The Journal of Minimally Invasive Gynecology

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2010-01-01

AAGL Practice Report: Practice Guidelines for Management of Intrauterine Synechiae

AAGL Advancing Minimally Invasive Gynecology Worldwide — 2010-01-01

Intrauterine adhesions (IUAs) have been recognized as a cause of secondary amenorrhea since the end of the 19th century , and in the mid-20th century, Asherman further described the eponymous condition occurring after pregnancy . The terms “Asherman syndrome” and IUAs are often used interchangeably, although the syndrome requires the constellation of signs and symptoms (in this case, pain, menstrual disturbance, and subfertility in any combination) and the presence of IUAs . The presence of IUAs in the absence of symptoms may be best referred to as asymptomatic IUAs or synechiae.

Practical Guide to Laparoscopic Pain Mapping

Amanda Yunker, John Steege — 2010-01-01

Abstract: Conscious laparoscopic pain mapping, a technique that has been described in the literature for more than a decade, can be a particularly helpful tool to assist with pelvic pain diagnosis and treatment decisions. Several factors, when optimized, increase the likelihood of a good outcome. Herein, we review the literature and address common questions about pain mapping including appropriate patient selection, standard technique, typical outcomes, and how the results might influence treatment.

Transcervical Embryoscopy: Images of First-Trimester Missed Abortion

Lucía T. Abdala, Jesús A. Ruiz, Humberto Espinosa — 2010-01-01

Transcervical embryoscopy is a hysteroscopy performed before obstetric curettage in cases of first-trimester missed abortion. It allows clear visualization of the demised embryo “in uterus,” adding useful information for the diagnosis of the cause of pregnancy failure .

Nerve-Sparing Laparoscopic Radical Excision of Deep Endometriosis with Rectal and Parametrial Resection

2010-01-01

The pelvic laparoscopic nerve-sparing approach for treatment of deep endometriosis starts retroperitoneally from the promontory. Blunt dissection of loose fatty tissue of the rectosacral and pararectal spaces to the level of the rectosacral-fascia and rectal wings enables identification of the sympathetic superior hypogastric plexus, hypogastric nerves, and lumbosacral trunks and ganglia. Moreover, identification of the parasympathetic pelvic splanchnic nerves at their origin from the sacral roots enables safe dissection of the rectal wings and of the posterior parametrial and lower mesorectal planes.

A Comparative, Single-Blind, Randomized Trial of Pain Associated with Suction or Non-Suction Drains after Gynecologic Laparoscopy

2009-06-01

Abstract: Study Objective: To estimate the difference in pain associated with the wearing or removal of suction or non-suction drains after gynecologic laparoscopic surgery.Design: A randomized controlled trial from August 2006 through October 2007 (Canadian Task Force Classification I).Setting: Royal Hospital for Women, Department of Endo-Gynaecology and School of Women's and Children's Health University of New South Wales.Patients: A total of 168 women undergoing gynecologic laparoscopy requiring postoperative drainage.Interventions: Patients were randomized to receive either a suction or non-suction drain after surgery.Measurements and Main Results: Pain was assessed before, during, and after drain removal with a 4-point verbal descriptor scale and 10-cm visual analogue scale. Visual analogue scale and verbal descriptor scale scores for suction versus non-suction groups were 3 versus 3 (p=.654) and 1 versus 1 (p=.686) before removal, 9 versus 7 (p=.016) and 3 versus 2 (p=.029) during removal, and 7 versus 5 (p=.058) and 2 versus 2 (p=.122) after removal.Conclusion: There is no significant difference in patient discomfort while wearing or after removal of suction or non-suction drains. However, suction drains are more painful to have removed.

Peritoneal Vascular Density Assessment Using Narrow-Band Imaging and Vascular Analysis Software, and Cytokine Analysis in Women With and Without Endometriosis

2009-11-05

Abstract: The development and onset of endometriosis is associated with angiogenesis and angiogenic factors including cytokines. We analyzed intrapelvic conditions in women with endometriosis via vascular density assessment of grossly normal peritoneum and determination of cytokine levels in peritoneal fluid. Seventy-three patients underwent laparoscopic surgery because of gynecologic disease including endometriosis in our department using a narrow-band imaging system. Each patient was analyzed for peritoneal vascular density using commercially available vascular analysis software (SolemioENDO ProStudy; Olympus Corp, Tokyo, Japan). Each patient was also subjected to analysis of interleukin 6 (IL-6), IL-8, tumor necrosis factor-α, and vascular endothelial growth factor concentrations in peritoneal fluid. We defined 4 groups as follows: group 1, endometriosis: gonadotropin-releasing hormone (GnRH) agonist administration group (n=27); group 2, endometriosis: GnRH agonist nonadministration group (n=15); group 3, no endometriosis: GnRH agonist administration group (n=18); and group 4, no endometriosis: GnRH agonist nonadministration group (n=13). No significant differences in peritoneal vascular density between the 4 groups were found under conventional light; however, under narrow-band light, vascular density in the endometriosis groups (groups 1 and 2) was significantly higher. Cytokine analysis of the 4 groups determined that IL-6 and IL-8 concentrations were significantly higher compared with the no endometriosis groups (groups 3 and 4). Tumor necrosis factor-α and vascular endothelial growth factor concentrations were not significantly different between groups. In endometriosis, peritoneal vascular density was significantly higher as assessed using the narrow-band imaging system and SolemioENDO ProStudy, whereas GnRH agonist did not obviously decrease vascular density but IL-6 concentration was lower in the GnRH agonist administration group.

