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1.
Study Objective
To demonstrate a technique of performing laparoscopic resection of a post–cesarean section scar uterine cyst.Design
Technical video (Canadian Task Force classification III).Setting
University Hospital.Patient
A 38-year old woman.Intervention
Laparoscopic excision of a uterine cyst within a cesarean section scar.Measurements and Main Results
A 38-year-old woman presented with secondary subfertility requesting removal of a cesarean section scar defect to prepare the uterine cavity for in vitro fertilization. Preoperative ultrasound demonstrated a 17.7?×?12.2?mm scar defect. At rigid hysteroscopy the anterior uterine wall cyst was observed and noted to be narrowing the uterine cavity. A laparoscopic approach was used to excise the uterine cyst. We carefully mobilized the bladder from its adhesions at the site of the previous cesarean section scar. The uterine cyst was located and margins of the defect identified. An ultrasonic-energy device was used to enucleate and excise the cyst. A uterine manipulator helped to identify the cervical canal and protect the posterior wall from inadvertent suture placement. The defect was closed with 1 vicryl interrupted sutures, being careful to incorporate the full thickness of the uterine wall to an able maximal opposition. An adhesion barrier was applied to the area. Transvaginal ultrasound scanning performed 6 weeks postoperatively demonstrated full healing with no residual defect.Conclusion
Niches are recognized complications of cesarean sections resulting from incomplete healing of the scar and more likely in single-layer closures [1]. They can be associated with postmenstrual spotting, dysmenorrhea, chronic pain, subfertility, and poorer reproductive and obstetric outcomes 1, 2, 3, 4, 5. Laparoscopic resection of niches is well established, showing symptomatic relief and an increase in residual myometrium [6]. Although cesarean section scar defects have been described as niches, we presented a further variety of defect that has not been previously described, a uterine cyst. 相似文献2.
Ahmet Kale Gulfem Basol Taner Usta Isa Cam 《Journal of minimally invasive gynecology》2019,26(2):360-361
Study Objective
To demonstrate the laparoscopic approach to malformed branches of the vessels entrapping the nerves of the sacral plexus.Design
A step-by-step explanation of the surgery using video (educative video) (Canadian Task force classification II). The university's Ethics Committee ruled that approval was not required for this video.Setting
Kocaeli Derince Education and Research Hospital, Kocaeli, Turkey.Patient
A 26-year-old patient who had failed medical therapy and presented with complaints of numbness and burning pain on the right side of her vagina and pain radiating to her lower limbs for a period of approximately 36 months.Intervention
The peritoneum was incised along the external iliac vessels, and these vessels were separated from the iliopsoas muscle on the right side of the pelvis. The laparoscopic decompression of intrapelvic vascular entrapment was performed at 3 sites: the lumbosacral trunk, sciatic nerve, and pudendal nerve. The aberrant dilated veins were gently dissected from nerves, and then coagulated and cut with the LigaSure sealing device (Medtronic, Minneapolis, Minn).Measurements and Main Results
The operation was completed successfully with no complications, and the patient was discharged from the hospital 24 hours after the operation. At a 6-month follow-up, she reported complete resolution of dyspareunia and sciatica (visual analog scale score 1 of 10).Conclusion
A less well-known cause of chronic pelvic pain is compression of the sacral plexus by dilated or malformed branches of the internal iliac vessels. Laparoscopic management of vascular entrapment of the sacral plexus has been described by Possover et al 1, 2 and Lemos et al [3]. This procedure appears to be feasible and effective, but requires significant experience and familiarity with laparoscopy techniques and pelvic nerve anatomy. 相似文献3.
