The Journal of Minimally Invasive Gynecology

Cover 1

2010-07-01

Operative Laparoscopy Revisited

Stephen L. Corson — 2010-07-01

In 1992, Dr. Roy Pitkin, the editor of Obstetrics & Gynecology, wrote an editorial entitled “Operative Laparoscopy: Surgical Advance or Technical Gimmick?” . In the text, he posed 5 related questions. The first had to do with technical feasibility vs therapeutic appropriateness. This question can be best answered by randomized clinical studies with comparison to what was at the time the standard of care, namely, laparotomy. However, speaking from personal experience, it was not easy in the early days to have one's research efforts in this area published. The negative bias of the academic community toward laparoscopy and its proponents was intense. We were called “cowboys,” a derogatory term then but perhaps less so now. I would rather be a cowboy than an investment banker; the pay is less but the public image is better.

Promises and Pitfalls of the AAGL LISTSERV: A Descriptive Analysis

Kevin J. Lee, Frank F. Tu, Huong G. Nghiem, Andrew I. Sokol — 2010-07-01

Abstract: The objectives of this retrospective database review were to describe and quantify the information contained in the Issues in Endoscopy LISTSERV database and to determine the sensitivity and specificity of the LISTSERV search engine for common topics in minimally invasive gynecology. All LISTSERV entries from January 1 to December 31, 2008, were reviewed for 30 commonly discussed minimally invasive gynecology topics. Each entry was categorized by primary topic(s), and the database was used to search for terms related to total laparoscopic hysterectomy and endometrial ablation. The search engine sensitivity and specificity were calculated for both topics. In 2008, 812 entries were recorded from at least 27 countries. The most frequently discussed topics were hysterectomy and endometrial ablation. Approximately 10% of posts cited literature. The term “TLH” had 69.2% sensitivity and 97.2% specificity for identifying posts in which the subject was total laparoscopic hysterectomy. The addition of the term “total lap hysterectomy” increased the sensitivity to 90.4%. Additional terms led to minimal improvements in sensitivity. A second search using the term “endometrial ablation” yielded sensitivity and specificity of 68.1% and 96.7%, respectively. The addition of the search terms “NovaSure” and “ThermaChoice” changed the sensitivity to 90.4%, and specificity to 95.7%. Although the sensitivity and specificity of the search engine is reasonable for commonly used terms, the use of nontraditional medical terms and abbreviations limits the utility of the LISTSERV database for research. The presence of more than 800 posts in 2008 suggests that surgeons worldwide frequent the forum to discuss various topics. However, minor changes such as the addition of a topic selection menu for entry submission may improve the accuracy of the database search engine. Standardized post hoc filtering of the database at regular intervals may be preferable to substantially altering the current user-friendly entry format.

Laparoscopic Ovarian Transposition with Potential Preservation of Natural Fertility

Michele Kwik, Aoife O'Neill, Yaron Hamani, Michael Chapman, Danny Chou — 2010-07-01

Radiotherapy doses greater than 6 Gy lead to irreversible ovarian damage by reducing the number of primordial follicles . Ovarian transposition preserves fertility potential and prevents premature menopause in 83% to 88.6% of patients undergoing pelvic irradiation .

Omental Feeder Vessel in a Large Cornual Subserosal Myoma

2010-07-01

A 38-year-old woman who had had pelvic heaviness for 1 month was admitted for laparoscopic myomectomy. She had 2 children, both delivered by cesarean section. Clinical examination revealed a pelvic mass measuring up to 24 weeks in size. Ultrasonography revealed a bulky uterus with a posterior wall myoma measuring 15×7 cm. Laparoscopy revealed a 15-cm left cornual pedunculated myoma that was vascular and had large feeder vessels arising from the omentum. The myoma occupied the entire pouch of Douglas. Another 2-cm posterior wall intramural myoma was also observed.

Brachial Plexus Injury after Laparoscopic and Robotic Surgery

David Shveiky, John N. Aseff, Cheryl B. Iglesia — 2010-07-01

Abstract: The objective of this article was to review the literature regarding brachial plexus injury (BPI) in laparoscopic and robotic surgery. BPI complicates gynecologic laparoscopic surgery with an estimated incidence of 0.16%. Nevertheless, as the numbers of advanced laparoscopic and robotic procedures increase, the anticipated risk of this complication may rise as well. Robotic surgery often requires steeper Trendelenburg positioning and longer operative times when compared with traditional laparoscopic surgery. In this article we review the anatomy, pathophysiology, diagnosis, and treatment of position-related BPI in the context of laparoscopic and robotic gynecologic surgery. We suggest a multidisciplinary approach to the diagnosis and treatment of BPI. Recommendations for prevention of this complication are also provided.