Single-Port Laparoscopic Salpingectomy for the Surgical Treatment of Ectopic Pregnancy

2009-11-19

Abstract: Study Objective: To evaluate the feasibility of a single-port laparoscopic salpingectomy in the surgical treatment of tubal pregnancy.Design: Prospective cohort study (Canadian Task Force classification II-2).Setting: University teaching hospitalPatients: Twenty women with tubal pregnancy, as determined by ultrasonography.Intervention: All patients have undergone single-port laparoscopic salpingectomy. Entry through a single port was established with a wound retractor as fascial retractor and a surgical glove, which served as the working channels for the laparoscopic equipment. A 30-degree laparoscope and a rigid or flexible grasper were used during the procedure.Measurements and Main Results: Single-port laparoscopic salpingectomy was successfully performed in all 20 patients with ectopic pregnancy. The median operative time was 55minutes (range 25-85minutes), and blood loss in all patients was minimal. The median difference between preoperative and postoperative hemoglobin was 1.8g/dL (range 0–3.2g/dL). The median postoperative hospital stay was 2 days (range 2-4 days). No complication was encountered, nor was there any need for conversion to conventional laparoscopy.Conclusions: Single-port laparoscopic salpingectomy is feasible and promising. However, for drawing the definite conclusion of the surgical efficacy, additional investigations to compare this approach with conventional laparoscopy are needed.

Hysteroscopic Appearance of Endometrial Cavity after Microwave Endometrial Ablation

Xiping Luo, Chi Eung Danforn Lim, Li Li, Wu Shun Felix Wong — 2010-01-01

Abstract: Study Objective: To assess the appearance of the endometrial cavity after microwave endometrial ablation.Design: Prospective observational study.Setting: GuangDong Women's and Children's Hospital, GuangDong, China.Patients: A total of 349 patients who underwent microwave endometrial ablation from January 2000 through August 2008 were followed up for 1 month to 8 years. At follow-up in 2007 and 2008, patients were advised of this clinical study and were randomly selected for participation if they agreed to undergo outpatient hysteroscopy to assess the uterine cavity during follow-up visits. Fifty three patients (median [range] age, 43.1 [33–53] years) were recruited into the study at the time of endometrial ablation.Intervention: Outpatient hysteroscopy.Main Results: Within the first 3 months after ablation, outpatient hysteroscopy revealed varying amounts of necrotic tissue from the endometrium and superficial myometrium of the uterus. Six months postablation, a granulomatous reaction and fibrosis were present. A fibrotic cavity was also evident, and menstrual flow was reduced or had ceased. One year after ablation, hysteroscopy demonstrated a fibrotic cavity with myofibrous scars. Most patients developed amenorrhea at this time. Two years or more postablation, a second hysteroscopy demonstrated various types of intrauterine adhesions in 28 of the 53 women (52.8%). A cervical adhesion was observed in 1 patient (1.9%), focal adhesions in the fundal area in 12 (22.6%), a narrowed and scarred uterine cavity with bilateral stenotic tubal ostia in 11 (20.7%), and complete obliteration of the cavity in 4 (7.5%). Of these 28 women, 22 had amenorrhea, 3 had vaginal spotting during menstruation, and 2 had hypomenorrhea. Of those without intrauterine adhesions, only 5 had amenorrhea, 10 had vaginal spotting, and 8 had hypomenorrhea.Conclusion: The hysteroscopic appearance of the uterine cavity after microwave endometrial ablation varies considerably. In this study, the menstrual outcome was correlated with postablation uterine cavity appearance.

Laparoscopic Nerve-Sparing Radical Trachelectomy: Surgical Technique and Outcome

Angel Martin, Anna Torrent — 2010-01-01

Abstract: Study Objective: To assess the feasibility of the laparoscopic approach in fertility-preserving and radical surgery of cervical cancer in young patients.Design: Retrospective study (Canadian Task Force classification I).Setting: Hospital Son Llatzer, Palma de Mallorca, Spain.Patients: Nine women with early cervical cancer.Intervention: Laparoscopic nerve-sparring radical trachelectomy.Measurements and Main Results: Data for 9 consecutive women undergoing laparoscopic nerve-sparing radical trachelectomy because of FIGO IA2 (n = 2) or FIGO IB1 (n = 7) infiltrating cervical carcinoma of the squamous type (n = 6) or adenocarcinoma (n = 3) were analyzed. Resection of the pericervical ligaments was laparoscopically performed, preserving innervation of the bladder and the arterial supply of the uterus. The laparoscopic approach enabled completion of the operation via the vaginal route without difficulties. The mean duration of surgery was 270 minutes. No relevant perioperative complications occurred. Two women became pregnant: 1 underwent an elective cesarean section delivery at week 38, and hysterectomy was performed 6 months later; and the other woman was pregnant at the time of this writing. Mean duration of follow-up was 28 months. Six patients currently have regular menses without evidence of disease. One patient had a central recurrence at 14 months, which was treated using surgery and radiochemotherapy, and she was free of disease at the last follow-up.Conclusions: Laparoscopic nerve-sparring radical trachelectomy may be an alternative in fertility-preserving surgery for cervical cancer in centers in which specialization in radical vaginal surgery is lacking. The procedure enables preservation of autonomic innervation of the urinary bladder and the arterial supply of the uterus.

