Laparoscopic Tips and Tricks: Advancing Your Skills (Didactic) · Laparoscopic Tips and Tricks:...

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Sponsored by AAGL Advancing Minimally Invasive Gynecology Worldwide Laparoscopic Tips and Tricks: Advancing Your Skills (Didactic) PROGRAM CHAIR Stephanie N. Morris, MD Andrew I. Brill, MD James K. Robinson, MD

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  • Sponsored by

    AAGLAdvancing Minimally Invasive Gynecology Worldwide

    Laparoscopic Tips and Tricks:Advancing Your Skills (Didactic)


    Stephanie N. Morris, MD

    Andrew I. Brill, MD James K. Robinson, MD

  • ProfessionalEducationInformationTargetAudienceEducationalactivitiesaredevelopedtomeettheneedsofsurgicalgynecologistsinpracticeandintraining,aswellas,otheralliedhealthcareprofessionalsinthefieldofgynecology.AccreditationAAGLisaccreditedbytheAccreditationCouncilforContinuingMedicalEducationtoprovidecontinuingmedicaleducationforphysicians.TheAAGLdesignatesthisliveactivityforamaximumof3.75AMAPRACategory1Credit(s).Physiciansshouldclaimonlythecreditcommensuratewiththeextentoftheirparticipationintheactivity.DISCLOSUREOFRELEVANTFINANCIALRELATIONSHIPSAs a provider accredited by theAccreditation Council for ContinuingMedical Education,AAGLmustensurebalance,independence,andobjectivityinallCMEactivitiestopromoteimprovementsinhealthcareandnotproprietaryinterestsofacommercialinterest.Theprovidercontrolsalldecisionsrelatedtoidentification of CME needs, determination of educational objectives, selection and presentation ofcontent, selection of all persons and organizations thatwill be in a position to control the content,selection of educationalmethods, and evaluation of the activity. Course chairs, planning committeemembers, presenters, authors,moderators, panelmembers, and others in a position to control thecontentofthisactivityarerequiredtodiscloserelevantfinancialrelationshipswithcommercialinterestsrelated to thesubjectmatterof thiseducationalactivity.Learnersareable toassess thepotential forcommercial bias in information when complete disclosure, resolution of conflicts of interest, andacknowledgmentof commercial supportareprovidedprior to theactivity. Informed learnersare thefinalsafeguardsinassuringthataCMEactivityisindependentfromcommercialsupport.WebelievethismechanismcontributestothetransparencyandaccountabilityofCME.

  • TableofContentsCourseDescription........................................................................................................................................1Disclosure......................................................................................................................................................3EssentialPelvicAnatomyforAdvancedLaparoscopicSurgeryA.I.Brill.........................................................................................................................................................5DifficultPeritonealAccess:OvercomingAdhesionsandObesityJ.K.Robinson..............................................................................................................................................13SurgicalTechniquesforSuperficialandDeepEndometriosisA.I.Brill........................................................................................................................................................18OvarianCystectomy:PreservationofFertilityS.N.Morris.................................................................................................................................................23TheLargeUterus:TipsforSuccessfulLaparoscopicHysterectomyS.N.Morris.................................................................................................................................................27SimplifyingLaparoscopicMyomectomyS.N.Morris.................................................................................................................................................32StrategiesforSafeandEfficientTissueRemovalA.I.Brill.......................................................................................................................................................37CuffManagement:IssuesofSupportandControversiesoftheCervixJ.K.Robinson..............................................................................................................................................45CulturalandLinguisticsCompetency.........................................................................................................49

  • PG 109 Laparoscopic Tips and Tricks: Advancing Your Skills (Didactic)

    Stephanie N. Morris, Chair

    Faculty: Andrew I. Brill, James K. Robinson

    Course Description This course will help gynecologic surgeons advance their skills by providing strategies to overcome

    common clinical challenges and expand their surgical armamentarium. This will be accomplished through an in-depth review of key laparoscopic pelvic anatomy and tips to help navigate challenging clinical situations, such as obesity and difficult peritoneal access. Techniques for mastering challenging surgical

    procedures encountered in general practice, such as hysterectomy for the large uterus, support of the

    vaginal/cervical cuff at the time of hysterectomy, myomectomy, large ovarian cystectomy, tissue extraction, and the surgical management of endometriosis will be explored in detail. Experienced

    surgeons will utilize videos, evidence-based medicine and clinical expertise to provide participants with relevant knowledge, practical solutions, and step-by-step strategies which can be incorporated into

    current practice in order to safely and successfully complete more advanced surgery. The course is

    aimed at surgeons with some laparoscopic experience who are looking to advance their skills.

    Course Objectives At the conclusion of this course, the participant will be able to: 1) Locate the essential anatomy of the

    deep pelvic side wall; 2) apply strategies for difficult peritoneal access; 3) explain safe techniques for

    tissue extraction; 4) demonstrate steps used to simplify laparoscopic myomectomy; 5) implement approach to hysterectomy with a large uterus; and 6) apply techniques to support the vaginal cuff after

    hysterectomy in appropriate cases.

    Course Outline 8:00 Welcome, Introductions and Course Overview S.N. Morris

    8:05 Essential Pelvic Anatomy for Advanced Laparoscopic Surgery A.I. Brill

    8:30 Difficult Peritoneal Access: Overcoming Adhesions and Obesity J.K. Robinson

    8:55 Surgical Techniques for Superficial and Deep Endometriosis A.I. Brill

    9:20 Ovarian Cystectomy: Preservation of Fertility S.N. Morris

    9:45 Questions & Answers All Faculty

    9:55 Break

    10:10 The Large Uterus: Tips for Successful Laparoscopic Hysterectomy S.N. Morris


  • 10:35 Simplifying Laparoscopic Myomectomy S.N. Morris

    11:00 Strategies for Safe and Efficient Tissue Removal A.I. Brill

    11:25 Cuff Management: Issues of Support and Controversies of the Cervix J.K. Robinson

    11:50 Questions & Answers All Faculty

    12:00 Course Evaluation


  • PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Viviane F. Connor Consultant: Conceptus Incorporated Frank D. Loffer, Executive Vice President/Medical Director, AAGL* Linda Michels, Executive Director, AAGL* Jonathan Solnik Other: Lecturer - Olympus, Lecturer - Karl Storz Endoscopy-America SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: CooperSurgical, Ethicon Women's Health & Urology, Intuitve Surgical Other: Royalties - CooperSurgical Linda Bradley Grants/Research Support: Elsevier Consultant: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharmaceuticals Speaker's Bureau: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharm Keith Isaacson Consultant: Karl Storz Endoscopy Rosanne M. Kho Other: Honorarium - Ethicon Endo-Surgery C.Y. Liu* Javier Magrina* Ceana H. Nezhat Consultant: Intuitve Surgical, Lumenis, Karl Storz Endoscopy-America Speaker's Bureau: Conceptus Incorporated, Ethicon Women's Health & Urology William H. Parker Grants/Research Support: Ethicon Women's Health & Urology Consultant: Ethicon Women's Health & Urology Craig J. Sobolewski Consultant: Covidien, CareFusion, TransEnterix Stock Shareholder: TransEnterix Speaker's Bureau: Covidien, Abbott Laboratories Other: Proctor - Intuitve Surgical FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the best available evidence from medical literature (in alphabetical order by last name). Stephanie N. Morris* Andrew I. Brill Consultant: Karl Storz Endoscopy-America, Ethicon Endo-Surgery, Conceptus Incorporated, CooperSurgical Speaker's Bureau: Karl Storz Endoscopy-America, Ethicon Endo-Surgery, Conceptus Incorporated, CooperSurgical


  • James K. Robinson Consultant: Gyrus ACMI (Olympus), Intuitve Surgical Jubilee Brown* Asterisk (*) denotes no financial relationships to disclose.


