The Journal of Minimally Invasive Gynecology

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2012-05-01

Trendelenburg or Trendelenberg, What’s in a Name?

Stephen L. Corson — 2012-05-01

You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-19-2-12-00009

Surgical Simulation: Where Have We Come From? Where Are We Now? Where Are We Going?

Malcolm G. Munro — 2012-05-01

Abstract: It is now clear to most stakeholders that acquisition of surgical psychomotor skills is best achieved outside of the clinical operating room, in the context of a simulated environment. Endoscopic simulation can be accomplished using simple “box” simulators or video trainers, and virtual reality simulation is now possible using microprocessor-controlled systems. Structured surgical training performed outside of the operating room environment is relatively new to health care, a circumstance different from the process of pilot training, in which simulation has been a mainstay for more than 75 years and in which virtual reality simulation is now the norm. Those charged with surgical education are faced with a dilemma as, while attempting to understand the basic goals of simulation, they are simultaneously faced with choice between relatively inexpensive video trainers and the often prohibitively expensive virtual reality systems. This article explores the history of simulation, reports the results of a modified systematic review of currently available systems and performance, and identifies the gaps in current research and development. It is apparent that available video trainers provide the opportunity for skill development that at present is not surpassed by virtual reality systems. In the future, there will likely be an increasing role for virtual reality; however, challenges remain that include determination of the appropriate metrics and system design, and the fiscal resources necessary for the required hardware and related software development.

Localized Subendometrial Leiomyomatosis at Hysteroscopy

Atul Kumar, Alka Kumar — 2012-05-01

You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-19-3-11-00295

Recurrent Torsion of a Noncystic Adnexa After Plication of the Utero-Ovarian Ligament

Noga Fuchs, Zvi Vaknin, Sharon Berger, Moty Pansky — 2012-05-01

You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-19-3-11-00318

Uterine Smooth Muscle Tumors of Uncertain Malignant Potential: Diagnostic Challenges and Therapeutic Dilemmas. Report of 2 Cases and Review of the Literature

2012-05-01

Abstract: Morphologically, there exist variants of uterine smooth muscle tumors that cannot be clearly interpreted and classified as benign or malignant. Because their behavior and clinical prognosis is also uncertain, the World Health Organization has termed these “smooth muscle tumors of uncertain malignant potential” (STUMP). Herein we describe 2 cases, present a review of the literature, and highlight the diagnostic challenges and therapeutic dilemmas associated with uterine STUMP in myomectomy specimens from women who wish to maintain or enhance their fertility. The clinical course of residual STUMP remains speculative.

Redefining Reproductive Surgery

Togas Tulandi, Alicia Marzal — 2012-02-20

Abstract: With the availability of and improvements in in vitro fertilization (IVF), the role of reproductive surgery has been questioned. Yet, the scope of reproductive surgery today is much larger than in the past. Hysteroscopic correction of intrauterine disease is an important endoscopic procedure in women with infertility. Evidence suggests that correction of intrauterine disease is often followed by spontaneous pregnancy and improved IVF outcome. Hysteroscopic examination should be considered after 1 failed IVF. Today, it is clear that removal of the hydrosalpinx leads to a higher IVF-related live birth rate. The procedure should be performed thoroughly without compromising the ovarian blood supply. The IVF pregnancy rate is not affected by the presence of ovarian endometriomas, and small endometriomas need not be removed; however, large and symptomatic endometriomas that interfere with oocyte retrieval should be excised. When excision of the cyst wall is difficult, fenestration and ablation should be considered. This might lead to an increased recurrence rate, but is associated with less interference of the ovarian reserve. Although the role of reproductive surgery as primary treatment for tuboperitoneal infertility is limited, it has an important role in enhancing the outcome of IVF treatment and in preservation of fertility. Surgical preservation of fertility consists of ovarian suspension, ovarian excision for cryopreservation, and ovarian tissue transplantation.