Surgical Treatment of Endometriosis in Private Practice: Cohort Study with Mean Follow-up of 3 Years

Jose Daniel Roman — 2010-01-01

Abstract: Study Objective: To describe our experience with surgical treatment of endometriosis.Design: Observational cohort study (Canadian Task Force classification II-2).Setting: Private hospital.Patients: One hundred sixty-three patients with histologically confirmed endometriosis who had completed a preoperative questionnaire, had available intraoperative findings and photographic documentation, and had been followed up to 6 years.Intervention: Laparoscopic electrosurgical excision of endometriotic implants.Measurements and Main Results: Patients completed a visual analogue scale (VAS) for 6 components of endometriosis-related symptoms. The EuroQol Group EQ-5D questionnaire was used for evaluation of quality of life. Long-term follow up was performed using a questionnaire and review of patient medical records. Mean (SD; 95% confidence interval) patient age at surgery was 31.01 (8.5; 29.7–32.3) years. The primary symptom at initial consultation was dysmenorrhea in 94 patients (57.67%, nonmenstrual pelvic pain in 44 (27%), dyspareunia in 11 (6.75%), menorrhagia in 8 (4.9%), infertility in 4 (2.45%), and pelvic mass in 2 (1.23%). Thirty-three patients (20%) had undergone previous surgery because of endometriosis. At surgery, endometriosis was stage I in 50 patients (30.67%), stage II in 65 (39.88%), stage III in 23 (14.11%), and stage IV in 25 (15.34%). Other surgical procedures performed with the index surgery were cystoscopy in 48 patients (29.45%), laparoscopic ovarian cystectomy in 24 (14.72%), laparoscopic hysterectomy in 15 (9.2%), laparoscopic appendectomy in 9 (5.5%), sigmoidoscopy in 6 (3.68%), laparoscopic oophorectomy in 6 (3.68%), extensive laparoscopic adhesiolysis in 5 (3.07%) bowel resection in 2 (1.25%), laparoscopic myomectomy in 1 (0.61%), and bladder resection in 1 (0.61%). Surgery proceeded to laparotomy in 6 patients (3.68%). Major surgical complications included bowel perforation, severe pelvic pain 1 week after laparoscopic excision, and temporary numbness of the right side of the perineum in 1 patient each. Minor postoperative complications included urinary tract infection in 3 patients and port site infections that resolved with oral antibiotic therapy in 2 patients. Follow-up was 37.82 (20.09; 34.74–40.92) months. Surgical excision of endometriosis had a positive effect on endometriosis-related symptoms. Four pain scores were reduced, with statistically significant differences (p <.001 and p <.05): dysmenorrhea, pelvic pain not related to menstruation, dyspareunia, and dyschezia. The positive effect of surgical excision on patient quality of life was demonstrated by a statistically significant difference on the EQ-5D index (p <.001) and the EQ-5D VAS (p <.001). Thirty-two (20%) patients underwent a second procedure after the index surgery. Endometriosis stage affects the probability of requiring further surgery because of recurrent symptoms. There was evidence of endometriosis at histologic analysis in only 13 (40.62%) patients who required further surgery.Conclusion: Laparoscopic excision of endometriosis significantly reduces pain and improves quality of life as measured by both the EQ-5D index and the EQ-5D VAS, with a low complication rate.

Controlled Clinical Trial Assessing the Effect of Laparoscopic Uterine Arterial Occlusion on Ovarian Reserve

Xiaoyan Qu, Zhongping Cheng, Weihong Yang, Lizhen Xu, Hong Dai, Liping Hu — 2010-01-01

Abstract: Study Objective: To assess the effect on ovarian reserve function after laparoscopic uterine artery occlusion (LUAO) compared with laparoscopic surgery supracervical hysterectomy (LSH) and laparoscopic myomectomy (LM).Design: Prospective cohort study (Canadian Task Force classification II-1).Setting: Hospital with experience in gynecologic minimal access surgery.Patients: Ninety patients with uterine myomas operated on from August through December 2007.Intervention: Ninety patients were divided into 3 groups of 30 patients each: the study group underwent LUAO and myomectomy (LUAO-M), control group 1 underwent LSH, and control group 2 underwent LM only.Measurements and Main Results: Blood samples were collected before surgery and at 1, 3, and 6 months postoperatively. Concentrations of follicle-stimulating hormone (FSH), leuteinizing hormone (LH), and estradiol (EZ) were determined using an immunoassay, and serum inhibin B (INHB) concentration was evaluated using an enzyme-linked immunosorbent assay. No significant differences in preoperative hormone concentrations between the 3 groups were found (p >.05). In the LSH group, FSH, LH, and E2 concentrations were significantly increased, whereas the INHB concentration was significantly decreased at 1 month postoperatively (p .05). Serum concentrations of FSH, LH, and INHB in the LSH group were significantly different from those in the study group at 1 and 3 months postoperatively (p .05).Conclusion: At short-term follow-up, no significant effect on ovarian reserve in patients with myoma who underwent LUAO was found.

Opportunities and Risk Factors for Premalignant and Malignant Transformation of Endometrial Polyps: Management Strategies

Jian-Hua Wang, Jin Zhao, Jun Lin — 2010-01-01

Abstract: Study Objective: To estimate the prevalence of benign, premalignant, and malignant endometrial polyps and the associated clinical risk factors for premalignant and malignant endometrial polyps.Design: Retrospective study (Canadian Classification II-3).Setting: Teaching hospital.Patients: Seven hundred sixty-six patients with endometrial polyps.Interventions: Hysteroscopic removal of endometrial polyps.Measurements and Main Results: Patient clinical data were identified and analyzed. Frequency of premalignant and malignant histopathologic features in endometrial polyps was calculated. Clinical risk factors for premalignant and malignant endometrial polyps were analyzed. Endometrial polyps were histologically benign in most patients (96.21%). Hyperplasia with atypia in a polyp (premalignant polyp) was found in 3.26% of patients, and endometrial carcinoma in a polyp (malignant polyp) was detected in only 0.52 % of patients. Independent variables that were significantly related to premalignant and malignant polyps (all p <.05) in a binary logistic regression analysis included polyp diameter (odds ratio [OR], 2.93; 95% confidence interval [CI], 1.191–7.20), menopause status (OR, 4.85; 95% CI, 2.09–11.27), and abnormal uterine bleeding (OR, 3.97; 95% CI, 1.71–9.18).Conclusion: Polyp diameter larger than 1.0cm, menopause status, and abnormal uterine bleeding may increase the risk of premalignant and malignant endometrial polyps.

