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Surgical Technology International XXVII contains 41 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.
Nov, 2015 - ISSN:1090-3941
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Gynecology
Does Laparoscopic Hysterectomy Increase the Risk of Vaginal Cuff Dehiscence? An Analysis of Outcomes from Multiple Academic Centers and a Review of the Literature
Emad Mikhail, MD, Fellow of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, University of South Florida/Morsani College of Medicine, Tampa, Florida, Mary Ashley Cain, MD, Assistant Professor, Department of Obstetrics and Gynecology, University of South Florida/, Morsani College of Medicine, Tampa, Florida, Madhvi Shah, Medical Student, Marshall University Joan C. Edwards School of Medicine , Huntington, West Virginia, M. Jonathon Solnik, MD, FACOG, FACS , Associate Professor, Head of Gynecology and MIS, Department of Obstetrics and Gynecology , Faculty of Medicine, University of Toronto , Mt. Sinai Hospital, Toronto, Canada, Craig J. Sobolewski, MD , Assistant Professor, Department of Obstetrics and Gynecology Division , Chief, Minimally Invasive Gynecologic Surgery, Duke University School of Medicine, Durham, North Carolina , Stuart Hart, MD, MBA, MS, FACOG, FACS, Associate Professor, Division of Female Pelvic Medicine and , Reconstructive Surgery , Department of Obstetrics and Gynecology, Chief Medical Officer of Innovation, USF Health Center for Advanced Medical Learning and Simulation (CAMLS), University of South Florida Morsani College of Medicine, Tampa, Florida
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Vaginal cuff dehiscence represents a serious, but infrequent complication after hysterectomy, with a reported increased incidence following a laparoscopic approach. Various risk factors have been proposed including laparoscopically placed suture, surgical experience, use of electrosurgery, surgical indication, and obesity. Technical aspects of the procedure itself have also been questioned such as the variable use of monopolar electrosurgery during colpotomy and the suture type or number of layers chosen to reapproximate the vaginal cuff. Nothwithstanding the tendency for cuff dehiscence to occur following laparoscopic approach, there remains a paucity of high-quality data that supports or refutes this finding or clearly defines the mechanism(s) by which this event occurs allowing for the proposal of objective guidelines for reducing risk. Various techniques have been proposed to decrease the risk of vaginal cuff dehiscence during endoscopic hysterectomy, including use of monopolar current on cutting mode, achievement of cuff hemostasis with sutures rather than electrocoagulation, use of a two-layer cuff closure with polydioxanone suture, and use of bidirectional barbed suture for cuff closure.
Laparoscopic Paravaginal Defect Repair: Surgical Technique and a Literature Review
Dr. Orawee Chinthakanan, MD, MPH, Urogynecologist, International Urogynecology Associates , of Atlanta and Beverly Hills, Alpharetta, Georgia, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand , Dr. John R. Miklos, MD, Urogynecologist, International Urogynecology Associates, of Atlanta and Beverly Hills, Alpharetta, Georgia, Dr. Robert D. Moore, DO , Urogynecologist , International Urogynecology Associates , of Atlanta and Beverly Hills, Alpharetta, Georgia
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Paravaginal defects, commonly seen in patients with anterior vaginal wall prolapse, are due to the detachment of pubocervical fascia from the arcus tendineus fascia pelvis (ATFP), at or near its lateral attachment. The majority of anterior vaginal wall prolapse is thought to be caused by paravaginal defects. Richardson et al. first described and demonstrated the anatomy of the paravaginal defect, as well as described the initial technique of the abdominal approach to repair. Since that time, the laparoscopic approach for repair has been developed and described with success rates of laparoscopic paravaginal defect repair reported in the range of 60% to 89%. This minimally invasive approach to address anterior wall prolapse eliminates the need for a vaginal incision, reduces risk of vaginal shortening and can be completed at the same time as other laparoscopic procedures, such as hysterectomy, sacralcolpopexy, and/or Burch Urethropexy. Compared to the open abdominal approach, there is improved visualization, less risk of bleeding, and faster recovery with the laparoscopic method. Compared to an anterior colporrhaphy, laparoscopic paravaginal repair is a much more anatomic repair of lateral defects and does not result in vaginal shortening. The laparoscopic paravaginal repair should be considered as the first-line treatment of anterior vaginal wall prolapse caused by lateral defects, including at time of laparoscopic/robotic sacralcolpopexy.