Past, Present, and Future of Hysterectomy

Chris Sutton — 2010-07-01

Abstract: Until the late 1930s, the standard type of abdominal hysterectomy was subtotal, leaving the cervix behind to decrease the risk of peritonitis with its attendant high mortality. With the discovery of antibiotics, careful attention to antisepsis, and other medical and surgical advances, this method was gradually replaced by total abdominal hysterectomy in the United States and the United Kingdom, although the subtotal approach still remained popular, in particular in Scandinavian countries. With the advent of laparoscopic hysterectomy, many surgeons, wanting a simpler approach and for a variety of other reasons, have returned to performance of subtotal hysterectomy. The objectives of the present article is to review the development of the operation from a historical perspective, and to attempt to answer some of the dilemmas posed when choosing between a total and subtotal procedure, using results from evidence-based research when possible.

Review of New Office-Based Hysteroscopic Procedures 2003–2009

2010-07-01

Abstract: Office operative hysteroscopy is a recent technique that enables treatment of uterine pathologic disorders in the ambulatory setting using miniaturized hysteroscopes with mechanical or electric instruments. The available international literature from 1990 to 2002 has clearly demonstrated that such technique enables performance of hysteroscopically directed endometrial biopsy and treatment of uterine adhesions, anatomic disorders, polyps, and small myomas safely and successfully without cervical dilation and the need for anesthesia. This review provides a comprehensive survey of further advancements of office operative hysteroscopy in the treatment of other gynecologic pathologic conditions that have not been included in the schema of treatment indications for office procedures proposed in 2002. A search of MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews identified articles published from 2003 to 2009. Eighteen articles were identified: 9 on hysteroscopic sterilization; 1 on office-based metroplasty, 8 on office-based treatment of some uncommon gynecologic pathologic conditions (e.g., hematometra, diagnosis and treatment of vaginal lesions, treatment of uterine cystic neoformations, bleeding from the cervical stump, diagnosis and treatment of endocervical ossification, and removal of uterovaginal packing). All performed procedures were carried out safely and successfully in the office setting, with high patient tolerance and minimal discomfort. The success of the procedures has been confirmed by resolution of symptoms and at follow-up ultrasonographic and hysteroscopic examinations. Currently, as a result of technologic advancements and increased operator experience, an increasing number of gynecologic pathologic conditions traditionally treated in the operating room may be treated safely and effectively using office operative hysteroscopy.

Clinical Use of Misoprostol in Nonpregnant Women: Review Article

Chainarong Choksuchat — 2010-07-01

Abstract: Misoprostol, a prostaglandin E1 derivative, has been widely used in nonpregnant women because of its cervical ripening and uterotonic effects. A large number of studies have demonstrated its effectiveness in enhancing ease of cervical dilation. This review article describes its pharmacokinetic profile and the relationship between prostaglandins and cervical ripening and uterine contraction and provides a review of the clinical use of misoprostol in nonpregnant women including cervical priming before hysteroscopy, before insertion of an intrauterine device, in endometrium biopsy, preoperatively in myomectomy, and before intrauterine insemination to improve pregnancy rates. Adverse effects are also described.

Single Port Access Laparoscopic-Assisted Vaginal Hysterectomy for Large Uterus Weighing Exceeding 500 Grams: Technique and Initial Report

2010-05-17

Abstract: Study Objective: To present our initial experience with single-port access laparoscopic-assisted vaginal hysterectomy (SPA-LAVH) in a large uterus weighing in excess of 500 g.Design: A prospective single-center study (Canadian Task Force classification III).Setting: University hospitalPatients: Fifteen patients with an extirpated uterine weight of more than 500 g were enrolled from May 2008 to September 2009.Interventions: SPA-LAVH.Measurements and Main Results: There were 11 cases with uterine myomas and 4 cases of adenomyosis. All patients had symptoms related to these diagnoses including menorrhagia, dysmenorrhea, and pelvic pressure symptoms such as urinary frequency. The median and range are used to describe data not distributed normally. The median operation time, weight of the uterus, and estimated blood loss were 125 minutes (80 to 236 minutes), 690 g (503 to 1260 g), and 500 mL (150 to 1000 mL), respectively. There was a significant linear correlation between the operation time and the extirpated uterine weight (p < .002). Thirteen procedures were successfully performed with SPA-LAVH. The SPA procedure failed in 2 cases: 1 (uterine weight, 732 g) required 1 ancillary 5-mm port to manipulate with a myoma screw, and in the other we inserted 1 additional 15-mm port to use for a laparoscopic morcellator. There were no umbilical complications, additional procedures, or surgical complications.Conclusion: The SPA-LAVH procedure for a large uterus weighing in excess of 500 g was as safe and effective as the conventional LAVH. Additional experience and continued investigation are warranted.