Hysteroscopic Management of Large Symptomatic Submucous Uterine Myomas

M. Camanni, Luca Bonino, E.M. Delpiano, B. Ferrero, G. Migliaretti, F. Deltetto — 2010-01-01

Abstract: Study Objective: To evaluate the feasibility of hysteroscopic resection of large submucous uterine myomas.Design: Prospective study (Canadian Task Force classification II-3).Setting: Surgery unit of minimally invasive gynecology.Patients: Thirty-three women with submucous myomas 5 cm or larger in diameter with menorrhagia, dysmenorrhea, or infertility.Intervention: Hysteroscopic myomectomy.Measurements and Main Results: Satisfaction with the surgery and an improvement in symptoms were the primary outcomes. Possibility of 1-step resection; complication rate, and disease recurrence were also considered. Menorrhagia was the most frequent indication (91%). According to the Wamsteker classification, 84.8% were type II myomas, whereas 93.9% scored 5 or higher according to the classification of Lasmar and colleagues. Mean operating time was 50 minutes (interquartile range, 35–65). One-step excision was achieved in 81.8% of patients. Of 5 women with incomplete resection, 3 needed a second surgery, and 2 were symptom-free. Patients with myomas larger than 5 cm or with a Lasmar score higher than 7 were more likely to undergo a 2-step procedure. In patients with myomas larger than 6 cm, recovery time was significantly longer than in those with smaller myomas. We recorded 3 complications: intravasation, uterine perforation, and postoperative anemia, in 1 patient each; at present, all 3 women are symptom-free. Median (range) follow-up was 10 (6–22) months. Twenty-seven patients (81.2%) reported they were very satisfied; 5 patients (15.2%) were satisfied; and 1 patient (3%) was dissatisfied.Conclusions: Hysteroscopic myomectomy can be the treatment of choice in symptomatic patients with a submucous myoma with diameter of 6 cm or less. Although this technique raises the possibility that complete resection may require 2 surgical sessions, it is a feasible surgical procedure. However, for myomas 6 cm or larger in diameter, this approach is less attractive. Nevertheless, we believe that all of the limiting criteria defined in the available literature should be evaluated individually, bearing in mind each patient's particular condition and the surgeon's experience and skill.

Clinical and Sonographic Findings in Suspected Retained Trophoblast after Pregnancy Do Not Predict the Disorder

Ishai Levin, Benny Almog, Baris Ata, Gilad Ratan, Ariel Many — 2010-01-01

Abstract: Study Objective: Our aim was to estimate whether there are clinical, sonographic, or intraoperative parameters that have good correlation with the final histologic study after hysteroscopic removal of suspected retained trophoblast of conception.Design: Retrospective case control study (Canadian Classification II-2).Setting: A tertiary referral hospital.Patients: Sixty-four patients after hysteroscopic removal of suspected retained pregnancy material.Interventions: We divided our patients into those with true trophoblast on histologic evaluation (group A, n = 40) and patients with other histologic findings (group B, n = 24). Clinical parameters, as well as sonographic evidence leading to hysteroscopy were correlated with final pathology report.Measurements and Main Results: Age, obstetric history, type of obstetric event, and time between primary event and hysteroscopy were not statistically different between the true trophoblast and nontrophoblast groups. Clinical signs and symptoms (fever, bleeding, and abdominal pain), as well as sonographic findings (size of retained mass and Doppler flow) were not statistically different between the 2 groups and thus could not predict the final disease. The only parameter correlated significantly to final histologic findings was the intraoperative surgeon's opinion of the retained material.Conclusions: Various clinical parameters, as well as sonographic findings including the size of the mass and Doppler test results in patients with suspected retained trophoblast, do not predict the final diagnosis. The surgeon's opinion regarding the tissue seen during hysteroscopy is the only parameter tested that correlates well with the final histologic evaluation. Thus selective removal of retained trophoblast can be performed on the basis of the surgeon's opinion during the procedure, whereas further potentially harmful interventions (curettage) can be avoided when true trophoblast is not suspected to minimize complications.

Quantifying Electrosurgery-Induced Thermal Effects and Damage to Human Tissue: An Exploratory Study with the Fallopian Tube as a Novel In-Vivo In-Situ Model

2009-11-30

Abstract: Objective: To develop a human in vivo in situ model for analyzing the extent and the basic mechanisms of thermal spread and thermal tissue damage.Design: Prospective, open, uncontrolled, nonrandomized, single-center exploratory study.Setting: University hospital.Patients: Eighteen adult patients undergoing open abdominal hysterectomy for benign disease.Interventions: Unilateral fallopian tube tissue desiccation (10 seconds) with a laparoscopic bipolar clamp at routine settings.Main Outcome Measures: Deep tissue temperature (thermal probe), tissue surface temperature (thermal camera), and gross and histologic assessments of lesions with a newly developed composite scoring system.Results: Fifteen specimens from 18 patients were evaluated. Lateral thermal damage (LTD; determined by lactate dehydrogenase staining), was strongly correlated with maximum desiccation temperature. Deep tissue LTD and surface LTD were linearly related. Histologic and macroscopic criteria for thermal effects and damage and the corresponding scores proved functional and strongly correlated with LTD. Measurement of deep tissue and tissue surface temperatures consistently yielded complete temporal and spatial temperature distributions that were describable by the heat equation.Conclusions: Our novel in vivo in situ model allows standardized, reproducible, quantitative assessment of electrosurgery-induced thermal effects and damage in human tissue. It will likely provide further insight into the underlying biothermomechanics and may prove useful in the development of safety guidelines for laparoscopic electrosurgery.