  • Essential Retroperitoneal and Topographic Essential Retroperitoneal and Topographic AnatomyAnatomy For The Laparoscopic SurgeonFor The Laparoscopic Surgeon

    Andrew I. Brill, MDAndrew I. Brill, MDDirector, Minimally Invasive Gynecology & Reparative SurgeryDirector, Minimally Invasive Gynecology & Reparative Surgery

    California Pacific Medical CenterCalifornia Pacific Medical CenterSan Francisco, CASan Francisco, CA

    DisclosuresDisclosures ::

    Consultant: Karl Storz EndoscopyConsultant: Karl Storz Endoscopy--America, Ethicon EndoAmerica, Ethicon Endo--Surgery, Surgery, Conceptus Incorporated, CooperSurgicalConceptus Incorporated, CooperSurgicalConceptus Incorporated, CooperSurgicalConceptus Incorporated, CooperSurgical

    Speaker's Bureau: Karl Storz EndoscopySpeaker's Bureau: Karl Storz Endoscopy--America, Ethicon EndoAmerica, Ethicon Endo--Surgery, Surgery, Conceptus Incorporated, CooperSurgicalConceptus Incorporated, CooperSurgical

    Learning Objectives: Able to describe.Learning Objectives: Able to describe...::

    Describe topographical Describe topographical pelvic anatomypelvic anatomy

    Review the keyReview the key vascular anatomy of abdominal wallvascular anatomy of abdominal wallReview the key Review the key vascular anatomy of abdominal wall vascular anatomy of abdominal wall

    Identify the link Identify the link between anatomy and techniquebetween anatomy and technique

    Discuss the anatomical Discuss the anatomical components of pelvic sidewallcomponents of pelvic sidewall

    Why Master Surgical Anatomy?Why Master Surgical Anatomy?

    More Efficient More Efficient FasterFaster

    Can Minimize Complications!Can Minimize Complications!

    More Effective More Effective Better ResultsBetter Results

    More Confident More Confident SaferSafer

    a significant amount of medical a significant amount of medical ill b itt d!ill b itt d!errors will be committed!errors will be committed!

    No procedure should ever be No procedure should ever be considered a total failureconsidered a total failure

    It can always be It can always be It can always be It can always be used as a bad example!used as a bad example!


  • Present surgical education systems are deficient Present surgical education systems are deficient

    in evaluating performance and competencyin evaluating performance and competencyg p p yg p p yAnatomyAnatomy DissectionDissection

    Indication: Indication: endometriosisendometriosis

    Good Technique Good Technique WithoutWithoutAnatomyAnatomy Good Technique Good Technique WithoutWithout AnatomyAnatomy

    Always think of whats under the surfaceAlways think of whats under the surface

    urachusurachusOblit Oblit umb a.umb a.

    Oblit Oblit umb a.umb a.


  • umbilicusumbilicus

    Major Vessels of Abdominal WallMajor Vessels of Abdominal Wall

    Superficial Epigastric VesselsSuperficial Epigastric Vessels Superficial Epigastric VesselsSuperficial Epigastric Vessels

    Inferior Epigastric VesselsInferior Epigastric Vessels Inferior Epigastric VesselsInferior Epigastric Vessels-- anatomic origins anatomic origins --


  • Identifying the Inferior Epigastric VesselsIdentifying the Inferior Epigastric Vessels

    11 22 33



    Peritoneal Tenting

    Left Upper QuadrantLeft Upper Quadrant

    LUQ = 3






  • Superior epigastric vessels (se)


    se se

    rectus sheathrectus sheathMCLMCL


    Relinquishing the Big PictureRelinquishing the Big Picture

    Where am I?Where am I?

    3 Us: ureter 3 Us: ureter uterosacral uterosacral uterine auterine a


  • Out of sight never out of mindOut of sight never out of mind Dissecting the Lateral SidewallDissecting the Lateral Sidewall

    AnatomyAnatomy DissectionDissection


  • Medial Umbilical LigamentMedial Umbilical Ligament

    Pelvic Sidewall Pelvic Sidewall 3 Surgical Layers3 Surgical Layers


    I l ili lI l ili lavascular

    Internal iliac vessels Internal iliac vessels Cardinal ligament sheathCardinal ligament sheath

    External iliac vessels External iliac vessels Obturator vessels and muscle Obturator vessels and muscle


    Pelvic Sidewall Pelvic Sidewall 3 Surgical Layers3 Surgical LayersPelvic Sidewall DissectionPelvic Sidewall Dissection


  • ThinkThink


    Anatomical surgery demands Anatomical surgery demands awarenessawareness..


  • DifficultPeritonealAccess:OvercomingAdhesionsand



    Consultant:Gyrus ACMI(Olympus),IntuitveSurgical

    Attheconclusionofthissessiontheparticipantwillbeableto: Identifytherisksinherentinprimaryperitonealaccess. Identifydifferentapproachestoprimaryperitonealaccess. Identifypatientsatthehighestriskofperitonealaccess

    li icomplications. Identifyprincipalsandtechniquestominimizerisksassociatedwithhighriskperitonealaccess.




    PrimaryAccess ComplicationsData(2slides)

    Video(BowelInjury,VascularInjury) Approachesandassociatedcomplications(3slides)

    Veress,Open,Direct UmbilicalApproach

    Video(accessvideo,compressionvideo) Highriskpatients

    Images Alternativeaccess PalmersPointApproach

    Videos(Lapviewofgastricdilationanddecompression,needleplacementandpressures) Microlaparoscopy PreliminaryUltrasoundevaluation

    SecondaryAccessandAdhesions ComplicationsData

    Videos(BladderInjury,adhesiolysis) Location

    Closure Video(CarterThomason)


    SurgicalTrocarsassociatedwithsurgicalcomplicationsmorethananyotherlaparoscopicdevice Trocars33%,Clips9%,Veress8%,Coagulationdevice5%,

    Scissors/scalpel 3%Scissors/scalpel3%

    >25%ofallsurgicalmalpracticeclaimssitetrocarinsertion asthemaincauseifinjury

    FatalTrocarinjuries Vascular>Bowel

    Maude Data Base. JMIG. 2005;12:302


    Omentaland/orBowel Priorsurgicalscar

    Pfannensteil 27% LowVertical 55%


    Obstetrical 22% Nodifferenceb/w

    pfannensteil vs midline HighVertical 67%

    Whenadhesionsexist Omentalonly 84% OmentalandBowel 16%


    Gynecologic 42% Pfannensteil 31% Midline 70%

    Brill. Obstet Gynecol. 1995;85:299.


  • EntryInjuryVideos VascularInjury

    BowelInjuryj y

    Modified10StepVeressApproach1. Consideralternateapproachinhighriskpatients(openorPalmers)2. Safetycheck patientflat,veressfunctional,noperiumbilicalmasses

    foleyplaced3. Incision 510mmintraumbilicalincision(everttheumbilicus)4. Insertionofveress 90degrees,elevateumbilicalsheath5. Donotmovetheveressneedle toavoidenlarginganinjury6. Pressurecheck

  • HighRiskPatients

    RiskFactors PriorMidlineLaparotomy MorbidObesity VeryThin


    y Pregnancy LargePelvicorabdominal


    PalmersPoint FirstdescribedbyRaoulPalmerin1974. Idealfor:

    Pelvicmass Predictableadhesions Pregnancy Failedumbilicalattempt

    Relativecontraindications: Hepatosplenomegaly Priorgastricbypassorsplenectomy LUQmass

    Palmer R. J Reprod Med. 1974;13:1-5.Granata M. Fertil Steril. 2010;94:2716.


