Sponsored by

AAGLAdvancing 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

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

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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

2

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

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

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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!

5

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.

6

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 --

7

Identifying the Inferior Epigastric VesselsIdentifying the Inferior Epigastric Vessels

11 22 33

112233112233

LUQLUQ

Peritoneal Tenting

Left Upper QuadrantLeft Upper Quadrant

LUQ = 3

Pop

1

2

3

8

Superior epigastric vessels (se)

MCLMCL

se se

rectus sheathrectus sheathMCLMCL

4-5FB

Relinquishing the Big PictureRelinquishing the Big Picture

Where am I?Where am I?

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

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

AnatomyAnatomy DissectionDissection

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Medial Umbilical LigamentMedial Umbilical Ligament

Pelvic Sidewall Pelvic Sidewall 3 Surgical Layers3 Surgical Layers

UreterUreter

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

avascular

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

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ThinkThink

AnatomyAnatomy

Anatomical surgery demands Anatomical surgery demands awarenessawareness..

12

DifficultPeritonealAccess:OvercomingAdhesionsand

ObesityJamesK.Robinson,MD,MS

TheGeorgeWashingtonUniversity

Consultant:Gyrus ACMI(Olympus),IntuitveSurgical

Attheconclusionofthissessiontheparticipantwillbeableto: Identifytherisksinherentinprimaryperitonealaccess. Identifydifferentapproachestoprimaryperitonealaccess. Identifypatientsatthehighestriskofperitonealaccess

li icomplications. Identifyprincipalsandtechniquestominimizerisksassociatedwithhighriskperitonealaccess.

Identifyprincipalsandtechniquesofintraoperativeadhesiolysis.

Identifyprincipalsandtechniquesofportsiteclosure.

9videos=10minutesDidactic=10minutes(20slides)

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)

ComplicationsAssociatedwithTrocars

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

Scissors/scalpel 3%Scissors/scalpel3%

>25%ofallsurgicalmalpracticeclaimssitetrocarinsertion asthemaincauseifinjury

FatalTrocarinjuries Vascular>Bowel

Maude Data Base. JMIG. 2005;12:302

RiskofAdhesionswithPriorLaparotomy

Omentaland/orBowel Priorsurgicalscar

Pfannensteil 27% LowVertical 55%

TypeofPriorSurgeryandAdhesions

Obstetrical 22% Nodifferenceb/w

pfannensteil vs midline HighVertical 67%

Whenadhesionsexist Omentalonly 84% OmentalandBowel 16%

pfannensteilvsmidline

Gynecologic 42% Pfannensteil 31% Midline 70%

Brill. Obstet Gynecol. 1995;85:299.

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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

Images

y Pregnancy LargePelvicorabdominal

mass

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.

PalmersPointTechnique

ClosedVeresstechnique 25mmincision3cmbelowtheleftcostalmargininthemidclavicularline

Gastricsuctioning ConsiderTrendelenburg

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

Proximityofstomachandeffectofgastrici

PalmersPoint

suction

Entrytechniqueandlaparoscopicviewofperiumbilicaladhesions

MicrolaparoscopyatPalmersPoint Microlaparoscopicveress/trocarisinsertedviaPalmerspoint

1.2mmlaparoscopeisi t d d th h thintroducedthroughtheveress/trocarinordertoinspectforperiumbilicaladhesions.

MicrolaparoscopyandAdhesions

814consecutivepatientsdividedinto4categories Group1(469) Noprior

abdominal surgery

MicrolaparoscopyatPalmerspointwithumbilicaladhesionanalysis 9.82%overall

abdominalsurgery Group2(125) Prior

laparoscopicsurgery Group3(131) Priorsuprapubic

laparotomy Group4(89) Priormidline

laparotomy

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.

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VisceralSlideandPUGSI

VisceralSlide Thelongitudinaldistance

theintestineoromentumtravelsasvisualizedbyt bd i l US d i

PUGSI Periumbilicalultrasound

guidedsalineinfusion Tendabdomanwithtowel

ltransabdominalUSduringanexaggeratedinspirationandexpirationcycle Exaggerated=1.5xnormal

tidalvolume Normalis=or>1cm

movement

clamps Observe19ganeedleenter

peritoneum Inject10mlssterilesaline Localizedfluidpocketis

abnormalfinding

VisceralSlideandPUGSI

AbnormalPUGSIhadasensitivityandspecificityof100%forobliteratingperiumbilicaladhesions

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

AncillaryTrocarPlacement

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

Alwaysdrainthebladderpriortosuprapubicportplacement

Considerbackfillingthebladdertodelineatetheborder

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

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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.