Study Objective
To provide surgeons with techniques for preemptive analgesia during minimally invasive gynecologic surgery. Postoperative pain management is an important component of patient care after gynecologic surgery. There have been numerous advances in pain management, including studies that show that preoperative administration of analgesics decreases postoperative pain scores and narcotic medication requirements 1, 2, 3. However, there is limited information on the techniques for preemptive analgesia 4, 5.Design
An instructional video showing a variety of preemptive analgesia techniques and the corresponding neuroanatomy (Canadian Task Force classification III). Mayo Clinic Institutional Review Board approval was not required for this video article.Setting
Academic Medical CenterInterventions
Relevant abdominopelvic neuroanatomy is reviewed. This is followed by a demonstration of the preemptive analgesia techniques based on neuroanatomy principles.Conclusion
Techniques for preemptive analgesia are simple and effective. These tools can be used for patients undergoing gynecologic surgeries via a vaginal or abdominal approach and can help optimize postoperative pain and narcotic usage. 相似文献4.
Study Objective
To demonstrate a modified technique of laparoscopic lateral suspension for pelvic organ prolapse (POP).Design
A video illustrating this modified technique of laparoscopic lateral suspension (Canadian Task Force classification III).Setting
The benign gynecology department at a university hospital.Interventions
Laparoscopic lateral suspension using mesh is a minimally invasive technique that effectively treats POP [1, 2, 3, 4]. We present a modified technique of laparoscopic lateral suspension that differs from previously described methods [1, 2, 3, 4]. The prominent differences are as follows: first, our modified technique uses Mersilene tape on a 48-mm round-bodied needle (Ethicon Inc, Somerville, NJ,USA). We suspend the vaginal vault, taking a double bite using Mersilene tape without knotting placed as a transversal hammock. Thanks to the Mersilene tape, meshes, sutures, tackers, or fasteners are not needed. Mersilene tape ensures much easier suturing and an inexpensive artificial material. The second difference is that port placement sites (Fig. 1). The third difference is the number of incisions we make (Fig. 1). We do not need 2 additional incisions as used in previously described methods references [1, 2, 3, 4]. We use the same incision for lateral trocar insertion and for pulling out the distal end of the Mersilene tape, which is 2 cm above the iliac crest and 4 cm posterior to the anterior superior iliac spine (Fig. 1). Our technique has the potential to be easier, shorter, more cost-efficient, less invasive, and safer when compared with previously described methods.Conclusion
Modified laparoscopic lateral suspension, the so-called Mulayim technique, might be considered as an alternative treatment for POP surgery; however, studies should be conducted in a larger number of patients with longer postoperative follow-up periods (Fig. 1). 相似文献5.
Wancheng Zhao Qing Yang Ningning Zhang Yu Wang Guangwei Wang Dandan Wang 《Journal of minimally invasive gynecology》2019,26(4):605-606
Study Objective
To introduce an effective assisted method using the hysteroscopy transmittance test and a Foley catheter to repair previous cesarean scar defect (PCSD) by laparoscopy.Design
A step-by-step explanation of the surgery using video.Setting
A university hospital.Patients
A young woman with abnormal uterine bleeding.Interventions
First, we inspected the pelvic cavity and detached the adhesion, opened the uterovesical peritoneal reflection, and pushed down the bladder. Then, the hysteroscopy transmittance test was used to confirm the site and the size of the PCSD. Next, a Foley catheter was inserted into the diverticulum through the cervical canal, and then we removed the diverticulum along the outer edge 1, 2, 3, 4. The myometrium and the serosal layer were sutured continuously with absorbable sutures. At this point, a second hysteroscopy transmittance test was performed to verify the repair effect. Finally, we placed antiadhesive film.Measurements and Main Results
The location, size, and boundary of the PCSD can be exactly marked by this method. The operative time was 68 minutes, blood loss was 20mL, and no complications occurred.Conclusion
This surgical method has the following benefits: the resection of the diverticulum is complete, and the suture is exact; it is suitable for patients with a thin diverticulum wall, large diverticulum cavity, and a long duration of bleeding after menstruation; the hysteroscopy transmittance test was used to confirm the site of the PCSD and verify the repair effect; and the Foley catheter can marker the resection site, prevent gas leakage, and stop bleeding by local compression. 相似文献6.