    ClosedVeresstechnique 25mmincision3cmbelowtheleftcostalmargininthemidclavicularline

    Gastricsuctioning ConsiderTrendelenburg

    Tulikangas. Fertil Steril. 2003;79:411-2.





    MicrolaparoscopyatPalmersPoint Microlaparoscopicveress/trocarisinsertedviaPalmerspoint

    1.2mmlaparoscopeisi t d d th h thintroducedthroughtheveress/trocarinordertoinspectforperiumbilicaladhesions.


    814consecutivepatientsdividedinto4categories Group1(469) Noprior

    abdominal surgery

    MicrolaparoscopyatPalmerspointwithumbilicaladhesionanalysis 9.82%overall

    abdominalsurgery Group2(125) Prior

    laparoscopicsurgery Group3(131) Priorsuprapubic

    laparotomy Group4(89) Priormidline


    adhesionrate Omental Bowel

    Group1 0.68% 0.42% Group2 1.6% 0.80% Group3 19.8% 6.87% Group4 51.7% 31.46%

    Audebert A. Fert Steril. 2000;73:631.


  • VisceralSlideandPUGSI

    VisceralSlide Thelongitudinaldistance

    theintestineoromentumtravelsasvisualizedbyt bd i l US d i

    PUGSI Periumbilicalultrasound

    guidedsalineinfusion Tendabdomanwithtowel

    ltransabdominalUSduringanexaggeratedinspirationandexpirationcycle Exaggerated=1.5xnormal

    tidalvolume Normalis=or>1cm


    clamps Observe19ganeedleenter

    peritoneum Inject10mlssterilesaline Localizedfluidpocketis




    Nezhat C. Fertil Steril. 2009;91:2714.


    DIRECTVISUALIZATION toavoid:Vascular InferiorEpigastrics(Video)BowelBladder (Video)Bladder (Video)



    Adhesiolysis Createplanes Createwindows Applytraction Donottear Usecoldscissorsclosetoviscera Stayintraperitoneal Takeyourtime!!! Runthebowel

    PortSiteClosure PortSiteHerniaIncidence 0.652.8%inGeneralSurgeryLiterature

    Allports>or=10mmrequirefascialclosure 5 and 8 mm ports sites should be closed if5and8mmportssitesshouldbeclosedifextensivemanipulationcouldhaveexpandedthefascialdefect

    Tonouchi H. Arch Surg. 2004;139:1248.

    Carter Thomason Video


  • TonouchiH.ArchSurg.2004;139:1248. MaudeDatabase.JMIG.2005;12:302. Brill.ObstetGynecol.1995;85:299. HassonHM.ObstetGynecol.2000;96:763. TinelliA.SurgInnov.2011;18:201. LiuHF.ChinMedJ(Engl).2009;122:2733. AhmadG.CochraneDatabase.2008;16(2). PalmerR.JReprodMed.1974;13:15. GranataM.FertilSteril.2010;94:2716. Tulikangas.FertilSteril.2003;79:4112. AudebertA.FertSteril.2000;73:631. Varma.SurgEndosc.2008;22:2686. NezhatC.FertilSteril.2009;91:2714. TonouchiH.ArchSurg.2004;139:1248.


  • EndometriosisEndometriosisTechniques for Superficial & Deep Endometriosis Techniques for Superficial & Deep Endometriosis

    ????Andrew I. Brill, M.D.

    Director, Minimally Invasive GynecologyCalifornia Pacific Medical Center


    Consultant: Karl Storz EndoscopyConsultant: Karl Storz Endoscopy--America, America, Ethicon EndoEthicon Endo--Surgery, Conceptus Incorporated, Surgery, Conceptus Incorporated, CooperSurgicalCooperSurgicalCooperSurgicalCooperSurgical

    Speaker's Bureau: Karl Storz EndoscopySpeaker's Bureau: Karl Storz Endoscopy--America, Ethicon EndoAmerica, Ethicon Endo--Surgery, Conceptus Surgery, Conceptus Incorporated, Incorporated, CooperSurgicalCooperSurgical

    Learning ObjectivesLearning Objectives

    Describe the laparoscopic appearance of Describe the laparoscopic appearance of endometriosisendometriosis

    Explain the relationship between Explain the relationship between endometriosis and pelvic painendometriosis and pelvic pain

    List the potential limits of medical and List the potential limits of medical and surgical therapy for endometriosissurgical therapy for endometriosis

    Incorporate strategy for anatomical Incorporate strategy for anatomical removal of pelvic endometriosisremoval of pelvic endometriosis


    General ConsiderationsGeneral Considerations


    Progressive diseaseProgressive disease

    May exist in subclinical, microscopic forms that are not May exist in subclinical, microscopic forms that are not

    visible at time of laparoscopic evaluationvisible at time of laparoscopic evaluation

    Patients with higher stages more likely to experience Patients with higher stages more likely to experience

    recurrences and to have them earlier than women with recurrences and to have them earlier than women with

    lower stageslower stages

    Women with deeply infiltrative disease more likely to Women with deeply infiltrative disease more likely to

    experience painexperience pain

    EndometriosisEndometriosisA myriad of appearancesA myriad of appearances


  • EndometriosisEndometriosisProgenitors of PainProgenitors of Pain

    Location of lesion related to visceraLocation of lesion related to viscera

    Type of lesionType of lesion

    T t l b f l iT t l b f l i Total number of lesionsTotal number of lesions

    Depth of penetration of lesionDepth of penetration of lesion


    Stretching/scarring of tissueStretching/scarring of tissue

    ? Chemical expressions? Chemical expressions

    Deep culDeep cul--dede--sac and paravaginal endometriosissac and paravaginal endometriosiscorrrelate corrrelate

    with with

    focal points of tendernessfocal points of tendernessfocal points of tendernessfocal points of tenderness

    Ripps & Martin J Reprod Med 1992Ripps & Martin J Reprod Med 1992

    digital rectal examdigital rectal examisis

    sine qua non! sine qua non!

    Relevance of rRelevance of r--AFS ClassificationAFS ClassificationVercellini et al F&S 1996Vercellini et al F&S 1996

    Not correlated with frequency of pain symptomsNot correlated with frequency of pain symptoms

    Not correlated with severity of pain symptomsNot correlated with severity of pain symptoms

    Why? Why? -- does not take into accountdoes not take into account

    Cellular activityCellular activity

    Depth of infiltrationDepth of infiltration

    Individual lesionsIndividual lesions

    EndometriosisEndometriosisSupport of Surgical TreatmentSupport of Surgical Treatment

    Primal arguments favoring seePrimal arguments favoring see--andand--treattreat

    Decreased treatment timeDecreased treatment time

    D d tD d t Decreased costDecreased cost

    Decreased number of side effectsDecreased number of side effects

    No need for second operative laparoscopyNo need for second operative laparoscopy

    Appeals to will of surgical egoAppeals to will of surgical ego

    EndometriosisEndometriosisSurgical Treatments Pro v ConSurgical Treatments Pro v Con

    Sharp excisionSharp excision Dissection of implants from normal tissueDissection of implants from normal tissue ProPro-- tissue specimentissue specimen ConCon-- injury to adjacent structures and bleedinginjury to adjacent structures and bleeding Requires certain level of expertiseRequires certain level of expertise

    ElectrocoagulationElectrocoagulationElectrocoagulationElectrocoagulation Destruction of implants by thermal energyDestruction of implants by thermal energy ProPro-- familiar technology and hemostasisfamiliar technology and hemostasis ConCon-- injury to structures , lack of specimen, and injury to structures , lack of specimen, and

    possibility of incomplete destruction of implantpossibility of incomplete destruction of implant Laser vaporizationLaser vaporization

    Sharp dissection or vaporization with high density energySharp dissection or vaporization with high density energy ProPro-- ease of use and hemostasisease of use and hemostasis ConCon-- lack of specimen, risk of incomplete destruction, lack of specimen, risk of incomplete destruction,

    injury to adjacent structure, expense of upkeep of laserinjury to adjacent structure, expense of upkeep of laser

    EndometriosisEndometriosisCan Surgery be Curative?Can Surgery be Curative?