Single-Port Access Subtotal Hysterectomy with Transcervical Morcellation: A Pilot Study

2009-11-19

Abstract: We evaluated the feasibility, safety, and operative outcome of management of myomas and adenomyosis using single-port access subtotal hysterectomy with transcervical morcellation using a wound retractor and a surgical glove. We conclude the single-port access subtotal hysterectomy is safe and effective and results in almost no visible scar. With more experience and advanced instruments, this surgical procedure can offer a safe and effective option to hysterectomy with an excellent cosmetic outcome.

Clinical Evaluation of a Third-Generation Thermal Uterine Balloon Therapy System for Menorrhagia Coupled with Curettage

2010-01-01

Abstract: Study Objectives: To estimate the incidence of amenorrhea 12 months after treatment with a third-generation thermal uterine balloon therapy (UBT) system. Secondary objectives were to compare the incidence of amenorrhea observed with this third-generation system with that of a first-generation system, to estimate the effect of postprocedure curettage on patient outcome, and to evaluate the workings of this new system.Design: Multicenter, controlled study (Canadian Task Force classification I).Setting: Thirteen hospitals: 12 in the United States and 1 in Mexico.Patients: Two hundred fifty premenopausal women aged 30 years or older with menorrhagia not responsive to previous medical therapy for at least 3 months.Intervention: After treatment with a third-generation thermal UBT system, patients were randomly assigned to receive postprocedure curettage or no further treatment.Measurements and Main Results: The rate of amenorrhea 12 months after treatment with the third-generation thermal UBT system was similar in patients receiving postprocedure curettage (33.3%) and those receiving no further treatment (37.1%; p = .53). In addition, postprocedure curettage did not have any significant effect on any other patient outcome, for example, pain. Patients who were matched to historic control patients treated with the original first-generation system demonstrated a significantly greater success rate (amenorrhea) at 12 months (32.6%) compared with those treated with the first-generation system (13.7%). The third-generation thermal UBT instrument functioned as designed, with no unanticipated adverse device effects.Conclusion: The third-generation thermal UBT system shows greater efficacy in producing amenorrhea than the original first-generation system, with no significant safety issues. Postprocedural curettage did not alter amennorhea rates.

Laparoscopic Myomectomy at 25 Weeks of Pregnancy: Case Report

2010-01-01

Abstract: We performed laparoscopic myomectomy for treatment of a large, twisted, subserous myoma at 25 weeks of pregnancy in a woman with acute abdominal pain that did not respond to analgesic therapy. There are few reports in literature about laparoscopic management of uterine leiomyoma during the first half of pregnancy that demonstrate its feasibility in selected cases. Laparoscopic myomectomy can be considered a minimally invasive alternative to the traditional laparotomy when myomectomy is necessary during the second half of pregnancy, resulting in less postoperative pain and shorter recovery time.

Retained Uterine Fundus after Vaginal Hysterectomy

2010-01-01

Abstract: We report a case of retained uterine fundus after vaginal hysterectomy that was subsequently removed at laparoscopy. The patient had undergone vaginal hysterectomy 8 years previously and came to our hospital with abdominal pain. Examination revealed a supravesical mass. Laparoscopy was performed and showed the uterine fundus with its cornual attachments. The mass was excised and sent for histopathologic analysis, which confirmed that it was uterine tissue. Retained uterine tissue or myoma tissue has been reported, usually after morcellation. However, to our knowledge, our case is only the second reported case of retained fundus after complete vaginal hysterectomy. Because of adhesions, it is possible that the uterus was not completely removed. In such cases, laparoscopic assistance is extremely useful.

Rare Case of Ovarian Cystic Lymphangioma

Tomer Singer, Gilad Filmar, Susan Jormark, Tamer Seckin, Michael Divon — 2010-01-01

Abstract: Lymphangiomas are rare, generally benign tumors of the lymphatic system comprised of multiple cystic spaces lined with endothelium. Lymphangiomas may arise in any part of the body. Lymphangioma of the ovary is rare; we have identified only 13 reports in a 50-year literature survey (PubMed 1959–2009). Typically, lymphangiomas are slow-growing tumors that remain asymptomatic for a long time. They are most often found incidentally in abdominal or pelvic imaging studies or at surgery or autopsy. Wide excision of the lesion with microscopically clear margins is the best approach when feasible. A postmenopausal woman had a symptomatic pelvic mass. Imaging studies demonstrated a complex left ovarian cyst. Complete removal of a cystic lymphangioma was successfully performed at laparoscopy. Cystic lymphangiomas should be included in the differential diagnosis of an ovarian cystic mass, and laparoscopic excision may be the method of treatment.