Study Objective
To show a step-by-step approach to laparoscopic enucleation and excision of retroperitoneal cysts using a technical video.Design
A technical video (Canadian Task Force classification III).Setting
A benign gynecology department at a university hospital.Intervention
Laparoscopic enucleation and excision of retroperitoneal cysts.Conclusion
Retroperitoneal cysts are rare lesions associated with numerous complications including compression on neighboring organs, infection, rupture, and malignant transformation. Excision of retroperitoneal cysts can be challenging, and dissection of the retroperitoneal space is associated with bowel and vascular injury [1]. Laparoscopic drainage and fenestration have been promoted to prevent visceral injury [2]. Such approaches are ineffective, with increased recurrences and fluid accumulation requiring repeat surgical procedures 3, 4. Successful laparoscopic excision of retroperitoneal cysts has been reported although there are no published videos of the technique [5]. In this video, we use 2 separate cases to show our step-by-step laparoscopic approach to enucleate and excise retroperitoneal cysts. Various methods to safely enter retroperitoneal spaces to avoid inadvertent damage to surrounding structures are detailed. A combination of careful blunt and sharp dissection is used to find specific planes to separate the cyst from the overlying peritoneum and underlying pelvic sidewall structures such as the ureter, vasculature, and nerves. We minimize energy use, and, when it is used, we are mindful regarding active blade positioning of the ultrasonic dissector to prevent inadvertent cyst rupture and injury to the surrounding structures. Keeping the cysts intact aids in leverage and prevents inadvertent spillage of potentially malignant contents. The cysts are retrieved laparoscopically by contained bag decompression. 相似文献7.
8.
Xuyin Zhang Yan Ding Keqin Hua Songping Liu Nan Jia 《Journal of minimally invasive gynecology》2019,26(3):396-397
Study Objective
To introduce a creation that combines laparoscopic and Wharton-Sheares-George cervicovaginal reconstruction using a small intestinal submucosa (SIS) graft in a patient with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome who had a rudimentary cavity (U5aC4V4) [1].Design
A video article introducing a new surgical technique.Setting
A university hospital.Patients
A 24-year-old patient had primary amenorrhea and irregular lower abdominal pain for 9 years. The patient was Tanner stage 3 for pubic hair and Tanner stage 4 for breast development. The physical examination revealed no vagina. A primordial uterus and a uterus with a rudimentary cavity were detected by magnetic resonance imaging 2, 3. However, the rudimentary cavity had no hematometra. Magnetic resonance imaging also found a left solitary kidney. The diagnosis was MRKH syndrome with a rudimentary cavity (U5aC4V4) [4]. The patient desired resumption of menses and possible future fertility.Interventions
Combined laparoscopic and Wharton-Sheares-George cervicovaginal reconstruction using an SIS graft was performed.Measurements and Main Results
With the Wharton-Sheares-George neovaginoplasty, a vaginal mold with a surrounding SIS graft was inserted into the newly created cavity [5]. Using laparoscopy, the lower uterine segment was incised by shape dissection. The proximal segment of the SIS graft to the lower uterine segment was sutured. A T-shaped intrauterine device with a Foley catheter was fixed in the uterine cavity by the delay of absorbed sutures to prevent cervical or vaginal stenosis. The distal segment of the SIS graft was sutured with the high vaginal or vestibular mucosa vaginally. The operation was successfully completed. The operating time was 2 hours. Hospitalization was 4 days. There were no blood transfusions or complications. The patient had resumption of menses for 2 cycles postoperatively, and she had no dysmenorrhea. The patient did not have sexual intercourse because of the mode in the vagina to prevent vagina stenosis. No cervical stenosis occurred because of the Foley catheter.Conclusion
In the past, a uterus with a rudimentary cavity in patients with MRKH was always excised, and patients lost the chance of menstrual onset and fertility. Combined laparoscopic and Wharton-Sheares-George cervicovaginal reconstruction using an SIS graft provided a minimally invasive, safe, and effective surgical option for the young patient with MRKH syndrome with a rudimentary cavity. The technique is not complex, is easy to learn and perform, and provided a result with functional and anatomic satisfaction. No special surgical apparatus is needed with this technique. 相似文献9.