Laparoscopic Peritoneal Entry with the Reusable Threaded Visual Cannula

2010-07-01

Abstract: Study Objective: To estimate the feasibility, reproducibility, and safety of laparoscopic port establishment using a trocarless and externally threaded visual cannula (TVC).Design: Multicentre, prospective, observational study (Canadian Task Force classification II-2).Setting: Three university-affiliated teaching hospitals.Patients: Four thousand seven hundred twenty-four women (median age, 34 years; median body mass index, 25) underwent laparoscopic surgery.Intervention: After administration of general anesthesia, the Veress needle was inserted at the umbilicus or the left upper quadrant (LUQ) using Veress intraperitoneal pressure of 10 mm Hg or less as proxy for correct placement. Transient high intraperitoneal pressure of 20 to 30 mm Hg was attained, and primary and ancillary ports were established using the reusable trocarless TVC.Measurements and Main Results: Institutional research ethics board approval and patient consent for video capture were obtained. Primary umbilical entry was established in 4598 patients (97.33%), primary LUQ entry in 123 (2.60%), and primary suprapubic entry in 3 (0.06%) patients. Peritoneal preinsufflation was abandoned when 3 consecutive umbilical or LUQ Veress needle insertion attempts failed. Some patients at high risk with known peritoneal adhesions or previous lower abdominal midline scars did not undergo preinsufflation, and the trocarless TVC was applied directly. Surgery was postponed in 3 patients in whom insufflation failed, to enable further counseling and appropriate consenting. There were no serious abdominal wall or intraabdominal vascular injuries. One transverse colon, densely adhered to the umbilical region, was injured, which was recognized and repaired intraoperatively. Residents, fellows, or faculty recorded entry-related data on forms postoperatively for study and analysis.Conclusions: Establishing peritoneal ports with the trocarless TVC is feasible, reproducible, and seems to be highly adoptable.

Laparoscopic Ureteroureteral Anastomosis for Distal Ureteral Injuries during Gynecologic Laparoscopic Surgery

2010-05-26

Abstract: Study Objective: To estimate the feasibility and surgical outcomes of laparoscopic ureteroureteral for treatment of distal ureteral injuries.Design: Retrospective clinical study (Canadian Task Force classification II-2).Setting: University teaching hospital.Patients: Four women with ureteral transection or ureterovaginal fistula.Intervention: Laparoscopic ureteroureteral .Measurements and Main Results: Median age of patients was 44 (range, 33–63) years, and median operating time was 110 (range, 85–150) minutes. There were no conversions to laparotomy. No intraoperative or postoperative complications occurred. Follow-up ranged from 20 to 46 months. All patients have been asymptomatic, and follow-up intravenous pyelograms and ultrasound examinations have been normal.Conclusion: Laparoscopic ureteroureteral anastomosis is an alternative surgical option in women with distal ureteral injuries during gynecologic laparoscopic surgery.

One-Year Outcome of Concurrent Anterior and Posterior Transvaginal Mesh Surgery for Treatment of Advanced Urogenital Prolapse: Case Series