Surgical Management of Recurrent Ureteric Endometriosis Causing Recurrent Hypertension In a Postmenopausal Woman

Su-Yen Khong, Alan Lam, Graham Coombes, Stephen Ford — 2010-01-01

Abstract: Endometriosis is a common condition that affects as many as 10% to 20% of women of reproductive age. Because of the subtle clinical signs and symptoms and limitations of imaging methods, the diagnosis is frequently delayed or missed, with serious consequences including hypertension, hydronephrosis, and loss of kidney function. We present an unusual case of recurrent ureteric endometriosis in a postmenopausal woman to highlight the challenges of screening for and management of endometriosis.

Haemophilus influenzae abscess: Inclusion in the Differential Diagnosis of a Large Pelvic Mass?

D.R. Ambler, M.P. Diamond, J. Malone — 2010-01-01

Abstract: Background: This report describes an unusual first case in which an abscess containing Haemophilus influenzae incorporates the entire uterine cavity without overt signs of infection.Case: A 39-year-old woman presented with right lower quadrant abdominal pain and a large abdominal pelvic mass. Evaluation with computed tomography and ultrasonography showed a 20- × 14- × 10-cm cystic mass arising from the uterus. Tumor markers were negative. The patient underwent a total abdominal hysterectomy. Intraoperative findings included a 20-cm intramyometrial uterine abscess, completely replacing the uterine cavity. The abscess was densely adhered to the sigmoid colon. The mass was ruptured during the surgical procedure when mobilizing it off the colon, and cultures were obtained. Microbiologic culture illustrated H. influenzae. Pathologic diagnosis confirmed an intramyometrial abscess, originating from the wall of the uterus occupying the entire uterine cavity, lined with granulation tissue, foamy macrophages, and chronic inflammation.Conclusion: Intramyometrial abscesses can masquerade as degenerating fibroids and, even with microorganisms, can exist without overt signs or symptoms of an active infection.

Laparoscopic Resection of Endometriosis in a Patient with a Ventriculoperitoneal Shunt Using the LapDisc

Iris Kerin Orbuch, Russell Atkin, Gilad Filmar, Tomer Singer, Michael Y. Divon — 2010-01-01

Abstract: The surgical approach in a patient with a ventriculoperitoneal shunt in need of abdominal surgery remains controversial. The risk of increased intracranial pressure with pneumoperitoneum in laparoscopy is still unresolved. We used the LapDisc (Ethicon, Inc., Somerville, New Jersey) to access the shunt and temporarily seal it, which enabled us to perform laparoscopic resection of endometriosis without subjecting the shunt to high intraabdominal pressure. The benefits of this approach are the ability to perform laparoscopy, less skin-to-shunt contact minimizing infection, and elimination of possible increased intracranial pressure secondary to pneumoperitoneum.With the progress made in the management of hydrocephalus, patients with ventriculoperitoneal (VP) shunts enjoy a longer lifespan. Therefore, the gynecologic laparoscopic surgeon can expect to treat a patient with a VP shunt in place.

Internal Herniation of Adnexa Through a Defect of the Broad Ligament: Case Report and Literature Review

Habibe Demir, Bert Scoccia — 2010-01-01

Abstract: Internal herniation through a defect of the broad ligament occurs rarely. Herniation of the ovary rather than the small intestine or colon is extremely rare. We present only the third known case of herniation of the adnexa into a broad ligament defect. A 42-year-old woman, gravida 3, para 2, aborta 1, had severe continuing right lower quadrant pain that was resistant to medical and surgical treatments. The clinical history was significant for long-standing endometriosis, 2 previous laparoscopic procedures to treat endometriosis, and chronic pelvic pain despite medical and surgical treatments. At the second laparoscopic procedure, pelvic endometriosis was excised, and a large defect of the right broad ligament was noted but not treated. At the third operation, right salpingo-oophorectomy was performed to eliminate the large broad ligament defect and the possibility of internal herniation on the right side as a possible explanation for the patient's chronic right lower quadrant pain. Postoperatively, the pain resolved, and the patient has been pain-free for 9 months. This type of internal herniation should be considered in the differential diagnosis in female patients with pelvic pain.

Giant Pararectal Epidermoid Tumor Mimicking Ovarian Cyst: Combined Laparoscopic and Perineal Surgical Approach

2010-01-01

Abstract: Epidermoid cysts are benign tumors that can develop in any part of the human body. Pelvic cysts adjacent to the rectum develop rarely, and few cases have been described in the literature. We report the case of a 58-year-old woman who underwent laparoscopic and perineal excision of a giant pararectal cyst that was discovered during laparoscopy performed for preoperative provisional diagnosis of an adnexal mass detected on an imaging study. To our knowledge, this is the second case of a pararectal cyst excised using combined laparoscopic and perineal approaches. In the hands of skilled laparoscopic surgeons, we suggest a combined laparoscopic and perineal approach for excision of giant pararectal cystic tumors to avert laparotomy.

Vaginal Vault Leiomyoma: 25 Years After Total Abdominal Hysterectomy

Aslı Yarcı, Vugar Bayramov, Yavuz E. Şükür, Tuncay Yüce, Bülent Berker — 2010-01-01

Abstract: Leiomyomas are benign, mesenchymal, monoclonal tumors that typically originate from myometrium smooth-muscle cells, although atypical sites such as the vagina, lungs, vascular structures, and retroperitoneal area have been reported. We present the case of a leiomyoma that originated from the vaginal cuff in a 70-year-old woman, 25 years after total abdominal hysterectomy and bilateral salphingo-oophorectomy.

