Efficacy and safety of V-Loc™ barbed sutures versus conventional suture techniques in gynecological surgery: a systematic review and meta-analysis.

PURPOSE: One of the most challenging tasks in laparoscopic gynecological surgeries is suturing. Knotless barbed sutures are intended to enable faster suturing and hemostasis. We carried out a meta-analysis to compare the efficacy and safety of V-Loc™ barbed sutures (VBS) with conventional sutures (CS) in gynecological surgeries. METHODS: We systematically searched PubMed and EMBASE for studies published between 2010 and September 2021 comparing VBS to CS for OB/GYN procedures. All comparative studies were included. Primary analysis and subgroup analyses for the different surgery and suturing types were performed. Primary outcomes were operation time and suture time; secondary outcomes included post-operative complications, surgical site infections, estimated blood loss, length of stay, granulation tissue formation, and surgical difficulty. Results were calculated as weighted mean difference (WMD) or risk ratio (RR) and 95% confidence intervals (CI) with a random effects model, and a sensitivity analysis for study quality, study size, and outlier results was performed. PROSPERO registration: CRD42022363187. RESULTS: In total, 25 studies involving 4452 women undergoing hysterectomy, myomectomy, or excision of endometrioma. VBS were associated with a reduction in operation time (WMD - 17.08 min; 95% CI - 21.57, - 12.59), suture time (WMD - 5.39 min; 95% CI - 7.06, - 3.71), surgical site infection (RR 0.26; 95% CI 0.09, 0.78), estimated blood loss (WMD - 44.91 ml; 95% CI - 66.01, - 23.81), granulation tissue formation (RR 0.48; 95% CI 0.25, 0.89), and surgical difficulty (WMD - 1.98 VAS score; 95% CI - 2.83, - 1.13). No difference between VBS and CS was found regarding total postoperative complications or length of stay. Many of the outcomes showed high heterogeneity, likely due to the inclusion of different surgery types and comparators. Most results were shown to be robust in the sensitivity analysis except for the reduction in granulation tissue formation. CONCLUSION: This meta-analysis indicates that V-Loc™ barbed sutures are safe and effective in gynecological surgeries as they reduce operation time, suture time, blood loss, infections, and surgical difficulty without increasing post-operative complications or length of stay compared to conventional sutures.

A Simple Technique for the Placement of Seprafilm, a Sodium Hyaluronate or Carboxymethylcellulose Absorbable Barrier, during Laparoscopic Myomectomy.

This report describes a simple technique using conventional instrumentation for the placement of Seprafilm, a sodium hyaluronate or carboxymethylcellulose absorbable barrier for adhesion prevention. A total of 378 women with uterine myomas undergoing laparoscopic myomectomies had 737 Seprafilm pieces placed. Seprafilm sheet was softened through exposure to room air for 5 minutes, cut into 4 pieces (length, 5-10 mm), rolled up alongside a plastic sheet cut from a camera drape cover, and gently placed at the right paracolic gutter. The Seprafilm pieces unfolded semiautomatically on release and were then placed on the uterus. The median time to apply per Seprafilm piece was 1 (range: 0.8-3.5) minute. We failed to place 16 pieces (16 of 737, 2.2%) in 11 patients. Virginal status, myoma weight, and the number of removed myomas were the risk factors of failed placement. Our technique for Seprafilm placement during laparoscopic myomectomy is simple and safe.

Temporary Ligation of the Uterine Artery at Its Origin Using a Removable "Shoelace" Knot.

STUDY OBJECTIVE: To demonstrate a technique of temporary ligation of the uterine artery at its origin. DESIGN: A step-by-step demonstration of the surgery in an instructional video. SETTING: A private hospital in Mumbai, India. INTERVENTION: The peritoneum over the pelvic side wall was dissected bilaterally to expose the uterine arteries at their origins. Using a polyglactin absorbable suture, a double thread loop was used to create a removable "shoelace" knot (Video 1). Both uterine arteries were ligated in this manner. The myomectomy was completed uneventfully, and the myoma bed was sutured in 2 layers using polyglactin sutures. Once suturing was completed, the shoelace knot was untied by simply pulling one end of the thread to restore blood supply to the uterus. Intraoperative blood loss was 30 mL, and the total operation time was 120 minutes. CONCLUSION: Laparoscopic ligation of the uterine arteries at their origin is known to reduce intraoperative blood loss [1,2]. However, in patients desiring future fertility, the effect of permanent ligation of these vessels bilaterally remains under study [3-5]. The removable "shoelace" knot is a low-cost, readily available alternative to metallic titanium clips that requires no special surgical expertise to implement.

Predictors of Prolonged Operative Time for Robotic-Assisted Laparoscopic Myomectomy: Development of a Preoperative Calculator for Total Operative Time.