Study Objective
To demonstrate techniques of ureterolysis during complex laparoscopic hysterectomy.Design
Technical video demonstrating different approaches to ureterolysis for complex benign pathology during laparoscopic hysterectomy (Canadian Task Force classification III).Setting
Benign gynecology department at a university hospital.Intervention
Performance of ureterolysis during laparoscopic hysterectomy for benign pathology.Conclusion
Ureteric injury has significant morbidity and is the most common reason for litigation following hysterectomy, with an estimated risk of 0.02% to 0.4%. 1, 2. Ureterolysis is infrequently practiced by benign gynecologists; however, it may be necessary during complex surgery. Benign pathology requiring hysterectomy, such as endometriosis, myomas, large uteri, and adnexal masses, are recognized risk factors for ureteric injury [3]. Most injuries occur during division of the uterine artery at the level of the internal cervical os. The average distance between the ureter and cervix is 2 cm, but it is only 0.5 cm in 3.2% of the population with a normal pelvis [4]. Preventive strategies, such as the use of a uterine manipulator, may increase this distance, although it still might not be sufficient to prevent injury in women with normal anatomic variants and complex pathology. Visualizing the ureter at the pelvic brim and side wall without retroperitoneal dissection may be inadequate because the segment of ureter between the intersection of the uterine artery and the bladder is not visible. The ureter can be safely dissected up to 15 cm without compromising its viability. In this educational video, we demonstrate various simple, quick, and reproducible techniques to perform ureterolysis for complex benign pathology. These techniques can be used by both expert and novice surgeons to perform and teach ureterolysis. Our method determines the course of the ureter throughout the pelvis and relation to the uterine artery to reduce intraoperative injury. We have performed more than 350 cases with no injuries. 相似文献10.
Gabriele Centini Luca Labanca Karolina Afors Istvan Argay Rodrigo Fernandes Nassir Habib Arnaud Wattiez 《Journal of minimally invasive gynecology》2019,26(4):604
Study Objective
To point out the relevant anatomy of the ureter and to demonstrate its rules of dissection.Design
An educational video to explain how to use ureteral relevant anatomy and the principle of dissection to perform safe ureterolysis during laparoscopic procedures.Setting
A tertiary care university hospital and endometriosis referential center.Interventions
Anatomic keynotes of the ureter and examples of ureterolysis.Conclusion
This video shows the feasibility of laparoscopic ureteral dissection and provides safety rules to perform ureterolysis. Identification and dissection of the ureter should be part of all gynecologic surgeons’ background to reduce the risk of complications [1]. Knowledge of anatomy plays a pivotal role, allowing the surgeon to keep the ureter at a distance and minimizing the need for ureterolysis. Unfortunately, the need for ureteral dissection is not always predictable preoperatively, and gynecologic surgeons need to master this technique, especially when approaching more complex procedures such as endometriosis [2]. An implicit risk of damage cannot be denied when performing ureterolysis; therefore, the ureter should be dissected only when strictly necessary and handled with care to minimize the use of energy [3]. 相似文献11.
Study Objective
To demonstrate laparoscopic colposuspension for recurrent stress incontinence after failed tension-free vaginal tape (TVT).Design
A technical video showing laparoscopic colposuspension for previously surgically treated stress incontinence (Canadian Task Force classification III).Setting
A university hospital.Patient
A 58-year-old woman with previous TVT presents with recurrent stress urinary incontinence.Measurements and Main Results
Midurethral slings have equivalent cure rates to the more invasive colposuspension. They are preferentially used for stress urinary incontinence despite a mesh erosion rate of 3.5% with 2.5% requiring further surgery, sling removal, or revision over 9 years 1, 2. Recent negative publicity concerning synthetic mesh tape has led to a resurgence of interest in mesh-free alternatives, including urethral bulking agents, rectus fascia slings, and colposuspension. Laparoscopic colposuspension is a well-established minimally invasive surgery that avoids synthetic mesh, with a quicker recovery, less scarring, and equivalent success to an open approach [3]. Bladder neck mobility is an important marker during selection of this technique. In this video, we demonstrate our transperitoneal technique of colposuspension in the case of failed TVT. This technique allows clear visualization of the operating field and is faster and less bloody than a full dissection. Because complications can ensue from extensive excision and extraction, unless the previous TVT has caused problems such as pain, we normally leave it in situ. Careful dissection is undertaken into the Retzius space to the paravaginal tissues where the iliopectineal ligament is located. On each side, we apply 2 extracorporeally tied nonabsorbable Ethibond (Johnson and Johnson Medical NV, Bruxelles, Belgium) sutures as recommended [4], caudal and lateral to the TVT, lifting the paravaginal tissues to the ligament. The knot is placed on the ligament side to minimize erosion risk. The peritoneal defect is closed with a Vicryl 2.0 (Johnson and Johnson Medical NV) suture. This technique offers a viable mesh-free option for the treatment of recurrent stress incontinence in women who have had failed TVT. 相似文献12.