Laparoscopic Pelvic Lymphadenectomy in a Patient with Cervical Cancer Stage Ib1 Complicated by a Twin Pregnancy

2010-01-01

Abstract: Cervical cancer is the most frequently observed malignancy during pregnancy. The presence of nodal metastasis is the most important negative predictor factor, and its assessment is crucial in deciding whether the pregnancy can safely continue. To our knowledge, this is the first report of a twin pregnancy complicated by cancer of the uterine cervix that was sucessfully treated with laparoscopic pelvic lymphadenectomy and subsequently with neoadjuvant chemotherapy. A 35-year-old woman, gravida 2, para 1, with a dichorionic-diamniotic twin pregnancy underwent laparoscopic staging of the pelvic lymph nodes at 17 weeks of gestation. Cervical adenocarcinoma, grade 2, stage 1b1 with lymphovascular space invasion was diagnosed. Nineteen negative nodes were removed, and the patient was counseled to continue the pregnancy. On the basis of tumor size and detection of lymphovascular space invasion, cisplatin as neoadjuvant chemotherapy was administered until week 32 of gestation, when a cesarean section delivery was performed, along with radical hysterectomy. No complications to the neonates or to the mother due to the therapy were observed. This case demonstrates the safety of operative nodal staging during gestation, even in a twin pregnancy. Exclusion of nodal metastasis may improve oncologic outcomes, and neoadjuvant chemotherapy should be administered when indicated.

Diagnostic Laparoscopy Complicated by Group A Streptococcal Necrotizing Fasciitis

Rasiah Bharathan, Mark Hanson — 2010-01-01

A 33-year-old multiparous woman came to our emergency gynecology clinic with a 1-day history of acute abdominal pain. Her last menstrual period occurred 6 weeks previously. She described intermittent crampy central and lower abdominal pain for 24hours that was associated with 4 episodes of vomiting and 1 episode of diarrhea. She denied vaginal bleeding, shoulder tip pain, and dizziness. Her history included appendectomy, 2 transverse laparotomy procedures (1 salpingectomy because of tubal ectopic pregnancy and 1 because of torsion of a luteal cyst), and 1 midline laparotomy because of ovarian torsion. Subsequently, she had 3 emergency cesarean section deliveries. She had been using an oral contraceptive pill.

Laparoscopic Approach to Right Diaphragmatic Endometriosis with Argon Laser: Case Report

2010-01-01

Abstract: Diaphragmatic involvement by an endometriotic cyst is a rare entity that may be responsible for chronic thoracic pain. Herein we present a case report of a 6-cm right diaphragmatic endometrioma treated using laparoscopic partial excision and argon laser coagulation of the inner cyst wall. The laparoscopic approach to upper abdomen endometriosis is feasible and safe when accurate evaluation of the case is performed.

Laparoscopic Management of Placenta Percreta

Melanie Endres Ochalski, Amy Broach, Ted Lee — 2010-01-01

Abstract: The incidence of abnormal placentation is increasing as a result of the rise in the cesarean delivery rate. Management of placenta percreta involving the urinary bladder often requires extensive surgery including bladder resection. A 27-year-old woman with placenta previa percreta that invaded the urinary bladder underwent delayed total laparoscopic hysterectomy performed after the portion of the placenta invading the bladder had regressed. This approach decreased blood loss associated with immediate resection and preserved the bladder intact. To our knowledge, this is the first report of a minimally invasive approach to placenta percreta involving the bladder.

Laparoscopic Uterosacral Nerve Ablation for Alleviating Chronic Pelvic Pain: A Randomized Controlled Trial

Stephen L. Corson — 2010-01-01

A multicenter British study group from 18 hospitals in the United Kingdom evaluated the ability of the laparoscopic uterosacral nerve ablation (LUNA) procedure to ameliorate chronic pelvic pain in 487 women randomized to active treatment versus laparoscopy without LUNA for women with minimal endometriosis, pelvic adhesions or pelvic inflammatory disease. Follow-up was a median of 69 months, and 3 types of pain were evaluated; noncyclical, dysmenorrhea, and dyspareunia as well as the worst level of pain encountered. A quality of life questionnaire was used as well. Randomization was performed during surgery to balance group allocations. The procedure was performed bilaterally with a laser or electrosurgical energy as close to the cervix as possible, extending at least 1cm posterolaterally and with full or partial separation of the ligament.

Comparison of Liquid-Based Cytology with Conventional Cytology for Detection of Cervical Cancer Precursors: A Randomized Controlled Trial

Stephen L. Corson — 2010-01-01

Since introduction of liquid phase cytologic cervical screening, questions have been raised about its superiority over the traditional Papanicolaou smear, especially considering the cost differential. Although quite a few studies have been published, before this report only 3 were randomized (see original paper for references), and sufficient power was not reached in any, although none showed superiority for the liquid phase method. This study was a cluster-randomized controlled trial with 89 784 women aged 30 to 60 years within a Dutch cervical screening program at 246 family practices. Each practice used only 1 of the techniques.

Letter to the Editor

John E. Morison — 2010-01-01

To the Editor: I am writing regarding the recent Images in Endoscopy article that appeared in the July/August 2009 issue of the Journal . Many questions were raised about hernias, and because of the common nature of this condition, I believe this provides a good opportunity to elaborate on the approach to hernias found during surgery.

Letter to the Editor

Paolo Ricci — 2010-01-01

To the Editor: I appreciate the comments by Morrison regarding our article . I agree with all comments in the letter about asymptomatic hernias. We wished to discuss each topic raised by Morrison; however, the text accompanying the images was limited because of space. I believe the important thing to remember is that the diagnosis of asymptomatic hernia is possible during gynecologic laparoscopy. In our experience, we have found 2 asymptomatic abdominal wall hernias in a series of 200 consecutive laparoscopic gynecologic surgical procedures.