STUDY OBJECTIVE: To develop a preoperative calculator to predict the total operative time (TOT) for robotic-assisted laparoscopic myomectomy (RALM). DESIGN: Retrospective cross-sectional study. SETTING: University medical center. PATIENTS: Women who underwent RALM performed by 3 high-volume surgeons at a single institution between January 2014 and December 2017. INTERVENTIONS: Demographic characteristics, indication for surgery, surgical history, myoma burden on imaging, and TOT were collected. RALM operative time was classified as <3 hours, 3 to 5 hours, and >5 hours. We identified preoperative characteristics predictive of increased operative time and developed a preoperative calculator to estimate TOT. MEASUREMENTS AND MAIN RESULTS: A total of 126 women underwent RALM during the study period, with a mean TOT of 213 minutes ± 66 minutes. The mean total weight of myomas removed was 264 g ± 236 g, and mean largest myoma diameter was 8.5 cm ± 2.6 cm. Overall, mean number of myomas removed was 2.5 ± 2.4, and estimated blood loss (EBL) was 215 ± 212 mL. Five patients (4.0%) received a blood transfusion, and 4 patients (3.2%) underwent conversion to laparotomy. Preoperative factors significantly associated with TOT included patient age, personal history of diabetes mellitus, uterine volume, number of myomas, number of myomas >3 cm, diameter of the dominant myoma, and surgeon experience. The mean uterine volume was 282 cm3 for procedures with a TOT <3 hours, 461 cm3 for procedures with a TOT of 3 to 5 hours, and 532 cm3 for procedures with a TOT >5 hours (p = .004). Body mass index, personal history of hypertension, previous abdominal/pelvic surgery, surgical indication, location of dominant myoma (anterior, posterior, or fundal) and classification of dominant myoma (submucosal, intramural, subserosal, or other) were not associated with TOT. Our preoperative calculator correctly predicted TOT category in 88% of the patients and estimated TOT within a 1-hour margin in 80% of patients. CONCLUSION: RALM is becoming a more popular surgical approach for the management of uterine myomas. Preoperative radiographic evaluation and a thorough patient history may enhance patient counseling and surgical planning. Uterine volume and myoma number and size appear to be more predictive of TOT compared with myoma location.

In Vitro Leakage Testing of Tissue Containment Bags When Subjected to Power Morcellation Forces.

STUDY OBJECTIVE: To determine the ability of tissue containment systems to prevent leakage of cancer cell surrogates when subjected to forces encountered during power morcellation procedures. DESIGN: In vitro study. SETTING: Medical device research laboratory. INTERVENTIONS: Samples from 7 different legally marketed tissue containment bags (1 of which is indicated for power morcellation) were subjected to dye and bacteriophage penetration tests at pressures ranging from 0.5 to 50 times the insufflation pressure. The minimum pressure required to cause bag leakage was measured. Subsequently, the morcellation leakage safety factor for each bag was determined as the ratio of the minimum leakage pressure of the bag to the total pressure contributed from insufflation pressure and mechanical forces acting during the power morcellation procedure. MEASUREMENT AND MAIN RESULTS: The leakage performance of the bags varied markedly from brand to brand. No correlation was found between leakage pressure and the bag material or the total bag thickness. The leakage pressures ranged from 26 mmHg to >1293 mmHg for the 7 bags, and safety factors ranged from 1 to 50 when only the insufflation pressure was considered. However, if the morcellation forces were included in the calculation, the safety factor dropped by 6-fold for all brands and dropped below 1, indicating likelihood of leakage, for 2 of the 7 brands. CONCLUSION: This study provides a mechanism for more realistically simulating the conditions experienced by containment bags during morcellation and quantifying the level of safety provided by the bags.

Single-Port/Pneumovagina Technique for Two Further Applications.