Tsia-Shu Lo — 2010-05-26

Abstract: Study Objective: To estimate the safety and efficacy of performing concurrent anterior and posterior transvaginal mesh surgery using a commercially available kit (Gynecare PROLIFT Pelvic Floor Repair System; Ethicon, Inc., Somerville, NJ) for treatment of advanced urogenital prolapse (stage III or higher, Pelvic Organ Prolapse Quantification [POP-Q] system staging).Design: Case control series study (Canadian Task Force classification II-2).Setting: Medical school–affiliated hospital.Patients: Forty-three patients with severe prolapse, POP-Q stage III (n = 23) or IV (n = 20), underwent surgery and were followed up for more than 1 year. In patients with any prolapse greater than stage I, surgery were considered to have functional failure. The Surgical Satisfaction Questionnaire was used for subjective evaluation at 1 year postoperatively.Interventions: Extensive pelvic reconstructive procedures were primarily performed using a combination of the PROLIFT anterior and posterior pelvic systems (i.e., similar to sparing the intermediate section of the PROLIFT total pelvic system). The concurrent pelvic surgery included sequential vaginal total hysterectomy, perineorrhaphy, and suburethra sling, if indicated. Additional subjective and objective evaluations included POP-Q staging, urodynamic assessment, and preoperative and 12-month postoperative questionnaires.Measurements and Main Results: Objective and subjective data were available for 42 patients. The subjective cure rate and objective success rate for prolapse at 12-month follow-up was 95.2% and 97.6%, respectively. Mean follow-up was 15.7 months, operation time was 79.2 minutes, operative blood loss was 109.1 mL, and postoperative hospital stay was 4.1 days. Intraoperative and postoperative complications were minor. All patients voided spontaneously before discharge. One mesh extrusion, no wound defective healing, and no rejection were observed. Two patients developed asymptomatic recurrent rectocele (stage II, POP-Q staging) that required no surgical intervention. Urodynamic parameters related to voiding dysfunction improved after surgery. Significant improvements were found using the Incontinence Impact Questionnaire and the Urogenital Distress Inventory.Conclusion: Using concurrent anterior and posterior transvaginal mesh for pelvic reconstructive surgery is a safe and an effective method for treating advanced pelvic prolapse. Mesh-related complications are likely minimal, and mesh protrusion at the apex is likely to not occur. Further studies with longer follow-up are required to evaluate long-term effectiveness.

Incidence of Complications during Gynecologic Laparoscopic Surgery in Patients after Previous Laparotomy

2010-05-17

Abstract: Study Objective: To estimate the incidence of complications arising during gynecologic laparoscopic surgery in patients who have undergone previous abdominal surgeries and to assess predictable factors associated with complications based on the characteristics of the previous laparotomy.Design: Retrospective study (Canadian Task Force classification II–2).Setting: University-affiliated hospital.Patients: We enrolled 307 patients with a history of laparotomy who underwent laparoscopic surgery at our hospital between January 2002 and June 2009.Interventions: The closed primary approach via either the ninth intercostal space or the posterior vaginal fornix was used to avert bowel injury. Complications were defined as organ injury that required repair during surgery and immediate conversion to laparotomy because of technical difficulties. Factors influencing complications during laparoscopic surgery were analyzed using logistic regression.Measurements and Main Results: No complications developed during primary entry. Adhesiolysis was required in 195 areas of adhesion in 146 patients before laparoscopic surgery could proceed. These areas comprised 45 (14.7%) and 31 (10.1%) abdominal wall adhesions without and within the umbilicus, respectively, and 119 (38.8%) with intrapelvic adhesions. Complications in 41 patients (13.4%) included bowel damage (n = 35), urinary system damage (n = 4), and conversion to laparotomy because of technical difficulties (n = 2). Overall, 38 complications were laparoscopically repaired, and 1 complication was repaired at minilaparotomy. Intrapelvic adhesions were found in all patients with complications, and bowel adherent to the intrapelvis was identified in 38 of these (92.7%). The most significant predictive factors positively associated with development of complications according to logistic regression analysis were a history of abdominal myomectomy (odds ratio, 6.27; 95% confidence interval, 2.95–13.38; p <.001) and excisional endometriosis surgery (odds ratio, 5.80; 95% confidence interval, 2.08–16.13; p = .001). No patients developed severe delayed complications after surgery.Conclusion: Our findings suggest that potential predictive factors of complications are a history of abdominal myomectomy and excisional endometriosis surgery performed because of intrapelvic adhesions.