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

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

Director, Minimally Invasive GynecologyCalifornia Pacific Medical Center

DisclosuresDisclosures

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

EndometriosisEndometriosis

General ConsiderationsGeneral Considerations

EndometriosisEndometriosisOverviewOverview

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

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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

InflammationInflammation

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?

19

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

66% 66% (PERIT POCKETS)(PERIT POCKETS) 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)

ComplicationsComplications

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

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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

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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)

22

OvarianCystectomy:Preservationoffertilityy

StephanieMorris,MDNewtonWellesleyHospital,MA

HarvardMedicalSchool

Disclosure

Ihavenofinancialrelationshipstodisclose.

Objectives:

Explaintherisksassociatedwithovariancystectomyandtheclinicalimplications

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

Laparoscopyvs.Laparotomy

Laparoscopicsurgeryforbenignovariantumorswasassociatedwith Feweradverseoutcomes

(intraop complications,postopfever/infections) Lesspostoppain Fewerdaysinthehospital

Laparoscopyvs.Laparotomyforbenignovariantumors.CochraneDatabaseofSystematicReviews.11,2010ACOGPB#83

23

Surgicaltechnique

Incision Removalofcystwall Preservationofovariantissue +/ Closureofovariancortex Adhesionprevention

Cystrupture/spill:Whatdoesitreallymean?

Laparoscopyvs.laparotomy ClinicalSignificance

Peritonitiswithdermoidcysts Malignancy

Dermoidcyst:Riskofperitonitis

+/ 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

MinimizingRiskofPeritonitis

Containspillage Withinbag WithinculdesacC i i i ti Copiousirrigation

Whatdoesrupture/spillageofanmalignancymeanclinically?

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

Suturevs.BipolarforHemostasis

Intraovariansutureforhemostasiscauseslesspostopadhesionsthanbipolar PellicanoM.FertilSteril,2008

Bipolar electrocoagulation adversely affectsBipolarelectrocoagulationadverselyaffectsovarianfunction,comparedwithsuture FedeleL.JAAGL,2004

24

ToCloseorNottoClose

Closureofovariancortex

Cystectomyandfertility

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

Bilateralendometriomahasmoreprofoundnegativeimpactthanunilateralendometrioma(regardlessofeitherconservativeorsurgicalintervention)

HwuY.ReprodBioEndo,2011 ?Morequantitativeratherthanqualitativedamage

RagniG.AmJObGyn2005

Surgicaltreatment

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

Excision

Ablationvs.excision

Excisionwasassociatedwith Reducedrateofrecurrence ReducedneedforfurthersurgeryReduced rate of symptoms Reducedrateofsymptoms

dysmenorrhea,dyspareuniaandnonmenstrualpain Increasedrateofspontaneouspregnancy

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

25

Ablationvs.excision

Markersofovarianfunctiondecreasedafterbothcystectomyandcoagulationofendometrioma,butmoreaftercystectomy Antralfolliclecountdecreasedafterbothcystectomyy yandcoagulation,butmoreaftercystectomy

Ovarianresponsetoovulationinductionwasreducedincystectomycomparedtocoagulationgroup

RCTofwomenwithbilateralendometriomas onesidecystectomyanonesidecoagulation

Var T. Fertil Steril, 2011

Howbigistoobig?

Sizenotnecessarilyacontraindicationtolaparosocpy

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,

2011.

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.

26

TheLargeUterus:TipsforLaparoscopicHysterectomy

StephanieMorris,MD

NewtonWellesleyHospital,MAHarvardMedicalSchool

Ihavenofinancialrelationshipstodisclose.

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

Uterus

Bladder Bladder

UterusUterosacral Ligaments

Uterus

27

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

28

6.Roundligamentandbladderflap Round ligament:

Open up round ligament Stay lateral Go through whole round ligament

Anterior Leaf/Bladder Flap

VIDEO OPENING UP ROUND

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

VIDEO USE OF 30 DEGREE

VIDEO USE OF MANIPULATOR TO PUSH BLADDER UP

6.Roundligamentandbladderflap

6.Roundligamentandbladderflap 7. The adnexa

Stay close to ovary BSO or no BSO

Avoid ascending branch of the uterine vessels

VIDEO ADNEXA RELEASE

Back bleeding can be hard to control

7. The adnexa 8.PosteriorleafandUterineVessels

Release ureter laterally

Allow skelotonization of uterine vessels

VIDEO POST LEAF RELEASE URETER LATERALLY

VIDEO POST LEAF Peel fibroid out of

broad ligamentSKELONTIZATION OF UTERINE VESSLES

VIDEO PEEL FIBROID OUT OF BROAD LIGAMENT

29

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

VIDEOSKELOTONIZATIONOFUTERINEVESSLES

PICTURELOCATIONOF Push manipuler cephalad to

displace bladder and uterters

Secure both sides before transection of the vessels

UTERINEVESSELS

Uterine vessels for TLH Now with a lateral fibroid

30

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

VIDEO BACK FILLING BLADDER

OVER SEW BLADDER

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

31

SimplifyingLaparoscopicMyomectomy

StephanieMorris,MD

NewtonWellesleyHospital,MAHarvardMedicalSchool

Ihavenofinancialrelationshipstodisclose.

Demonstratestepstosimplifylaparoscopicmyomectomy PreoperativeplanningWays to reduce intra operative blood loss Waystoreduceintraoperativebloodloss

Surgicaltechniques Tipsforremovingdifferenttypesoffibroids

Patientselection

Numberoffibroids Sizeoffibroids

Howbigistoobig?

Patientselection

Numberoffibroids Sizeoffibroids

Howbigistoobig? Location

PreOperativeImaging Ultrasound

Limitedwhennumerousfibroids

9cm

32

PreOperativeImaging MRI

Greatformappingfibroidlocationandnumber

PreoperativeuseofGnRHAgonists

Improvespre andpostophgb/hct Decreasesuterinevolumeandfibroidsize

3565%

Decreasesprocedurerelatedbloodloss Doesnotchangeneedforbloodtransfusion

+/ DecreaseinORtime Studiesvary SeveralindividualRCTstudiesshowlessORtime Metaanalysis,nodifferenceinORtime(Cochrane)

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

IntheOR

Portplacement Higherlateralports HighermidlineportsLUQ

Trocar Placement

LUQport 5mmand10mm

Portplacement

Right LateralLeft Lateral

Midline Suprapubic5 mm

g5/12 mm5/12 mm

Umbilical5 mm

Head

IntheOR

EnergySourceBipolarMonopolarUltrasonicEnergy Laser

IntheOR Myomamanipulators

Morcellator Efficiency

33

IntraoperativeHemostasis: Vasopressin

bloodlossneedfortransfusion Cochranereview:300cclessEBL300cclessEBL

Dilutevasopressin(0.050.3units/ml)

Moststudiesforopenmyomectomies

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

Hemostasis

PreopLupron Vasopressin Laparoscopictourniquet Direction of incision Directionofincision Pedicle ofthefibroid Useofthermalenergy

IntraOperativeVasopressin

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

DecreasebloodlossandneedfortransfusionB tt th i t i t Betterorthesameasusingatourniquet

Cochranereview:300cclessEBLwithvasopressin Moststudiesforopenmyomectomies VIDEOOFVASOPRESSININJECTION

Subserosalandbase

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

DirectionofIncision

Verticalortransverse Considerations:

Vasculature Easeofrepairp

VIDEO

Pedunculatedfibroids

Fibroid

34

Pedunculatedfibroids:Usingaloopligasure Intramuralandsubserosalfibroids

Suturingtechniquesandaides

Sametechniqueasopen Multiplelayerclosure Suturingaides

Unidirectionalbarbedsuture Quill,VLock Sutureclips LapraTy

Multilayeredclosure

Sutureclips Submucosalfibroids

35

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

laparoscopicmyoectomy:Efficacyandultrasonographicpredictors.AmJObstetGyencol1998;178(1):10812.

36

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

DisclosuresDisclosures

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

OR.OR...

Equipment Wont Work!Equipment Wont Work!

37

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

FatigueFatigue

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!

38

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

39

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

CuldotomyCuldotomy

Open laparoscopyOpen laparoscopy

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

Electromechanical morcellationElectromechanical morcellation

Manual morcellationManual morcellation

CuldotomyCuldotomy

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

40

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

CuldotomyCuldotomyAdvantagesAdvantages

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

41

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

TechniqueTechnique

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

fixedfixed

42

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

43

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

Tissue DensityTissue Densityperper

Visual and Auditory CuesVisual and Auditory Cues

SoftSoft==

AdenomyosisAdenomyosis

FirmFirm==

HardHard==AdenomyosisAdenomyosis

Degenerated MyomaDegenerated Myoma Uterus and MyomaUterus and Myoma MyomaMyoma

CoreCoreandand

SteerSteerUnpeelUnpeel

UnpeelUnpeel

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

Close fascial Close fascial andand peritoneal peritoneal defects!defects!