Anatomic and Functional Outcomes with the Prolift Procedure in Elderly Women with Advanced Pelvic Organ Prolapse Who Desire Uterine Preservation

2012-01-30

Abstract: Study Objective: To assess the clinical outcomes of total mesh repair with the Prolift technique as treatment of advanced pelvic organ prolapse in elderly patients who desire uterine preservation.Design: Case control series study (Canadian Task Force classification II-2).Setting: Medical school–affiliated hospital.Patients: Sixty-eight patients over the age of 70 years with advanced pelvic organ prolapse, Pelvic Organ Prolapse Quantification stage III (n = 59) or IV (n = 9), underwent a total Prolift procedure and were followed up for a minimum of 2 years.Interventions: Transvaginal pelvic floor repairs were performed with a total Prolift system. The concurrent pelvic surgery included midurethral sling operation with a TVT-O, if indicated. The assessment included intraoperative and postoperative complications, Urogenital Distress Inventory scores, and Incontinence Impact Questionnaire scores.Measurements and Main Results: Objective and subjective data were available for 68 patients. The anatomic success rate was 97.1% after 2 years. Complications included bladder perforation in 1 patient (1.5%), de novo stress urinary incontinence in 20 patients (29.4%), dyspareunia in 4 patients (22.2%), and vaginal erosion in 1 patient (1.5%). The Pelvic Organ Prolapse Quantification stages, Urogenital Distress Inventory scores, and Incontinence Impact Questionnaire scores all improved significantly after surgery.Conclusions: The total Prolift procedure is an alternative surgical option that uses a minimally invasive transvaginal approach to surgically treat elderly patients with advanced pelvic organ prolapse.

New Challenges in Detecting, Grading, and Staging Endometrial Cancer After Uterine Morcellation

Colleen Rivard, Alia Salhadar, Kimberly Kenton — 2012-03-15

Abstract: Study Objective: To evaluate the accuracy in diagnosing endometrial disease after uterine morcellation.Design: Prospective case series.Setting: University medical center.Patients: Five women undergoing hysterectomy without morcellation because of benign indications and 5 women with endometrial cancer.Interventions: Uterine specimens were obtained from all 10 study patients. The uteri were sent for pathologic analysis, processed, and fixed according to standard protocols. A single investigator then morcellated all 10 uteri. A single pathologist blinded to specimen group reviewed each specimen.Main Results: The pathologist identified endometrial cancer in 4 of 5 specimens of known cancer. The fifth specimen was interpreted as benign despite the presence of grade 1, stage IA endometrial adenocarcinoma. None of the morcellated specimens could be staged.Conclusion: The increasing use of uterine morcellation will result in new challenges for gynecologic oncologists secondary to difficulty in detection, and accurate grading and staging of endometrial cancer.

Patients With Endometriosis of the Rectosigmoid Have a Higher Percentage of Natural Killer Cells in Peripheral Blood

2012-02-20

Abstract: Study Objective: To estimate the concentration of natural killer (NK) cells in the peripheral blood in patients with and without endometriosis.Design: Case-control study (Canadian Task Force classification II-2).Setting: Tertiary referral hospital.Patients: One hundred fifty-five patients who had undergone videolaparoscopy were divided into 2 groups: those with endometriosis (n = 100) and those without endometriosis (n = 55).Interventions: The percentage of NK cells relative to peripheral lymphocytes was quantified at flow cytometry in 155 patients who had undergone laparoscopy. In addition to verifying the presence of endometriosis, stage of disease and the sites affected were also evaluated.Measurements and Main Results: The mean (SD) percentage of NK cells was higher (15.3% [9.8%]) in patients with endometriosis than in the group without the disease (10.6% [5.8%]) (p < .001). The percentage of NK cells was highest (19.8 [10.3%]) in patients with advanced stages of endometriosis and in those in whom the rectosigmoid colon was affected. In a statistical model of probability, the association of this marker (NK cells ≥11%) with the presence of symptoms such as pain and intestinal bleeding during menstruation and the absence of previous pregnancy yielded a 78% likelihood of the rectosigmoid colon being affected.Conclusion: Compared with patients without endometriosis, those with endometriosis demonstrate a higher concentration of peripheral NK cells. The percentage of NK cells is greater, primarily in patients with advanced stages of endometriosis involving the rectosigmoid colon. Therefore, it may serve as a diagnostic marker for this type of severe endometriosis, in particular if considered in conjunction with the symptoms.