    Make a diagnosisMake a diagnosis

    / d/ d llll didi Remove / destroy Remove / destroy allall disease?disease?

    Prevent recurrence?Prevent recurrence?

    Identify a lesion?Identify a lesion?


  • Endometriosis: Microscopic DiseaseEndometriosis: Microscopic Disease

    AuthorAuthor ResultsResults MethodologyMethodology

    Murphy, 1986Murphy, 1986 25%25% SEMSEM

    Vasquez 1984Vasquez 1984 75%75% LM & SEMLM & SEMVasquez, 1984Vasquez, 1984 75%75% LM & SEMLM & SEM

    Nicole, 1990Nicole, 1990 13% 13% (WITH ENDO)(WITH ENDO) LMLM6%6% (WITH INFERT)(WITH INFERT) LMLM

    Redwine, 1989Redwine, 1989 2%2% LMLM


    Portuondo, 1982Portuondo, 1982 65% 65% (PELVIC WASHINGS)(PELVIC WASHINGS) CYTOLOGYCYTOLOGY

    EndometriosisEndometriosisRecurrent NightmaresRecurrent Nightmares

    Patient MD

    Endometriosis: Excision of Deep LesionsEndometriosis: Excision of Deep LesionsKoninckx, F&S 1996Koninckx, F&S 1996

    N = 225N = 225

    complete excision 90%complete excision 90%

    Mean depth of penetration = 10mm Mean depth of penetration = 10mm (6(6--20mm)20mm)Mean depth of penetration 10mm Mean depth of penetration 10mm (6(6 20mm)20mm)


    Perforation into posterior vaginal fornix 14%Perforation into posterior vaginal fornix 14%

    Enterotomy & bowel resection 6%Enterotomy & bowel resection 6%

    Late bowel perforation/peritonitis 3%Late bowel perforation/peritonitis 3%

    Surgery for EndometriosisSurgery for EndometriosisNet ResultsNet Results

    Majority experience pain reliefMajority experience pain relief

    Recurrence rates are significantRecurrence rates are significant

    Stage I more apt to relapseStage I more apt to relapse

    Pregnancy rates are variablePregnancy rates are variable

    Treating Endometriosis with SurgeryTreating Endometriosis with SurgeryObservationsObservations

    Conservative surgery results in varied success ratesConservative surgery results in varied success rates

    All ablative techniques (laser, thermal, monopolar, All ablative techniques (laser, thermal, monopolar, and bipolar) are equivalentand bipolar) are equivalent

    Resection has been regarded as superior; however Resection has been regarded as superior; however Resection has been regarded as superior; however, Resection has been regarded as superior; however, complete resection may not be possible secondary complete resection may not be possible secondary to microscopic disease and increased risk of to microscopic disease and increased risk of complicationscomplications

    Surgical complications are prevalent and underSurgical complications are prevalent and under--reportedreported

    Results are, and will always be surgeon dependentResults are, and will always be surgeon dependent

    Putative Reasons for Surgical FailuresPutative Reasons for Surgical Failures

    Microscopic lesions not destroyedMicroscopic lesions not destroyed

    Atypical appearing lesions missed by surgeonAtypical appearing lesions missed by surgeon

    Inaccessible lesions (deep & behind structures)Inaccessible lesions (deep & behind structures)

    Incomplete ablation or resectionIncomplete ablation or resection

    Other causes of pain besides endometriosisOther causes of pain besides endometriosis

    Any combination of the aboveAny combination of the above


  • Endometriosis: Surgical PrinciplesEndometriosis: Surgical Principles

    Identify bladder, bowel, vessels, and ureterIdentify bladder, bowel, vessels, and ureter

    Restore anatomical relationshipsRestore anatomical relationships

    Treat endometrioma as last surgical stepTreat endometrioma as last surgical stepg pg p

    Mobilize / identify the ureter (ureterolysis)Mobilize / identify the ureter (ureterolysis)

    Mobilize / identify the rectum (probe/ ring)Mobilize / identify the rectum (probe/ ring)

    Preferentially use mechanical dissectionPreferentially use mechanical dissection

    Judiciously employ energyJudiciously employ energy--based devicesbased devices

    Retroperitoneal DissectionRetroperitoneal Dissection

    Peritoneal ResectionPeritoneal Resection PeriPeri--ureteral Dissectionureteral Dissection

    know your instrumentationknow your instrumentation Uterosacral ResectionUterosacral Resection


  • PeriPeri--rectal Excisionrectal ExcisionRectovaginal DissectionRectovaginal Dissection

    Observations Observations Surgical treatmentsSurgical treatments

    Efficacious for reduction or elimination Efficacious for reduction or elimination in symptomsin symptoms

    Rates of recurrence are quite similar to Rates of recurrence are quite similar to medical therapymedical therapy

    Insufficient data to recommend best Insufficient data to recommend best approach (e.g., coagulation approach (e.g., coagulation vsvsresection)resection)


  • OvarianCystectomy:Preservationoffertilityy







    Demonstratetechniqueforlaparoscopicovarian cystectomy with the goal of fertilityovariancystectomywiththegoaloffertilitypreservation

    WhototaketotheOR L/svs exlap

    Compl Cystrupture

    Dermoid MalignancyMalignancy

    Surgicaltechnique Folliclesinthecortex

    Endometrioma andfertility Affectfertility? Surgeryaffectfertility Removalvs coagulation

    Fertilityaftercystectomyvs oophrectomy Sizelimits drainage

    Preoperativeevaluation Imaging:Ultrasound Serummarkers Referraltogyn oncology(ACOG)

    Premenopausal(youngerthan50years) CA125levelsgreaterthan200units/mL Ascites Evidenceofabdominalordistantmetastasis Familyhistoryofbreastorovariancancer(inafirstdegreerelative)

    ACOG PB 83


    Laparoscopicsurgeryforbenignovariantumorswasassociatedwith Feweradverseoutcomes

    (intraop complications,postopfever/infections) Lesspostoppain Fewerdaysinthehospital



  • Surgicaltechnique

    Incision Removalofcystwall Preservationofovariantissue +/ Closureofovariancortex Adhesionprevention


    Laparoscopyvs.laparotomy ClinicalSignificance

    Peritonitiswithdermoidcysts Malignancy


    +/ Increasedriskofspillwithlaparoscopy Ratesvaryfrom15100% Reviewof14studiesw/470l/sdermoidcytectomies

    310caseswithspill(66%) Riskofperitonitis0.2%

    Cystsizenotrelatedtoriskofspill Trendtowardsincreasedspillwithincreasedsize

    LaparoscopydoesnotincreaseriskofperitonitisZanetta G. J Reprod Med, 1999Shawki O. Gynecol Surg, 2007Kondo W. BJOG, 2010Benezra V. Gynecol Surg, 2005


    Containspillage Withinbag WithinculdesacC i i i ti Copiousirrigation


    Earlyovariancancerprognosis Stage1A Stage1Cspontaneous Stage1Ciatrogenic

    Some studies suggest prognosis of 1C same with Somestudiessuggestprognosisof1Csamewithiatrogenicorspontaneousrupture

    Otherssuggestotherfactors tumorgrade,ascites,denseadhesions wereassocwithpooroutcomes

    ACOG PB # 83Mizuno M. Oncology, 2003Sainz de la Cuesta R. Obstet Gynecol, 1994Dembo A. Obstet Gynecol, 1990