Implementation of Advanced Laparoscopic Surgery in Gynecology: National Overview of Trends

A.R.H. Twijnstra, W. Kolkman, G.C.M. Trimbos-Kemper, F.W. Jansen — 2010-05-17

Abstract: Study Objective: To estimate the implementation of laparoscopic surgery in operative gynecology.Design: Observational multicenter study (Canadian Task Force classification II-2).Setting: All hospitals in the Netherlands.Sample: Nationwide annual statistics for 2002 and 2007.Interventions: A national survey of the number of performed laparoscopic and conventional procedures was performed. Laparoscopy was categorized for complexity in level 1, 2, and 3 procedures. Outcomes were compared with results from 2002 to evaluate trends.Measurements and Main Results: In 2002, 21 414 laparoscopic and 9325 conventional procedures were performed in 74 hospitals (response rate, 74%), and in 2007, 16 863 laparoscopic and 10 973 conventional procedures were performed in 80 hospitals (response rate, 80%). Compared with 2002, in 2007, level 1 procedures were performed significantly less often and level 2 and level 3 procedures were performed significantly more often. The mean number of performed laparoscopic procedures per hospital decreased from 289 to 211 procedures. Teaching hospitals performed more than twice as many therapeutic laparoscopic procedures as nonteaching hospitals do. Cystectomy, oophorectomy, and ectopic pregnancy surgery were preferably performed using the laparoscopic approach. Laparoscopic hysterectomy was performed significantly more often, accounting for 10% of all hysterectomies. Annually, 20% of hospitals in which laparoscopic hysterectomy was implemented performed 50% of all laparoscopic hysterectomies, and 50% of the hospitals performed 20% of laparoscopic hysterectomies.Conclusion: This study describes increasing implementation of therapeutic laparoscopic gynecologic surgery. Clinics increasingly opt to perform laparoscopic surgery rather than conventional surgery. However, implementation of advanced procedures such as laparoscopic hysterectomy seems to be hampered.

Cost-Minimization Analysis of Robotic-Assisted, Laparoscopic, and Abdominal Sacrocolpopexy

2010-07-01

Abstract: Study Objective: To perform a cost-minimization analysis comparing robotic-assisted, laparoscopic, and abdominal sacrocolpopexy.Design: Cost-minimization analysis using a micro-costing approach (Canadian Task Force classification III).Measurements and Main Results: A decision model was developed to compare the costs (2008 US dollars) of robotic, laparoscopic, and abdominal sacrocolpopexy. Our model included operative time, risk of conversion, risk of transfusion, and length of stay (LOS) for each method. Respective baseline estimates for robotic, laparoscopic, and abdominal sacrocolpopexy procedures included operative time (328, 269, and 170 minutes), conversion (1.4%, 1.8%, and 0%), transfusion (1.4%, 1.8%, 3.8%), and LOS (1.0, 1.8, and 2.7 days). Two models were used, the Robot Existing model, that is, current hospital ownership of a robotic system, and the Robot Purchase model, that is, initial hospital purchase of a robotic system, with purchase and maintenance costs amortized and distributed across robotic procedures. Sensitivity analyses were performed to assess the effect of varying each parameter through its range. For the Robot Existing robot model, robotic sacrocolpopexy was the most expensive, $8508 per procedure compared with laparoscopic sacrocolpopexy at $7353 and abdominal sacrocolpopexy at $5792. Robotic and laparoscopic sacrocolpopexy became cost-equivalent only when robotic operative time was reduced to 149 minutes, robotic disposables costs were reduced to $2132, or laparoscopic disposable costs were increased to $3413. Laparoscopic and abdominal sacrocolpopexy became cost-equivalent only when laparoscopic disposable costs were reduced to $668, mean LOS for abdominal sacrocolpopexy was increased to 5.6 days, or surgeon reimbursement for abdominal sacrocolpopexy exceeded $2213. The addition of robotic purchase and maintenance costs resulted in an incremental increase of $581, $865, and $1724 per procedure when these costs were distributed over 60, 40, and 20 procedures per month, respectively.Conclusion: Robotic sacrocolpopexy was more expensive compared with the laparoscopic or abdominal routes under the baseline assumptions.

Endometrial Cancer Surgery Costs: Robot vs Laparoscopy

2010-05-26

Abstract: Study Objective: To compare surgical costs for endometrial cancer staging between robotic-assisted and traditional laparoscopic methods.Design: Retrospective chart review from November 2005 to July 2006 (Canadian Task Force classification II-3).Setting: Non-university-affiliated teaching hospital.Patients: Thirty-three women with diagnosed endometrial cancer undergoing hysterectomy, bilateral salpingo-oophorectomy, and pelvic and paraaortic lymph node resection.Interventions: Patients underwent either robotic or traditional laparoscopic surgery without randomization.Measurements and Main Results: Hospital cost data were obtained for operating room time, instrument use, and disposable items from hospital billing records and provided by the finance department. Separate overall hospital stay costs were also obtained. Mean operative costs were higher for robotic procedures ($3323 vs $2029; p < .001), due in part to longer operating room time ($1549 vs $1335; p = .03). The more significant cost difference was due to disposable instrumentation ($1755 vs $672; p < .001). Total hospital costs were also higher for robotic-assisted procedures ($5084 vs $ 3615; p = .002).Conclusion: Robotic surgery costs were significantly higher than traditional laparoscopy costs for staging of endometrial cancer in this small cohort of patients.