Repeat Operation for Treatment of Persistent Pudendal Nerve Entrapment After Pudendal Neurolysis

Michael Hibner, Mario E. Castellanos, David Drachman, James Balducci — 2012-02-10

Abstract: Study Objectives: To describe a new approach to transgluteal pudendal neurolysis and transposition and to review the outcome in 10 patients who underwent repeat operation because of persistent pudendal neuralgia after failing to improve after initial surgical decompression.Design: Retrospective analysis (Canadian Task Force classification II-3).Setting: Academic chronic pelvic pain practice at St. Joseph’s Hospital and Medical Center in Phoenix, Arizona.Patients: Women and men with persistent pudendal neuralgia after undergoing transgluteal pudendal neurolysis and transposition.Intervention: Transgluteal decompression of the pudendal nerve was performed in all 10 patients. In brief, a transgluteal incision was made, and the pudendal nerve was identified via a nerve integrity monitoring system. Adhesiolysis was performed from the piriformis muscle to the distal Alcock canal using a Zeiss NC-4 surgical microscope. The nerve was then enclosed in NeuraWrap Nerve Protector and coated with activated platelet-rich plasma. An ON-Q PainBuster catheter was place along the nerve into the Alcock canal, and 0.5% bupivacaine was infused at 2 mL/hr. The sacrotuberous ligament was repaired using an Achilles or gracillis cadaver ligament. The overlying subcutaneous tissue and skin were then closed.Measurements and Main Results: From June 2008 to March 2010, 10 consecutive patients (7 women and 3 men; age range, 29–81 years) underwent repeat operation with transgluteal decompression of the pudendal nerve. Neuropathic pain was unilateral (n = 8) or bilateral (n = 2), in the clitoris or penis (30%), vulva or scrotum (70%), perineum (40%), and rectum (50%). Of the 10 patients, 1 patient was lost to follow-up. Mean follow-up was 23 months. Eight of 9 patients reported global improvement, with 2 patients reporting complete resolution of symptoms. One patient reported no change. Pain, as measured using an 11-point numerical scale, improved from a mean of 7.2 to 4.0 (p = .02), with 5 patients reporting clinically significant improvement (change, ≥2). Comfortable sitting or maximum time that the patient was able to sit without exacerbation of pain improved in 8 patients, with a change in median time of 5 to 45 minutes (p = .008). Change in the ability to sit correlated well with patient-reported global improvement (correlation coefficient, 0.86). No patient experienced worsening of symptoms.Conclusion: Patients with persistent pudendal neuralgia after surgical decompression may benefit from repeat operation via our novel approach. Ability to sit correlates well with reported improvement due to surgery.

MiniArc Single-Incision Sling in the Office Setting

James B. Presthus, Douglas Van Drie, Christopher Graham — 2012-03-01

Abstract: Study Objective: To report MiniArc single-incision sling efficacy results in the office setting and the feasibility of performing the procedure in the office.Design: Prospective, single-arm, nonrandomized, institutional review board–approved study (Canadian Task Force classification II-2).Setting: Three in-office clinical sites in the United States.Patients: Thirty-eight patients who underwent treatment of stress urinary incontinence using the MiniArc single-incision sling.Intervention: A MiniArc single-incision sling was placed in 38 patients in an office-based setting under intravenous or oral sedation and/or local anesthesia.Measurements and Main Results: Thirty-eight implant recipients were evaluated for effectiveness and safety via qualitative (Urinary Distress Inventory–Short Form [UDI-6] and Incontinence Impact Questionnaire–Short Form [IIQ-7]) and quantitative (1-hour pad-weight test and cough stress test) measurements at 3 clinical sites. Secondary outcome measures included procedure time, estimated blood loss, length of stay, perioperative complications, Wong-Baker Faces Pain Scale, and adverse events. During the study, 38 women (mean [SD; 95% CI] age, 48.1 (8.4; 45.3–50.8 years)) received slings. Mean procedure time was 10.6 minutes, estimated blood loss was 23.2 mL, and length of stay was 1.3 hours. At discharge, the Wong-Baker pain score was 0.2 (0.0–2.0). At 2 years, 31 patients were available for follow-up. Of these, 93.5% had normal findings on the cough stress test, and 90.3% had pad weight <1 g; and 90.6% and 87.5%, respectively, using last failure carried forward analysis in 32 patients. The UDI-6 and IIQ-7 median scores showed a statistically significant decrease from baseline (p < .001). There were no reports of serious adverse events or of bowel, urethral, bladder, or major vessel perforation.Conclusion: The in-office experience suggests that implantation of a single-incision sling for treatment of stress urinary incontinence with the patient under intravenous or oral sedation and/or local anesthesia can be performed safely, with effective results. Thus, performing this procedure in an office setting is a viable option.