    Intraovariansutureforhemostasiscauseslesspostopadhesionsthanbipolar PellicanoM.FertilSteril,2008

    Bipolar electrocoagulation adversely affectsBipolarelectrocoagulationadverselyaffectsovarianfunction,comparedwithsuture FedeleL.JAAGL,2004


  • ToCloseorNottoClose



    Endometrioma Nonendometriotic cysts Effectofsurgicaltechnique

    Endometriomaandfertility Effectofendometriomaonfertility

    IVFpatientswithpoorerresponse Treatmentofcystsdoesnotnecessarilyimprove responseimproveresponse Noconsensus ESHRErecommendsremovalofendometrioma>4cmtoconfirmdiagnosis,improveaccesstofolliclesandtopossiblyimproveovarianresponse

    Concernsre:effectofcystectomyonfertilitySomigliana E. Fert Steril 2006Tsoumpu I. Fertil Steril 2009. Kennedy S. Hum Reprod 2005

    Endometriomasandfertility Morefolliclesareremovedwithcystectomyforendometriomathanotherbenign

    ovariancysts ShiJ.IntJGynOb.2011 YES DoganE.IntJGynOb.2001 NO

    DecreasedserumAMHafterresectionofendometrioma LeeD.GynaecolEndo,2011.

    AMHdecreasedmorewithendometriomavs.nonendometriomacystsandmorewith bilateral cysts than unilateralwithbilateralcyststhanunilateral

    ChangH.FertilSteril,2010 Endometriomaandpriorovariancystectomyforendometriomabothdecreased

    serumAMH HwuY.ReprodBioEndo,2011


    HwuY.ReprodBioEndo,2011 ?Morequantitativeratherthanqualitativedamage



    Drainage notrecommended Recurrencerateofupto88%at6mo NoPathologyF t ti d bl ti Fenestrationandablation



    Excisionwasassociatedwith Reducedrateofrecurrence ReducedneedforfurthersurgeryReduced rate of symptoms Reducedrateofsymptoms

    dysmenorrhea,dyspareuniaandnonmenstrualpain Increasedrateofspontaneouspregnancy

    Excisional surgery vs ablative surgery for ovarian endometrioma. Cochrane Database Syst Rev 2005


  • Ablationvs.excision

    Markersofovarianfunctiondecreasedafterbothcystectomyandcoagulationofendometrioma,butmoreaftercystectomy Antralfolliclecountdecreasedafterbothcystectomyy yandcoagulation,butmoreaftercystectomy


    RCTofwomenwithbilateralendometriomas onesidecystectomyanonesidecoagulation

    Var T. Fertil Steril, 2011



    Sagiv R. Obstet Gynecol 2005

    References ACOGPracticeBulletin83.Managementofadenexalmasses,2007 SagivR.Laprpscopicmanagementofextremelylargeovariancysts,ObstetGynecol2005 BenezrV.Comparisonoflaparoscopyvslaparotomyforthesurgicaltreatmentofovariandermoidcysts.

    GynecolSurg,2005. ChangH.Impactoflaparoscopiccystectomyonovarianreserve:serialchangesofserumAMHlevels.Fertil

    Steril,2010 DemboA.PrognosticfactorsinpatientswithstageIepithelialovariancancer.ObstetGynecol1990 DoganE.retrospectiveanalysisoffolliclelossadrerlaproscopicexcisionofendometriomacomparedwith

    benignnonendometrioticovariancysts.IntJGynOb.2001 ExacoustosC.Laparoscopicremovalofendometriomas:sonographicevaultionofresidualfunctioning

    ovariantissue.AmJObGyn2004 FedeleL.Bipolarelextrocoagulationvssutureofsolitaryovaryafterlaparoscopicexcisionofovarian

    endometrioma.JAAGL,2004. HartR.Excisionalsurgeryvsablativesurgeryforovarianendometrioma.CochraneDatabaseSystRev2005 HwuY.TheimpactofendometriomaandlaparoscopiccystectomyonserumAMHlevels.ReprodBioEndo,


    KennedyS.ESHREguidelineforthediagnosisandtreatmentofendometriosis.HumReprod 2005 KondoW.Doespreventionofintraperitneal spillagewhenremovingadermoid cystorvent granulomatous

    peritonitis?BJOG,2010. Laparoscopyvs.Laparotomyforbenignovariantumors.CochraneDatabaseofSystematicReviews.11,2010 LeeD.EffectsoflaparoscopicsurgeryonserumAMHlevelsinreproductiveagedwomenwithendometrioma.

    Gynaecol Endo,2011. MizunoM.LongtermprognosisofstageIovariancarcinoma.Prognosticimportanceofintraoperativerupture.

    Oncology2003 PellicanoM.Ovarianendometrioma:postoperativeadhesionsfollowingbipolarcoagulationandsuture.Fertil

    Steril,2008 Ragni G.Damagetoovarianreserveassociatedwithlaparoscopicexcision:aquantitativeratherthana

    qualitativeinjury.AmJObGyn 2005 Sainz delaCuestaR.Prognosticimportanceofintraop erative ruptureofmalignantovarianepithelial

    neoplasms Obstet Gynecol 1994neoplasms.Obstet Gynecol 1994. Shawki O.LaparosocpicManagementofovariandermoid cyst:potentialfearofdermoid spill,mythandfacts.

    Gynecol Surg,2007 ShiJ.Folliclelossafterlaparoscopictreatmentofovarianendometriotic cysts.Int JGyn Ob,2011 Somigliana E.Thepresenceofovarianendometriomas isassociatedwithareducedresponsivenessto

    gonadotropins.Fert Steril 2006 Tsoumpu I.Theeffectofsurgicaltreatmentforendometrioma onIVFoutcomes:asystemicreviewandmeta

    analyisis.Fertil Steril 2009. Var T.Theeffectoflaparoscopicovariancystectomyvs.coagulationinbilateralendometriomas onovarian

    reserveasdeterminedbyantral follcle countandovarianvolume:aprospectiverandomizedstudy.Fertil Steril,2011

    Zanetta G.Laparoscopicexcisionofovariandermoid cystswithcontrolledintraoperativespillage.JReprodMed,1999.


  • TheLargeUterus:TipsforLaparoscopicHysterectomy




    Demonstrate step-wise approach to hysterectomy of the large fibroid uterus 5 Key Pre- & Peri-operative considerations

    5 Key Steps to performing laparoscopic 5 Key Steps to performing laparoscopic hysterectomy

    1.Preoperativeconsiderations Patient selection

    Set yourself up for success Prior surgery BMI

    Pre-operative lupron Improves pre and post operative Hgb/Hct Decreases uterine volume Decreases procedure related blood loss

    2. Patient positioning

    Arms tucked at sides Gel pad/foam Dorsal lithotomy

    Barnett et al., JMIG 2007;14(5):664-672

    3. Uterine manipulator Total vs supracervical Can be of limited use with very

    large uterus initially Take the time to place properly

    Use as a landmark part of the anatomy


    Bladder Bladder

    UterusUterosacral Ligaments



  • Using the Rumi-Koh 4. Port placement

    Camera port position Lateral port position

    Location of adenxa

    Trocar Placement

    5. 30 degree laparoscope

    Improves visualization Bladder flap Lateral view During transection of uterus During transection of uterus

    from vagina or cervix

    Use of a 30 degree scope

    Use of the 30 degree scope Hysterectomy Key Steps

    6. Round ligament and bladder flap 7. Adenxa - release lateral attachments 8. Post leaf and uterine vessels 9 Vaginal cuff: transection and closure 9. Vaginal cuff: transection and closure 10. Specimen removal


  • 6.Roundligamentandbladderflap Round ligament:

    Open up round ligament Stay lateral Go through whole round ligament

    Anterior Leaf/Bladder Flap


    VIDEO ANTERIOR LEAF Anterior Leaf/Bladder Flap

    30 degree scope Use cervical cup to help identify

    midline Identify cervix to help restore normal

    anatomy Push manipulator cephalad put

    bladder on stretch




    6.Roundligamentandbladderflap 7. The adnexa

    Stay close to ovary BSO or no BSO

    Avoid ascending branch of the uterine vessels


    Back bleeding can be hard to control

    7. The adnexa 8.PosteriorleafandUterineVessels

    Release ureter laterally

    Allow skelotonization of uterine vessels


    VIDEO POST LEAF Peel fibroid out of




  • 8.PosteriorleafandUterineVessels Distancing Your Ureters

    Pushing the uterus cephalad increases the distance between the colpotomy site, uterine vessels and ureters.