Use of Anti-Skid Material and Patient-Positioning To Prevent Patient Shifting during Robotic-Assisted Gynecologic Procedures

2010-05-17

Abstract: Study Objective: To estimate patient shifting with the current practice of use of an antiskid material and patient positioning during robotic procedures in gynecology.Design: Pilot observational study (Canadian Task Force classification).Setting: Tertiary referral center.Patients: Twenty-two women undergoing robotic-assisted gynecologic procedures.Intervention: Antiskid material (egg-crate pink foam) was placed beneath patients and patient positioning was used during robotic-assisted procedures.Measurements and Main Results: Patient position was marked before and after surgery. Measurements of shift distance before and after surgery were determined for each patient. Median (range) shift distance was 1.3 (0–7.5) cm. There was no significant association between shift in position and either body mass index or duration of the Trendelenburg position. No shoulder neuropathic injuries were observed during the study.Conclusion: Minimal patient shifting is observed with the use of an antiskid material and patient positioning described, without the use of shoulder braces and straps.

Robot-Assisted Laparoscopic Presacral Neurectomy: Feasibility, Techniques, and Operative Outcomes

Ceana Nezhat, Vadim Morozov — 2010-07-01

Abstract: Study Objectives: To report the feasibility and description of robot-assisted presacral neurectomy (RPSN) and to compare outcomes with laparoscopic presacral neurectomy (LPSN).Design: Prospective case series (Canadian Task Force classification III).Setting: Tertiary care center.Patients: Eighteen patients with central pelvic pain who underwent RPSN and 12 patients with central pelvic pain who underwent conventional LPSN in a metropolitan hospital between July 1, 2006, and April 30, 2008.Interventions: The da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) was used for the robotic portion of the procedure. Availability of the robot was the sole determining factor for the procedure chosen. Bipolar, monopolar, and ultrasonic instruments were used for conventional laparoscopy. All patients underwent several additional procedures performed laparoscopically including adhesiolysis, treatment of endometriosis, appendectomy, enterolysis, and salpingo-ovariolysis.Measurements and Main Results: All presacral neurectomies in both groups were successfully completed by excising the hypogastric nervous plexus within the interiliac triangle. Presence of nerve ganglion and fibers was confirmed at pathologic analysis in all cases. Mean duration of presacral neurectomy, from incision of the posterior peritoneum at the sacral promontory to complete excision of the superior hypogastric nerve plexus at the interiliac triangle (Cotte triangle) was less than 10 minutes in both groups. Mean estimated blood loss was less than 30 mL for the entire surgical procedure (29.4 mL for RPSN, and 28.8 mL for LPSN). Median (range) patient age was 25 (19–44) years in the RPSN group, and 26 (18–36) years in the LPSN group; gravidity was 0, and parity was 0. All patients had central pelvic pain, the primary indication for presacral neurectomy. Concomitant indications for surgery included ovarian cysts, endometriosis, and adhesions. There were no intraoperative or postoperative complications. At analysis, follow-up ranged from 13 to 36 months. No short- or long-term complications related to the surgical procedure were reported. All patients reported subjective improvement of pelvic pain.Conclusion: Robot-assisted laparoscopic presacral neurectomy is feasible and safe, without added risk of short- or long-term complications. It compares favorably to the conventional laparoscopic approach of presacral neurectomy. The surgical robot provides a better angle and 3-dimensional visualization of the operating field, similar to laparotomy, and supplemented with magnification. This combined with elimination of hand tremor enables better surgeon control.