Laparoscopic Supralevator Repair for Combined Apical and Posterior Compartment Prolapse

Elvis I. Seman, Nicholas D. Bedford, Robert T. O’Shea, Marc J.N.C. Keirse — 2012-02-13

Abstract: Study Objective: To analyze the objective outcome of laparoscopic supralevator repair in the treatment of rectoenterocele with the Pelvic Organ Prolapse Quantification (POPQ) system.Study Design: Retrospective cohort study 1999–2009 (Canadian Taskforce Classification II–2).Setting: University hospital in South Australia.Patients: A total of 166 women with a median age of 63 years (range 36–89) who underwent laparoscopic supralevator repair for rectoenterocele and treatment of associated conditions over a 10-year period.Interventions: All patients were assessed with the POPQ scoring system before surgery and at 6 weeks, 6 months, annually, and biannually after surgery.Measurements and Main Results: The median operating time was 151 minutes (range 35–390); median blood loss was 50 mL (range 50–600); and median hospital stay was 4 days (range 1–14). Four women, 2 of whom required laparotomy, had a major complication. Ten women (6%) needed day surgery to treat vaginal granulations or suture exposure. With a median follow-up time of 45 months (interquartile range 16–67) the overall objective success rate was 63% according to National Institute of Health criteria. The median time to failure was 24 months. Of 61 objective failures, 23 required further prolapse surgery, representing a 14% reoperation rate.Conclusion: Laparoscopic supralevator repair is a safe and effective procedure for the treatment of rectoenterocele.

Learning Curves for Single-Site Laparoscopic Ovarian Surgery

2012-02-10

Abstract: Study Objective: To compare learning curves for laparoendoscopic single-site surgery (LESS) for ovarian tumors according to the type of procedure (oophorectomy vs cystectomy).Design: A prospective cohort study. (Canadian Task Force Classification II-2).Setting: University hospital.Patients: One hundred fifteen patients who planned to undergo LESS for ovarian tumors by a surgeon between May 2008 and August 2010.Interventions: LESS.Measurements and Main Results: The learning curve was assessed through the graph between the operative time and sequence of cases. Proficiency, defined as the point at which the slope of the learning curve became less steep, and surgical outcome were compared between the two surgery groups. LESS was successfully completed in 103 of 115 patients (94.8%). Learning curve for oophorectomies (n = 59) showed a continued slow slope with no apparent proficiency, suggesting oophorectomies did not pose an initial technical challenge. However, proficiency in cystectomies (n = 56) was evident at the thirty-third case. Furthermore, the oophorectomy group had a shorter operative time and less need for additional ports than the cystectomy group (69.4 minutes vs 100.1 minutes; 5.1% vs 14.3%).Conclusion: Oophorectomy rather than cystectomy is recommended as the initial procedure to start with LESS for ovarian tumors.

Topical Anesthetic (Lidocaine-Prilocaine) Cream Application Before Speculum Examination in Postmenopausal Women

2012-03-15

Abstract: Study Objective: To evaluate the effectiveness of lidocaine–prilocaine (EMLA 5%) cream application to genital mucosa for reducing pain or discomfort associated with speculum examination in postmenopausal women.Design: A randomized controlled study (Canadian Task Force classification I).Setting: A university hospital.Patients: One-hundred thirty-four postmenopausal women.Interventions: The subjects were randomized to an EMLA cream group, a lubricant gel group, or a control group. General data was collected, including age, body weight, gravidity, parity, smoking habits, history of diabetes mellitus, previous gynecologic operations, dyspareunia, sexual activity, and duration of menopause. All patients were asked to score pain at 3 time points (insertion, dilation, and extraction of speculum) during the procedure using a visual analog scale. Pain intensity during speculum examination was compared between the groups.Measurements and Main Results: There was no statistically significant difference between the EMLA cream, the lubricant gel, and the control groups in terms of age, weight, gravidity, parity, dyspareunia, duration of menopause, sexual activity, smoking habit, diabetes mellitus, previous vaginal and other gynecological procedures, vaginal length, and serum follicle-stimulating hormone and estradiol levels (p > .05). The pain scores obtained during all phases of speculum application were significantly lower in the EMLA group than in both the lubricant gel and the control groups (p < .001). Comparing the gel and the control groups, a lower pain score was observed in the former, except for the second phase of the examination (p < .001).Conclusion: Topical application of EMLA 5% cream on genital mucosa of postmenopausal women before vaginal examination significantly reduces pain associated with speculum application.