    Uterine Manipulators:Uterine Manipulators:Importance of colpotomy cupImportance of colpotomy cup Uterine vessels

    Skelotonize uterine vessels Dessicate only the vessles Avoid ureters Koh cup above level of

    cup and dissect down


    PICTURELOCATIONOF Push manipuler cephalad to

    displace bladder and uterters

    Secure both sides before transection of the vessels


    Uterine vessels for TLH Now with a lateral fibroid


  • 9a.TheVaginalCuff:transection 9b. The vaginal cuff: closure

    9c: LSH: cervical stump 10. Specimen removal

    LSH Morcellation

    TLH Vaginal removalg Vaginal morcellation

    In bag Not in bag

    Laparoscopic morcellation

    Obstacles: bladder adhesions

    Back fill bladder VIDEO BLADDER ADHESIONS



    References Gutmann J et al. GnRH agonist therapy before myomectomy or

    hysterectomy. JMIG 2005; 12: 529-537. Lethaby A. Pre-operative GnRH analogue therapy before

    hysterectomy or myomectomy for uterine fibroids. Cochran Database System Rev, 2001. Updated 2011


  • SimplifyingLaparoscopicMyomectomy




    Demonstratestepstosimplifylaparoscopicmyomectomy PreoperativeplanningWays to reduce intra operative blood loss Waystoreduceintraoperativebloodloss

    Surgicaltechniques Tipsforremovingdifferenttypesoffibroids


    Numberoffibroids Sizeoffibroids



    Numberoffibroids Sizeoffibroids

    Howbigistoobig? Location

    PreOperativeImaging Ultrasound




  • PreOperativeImaging MRI



    Improvespre andpostophgb/hct Decreasesuterinevolumeandfibroidsize


    Decreasesprocedurerelatedbloodloss Doesnotchangeneedforbloodtransfusion

    +/ DecreaseinORtime Studiesvary SeveralindividualRCTstudiesshowlessORtime Metaanalysis,nodifferenceinORtime(Cochrane)

    ?AffectsurgicalplanesCochrane Review 2011; Lethaby A. 2002; Zullo F 1998; Gutmann, 2005;


    Portplacement Higherlateralports HighermidlineportsLUQ

    Trocar Placement

    LUQport 5mmand10mm


    Right LateralLeft Lateral

    Midline Suprapubic5 mm

    g5/12 mm5/12 mm

    Umbilical5 mm



    EnergySourceBipolarMonopolarUltrasonicEnergy Laser

    IntheOR Myomamanipulators

    Morcellator Efficiency


  • IntraoperativeHemostasis: Vasopressin

    bloodlossneedfortransfusion Cochranereview:300cclessEBL300cclessEBL



    Kongnyuy E. Cochrane Review, 2007 (2011); Zhao F 2011; Fletcher H. 1996;

    IntraoperativeHemostasis Vasopressin Laparoscopictourniquet Directionofincision Pedicle ofthefibroidU f h l Useofthermalenergyvs.suture

    Walocha JA Hum Reprod 2003


    PreopLupron Vasopressin Laparoscopictourniquet Direction of incision Directionofincision Pedicle ofthefibroid Useofthermalenergy


    Dilutevasopressin(0.050.3units/ml) 20unitsin100cc(0.2units/ml)

    DecreasebloodlossandneedfortransfusionB tt th i t i t Betterorthesameasusingatourniquet

    Cochranereview:300cclessEBLwithvasopressin Moststudiesforopenmyomectomies VIDEOOFVASOPRESSININJECTION


    Kongnyuy E. Cochrane Review, 2007 (2011); Zhao F 2011; Fletcher H. 1996;


    Verticalortransverse Considerations:

    Vasculature Easeofrepairp





  • Pedunculatedfibroids:Usingaloopligasure Intramuralandsubserosalfibroids


    Sametechniqueasopen Multiplelayerclosure Suturingaides

    Unidirectionalbarbedsuture Quill,VLock Sutureclips LapraTy


    Sutureclips Submucosalfibroids


  • Specimenremoval

    Morcellation Minilap

    References FletcherHetal.Arandomizedcomparisonofvasopressinandtourniquetathemostaticagents

    duringmyomectomy.ObstetGyencol1996;87:10148 GutmannJetal.GnRHagonisttherapybeforemyomectomyorhysterectomy.JMIG2005;12:529

    537. KongnyuyE,WiysongeS.Interventionstoreducehemorrhageduringmyomectomyforfibroids.

    CochranDatabaseSystemRev,2007.Updated2011 LethabyA.PreoperativeGnRHanaloguetherapybeforehysterectomyormyomectomyforuterine

    fibroids.CochranDatabaseSystemRev,2001.Updated2011 WalochaJAetal.Vascularsystemofintramuralleimyomatareviewedbycorrosioncastingand

    scanningelectronmicroscopy.HumReprod2003;18:1088. ZhaoFetal.Evaluationofloopligationoflargermyomapseedocapsulecombinedwithvasopressin

    onlaparoscopicmyomectomy.FertilityandSterility2011;95:762766 ZulloFetal.Aprospectiverandomizedstudytoevaluatelueprolideacetatetreatmentbefore



  • Strategies for Safe and Efficient Strategies for Safe and Efficient Tissue Removal Tissue Removal

    Andrew I. Brill, MDAndrew I. Brill, MDDirector, Minimally Invasive GynecologyDirector, Minimally Invasive Gynecology

    California Pacific Medical CenterCalifornia Pacific Medical CenterSan Francisco, CASan Francisco, CA


    Consultant: Karl Storz EndoscopyConsultant: Karl Storz Endoscopy--America, America, Ethicon EndoEthicon Endo--Surgery, Conceptus Incorporated, Surgery, Conceptus Incorporated, CooperSurgicalCooperSurgicalp gp g

    Speaker's Bureau: Karl Storz EndoscopySpeaker's Bureau: Karl Storz Endoscopy--America, America, Ethicon EndoEthicon Endo--Surgery, Conceptus Incorporated, Surgery, Conceptus Incorporated, CooperSurgicalCooperSurgical

    Learning ObjectivesLearning Objectives

    Describe methods for removal of Describe methods for removal of different types of tissuedifferent types of tissue

    List steps to minimize risk during tissue List steps to minimize risk during tissue morcellationmorcellationmorcellationmorcellation

    Employ methods to facilitate tissue Employ methods to facilitate tissue removal during laparoscopyremoval during laparoscopy

    Enumerate the types of instruments Enumerate the types of instruments available for laparoscopic tissue available for laparoscopic tissue extractionextraction

    learn tips and tricks for escape!learn tips and tricks for escape!

    Mass Tissue Removal Mass Tissue Removal Know Alternatives & ApproachesKnow Alternatives & Approaches

    Different AnatomyDifferent Anatomy Consistency of TissueConsistency of TissueConsistency of TissueConsistency of Tissue Volume of TissueVolume of Tissue


    Equipment Wont Work!Equipment Wont Work!