Medical Treatment of Cesarean Scar Pregnancy

2010-01-01

To the Editor: We read the interesting article by Qing Yang et al on the treatment of cesarean scar pregnancy (CSP). The authors describe the hysteroscopic removal of the trophoblastic tissue in 39 patients under ultrasonographic guidance. Two patients (5%) experienced excessive bleeding and required additional hysteroscopy. No follow-up on further fertility was available.

To the Editor

Qing Yang — 2010-01-01

We thank Dr. Hans Brolmann for his comments about our article on the treatment of cesarean scar pregnancy (CSP) . I would like to explain why we performed hysteroscopic therapy of CSP. We also have used transcervical aspiration and local methotrexate therapy to treat CSP. In addition, we have published an article entitled “Clinical Characteristics and Therapy of Ectopic Pregnancy in a Cesarean Section Scar” . We chose transcervical aspiration of the gestational sac under ultrasonic guidance after diagnostic hysteroscopy, followed by application of local methotrexate, 10 mg, around the implantation site, pressed with dry gauze. All 5 patients required a second curettage under ultrasonic guidance because of massive bleeding. Histopathologic results showed degenerated villi in the smooth muscle and coagulated blood. We believed aspiration could not remove the conceptive tissue completely, and considered hysteroscopic removal of conceptive tissue. Although these patients all recovered and the uterus was preserved, the remnant mass absorbed slowly, and it took some time for the serum β-human chorionic gonadotropin concentration to return to normal.

Erratum

2010-01-01

In the article by Yeung Jr. and Pasic entitled “Results of the live survey in Las Vegas, 2008, and the response of the AAGL” (Volume 16, Number 5, pp. 519-521), the following legend should have appeared next to Figures 1 and 2.

Meetings Calendar/Masthead

2010-01-01

Society Affiliations

2010-01-01

Editorial Board

2010-01-01

Board of Trustees

2010-01-01

The Journal of Minimally Invasive Gynecology

Cover 1

AAGL Practice Report: Practice Guidelines for Management of Intrauterine Synechiae

Practical Guide to Laparoscopic Pain Mapping

Transcervical Embryoscopy: Images of First-Trimester Missed Abortion

Nerve-Sparing Laparoscopic Radical Excision of Deep Endometriosis with Rectal and Parametrial Resection

A Comparative, Single-Blind, Randomized Trial of Pain Associated with Suction or Non-Suction Drains after Gynecologic Laparoscopy

Peritoneal Vascular Density Assessment Using Narrow-Band Imaging and Vascular Analysis Software, and Cytokine Analysis in Women With and Without Endometriosis

Single-Port Laparoscopic Salpingectomy for the Surgical Treatment of Ectopic Pregnancy

Hysteroscopic Appearance of Endometrial Cavity after Microwave Endometrial Ablation

Laparoscopic Nerve-Sparing Radical Trachelectomy: Surgical Technique and Outcome

Surgical Treatment of Endometriosis in Private Practice: Cohort Study with Mean Follow-up of 3 Years

Controlled Clinical Trial Assessing the Effect of Laparoscopic Uterine Arterial Occlusion on Ovarian Reserve

Opportunities and Risk Factors for Premalignant and Malignant Transformation of Endometrial Polyps: Management Strategies

Hysteroscopic Management of Large Symptomatic Submucous Uterine Myomas

Clinical and Sonographic Findings in Suspected Retained Trophoblast after Pregnancy Do Not Predict the Disorder

Quantifying Electrosurgery-Induced Thermal Effects and Damage to Human Tissue: An Exploratory Study with the Fallopian Tube as a Novel In-Vivo In-Situ Model

Single-Port Access Subtotal Hysterectomy with Transcervical Morcellation: A Pilot Study

Clinical Evaluation of a Third-Generation Thermal Uterine Balloon Therapy System for Menorrhagia Coupled with Curettage

Laparoscopic Myomectomy at 25 Weeks of Pregnancy: Case Report

Retained Uterine Fundus after Vaginal Hysterectomy

Rare Case of Ovarian Cystic Lymphangioma

Surgical Management of Recurrent Ureteric Endometriosis Causing Recurrent Hypertension In a Postmenopausal Woman

Haemophilus influenzae abscess: Inclusion in the Differential Diagnosis of a Large Pelvic Mass?

Laparoscopic Resection of Endometriosis in a Patient with a Ventriculoperitoneal Shunt Using the LapDisc

Internal Herniation of Adnexa Through a Defect of the Broad Ligament: Case Report and Literature Review

Giant Pararectal Epidermoid Tumor Mimicking Ovarian Cyst: Combined Laparoscopic and Perineal Surgical Approach

Vaginal Vault Leiomyoma: 25 Years After Total Abdominal Hysterectomy

Laparoscopic Pelvic Lymphadenectomy in a Patient with Cervical Cancer Stage Ib1 Complicated by a Twin Pregnancy

Diagnostic Laparoscopy Complicated by Group A Streptococcal Necrotizing Fasciitis

Laparoscopic Approach to Right Diaphragmatic Endometriosis with Argon Laser: Case Report

Laparoscopic Management of Placenta Percreta

Laparoscopic Uterosacral Nerve Ablation for Alleviating Chronic Pelvic Pain: A Randomized Controlled Trial

Comparison of Liquid-Based Cytology with Conventional Cytology for Detection of Cervical Cancer Precursors: A Randomized Controlled Trial

Letter to the Editor

Letter to the Editor

Medical Treatment of Cesarean Scar Pregnancy

To the Editor

Erratum

Meetings Calendar/Masthead

Society Affiliations

Editorial Board

Board of Trustees

Table of Contents