Total Laparoscopic Hysterectomy in Women with Previous Cesarean Sections

Rakesh Sinha, Meenakshi Sundaram, Smita Lakhotia, Aparna Hedge, Pratima Kadam — 2010-07-01

Abstract: Objective: To analyze the feasibility and technique of dissecting the urinary bladder from the lower uterine segment during total laparoscopic hysterectomy in women who have previously delivered by cesarean section.Design: Retrospective review (Canadian Task Force classification II-1).Setting: Dedicated high-volume gynecologic laparoscopy center.Patients: Two hundred sixty-one women who underwent total laparoscopic hysterectomy at our center. There were no exclusion criteria based on the size of the uterus or the number of previous cesarean section deliveries.Intervention: All patients underwent total laparoscopic hysterectomy and lateral dissection of the bladder.Measurements and Main Results: Of the study cohort, 52% had undergone 1 cesarean section, 42% had undergone 2 cesarean sections, and 6% had undergone 3 caesarean sections. Median (range) clinical size of the uterus was 12 (6–30) weeks; weight of the specimen was 200 (40–2200) g; total duration of surgery was 80 (30–240) min; and total blood loss was 50 (10–2000) mL.Conclusion: Total laparoscopic hysterectomy in patients with previous cesarean section deliveries is technically feasible. It can be performed by experienced surgeons irrespective of the size of the uterus or the number of previous cesarean sections.

Cost-Analysis Comparison of Outpatient See-and-Treat Hysteroscopy Service with Other Hysteroscopy Service Models

Ertan Saridogan, Dominic Tilden, David Sykes, Neil Davis, Dhinagar Subramanian — 2010-07-01

Abstract: Study Objective: To conduct a cost analysis of 3 different hysteroscopy service models.Design: Decision-analytic model constructed from the UK National Health Service perspective (Canadian Task Force classification III).Setting: Tertiary-care hospital.Patients: Women undergoing hysteroscopy (N = 1109).Interventions: Three hysteroscopy service models: outpatient see-and-treat service; outpatient diagnostic hysteroscopy followed by referral for operative hysteroscopy under general anesthesia (outpatient and referral service); and general anesthesia see-and-treat service.Measurements and Main Results: Costs were measured in 2008 UK pounds sterling. Of the 3 treatment arms, total costs were lowest with outpatient see-and-treat service. The lower cost of the outpatient see-and-treat service was observed across a number of patient subgroups (age, menopause status, and indication) and when subjected to sensitivity analyses.Conclusions: Outpatient see-and-treat hysteroscopy was associated with the lowest treatment costs. This service model may reduce the total cost of care in women referred for hysteroscopy.

An Inexpensive Polypropylene Patch Sling for Treatment of Intrinsic Sphincteric Deficiency

Beatriz Arias, Aimee L. Smith, James Raders, Oscar A. Aguirre, G. Willy Davila — 2010-07-01

Abstract: Study Objective: To evaluate an inexpensive polypropylene sling in patients with intrinsic sphincteric deficiency (ISD).Design: Case series (Canadian Task Force classification II-2).Setting: Cleveland Clinic Florida teaching hospital.Patients: Analysis of 161 patients with ISD who underwent a surgeon-assembled polypropylene (Prolene) patch sling procedure.Intervention: Polypropylene patch sling surgery was performed in all study patients with urinary stress incontinence due to ISD.Measurements and Main Results: All patients underwent urogynecologic evaluation including multichannel urodynamics. Outcome measures included a standardized stress test, patient-reported cure rate, surgical complications, and postoperative voiding dysfunction. Medical records for the 161 patients who underwent the procedure were available for review. Mean patient age was 62.4 years. Twenty-five patients (16%) had concomitant detrusor overactivity. Mean follow-up was 3.6 years. The stress test yielded negative findings in 93.4% of patients. Complete continence was reported by 80.3% of patients, and marked improvement by 7%. The estimated cost of the sling was $17 to $272, depending on the materials used. Two patients experienced urinary retention requiring urethrolysis. Three required sling revision because of healing problems.Conclusion: Use of a polypropylene patch sling is an effective treatment for ISD and is less expensive than currently available sling kits.

Pneumopericardium and Severe Subcutaneous Emphysema after Laparoscopic Surgery

Ma-Lee Ko — 2010-07-01

Abstract: Subcutaneous emphysema is a known complication of laparoscopic surgery. Occasionally, subcutaneous emphysema is severe enough to cause pneumopericardium. This case report describes a rare but potentially serious complication of pneumopericardium occurring after laparoscopy. Contributing factors and possible etiologies are discussed.