  • By Type of TissueBy Type of Tissue

    BenignBenignSterileSterile InfectiousInfectious Contamination (bag)Contamination (bag) Contamination (bag)Contamination (bag)

    Suspicious for MalignancySuspicious for MalignancySeeding (bag)Seeding (bag)

    MalignantMalignantSeeding (bag)Seeding (bag)

    Relative Tissue ConsistencyRelative Tissue Consistency

    Soft Soft Fallopian Tube / MyomaFallopian Tube / Myoma

    FluidFluid--filled filled Ovarian CystOvarian Cyst

    Particulate Particulate Dermoid CystDermoid Cyst

    Firm Firm Fundus / MyomaFundus / Myoma

    Hard Hard Calcified Myoma or DermoidCalcified Myoma or Dermoid

    Tissue CaptureTissue Capture

    GraspersGraspers Atraumatic Atraumatic 5 & 10 mm5 & 10 mm

    Less damage, less riskLess damage, less riskHold poorlyHold poorly


    Spoon ForcepsSpoon Forceps

    -- ultimate atraumatic grasper ultimate atraumatic grasper --

    Tissue CaptureTissue Capture

    TraumaticTraumatic 5 & 10 mm5 & 10 mmMore damage, more riskMore damage, more riskHold wellHold well

    Recommended PracticesRecommended PracticesInsert Instruments PARALLEL Insert Instruments PARALLEL

    totoAbdominal Wall!Abdominal Wall!


  • Recommended PracticesRecommended Practices

    Visualize instrument tipsVisualize instrument tips If not observed:If not observed:Keep tips closedKeep tips closed

    D t i t tD t i t tDo not move instrumentDo not move instrument AwarenessAwarenessSidewalls: vessels, nervesSidewalls: vessels, nervesBowelBowelBladderBladder

    Via CannulaVia CannulaPull tissue into cannulaPull tissue into cannulaOpen valve / disassemble & extractOpen valve / disassemble & extract Remove tissue with cannulaRemove tissue with cannula

    P ll ti th h t itP ll ti th h t it Pull tissue through port sitePull tissue through port site Widens peritoneal / fascial defectsWidens peritoneal / fascial defects Assess for entrapped fragmentsAssess for entrapped fragments

    Laparoscopic Retrieval BagsLaparoscopic Retrieval Bags

    Mechanical devicesMechanical devicesEasy to useEasy to useWeak bag materials!Weak bag materials!Risk Risk rupture and spreadrupture and spread

    Cook Lap SacCook Lap Sac

    Strong Strong parachute / nylon materialparachute / nylon material Harder to use Harder to use

    Cook Lap Sac Cook Lap Sac -- TechniqueTechnique

    Insertion Insertion roll up and push through roll up and push through cannula or abdominal defectcannula or abdominal defect

    Open neck with graspersOpen neck with graspersOpen neck with graspersOpen neck with graspers

    Fill with irrigating fluid to distendFill with irrigating fluid to distend

    Insert tissueInsert tissue

    Close neck with stringClose neck with string


  • Cook Lap Sac Technique (cont)Cook Lap Sac Technique (cont)

    Grasp string and neck of bag Grasp string and neck of bag

    Bring out abdominal wallBring out abdominal wall

    Suction fluid to decompressSuction fluid to decompress

    Morcellate/extract tissueMorcellate/extract tissue Under direct vision to avoid Under direct vision to avoid

    perforation of bagperforation of bag

    morcellation inmorcellation in--sacsac

    25cm solid25cm solid--cystic adnexal masscystic adnexal mass


    Open laparoscopyOpen laparoscopy

    Laparoscopic Mass Tissue RemovalLaparoscopic Mass Tissue Removal-- evolution evolution --

    Electromechanical morcellationElectromechanical morcellation

    Manual morcellationManual morcellation


    Extraction SitesExtraction Sites

    Umbilicus Umbilicus 10, 12 mm 10, 12 mm -- cuttingcuttingOperating scope and grasperOperating scope and grasperDirect removalDirect removal Easy to extend and repair incisionEasy to extend and repair incision Easy to extend and repair incisionEasy to extend and repair incision 5 mm scope in lower or LUQ port5 mm scope in lower or LUQ port

    Direct MorcellationDirect Morcellation ScalpelScalpel

    UQ Visual PortUQ Visual PortUmbilical MorcellationUmbilical Morcellation


  • Tissue Extraction SitesTissue Extraction Sites

    Lower ports Lower ports (lateral > median)(lateral > median) 5 mm 5 mm ectopic, simple cyst, hydrosalpxectopic, simple cyst, hydrosalpx

    101015 mm15 mmdermoid, myomadermoid, myoma

    Extraction SitesExtraction Sites


    Direct vision from aboveDirect vision from above

    Hold bowel awayHold bowel away

    Feed tissue from aboveFeed tissue from above

    Extraction SitesExtraction Sites

    CuldotomyCuldotomy Risks and disadvantagesRisks and disadvantages InfectionInfectionBl di / h tBl di / h tBleeding / hematomaBleeding / hematomaDyspareuniaDyspareuniaAdhesions?Adhesions?Need to reposition patientNeed to reposition patient

    Transcervical for LSHTranscervical for LSH

    Loop ExcisionLoop Excision

    Storz SuperLoop Storz SuperLoop andand Lina LoopLina LoopStrategyStrategyStrategyStrategy Clarity of vital anatomyClarity of vital anatomy Symmetric applicationSymmetric application Level of vascular pediclesLevel of vascular pedicles Velocity and gap for electrosectionVelocity and gap for electrosection

    Lina LoopLina Loop Storz SupraloopStorz Supraloop


  • Electromechanical MorcellationElectromechanical Morcellation

    Electromechanical Morcellation Electromechanical Morcellation Primary GoalsPrimary Goals

    Safety and EfficacySafety and Efficacy RisksRisks

    Tissue remnantsTissue remnants

    Electromechanical Morcellation Electromechanical Morcellation

    Vascular injuryVascular injury

    Visceral injuryVisceral injury

    Richters or fascial herniaRichters or fascial hernia

    Electromechanical MorcellationElectromechanical Morcellation


    Grasp tissue near edgeGrasp tissue near edgePULL tissue into devicePULL tissue into device

    Minimize movement of deviceMinimize movement of device

    Observe cutting edge at all timesObserve cutting edge at all times

    Electromechanical MorcellationElectromechanical Morcellation



  • Morcellation Port Locale?Morcellation Port Locale?

    Uterine / fibroid dimensions?Uterine / fibroid dimensions?

    Capacity of pelvis?Capacity of pelvis?

    Viscera and vessels?Viscera and vessels?

    Comfort with assistant?Comfort with assistant?