Endometrial Preparation With Estradiol Plus Dienogest (Qlaira) for Office Hysteroscopic Polypectomy: Randomized Pilot Study

2012-02-10

Abstract: Study Objective: To estimate the effectiveness of Qlaira for endometrial preparation in women undergoing hysteroscopic polypectomy in the office setting.Design: Randomized clinical pilot study (Canadian Task Force classification II-2).Setting: Academic research environment.Patients: Seventy-four cycling women undergoing hysteroscopic polypectomy (polyp size <1.5 cm).Interventions: Women were randomized to be operated on during the proliferative phase (cycle day 5–7) of a spontaneous cycle (group A) or after 9 to 11 days of Qlaira intake (group B). Polypectomy was performed by using forceps and bipolar electrodes when required.Measurements and Main Results: The quality of visualization of the uterine cavity during the procedure (visual analog score [VAS] 0–5, bad to optimal), total surgeon satisfaction (VAS 0–5, very difficult to easy to perform), and total patient satisfaction (VAS 0–5, severe pain to no pain) were compared. Endometrial thickness before and at the end of the procedure was significantly less in women in group B. Mean duration of interventions was shorter in group B than in group A. In addition, vision quality, and surgeon and patient satisfaction rates were significantly higher in women in group B.Conclusions: At 10 days before surgery, administration of Qlaira is effective for preparation of the endometrium for hysteroscopic polypectomy in the office setting. With preoperative administration of Qlaira, the surgical procedure can be performed more easily and faster, and both surgeon and patient satisfaction rates are improved.

Waiting Time and Pain During Office Hysteroscopy

2012-03-05

Abstract: Study Objective: To find a correlation between the waiting time between counseling about and performance of office hysteroscopy and the perception of pain.Design: Observational study (Canadian Task Force classification II-2).Setting: Academic environment.Patients: Two hundred eighty-four women undergoing hysteroscopy.Interventions: Diagnostic hysteroscopy with endometrial biopsy.Measurements and Main Results: Before examination, patients were asked to complete 2 forms, the STAI-S (State-Trait Anxiety Inventory, State) and STAI-T (State-Trait Anxiety Inventory, Trait) anxiety scales, for evaluation of their usual anxiety state and their state of anxiety during the examination. Patients were asked to quantify on a visual analog scale the pain felt during the examination. A statistically significant positive correlation, even if weak, was demonstrated between pain and waiting time (r = 0.45; p < .01) but not with the values for the anxiety state (r = 0.06; p = .56) and anxiety trait (r = −0.05; p = .66). Pain (≥4) was significantly associated with waiting time (≥60 minutes) (odds ratio [OR], 5.21; 95% confidence interval [CI], 1.29–35.50), age (OR, 1.57; 95% CI, 0.40–5.87) and menopause (OR, 2.81; 95% CI, 1.10–7.40) but not with STAI-S level (≥34) (OR, 0.87; 95% CI, 0.26–3.12) or STAI-T level (≥34) (OR, 0.65; 95% CI, 0.19–2.32).Conclusion: Office hysteroscopy is associated with a level of anxiety that can affect patient tolerability of the procedure. However, factors such as reducing waiting time may have a positive effect on patient compliance, making hysteroscopy easier and thereby increasing its diagnostic and therapeutic potential.

Orifice-Assisted Small-Incision Surgery: Case Series in Benign and Oncologic Gynecology

Jon I. Einarsson, Sarah L. Cohen, Shailesh Puntambekar — 2012-03-15

Abstract: This case series describes the feasibility of orifice-assisted small-incision surgery (OASIS), a novel technique that may incorporate benefits of single-incision and natural-orifice surgery while minimizing issues such as instrument crowding and interaction of optical access with operative instrumentation. In our multiple-site series, we included patients from a large academic medical center in the northeastern United States and a private gynecology clinic in India. Between the 2 centers, a total of 14 patients (5 with benign disease and 9 with oncologic disease) underwent the following procedures: OASIS total laparoscopic hysterectomy, laparoscopic supracervical hysterectomy, laparoscopic myomectomy, or laparoscopic radical hysterectomy with pelvic lymph node dissection. The initial 14 cases were safely completed. Oncologic clearance was consistent with specialty norms. Operating time ranged from 60 to 150 minutes, and estimated blood loss ranged from 10 to 500 mL. Detailed procedure descriptions and videos are provided. Based on preliminary case series experience, OASIS seems to be a safe and feasible addition to the advanced minimally invasive surgeons’ armamentarium for both benign and oncologic cases.