Berta Diaz-Feijoo Rocio Luna-Guibourg Silvia Cabrera Susana Manrique Antonio Gil-Moreno 《Journal of minimally invasive gynecology》2019,26(2):366
Study Objective
To show the feasibility of the laparoscopic extraperitoneal approach for pelvic metastatic lymph node debulking in locally advanced cervical cancer.Design
A surgical video article (Canadian Task Force classification III).Setting
A university hospital.Patient
A 52-year-old patient presented with stage IIA2 cervical adenocarcinoma according to Fédération Internationale de Gynécologie et d'Obstétrique classification. During the physical examination, a 45-mm tumor was discovered. Positron emission tomographic imaging was positive for hypermetabolic enlarged lymph nodes in the left external iliac region of 1.4-cm size and an standardized uptake value of 21 and in the right obturator region of 1.3-cm size and an standardized uptake value of 7.1; no aortic nodes were found using the imaging procedures. Before chemoradiation therapy, she underwent extraperitoneal aortic lymph node dissection for surgical staging at Vall d'Hebron University Hospital, Barcelona, Spain. Pelvic lymph node debulking was proposed to confirm positivity and, if so, to adjust the radiotherapy field and reduce lymph node radioresistance 1, 2.Interventions
After a complete extraperitoneal aortic infrarenal lymph node dissection as described by Querleu et al [3], the presacral space is created to expose the iliac vessels. The enlarged lymph nodes are identified and dissected using blunt dissection, monopolar energy, and a vessel sealing device.Measurements and Main Results
There were no intraoperative or postoperative complications. The anatomopathologic study confirmed positivity for adenocarcinoma metastasis in 3 pelvic nodes and 2 of 29 aortic nodes.Conclusion
Laparoscopic debulking of enlarged pelvic lymph nodes via the extraperitoneal approach is a feasible procedure. It can be performed as an extension of extraperitoneal aortic lymphadenectomy in selected patients with locally advanced cervical cancer. 相似文献13.
Adel Sedrati Amal Drizi Bruno van Herendael Dusan Djokovic 《Journal of minimally invasive gynecology》2019,26(1):29-30
Study Objective
To present and discuss the hysteroscopic aspects of incarcerated omentum through uterine perforation caused by previous dilation and curettage (D&C) for an incomplete first-trimester abortion.Design
A case report.Setting
Constantine University Hospital, Constantine, Algeria.Patient
A 40-year-old, gravida 3, para 2 patient, with a history of an incomplete first-trimester spontaneous abortion treated 6 months before by D&C requiring medical assistance because of moderate, chronic pelvic pain. No other clinical or biological alteration was found. The ultrasound showed intracavitary hyperechogenic formation infiltrating the myometrium posteriorly.Interventions
Hysteroscopy revealed a fatlike lesion arousing suspicion of a residual trophoblast; the differential diagnosis included intramyometrial fat metaplasia as well [1]. A mechanical cold loop resection was initiated. Instrumental manipulation of the mass released yellow drops, probably of lipid nature, subsequently leading to the discovery of a uterine perforation giving passage to the omentum. Histologic examination confirmed fat tissue. There was immediate resolution of symptoms. Laparoscopic repair was subsequently performed and consisted of suturing the defect. There were no further complications.Measurements and Main Results
Few cases of omentum incarceration in a perforated uterus diagnosed during laparotomy or by magnetic resonance imaging have previously been reported 2, 3, 4. To our knowledge, this is the first case revealed through hysteroscopy.Conclusion
In women with a history of intracavitary interventions such as D&C, omentum incarceration should be considered when hysteroscopy demonstrates a fatlike formation and yellow droplets released by pressing or mobilizing the formation. Surgeons should be cautious, never using electrosurgery on formations whose origin arouses suspicion. 相似文献14.
