Treatment of endometriomas has traditionally been limited to a surgical
route as medical therapy has not been shown to be effective. Whether
removal of asymptomatic endometriomas improves fertility is
should not be undertaken lightly.
Regardless of the indication for cystectomy, a major concern is that
resection of endometriomas results in the loss of small follicles adjacent
to the cyst wall; leading to a reduced oocyte pool. Lastly, removal of
endometriomas can be challenging surgery based on the coexisting
adhesions and endometriosis. There is often difficulty in developing
planes within the ovary to aid dissection and sometimes the rim of viable
cortex is small enough to make ovarian preservation problematic.
Given the above, alternative treatment regimens are sorely needed. Sclerosis
of cysts throughout the body has been widely described in the literature. We
present here two representative cases of ovarian endometrioma sclerosis.
616
Reduced Port Laparoscopic Excision of DIE Lesions: 1or 2 Incision
Technique
Sun C-H. Gyn Endoscopic Center, Lucina Women & Children Hospital,
Kaohsiung, Taiwan
DIE (deep infiltrating endometrisois) excision remains the most challenging
GYN laparoscopic surgery. Meanwhile, ‘‘LESS’’ (laparo-endoscopic single
site) surgery (or ‘‘single port’’ surgery) is getting more and more popular.
However, it is still difficult to do a complex laparoscopic DIE excision
surgery by ‘‘LESS’’ approach. In this video, we will demonstrate our
techniques to overcome some of the difficulties and problems during
a ‘‘LESS’’ DIE excision laparoscopic surgery.