New Hysteroscopy Pump to Monitor Real-Time Rate of Fluid Intravasation

Atul Kumar, Alka Kumar — 2012-03-19

Abstract: This article describes the benefit of monitoring the intravasation rate in addition to the conventional measurement of fluid deficit in hysteroscopic surgical procedures. The intravasation rate is the rate, in milliliters per minute, at which fluid enters the systemic circulation, whereas fluid deficit is the amount of irrigation fluid, in milliliters, already absorbed by the patient. To determine the intravasation rate, a manually operated intravasation monitoring pump was constructed, with which one of us (Dr. Atul Kumar) performed 966 hysteroscopic procedures from May 1993 to February 2010. Because the intravasation rate had to be manually calculated by an assistant, it was decided to replace the assistant with a controller to monitor intravasation rate. The surgical experience gathered from the manually operated pump was used to develop algorithms for the controller. The controller-operated intravasation monitoring pump was constructed, with which 41 hysteroscopic procedures were performed from March 2010 to August 2011. In hysteroscopic procedures, this pump simultaneously displays the real-time intravasation rate and the fluid deficit on an LCD screen.

Liability Exposure for Surgical Robotics Instructors

Yu L. Lee, Gokhan Kilic, John Y. Phelps — 2012-05-01

Abstract: Surgical robotics instructors provide an essential service in improving the competency of novice gynecologic surgeons learning robotic surgery and advancing surgical skills on behalf of patients. However, despite best intentions, robotics instructors and the gynecologists who use their services expose themselves to liability. The fear of litigation in the event of a surgical complication may reduce the availability and utility of robotics instructors. A better understanding of the principles of duty of care and the physician-patient relationship, and their potential applicability in a court of law likely will help to dismantle some concerns and uncertainties about liability. This commentary is not meant to discourage current and future surgical instructors but to raise awareness of liability issues among robotics instructors and their students and to recommend certain preventive measures to curb potential liability risks.

Disseminated Peritoneal Leiomyomatosis With Endometriosis

Florian Mueller, Kerstin Kuehn, Hermann Neudeck, Nina Siedentopf, Uwe Ulrich — 2012-05-01

Abstract: Herein is described the case of a 41-year-old woman with disseminated peritoneal leiomyomatosis with distinct endometriosis. The pathogenesis of both conditions is as yet unclear; however, the 2 main hypotheses are discussed. Metaplastic origin from the secondary müllerian system has been suggested, as well as metastatic development. Inasmuch as spontaneous regression is likely, and the course of the disease can be influenced by hormonal withdrawal, operative measures could be refined to ensure the correct diagnosis and benignity.

Cystically Degenerated Leiomyoma of the Rectosigmoid Managed Laparoscopically at 13 Weeks of Gestation

Nadim Hawa, James Robinson, Vincent Obias — 2012-05-01

Abstract: The safety of laparoscopic management of adnexal masses in pregnancy has been documented. Herein we report laparoscopic removal during pregnancy of a cystically degenerated leiomyoma of the sigmoid colon, which had been mistaken for an adnexal mass. When smooth muscle gastrointestinal tumors are observed, it is important that they be characterized with appropriate markers so that postoperative treatment can be individualized to the patient.

Combined Preoperative Angiography With Transient Uterine Artery Embolization Makes Laparoscopic Surgery for Massive Myomatous Uteri a Reasonable Option: Case Reports

Nadim Hawa, James Robinson, Britton Elizabeth Chahine — 2012-05-01

Abstract: Herein are reported perioperative outcomes in 2 women who underwent laparoscopic myomectomy and hysterectomy to treat massive leiomyomas. Although we counseled the patients about the high risk of conversion to laparotomy, we would not have attempted the laparoscopic approach without a preoperative angiogram and transient uterine artery embolization. Preoperative angiography and selective embolization enable identification of an aberrant parasitic blood supply and minimization of intraoperative bleeding. In the appropriate hands, these tools make a minimally invasive surgical approach possible even for the largest myomatous specimens.

Hysteroscopic Sterilization in an Immunosuppressed Patient

Vinita J. Speir, Ashkaun Razmara, Naghmeh S. Saberi — 2012-05-01

Abstract: Essure sterilization produces a local benign tissue response resulting in bilateral occlusion of the fallopian tubes 3 months after insertion. There is a precautionary warning about performing this procedure on immunosuppressed patients. We present a case of successful bilateral tubal occlusion with Essure in a patient with a history of kidney transplantation and receiving immunosuppressive medications.