Classification of Hypertrophy of Labia Minora: Consideration of a Multiple Component Approach
Pablo I. González, MD, Chief, Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Hospital Universitario San Jorge, Pereira, Colombia
Labia minora hypertrophy of unknown and under-reported incidence in the general population is considered a variant of normal anatomy. Its origin is multi-factorial including genetic, hormonal, and infectious factors, and voluntary elongation of the labiae minorae in some cultures. Consults with patients bothered by this condition have been increasing with patients complaining of poor aesthetics and symptoms such as difficulty with vaginal secretions, vulvovaginitis, chronic irritation, and superficial dyspareunia, all of which can have a negative effect on these patients' sexuality and self esteem. Surgical management of labial hypertrophy is an option for women with these physical complaints or aesthetic issues. Labia minora hypertrophy can consist of multiple components, including the clitoral hood, lateral prepuce, frenulum, and the body of the labia minora. To date, there is not a consensus in the literature with respect to the classification and definition of varying grades of hypertrophy, aside from measurement of the length in centimeters. In order to offer patients the most appropriate surgical technique, an objective and understandable classification that can be used as part of the preoperative evaluation is necessary. Such a classification should have the aim of offering patients the best cosmetic and functional results with the fewest complications.
Laparascopic Neurolysis of Deep Endometriosis Infiltrating Left Femoral Nerve: Case Report
Cláudia Andrade, MD, Minimally Invasive Gynecologic Surgery Fellow, Department of Obstetrics and Gynecology, Centro Hospitalar Lisboa Norte – Hospital Universitário de Santa Maria, Lisbon, Portugal, Gynecology and Obstetrics Resident, Department of Obstetrics and Gynecology, Centro Hospitalar Tondela-Viseu, Viseu, Portugal, Sónia Barata, MD, Clinical Assistant, Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Centro Hospitalar Lisboa Norte – Hospital Universitário de Santa Maria, Lisbon, Portugal, Francisco António, MD, Clinical Assistant, Department of Neurosurgery, Centro Hospitalar Lisboa Norte – Hospital Universitário de Santa Maria, Lisbon, Portugal, Conceição Alho, MD, Clinical Assistant, Department of Obstetrics and Gynecology, Centro Hospitalar Lisboa Norte – Hospital Universitário de Santa Maria, Lisbon, Portugal, Carlos Calhaz-Jorge, PhD, Professor of Gynecology , Department of Obstetrics and Gynecology, Centro Hospitalar Lisboa Norte – Hospital Universitário de Santa Maria, Lisbon, Portugal, Faculdade de Medicina de Lisboa, CAM – Centro Académico de Medicina de Lisboa, Lisbon, Portugal, Filipa Osório, MD, Clinical Assistant, Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Centro Hospitalar Lisboa Norte – Hospital Universitário de Santa Maria, Lisbon, Portugal, Faculdade de Medicina de Lisboa, CAM – Centro Académico de Medicina de Lisboa, Lisbon, Portugal
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Pelvic endometriosis may infiltrate somatic nerves causing severe neuropathic symptoms with a high impact on quality of life. It is a medical condition poorly known, and few published data about involvement of femoral nerve are available. We report an isolated unilateral endometriosis lesion of the left lumbar region infiltrating the femoral nerve in a 38-year-old woman. She described severe dysmenorrhea, dyspareunia, dischezia, and chronic pelvic pain with irradiation to the anterior part of the left thigh. After investigation, it was identified as a 5-centimeter endometriotic nodule involving the femoral nerve and the psoas muscle. The patient was treated by two laparoscopic surgeries with neurolysis of the involved somatic nerve by a multidisciplinary team, with improvement of the symptoms. Laparoscopic neurolysis is the first approach advocated in these cases, leading to relief of neurological symptoms resulting from nerve infiltration by endometriosis.
Postcoital Sperm Assessment Comparative Study
Michael J. Pelekanos, MD, Vice Chairman , Department of Obstetrics and Gynecology , Forbes Regional Hospital, Monroeville, PA
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This postcoital sperm assessment study was performed over a 10 month time period (November 2014–August 2015). Fifteen couples enrolled in the study. The study was a non-blinded, non-randomized, single-center comparison study comparing The Stork® OTC (Rinovum Women’s Health, Monroeville, PA) to natural intercourse (NI), using the subjects as their own control/baseline. This was an efficacy study designed to compare the number of sperm in the cervical mucus following the use of The Stork OTC conception aid with the number of sperm in the cervical mucus following natural intercourse. Subjects used both The Stork OTC conception system and the natural intercourse method to evaluate concentrations of sperm in the cervical mucus. Post-coital test (PCT) data was collected demonstrating higher concentrations of sperm within the cervical mucus with The Stork OTC conception system versus natural intercourse for 85% of test subjects in this study. Of the 15 couples enrolled in the study, 2 were lost to follow-up. Mean age for male subjects was 31.7 +/ 5.4 years of age and mean age for female subjects was 29.7+/- 5.4. The average sperm score value of the 85% of test subjects with higher sperm concentrations from The Stork OTC was 3.23 times the score value of sperm concentration compared to natural intercourse. The remaining 15% of test subjects showed no change in sperm score value between The Stork OTC and natural intercourse.