Antonio Mollo Antonio Raffone Francesco Paolo Improda Antonio Travaglino Gabriele Saccone Pierluigi Giampaolino Fulvio Zullo Giuseppe De Placido 《Journal of minimally invasive gynecology》2019,26(1):32-33
Study Objective
Angular pregnancy is a rare and life-threatening condition in which the embryo is implanted in the lateral angle of the uterine cavity, medial to the uterotubal junction and round ligament. Angular pregnancy is associated with a high risk of uterine rupture of about 23% [1]. No consensus has been achieved regarding the diagnostic and therapeutic approach of angular pregnancy [2]. Thus, the aim of this study was to report a case of hysteroscopic treatment of an angular pregnancy in a 34-year-old women.Design
Step-by-step video presentation of the surgical treatment (Canadian Task Force classification III).Setting
Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy.Patient
A 34-year-old woman. Written informed consent was obtained from the patient.Intervention
Hysteroscopy.Measurements and Main Results
A 34-year-old woman was admitted to our Department with pelvic pain at 6 weeks of gestation. β-Human chorionic gonadotropin (β-hCG) was 5331 mIU/mL. The transvaginal ultrasound showed a gestational sac of 15?×?11?mm in the left uterine angle of an embryo without cardiac activity. The woman opted for a conservative approach with multiple-dose methotrexate [3]. Five days later the β-hCG increased to 7589 mIU/mL with no regression of pregnancy at the transvaginal ultrasound. Therefore, a surgical approach was offered to the patient 4, 5. Laparoscopy showed normal salpinges, whereas hysteroscopy identified the gestational sac in the left uterine angle. A 5Fr bipolar electrode was used to open the gestational capsular decidua. The chorionic villi were progressively separated from the implantation site. Using grasping forceps we removed the specimen for histologic examination. Histologic examination confirmed the diagnosis of angular pregnancy. On the second postoperative day β-hCG was 1131 mIU/mL, and the patient was discharged the day after. At the 1-month follow-up visit, β-hCG and transvaginal ultrasound were negative for pregnancy. The office hysteroscopy showed an empty uterine cavity at 3-months' follow-up.Conclusion
Our case shows that hysteroscopy may be used as a diagnostic and therapeutic tool for angular pregnancy, providing a unique image of the intact removal of the gestational sac. 相似文献15.
Haider Jan Vishalli Ghai Stergios K. Doumouchtsis 《Journal of minimally invasive gynecology》2018,25(6):952-953
Study Objective
To demonstrate a mesh-free approach for uterine prolapse during a hysterectomy.Design
Technical video (Canadian Task Force classification III).Setting
Benign gynecology department at a university hospital.Patient
A 50-year-old woman.Intervention
Laparoscopic high uterosacral ligament suspension technique.Measurements and Main Results
A 50-year-old woman presented with irregular vaginal bleeding and grade 3 uterine prolapse. The patient was concerned regarding the use of mesh and erosion. After counseling the patient agreed to a mesh-free single procedure. The use of mesh for the treatment of pelvic organ prolapse has become the subject of controversy and litigation. Complications of mesh erosion have resulted in the US Food and Drug Administration reclassifying transvaginal meshes as high-risk devices in 2016 [1]. Mesh erosion risk is up to 23% with hysterectomy and concomitant laparoscopic sacrocolpopexy [2] and 3% with sacrohysteropexy [3]. We present an alternative laparoscopic approach of treating uterine prolapse with high uterosacral suspension during laparoscopic hysterectomy. Our method avoids the use of mesh, sacrocervicopexy and morcellation, or an interval sacrocolpopexy. Although high uterosacral ligament suspension can be performed vaginally, it carries up to an 11% risk of ureteric injury [4].Conclusion
In this video a bilateral ureterolysis is performed, before hysterectomy, isolating the uterosacral ligaments. These are then suspended to the vaginal vault in a purse-string fashion using Vicryl 0 (polyglactin 910) and intracorporeal knot-tying. Postprocedure the vault is well supported with a vaginal length of 12?cm. 相似文献16.