Inferior Epigastric Artery Pseudoaneurysm Following Trocar Injury

Karen L. Splinter, Colleen L. Cook — 2012-05-01

Abstract: Herein is described the development of an inferior epigastric pseudoaneurysm caused by a trocar injury during laparoscopic surgery. After the accessory trocar was placed in the left lower quadrant, the patient’s condition became clinically unstable, requiring blood transfusions postoperatively and transfer to our tertiary care center. On arrival, she continued to have pain, with a palpable tender mass in the left lower quadrant. A computed tomography scan revealed a 5 × 6-cm mass in the anterior rectus sheath, with central hyperattenuation. This was better characterized at ultrasonography. The findings were consistent with an unstable pseudoaneurysm from the left inferior epigastric artery, with surrounding hematoma. Urgent embolization was performed by Interventional Radiology using coils inserted distal, into, and proximal to the pseudoaneurysm. The patient’s condition was stable after the procedure, and she returned to the referring hospital for convalescence. Pseudoaneurysm of the inferior epigastric artery from a trocar injury is a rare occurrence. This case is the first report of a pseudoaneurysm forming in the inferior epigastric artery resulting from a trocar injury during gynecologic surgery.

Sacral Nerve Infiltrative Endometriosis Presenting as Perimenstrual Right-sided Sciatica and Bladder Atonia: Case Report and Description of Surgical Technique

2012-05-01

Abstract: Endometriosis infiltrating the sacral nerve roots is a rarely reported manifestation of the disease. The objectives of this article are to report such a case and to describe the surgical technique for laparoscopic decompression of sacral nerve roots and treatment of endometriosis at this site. The patient as a 38-year-old woman who had undergone 2 previous laparoscopic procedures for electrocoagulation of peritoneal endometriosis and self-reported perimenstrual right-sided sciatica and urinary retention. Clinical examination revealed allodynia (pain from a stimulus that does not normally cause pain) on the S2 to S4 dermatomes and hypoesthesia on part of the S3 dermatome. Magnetic resonance imaging showed an endometriotic nodule infiltrating the anterior rectal wall. Laparoscopic exploration of the sacral nerve roots demonstrated vascular compression of the lumbosacral trunk and endometriosis entrapping the S2 to S4 sacral nerve roots, with an endometrioma inside S3. The endometriosis was removed from the sacral nerve roots and detached from the sacral bone, and a nodulectomy of the anterior rectal wall was performed. Normal urinary function was restored on postoperative day 2, and pain resolved after a period of post-decompression. Intrapelvic causes of entrapment of sacral nerve roots are rarely described in the current literature, either because of misdiagnosis or actual rareness of the condition. Recognition of the clinical markers for these lesions may lead to an increase in diagnosis and specific treatment.

Letter to the Editor

Richard M. Soderstrom — 2012-05-01

In the November/December 2011 issue of the Journal, Basim Abu-Rafea et al published an article alerting the reader to an increased risk of bowel burns associated with the well-known electrical phenomenon of capacitance. Their study and conclusions are compelling and should be appreciated. The authors also alert the reader to the findings and recommendations of the Emergency Care Research Institute, to which I first raised this issue in 1978 .

Reply

Basim Abu-Rafea, George A. Vilos — 2012-05-01

We thank Dr. Soderstrom for his kind comments and remarks about our publication on single-port laparoscopy . We are also grateful to Dr. Soderstrom for sharing his wisdom and long-time work and experience on laparoscopy, electrosurgery, and medicolegal issues throughout his years involved with the AAGL and other medical societies .

Letter to the Editor

Mark A. Rettenmaier, Bram H. Goldstein — 2012-05-01

I enjoyed reading the article composed by Spencer and Schorge et al documenting their experience with same-day discharge in patients with endometrial cancer. The authors reported that 55% of their subjects were discharged on postoperative day 1, irrespective of disease stage. However, I was surprised by their implication in the publication’s title that same-day discharge is uncommon.

Reconstructive and Reproductive Surgery in Gynecology

Charles E. Miller — 2012-05-01

Reconstructive and Reproductive Surgery in Gynecology, edited by Victor Gomel and Andrew Brill, contains bountiful information that will, no doubt, instantaneously become a reference for both the young gynecologist in training, as well as the experienced practitioner whose practice is devoted to operative gynecology. Although costly ($378.00), given the vast context, the quality of paper used, the ample use of color surgical photographs, and illustrations, it is obvious that the publisher, Informa Healthcare, spared no expense in the production of this book.