Laparoscopic Approach for Fibroid Removal at 18 Weeks of Pregnancy
Alfredo Cortes Algara, MD, Chief of Robotics and Laparoscopy, Centro Mexicano de Cirugía de Invasión Mínima, Hospital San Ángel Inn , Chapultepec, México, Alfredo Góngora Rodríguez, MD, Medical Associate, Reproductive Endocrinology Division , Centro Mexicano de Cirugía de Invasión Mínima, Hospital San Ángel Inn , Chapultepec, México, Alfredo Cortes Vázquez, MD, Medical Associate, Reproductive Endocrinology Division, Centro Mexicano de Cirugía de Invasión Mínima, Hospital San Ángel Inn , Chapultepec, México, Florencia Elena Castañeda Valladares, MD, Medical Associate, Robotics and Laparoscopy Division, Centro Mexicano de Cirugía de Invasión Mínima, Hospital San Ángel Inn , Chapultepec, México , Pedro González Ramírez, MD, Medical Associate, Anesthesiology Division , Centro Mexicano de Cirugía de Invasión Mínima, Hospital San Ángel Inn , Chapultepec, México , Eleazar Lara Padilla, MD, Headmaster, Basic and Clinical Investigation service, Escuela Superior de Medicina, Instituto Politécnico Nacional, México City, México, Cindy Bandala, MD, Medical Associate, Basic and Clinical Investigation service, Escuela Superior de Medicina, Instituto Politécnico Nacional , México City, México, Saúl León Hernández, MD, Medical Associate, Basic and Clinical Investigation service, Escuela Superior de Medicina, Instituto Politécnico Nacional , México City, México
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Leiomyomas are the most frequently solid tumors found in pregnancy. This kind of tumor has a wide incidence depending on the age, race, and type of population studied. Most of the cases have an asymptomatic course; however, they could develop different kinds of complications during the pregnancy such as severe abdominal pain, often due to degeneration or torsion with ischemia. In these cases, a surgical approach is required because these tumors do not respond to the conventional treatment. Very few of these cases are reported in the literature. We report the case of a 36-year-old woman pregnant 18 weeks, who experienced acute abdominal pain without initial reponse to regular analgesics. She was taken to the operating room, and under laparoscopic exploration, torsion of a subserosal myoma was observed. The fibroid was resected laparoscopically, and she was released from the hospital without complications. Unfortunately, she was readmitted 45 days later with signs of preterm labor because of a motorcycle accident. An emergency cerclage was performed, but the pregnancy was compromised with amnionitis and early fetal demise. We concluded that the laparoscopic approach could be a successful alternative treatment in selected cases.
Now You See It: Using Angled Laparoscopes in Minimally Invasive Gynecologic Surgery (MIGS)
James Dana Kondrup, M.D. Assistant Clinical Professor of OB/GYN, Our Lady of Lourdes Memorial Hospital Department of OB/GYN, Binghamton, NY, Frances R. Anderson, PhD, RN,
Research Coordinator
Our Lady of Lourdes Memorial Hospital,
Binghamton, NY
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As minimally invasive gynecologic surgery becomes more complex and cases more difficult, surgeons must adapt to the challenges not only by using innovative equipment but also using the lessons learned from other disciplines. Many years after general surgeons learned the “art of laparoscopy,�? it is clear that general surgeons in the United States—and those around the world—have surpassed the “masters of laparoscopy�? (gynecologists) with their use of new techniques and new equipment. Surgeons are using less traumatic graspers and perform a higher percentage of surgeries laparoscopically than gynecologic surgeons. With the essential need for more integrated ergonomics and a suitable laparoscopic operating room environment, this article describes the benefits of using angled laparoscopes and includes basic techniques to enable gynecologic surgeons to master “driving�? the angled laparoscope.