Hiroyuki Kanao Yoichi Aoki Terumi Tanigawa Maki Matoda Sanshiro Okamoto Hidetaka Nomura Kohei Omatsu Kazuyoshi Kato Kuniko Utsugi Nobuhiro Takeshima 《Journal of minimally invasive gynecology》2019,26(4):598-599
Study Objective
To show a novel combination laparoscopic and open perineal approach to complete resection of aggressive angiomyxoma.Design
Step-by-step video demonstration of the combination approach (Canadian Task Force classification III).Setting
Combined laparoscopic and open perineal approach was performed in the tertiary center.Patient
A 46-year-old woman presented with an 8-cm vulvar mass, diagnosed as an aggressive angiomyxoma. The patient, who strongly desired to preserve her uterus and ovaries, provided informed consent for resection of the tumor by our combination approach, also approved by our Institutional Review Board.Intervention
Combined laparoscopic and open perineal approach.Measurements and Main Results
Aggressive angiomyxoma is a rare mesenchymal neoplasm that occurs most often in the female pelviperineal region [1]. Aggressive angiomyxoma is locally infiltrative, and high postoperative local recurrence rates (36%–72%) due to incomplete resection have been reported [2]. Therefore, until recently, wide surgical excision with tumor-free margins have been the most commonly accepted treatment. However, aggressive angiomyxoma is a benign, slow-growing tumor, and because extensive surgical resection, which is associated with high operative morbidity rates, has not been shown to have a significant effect on prognosis, a more conservative procedure may be preferable [3]. The mass was located mainly at the left ischiorectal fossa, but it extended above the pelvic diaphragm and was attached to internal obturator muscle, vagina, bladder, urethra, and rectum. We excised the tumor completely and without complications by a combined laparoscopic and open perineal approach. Twelve months have passed since the surgery, and there has been no adjuvant treatment and no sign of recurrence.Conclusion
Our combination approach to aggressive angiomyxoma in the pelviperineal region is technically feasible, and the good visualization and meticulous dissection provided during the laparoscopic portion of the surgery contribute to complete resection. 相似文献17.
Haider Jan Michael Katesmark Vishalli Ghai 《Journal of minimally invasive gynecology》2019,26(4):600-601
Study Objective
To demonstrate our approach to laparoscopic excision of a noncommunicating rudimentary horn (AmericanSociety for Reproductive Medicine classification II(b), European Society of Human Reproduction and Embryology/European Society of Gynaecological Endoscop classification class U4a).Design
Technical video (Canadian Task Force classification level III).Setting
University Hospital.Patient
A 25-year-old women with a left-sided pelvic mass.Intervention
Laparoscopic excision of noncommunicating rudimentary horn with hysteroscopy and cystoscopy. Institutional Review Board/Ethics Committee ruled that approval was not required for this study.Measurements and Main Results
Noncommunicating rudimentary horns are present in 20% to 25% of women with a unicornuate uterus [1]. Noncommunicating rudimentary horns may be associated with dysmenorrhea, pelvic pain, subfertility, and poor obstetric outcomes. Laparoscopic excision of rudimentary horns can be challenging and complex. Factors to consider in relation to the rudimentary horn are attachment to the uterus, presence and course of the ureter, and vascular supply. In this video we demonstrate our approach to laparoscopic excision of a rudimentary horn including preoperative imaging to plan surgical care. A 25-year-old women presented with pelvic pain and underwent a laparotomy for a left-sided pelvic mass. Intraoperatively, a rudimentary horn was suspected, and she was started on a gonadotropin-releasing hormone analogue pending diagnostic imaging and definitive surgery. Computed tomography demonstrated an absent left kidney and ureter. Intraoperatively, we began with a cystoscopy to identify