44

CuffManagement:IssuesofSupportandControversiesof

theCervixJamesK.Robinson,MD,MS

TheGeorgeWashingtonUniversity

Consultant:Gyrus ACMI(Olympus),IntuitveSurgical

Attheconclusionofthissessiontheparticipantwillbeableto: Identifyrisksandbenefitsoflaparoscopictotal(TLH)vssubtotal(LSH)

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

IdentifyprincipalsandtechniquestominimizevaginalcuffcellulitisanddehiscenceafterTLH

IdentifyprincipalsandtechniquestominimizegenitourinaryinjuryandfistulaformationafterLH

Outline 24slides+video Historicalperspective TLHvsLSH

MarforiData

CervicalManagement Amputationandendocervix(Videos amputation,dessication,closure)

Apical ProlapseApicalProlapse USLigsuspension(Video)

CuffInfectionanddehiscence Closure(Video)

Genitourinaryinjuryandfistulaformation SimpleCystoscopy(Video)

Timeline

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

1989,firstlaparoscopichysterectomybyReich 1990,firstlaparoscopicsupracervicalhystbyLyons

45%womenover70inUSiss/physt

LSHvsTLHDoIstayordoIgo?Summary(Eatdessertfirst)

LSHAdvantages Evisceration Cuffinfection GUinjury G l ti

TLHAdvantages Postoperativebleeding Dysplasiaandcervical

cancer No risk of future Granulation

?Impactinfuturevaultprolapse

Earlysa sfac onscores

Noriskoffuturetrachelectomy

LSHshouldbeusedcautiouslyinwomenwithCPP/knownendometriosis

Spreadofmalignancy(whenintact)

45

CervicalManagement CyclicBleeding

711%Okaroetal.BJOG2001.Oct;108(10):101720.

19%GhomiAetal.JMIG.2005;12:2015.

24%LiengMetal.BJOG115(13):160510,2008Dec.

2%ErianJetal.BJOG115(6):

Tips Reverseconization(videolink)

EndocervicalDessication( id li k)

( )7428,2008May

1000LH.(bothapprox1%)

HarmanliOHetal.AJOG2009;201:536.e17.

2009;116:58993.

CuffInfection

Tips Testandtreatpreoperativevaginitis ThoroughpreoperativevaginalpreparationPre incision antibiotics Preincisionantibiotics

Rapiddrainageofpostoperativeabscess Aggressive2weekantibiotictreatmentforallvaginalcuffinfections

46

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

2009;201:536.e17.

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

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

RoboticTLH 4.1% KohRetal.ObstetGynecol2009;

114:2315.

CuffDehiscenceRiskFactors*

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

TLHN=450

OR

Urinary TractInjury

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

UrinaryRetention

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.

Retention

Genitourinaryinjury

Prospectivecystourethroscopyofallhysterectomiesin3centers(n=471)

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

Fistula

NationalSwedishregistry19732003rates(100,000personyears)

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

morcellation:acasecontrolstudy

Disseminatedperitonealleiomyosarcomasafterlaparoscopicmyomectomyandmorcellation

Schuster M. JMIG. 2012;19:183.

Anapama R. JMIG. 2011;18:386.

Progressionofpelvicimplantstocomplexatypicalendometrialhyperplasiaafteruterinemorcellation

Disseminatedperitonealleiomyomatosisafterlaparoscopicsupracervicalhysterectomywithcharacteristicmolecularcytogeneticfindingsofuterineleiomyoma

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

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

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48

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 http://www.imq.org

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 http://www.usdoj.gov/crt/cor/pubs.htm.

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

Proficiency, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm 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. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsianIndo-Euro

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

49

http://www.imq.org/http://www.usdoj.gov/crt/cor/pubs.htmhttp://www.usdoj.gov/crt/cor/13166.htmhttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538

PG 109-OUTLINE-Morris-DidacticPG 109 Planner Disclosures0805 BRILL AAGL Final Anatomy 20120830 ROBINSON Difficult Peritoneal Access0855 BRILL EndometriosisBrill20120920 MORRIS Ov Cyst PG 1091010 MORRIS Hyst PG 1091035 MORRIS Myomectomy PG 1091100 BRILL TissueRemovalBrill20121125 ROBINSON Cuff ManagementCultural and Linguistic Competency LAST PAGE