    Electromechanical Morcellation Electromechanical Morcellation

    Port SelectionPort SelectionMidline SuprapubicMidline SuprapubicPort SelectionPort SelectionMidline SuprapubicMidline Suprapubic

    Electromechanical Morcellation Electromechanical Morcellation

    Port SelectionPort SelectionUmbilicalUmbilicalPort SelectionPort SelectionUmbilicalUmbilical

    Electromechanical Morcellation Electromechanical Morcellation

    Port SelectionPort SelectionLateral LowerLateral LowerPort SelectionPort SelectionLateral LowerLateral Lower

    In Situ In Situ Electromechanical MorcellationElectromechanical MorcellationEfficiency ParametersEfficiency Parameters

    Core guard opposite tissue contourCore guard opposite tissue contour

    Hammock created by assistantHammock created by assistant

    3030 degree lens to observe entry and exit pointsdegree lens to observe entry and exit points 3030-- degree lens to observe entry and exit pointsdegree lens to observe entry and exit points

    Pull steadily away from uterus with clawPull steadily away from uterus with claw

    Target interface between myoma and uterusTarget interface between myoma and uterus

    Finish the base of the myoma conventionallyFinish the base of the myoma conventionally

    Avoid for low lateral or submucous elementsAvoid for low lateral or submucous elements

    Create Tissue HammockCreate Tissue Hammock


  • Efficiency: Surfacing and UnpeelingEfficiency: Surfacing and UnpeelingElectromechanical Morcellation: Electromechanical Morcellation: EfficiencyEfficiency

    Tissue DensityTissue Densityperper

    Visual and Auditory CuesVisual and Auditory Cues





    Degenerated MyomaDegenerated Myoma Uterus and MyomaUterus and Myoma MyomaMyoma




    Preventing Hernia PostPreventing Hernia Post MorcellationMorcellationPreventing Hernia PostPreventing Hernia Post--MorcellationMorcellation

    Close fascial Close fascial andand peritoneal peritoneal defects!defects!


  • CuffManagement:IssuesofSupportandControversiesof



    Consultant:Gyrus ACMI(Olympus),IntuitveSurgical

    Attheconclusionofthissessiontheparticipantwillbeableto: Identifyrisksandbenefitsoflaparoscopictotal(TLH)vssubtotal(LSH)

    hysterectomyd f l d h l l f Identifyprincipalsandtechniquestominimizeapicalprolapseafterlaparoscopichysterectomy(LH)



    Outline 24slides+video Historicalperspective TLHvsLSH


    CervicalManagement Amputationandendocervix(Videos amputation,dessication,closure)

    Apical ProlapseApicalProlapse USLigsuspension(Video)

    CuffInfectionanddehiscence Closure(Video)

    Genitourinaryinjuryandfistulaformation SimpleCystoscopy(Video)


    Firstreportedelectivehysterectomy 1813,vaginalhysterectomybyConradLangenbeck 1863,firstabdominalhysterectomy(subtotal)byCharlesClay1929 fi l bd i l h EH Ri h d 1929,firsttotalabdominalhysterectomyEHRichardson

    1989,firstlaparoscopichysterectomybyReich 1990,firstlaparoscopicsupracervicalhystbyLyons



    LSHAdvantages Evisceration Cuffinfection GUinjury G l ti

    TLHAdvantages Postoperativebleeding Dysplasiaandcervical

    cancer No risk of future Granulation


    Earlysa sfac onscores





  • CervicalManagement CyclicBleeding





    Tips Reverseconization(videolink)

    EndocervicalDessication( id li k)

    ( )7428,2008May





    Tips Testandtreatpreoperativevaginitis ThoroughpreoperativevaginalpreparationPre incision antibiotics Preincisionantibiotics

    Rapiddrainageofpostoperativeabscess Aggressive2weekantibiotictreatmentforallvaginalcuffinfections


  • CuffDehiscence Incidence

    TAH/VH 0.14 0.28% IacoPEetal.EurJObstetGynecol

    ReprodBiol2006;125:1348. HurHetal.JMIG2007;14:311.

    TLH 0.794.93%

    LSH CaseReport HarmanliOHetal.AJOG


    0 9 93% HurHetal.JMIG2007.14:311. IacoPEetal.EurJObstetGynecol

    ReprodBiol2006;125:1348. AgdiMetal.JMIG2009;16:3137.

    RoboticTLH 4.1% KohRetal.ObstetGynecol2009;



    Menopause Cuffcellulitis/abscess Hematoma TissueIschemia

    Prevention* Preoperativevaginalestrogen PreventInfection Maintainhemostasis Minimizethermalinjury 1 ti bit

    * Level 3 Evidence

    Chronicvalsalva EarlyCoitus Immunosuppresion Cigarettesmoking

    1cmtissuebites Barbedsuture? Avoidliftingandchroniccough 8weeksvaginalrest Preoperativehealthmaintenance Useofdelayedabsorbablesuture

    Genitourinaryinjury Retrospectivereview

    1110ptsover10yrsby48surgeons HarmanliOHetal.AJOG2009;201:536.e17.

    Outcome LSHN=566



    Urinary TractInjury

    3 (0.5%) 10 (2.2%) 4.75 (1.2-18.5)


    4 (0.7%) 7 (1.6%) 1.7 (0.5-6.3)

    2.7%riskinjurywithTLHinFinlanddatabase(>1100) Harkki.AmJObstetGynecol1997;176:11822.

    0.29%inlargeseriesofLSH(>1700) BojahrBetalJMIG2006;13:1839.




    LH=2%bladder,0%ureter(n=49) AH=2.5%bladder,2.2%ureter(n=278) VH=6.3%bladder,1.4%ureter(n=144)

    Vakili B et al. AJOG 2005;192:1599-1604.

    24of25injuriesrecognizedintraoperatively 70%ofinjuriesnotrecognizeduntilthecystourethroscopy

    Simple Cystoscopy



    TAH 28 (371/117,000) SCH 14 (69/45,000) almostallbowel

    Forsgren C. Obstet Gynecol 2009,114:594-9.

    ( , ) TVH 20 (22/19,000) TLH/LAVH 96(7/1800) almostallurogenital

    MorcellationConsiderations Endometriosisafterlaparoscopicsupracervicalhysterectomywithuterine



    Schuster M. JMIG. 2012;19:183.

    Anapama R. JMIG. 2011;18:386.



    Kill L. Ostet Gynecol. 2011;117:447.

    Ordulu Z. Genes, Chromosomes & Cancer. 2010;49:1152.


  • Okaroetal.BJOG2001;108:101720. GhomiAetal.JMIG.2005;12:2015. LiengMetal.BJOG.2008;115:160510. ErianJetal.BJOG.2008;115:7428. LyonsT.JMIG.2007;14:2757. LearmanLAetal.ObstetGynecol.2003;102(3):


    HurHetal.JMIG2007;14:311. AgdiMetal.JMIG2009;16:3137. KohRetal.ObstetGynecol2009;114:2315. Harkki.AmJObstetGynecol1997;176:11822. VakiliBetal.AJOG2005;192:15991604. ForsgrenC.ObstetGynecol2009,114:5949. SchusterM.JMIG.2012;19:183.

    ThakarRetal.NEJM.2002;347:1318. DeLanceyJO.AmJObstetGynecol

    1992;166,6pt1:171724. Shenetal.JAmAssocGynecolLaparosc.

    2002;9:47480. BojahrBetal.JMIG2006;13:1839. HarmanliOHetal.AJOG2009;201:536.e17. GhezziFetal.BJOG.2009;116:58993. IacoPEetal.EurJObstetGynecolReprodBiol


    AnapamaR.JMIG.2011;18:386. KillL.OstetGynecol.2011;117:447. OrduluZ.Genes,Chromosomes&Cancer.



  • CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

    the AAGL, to assist in enhancing the cultural and linguistic competency of Californias physicians (researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

    recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

    California Business & Professions Code 2190.1(c)(3) requires a review and explanation of the laws

    identified above so as to fulfill AAGLs obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at

    Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

    discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

    origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

    program, the importance of the services, and the resources available to the recipient, including the mix of oral

    and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964

    Executive Order 13166,Improving Access to Services for Persons with Limited English

    Proficiency, signed by the President on August 11, 2000 was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

    including those which provide federal financial assistance, to examine the services they provide, identify any

    need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

    Dymally-Alatorre Bilingual Services Act (California Government Code 7290 et seq.) requires every

    California state agency which either provides information to, or has contact with, the public to provide bilingual

    interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.


    If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

    A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter.

    US Population

    Language Spoken at Home






    Language Spoken at Home




    19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%


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