and confirm an efflux from ureteral openings. A real-time hysteroscopy was performed to identify the unicornuate uterus from the rudimentary horn and to exclude vaginal or cervical anomalies. Through hysteroscopic transillumination the plane of dissection was identified between the rudimentary horn and uterus 2, 3. This technique is especially useful when the rudimentary horn is densely fused to the unicornuate uterus. Retroperitoneal dissection was performed ipsilateral to the rudimentary horn. A lateral approach was used to coagulate the uterine artery at its origin. The bladder was reflected from the horn to allow excision. A Thunderbeat device (Olympus Medical Systems, Tokyo, Japan) was used to excise the rudimentary horn, keeping very close to the specimen to ensure no penetration of the unicornuate uterus. Hemostasis was achieved, and no additional sutures were required. The specimen was removed using in-bag morcellation.Conclusion
A stepwise hysteroscopic and laparoscopic approach can be used to safely resect a rudimentary horn as demonstrated by this case. 相似文献18.
19.
Matthew T. Siedhoff Michelle Louie Meenal Misal Janelle K. Moulder 《Journal of minimally invasive gynecology》2019,26(1):25-28
Study Objective
To demonstrate techniques for addressing the unique challenges for a minimally invasive approach to hysterectomy presented by a massive myomatous uterus.Design
Technical video of an operation demonstrating the methods used to perform hysterectomy in this setting, highlighting such aspects as port placement (Fig. 1), uterine manipulation (Fig. 2), exposure, and vascular control (Fig.?3, Fig.?4) (Canadian Task Force classification III).Setting
Academic tertiary care hospital.Intervention
A 49-year-old woman elected to proceed with laparoscopic hysterectomy after years of suffering from bleeding and bulk symptoms from a massively enlarged myomatous uterus. A computed tomography scan estimated uterine dimensions of 32?×?27?×?24?cm, for a volume of >7000?mL (Fig. 5). Her surgical history included a ventral herniorrhaphy with mesh, and her body mass index was 43?kg/m2. She was a Jehovah's Witness, and thus blood transfusion was not an acceptable option for her due to a religious prohibition. Intraoperatively, the uterus extended deep into the pararectal and paravesical spaces on the right, from the caudad below the cervix (Fig. 6) to superiorly near the liver edge (Fig. 7).Measurements and Main Results
Laparoscopic hysterectomy was successfully completed (Table), and the patient was discharged on the day after surgery. Final pathology revealed a 6095-g uterus with benign leiomyomata. She presented 9 days after surgery with nausea and vomiting, suspicious for an incarcerated hernia at the tissue extraction site. Her symptoms were ultimately determined to be due to either ileus or small bowel obstruction, which likely could have been managed nonoperatively with bowel rest and fluids. She stayed an additional 2 days after readmission and was then discharged, with no further complications.Conclusions
The size of the uterus was once considered a barrier to the use of laparoscopy for hysterectomy, but experience has shown that the benefits of minimally invasive surgery are particularly relevant for large myomas 1, 2, 3, 4, given that a vaginal approach is not feasible and that other risks, such as wound complications and venous thromboembolism, would be greater with the large incision required to perform the procedure by laparotomy. This video uses a particularly challenging case to demonstrate a roadmap for addressing myomas in laparoscopic hysterectomy through exposure and vascular control. Although the presentation focused on the initial steps of the procedure and not on uterine extraction, this patient's readmission highlights potential complications associated with various methods of tissue removal for very large specimens. 相似文献20.
Emilie Schwartz Emilie Faller Chérif Youssef Akladios Michel Greget Catherine Roy Arnaud Wattiez 《Journal of minimally invasive gynecology》2019,26(2):363-364