Aromatase Inhibition for Refractory Endometriosis-Related Chronic Pelvic Pain

Gary N. Frishman — 2012-05-01

This retrospective study from Northwestern University in Chicago looked at 16 women with chronic pain and endometriosis in whom previous conventional medical or surgical therapy had failed. Patients were treated with the aromatase inhibitor letrozole at a dose of 2.5 mg/d alongside either norethindrone acetate (2.5 mg/d) or combination oral contraceptives acting as a gonadotropin suppressor. Total treatment time averaged 6 months. The median pain scale score dropped from 7 at baseline to 1.5. Five of 16 patients discontinued therapy because of either side effects (n = 3) or persistent pain (n = 2). Similar to other medical modalities, pain recurred after discontinuation of therapy in most women.

Ovarian Endometrioma Ablation Using Plasma Energy Versus Cystectomy: A Step Toward Better Preservation of the Ovarian Parenchyma in Women Wishing To Conceive

Gary N. Frishman — 2012-05-01

Cystectomy for endometriomas is historically accepted as both the most successful treatment to reduce recurrence as well as a technique that unavoidably removes healthy ovarian tissue thus potentially compromising function.

Groin Pain in Women: Use of Sonography to Detect Occult Hernias. Review

Frances R. Batzer — 2012-05-01

Evaluation of groin pain in women can be difficult. Multiple causes associated with the reproductive, urologic, musculoskeletal, neurologic and gastrointestinal systems may be involved. Groin hernia, often occult, is one of the more difficult conditions to diagnose. Although groin hernia repair is among the most common surgical procedures, only 6% to 8% are performed in women.

Meetings Calendar/Masthead

2012-05-01

Society Affiliations

2012-05-01

Editorial Board

2012-05-01

Board of Trustees

2012-05-01

The Journal of Minimally Invasive Gynecology

Cover 1

Trendelenburg or Trendelenberg, What’s in a Name?

Surgical Simulation: Where Have We Come From? Where Are We Now? Where Are We Going?

Localized Subendometrial Leiomyomatosis at Hysteroscopy

Recurrent Torsion of a Noncystic Adnexa After Plication of the Utero-Ovarian Ligament

Uterine Smooth Muscle Tumors of Uncertain Malignant Potential: Diagnostic Challenges and Therapeutic Dilemmas. Report of 2 Cases and Review of the Literature

Redefining Reproductive Surgery

Anatomic and Functional Outcomes with the Prolift Procedure in Elderly Women with Advanced Pelvic Organ Prolapse Who Desire Uterine Preservation

New Challenges in Detecting, Grading, and Staging Endometrial Cancer After Uterine Morcellation

Patients With Endometriosis of the Rectosigmoid Have a Higher Percentage of Natural Killer Cells in Peripheral Blood

Repeat Operation for Treatment of Persistent Pudendal Nerve Entrapment After Pudendal Neurolysis

MiniArc Single-Incision Sling in the Office Setting

Laparoscopic Supralevator Repair for Combined Apical and Posterior Compartment Prolapse

Learning Curves for Single-Site Laparoscopic Ovarian Surgery

Topical Anesthetic (Lidocaine-Prilocaine) Cream Application Before Speculum Examination in Postmenopausal Women

Endometrial Preparation With Estradiol Plus Dienogest (Qlaira) for Office Hysteroscopic Polypectomy: Randomized Pilot Study

Waiting Time and Pain During Office Hysteroscopy

Orifice-Assisted Small-Incision Surgery: Case Series in Benign and Oncologic Gynecology

New Hysteroscopy Pump to Monitor Real-Time Rate of Fluid Intravasation

Liability Exposure for Surgical Robotics Instructors

Disseminated Peritoneal Leiomyomatosis With Endometriosis

Cystically Degenerated Leiomyoma of the Rectosigmoid Managed Laparoscopically at 13 Weeks of Gestation

Combined Preoperative Angiography With Transient Uterine Artery Embolization Makes Laparoscopic Surgery for Massive Myomatous Uteri a Reasonable Option: Case Reports

Hysteroscopic Sterilization in an Immunosuppressed Patient

Inferior Epigastric Artery Pseudoaneurysm Following Trocar Injury

Sacral Nerve Infiltrative Endometriosis Presenting as Perimenstrual Right-sided Sciatica and Bladder Atonia: Case Report and Description of Surgical Technique

Letter to the Editor

Reply

Letter to the Editor

Reconstructive and Reproductive Surgery in Gynecology

Aromatase Inhibition for Refractory Endometriosis-Related Chronic Pelvic Pain

Ovarian Endometrioma Ablation Using Plasma Energy Versus Cystectomy: A Step Toward Better Preservation of the Ovarian Parenchyma in Women Wishing To Conceive

Groin Pain in Women: Use of Sonography to Detect Occult Hernias. Review

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