Bilateral Interruption of Mid-Fallopian Tubes and Ovarian Anomalies Including Ectopic Ovary and Cystic Teratoma, a Previously Unreported Combination

Sachie Nishiyama, Yutaka Hirota, Haruki Nishizawa, Shin Tada, Yasuhiro Udagawa — 2010-07-01

Abstract: A 25-year-old infertile woman underwent laparoscopy because of a dermoid cyst of the left ovary and was found to have an ectopic ovary, to which an abnormal right fimbria was connected, with an isolated right ovary in the normal position and the bilateral segmental absence of the middle portion of the fallopian tubes. The complex of these anomalies is rare. A fundamental error might have existed in the mesenchyme of the gonadal ridges of the early embryo, rather than the epithelial origin of the müllerian and wolffian ducts.

Pain and Endometrioma Recurrence after Laparoscopic Treatment of Endometriosis: A Long-Term Prospective Study

Gary Frishman — 2010-07-01

This study, out of Rome, Italy, studied 166 consecutive women in a prospective observational fashion over a 6-year time period, with recruitment ending in June 2004, followed by at least 3 years follow-up. All patients had unilateral or bilateral endometriomas (mean size 4.9 cm) treated by laparoscopic cystectomy. Fifty-seven percent had American Fertility Society Classification of Endometriosis stage III, and 43% had stage IV disease. The mean age was 31.5 years, and the most common complaint was pain (76.5%).

Erratum

2010-07-01

In the article by Fanfani et al entitled “Narrow band imaging in borderline ovarian tumor (Volume 17, Number 2, pp. 146-147), the legends for the figures were incorrectly transposed. Below are the figures with the correct legends.

Erratum

2010-07-01

In the article by Merizio Borges et al entitled “Findings in patients with postmenstrual spotting with prior cesarean section” (Volume 17, Number 3, pp. 755-760), the spelling of a coauthor's name was incorrect. The correct spelling of the fourth author is Umberto Gazi Lippi.

Meetings Calendar/Masthead

2010-07-01

Society Affiliations

2010-07-01

Editorial Board

2010-07-01

Board of Trustees

2010-07-01

The Journal of Minimally Invasive Gynecology

Cover 1

Operative Laparoscopy Revisited

Promises and Pitfalls of the AAGL LISTSERV: A Descriptive Analysis

Laparoscopic Ovarian Transposition with Potential Preservation of Natural Fertility

Omental Feeder Vessel in a Large Cornual Subserosal Myoma

Brachial Plexus Injury after Laparoscopic and Robotic Surgery

Past, Present, and Future of Hysterectomy

Review of New Office-Based Hysteroscopic Procedures 2003–2009

Clinical Use of Misoprostol in Nonpregnant Women: Review Article

Single Port Access Laparoscopic-Assisted Vaginal Hysterectomy for Large Uterus Weighing Exceeding 500 Grams: Technique and Initial Report

Laparoscopic Peritoneal Entry with the Reusable Threaded Visual Cannula

Laparoscopic Ureteroureteral Anastomosis for Distal Ureteral Injuries during Gynecologic Laparoscopic Surgery

One-Year Outcome of Concurrent Anterior and Posterior Transvaginal Mesh Surgery for Treatment of Advanced Urogenital Prolapse: Case Series

Incidence of Complications during Gynecologic Laparoscopic Surgery in Patients after Previous Laparotomy

Implementation of Advanced Laparoscopic Surgery in Gynecology: National Overview of Trends

Cost-Minimization Analysis of Robotic-Assisted, Laparoscopic, and Abdominal Sacrocolpopexy

Endometrial Cancer Surgery Costs: Robot vs Laparoscopy

Use of Anti-Skid Material and Patient-Positioning To Prevent Patient Shifting during Robotic-Assisted Gynecologic Procedures

Robot-Assisted Laparoscopic Presacral Neurectomy: Feasibility, Techniques, and Operative Outcomes

Total Laparoscopic Hysterectomy in Women with Previous Cesarean Sections

Cost-Analysis Comparison of Outpatient See-and-Treat Hysteroscopy Service with Other Hysteroscopy Service Models

An Inexpensive Polypropylene Patch Sling for Treatment of Intrinsic Sphincteric Deficiency

Pneumopericardium and Severe Subcutaneous Emphysema after Laparoscopic Surgery

Bilateral Interruption of Mid-Fallopian Tubes and Ovarian Anomalies Including Ectopic Ovary and Cystic Teratoma, a Previously Unreported Combination

Pain and Endometrioma Recurrence after Laparoscopic Treatment of Endometriosis: A Long-Term Prospective Study

Erratum

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