OBJECTIVE: To demonstrate a novel technique to surgically treat certain vaginal conditions. DESIGN: Technical video demonstrating 2 cases in which the technique is used. SETTING: Gynecological Minimally Invasive and Robotic Surgery Unit at Clínica Universitaria (private clinic), Concepción, Chile. INTERVENTIONS: Local institutional review board was consulted, and this study was exempted from approval. Institutional ethics committee approved the study and publication of these data. A 35-year-old woman with a bicornuate unicollis uterus presented with dyspareunia. Her examination revealed an incomplete longitudinal vaginal septum. Her right hemivagina was slightly wider than the left one. With the patient under spinal anesthesia, we performed a complete resection of the septum using the single-port/pneumovagina technique (SPPT). A 36-year-old woman who was nulligravida presented with dyspareunia. On clinical exam she had a 3-cm leiomyoma in the proximal vaginal third. Doppler-powered pelvic ultrasound ruled out any vascular communication with the cervix. We performed a vaginal myomectomy using the SPPT under spinal anesthesia. In this particular case we used a fourth trocar in the gel cap to use a myoma screw. With this technique we created a pneumovagina occluding the introitus with the aid of a single-port device (GelPoint Path; Applied Medical, Rancho Santa Margarita, CA). We selected this particular device, designed for transanal surgery, because its access channel avoids gas leakage after applying gentle pressure on the cap. The working cannel is 4 × 4.5 cm, and up to 4 trocars can be inserted in the gel cap. We use 12 mm Hg of pressure to create the pneumovagina and 5 L/min flow to maintain it. Similar approaches have been described for treating eroded and/or infected sacrocolpopexy mesh [1-3]. One could question the utility of this approach over conventional vaginal surgery, and in this sense we believe it provides both the surgeon and surgical assistant a much more comfortable and ergonomic position while performing surgery. It also improves the view of anatomic structures for the surgical team, which in conventional vaginal surgery is limited only to the surgeon. Both procedures were uneventful. The operation time for the first patient was 5 minutes, and the patient was discharged 4 hours later. The operation time for the second patient lasted 35 minutes, and she was discharged 12 hours later. CONCLUSION: The creation of a pneumovagina with the application of a single-port device provides an excellent view of vaginal structures and allows the application of laparoscopic techniques to perform vaginal surgeries in a much more ergonomic fashion compared with conventional vaginal surgery.

Reproductive Outcomes following Use of Barbed Suture during Laparoscopic Myomectomy.

STUDY OBJECTIVE: To review pregnancy outcomes after laparoscopic myomectomy with the use of barbed suture. DESIGN: Retrospective cohort study and follow-up survey. SETTING: Single, large academic medical center. PATIENTS: Patients who underwent laparoscopic myomectomy with the use of barbed suture for myometrial closure between 2008 and 2016. INTERVENTION: Laparoscopic myomectomy and a follow-up survey regarding pregnancy outcome. MEASUREMENTS AND MAIN RESULTS: A total of 486 patients met inclusion criteria and underwent a laparoscopic myomectomy between 2008 and 2016. Of the 428 with viable contact information, 240 agreed to participate (56%). Of those who responded to the survey, 101 (42%) attempted to get pregnant, and there were 4 unplanned pregnancies. There were 110 pregnancies among 76 survey respondents. In total, of the women attempting a postoperative pregnancy, 71% had at least 1 pregnancy. Comparing the women who did and did not conceive postoperatively, the group who got pregnant was on average younger, 33.8 ± 4.5 years vs 37.5 ± 6.5 years (p = .001); had fewer myomas removed, median = 2 (range 1-9) vs median = 2 (range 1-16) myomas (p = .038); and had a longer follow-up period, 30 months ( vs 30 (11-93 months) ± 20 (p <.001). The mean time to first postoperative pregnancy was 18.0 months (range 2-72 months). Of the 110 reported postoperative pregnancies, there were 60 live births (55%), 90% by means of cesarean section. The mean gestational age at birth was 37.8 weeks. In the cohort, there were 8 preterm births, 3 cases of abnormal placentation, 2 cases of fetal growth restriction, 3 cases of hypertensive disorders of pregnancy, and 2 cases of myoma degeneration requiring hospitalization for pain control. There were no uterine ruptures reported. CONCLUSION: According to our findings, pregnancy outcomes after laparoscopic myomectomy with barbed suture are comparable with available literature on pregnancy outcomes with conventional smooth suture.

Medicolegal Issues in Power Morcellation: Cautionary Rules for Gynecologists to Avoid Unfavorable Outcomes.

Power morcellation in laparoscopic surgery enables specialists to carry out minimally invasive procedures such as hysterectomies and myomectomies by cutting specimens into smaller pieces using a rotating blade and removing pieces through a laparoscope. Unexpected uterine sarcoma treated by surgery involving tumor disruption could be associated with poor prognosis. The current study aims to shed light on power morcellation from a medicolegal perspective: the procedure has resulted in adverse outcomes and litigation, and compensation for plaintiffs, as published in various journals cited in PubMed and MEDLINE, Cochrane Library, EMBASE, and GyneWeb. Considering the claims after the US Food and Drug Administration warnings on morcellation, the current study broadens the scope of research by including search engines, legal databases, and court filings (DeJure, Lexis Nexis, Justia, superior court of New Jersey, and US district court of Minnesota) between 1995 and 2019. Legal records show that courts determine professional responsibility regarding complications, making it essential to document adherence to safety protocols and specific guidelines, when available. Sound medical practices and clearly stated institute best practices result in better patient outcomes and are important when unfavorable clinical outcomes occur; adverse legal decisions can be avoided if there are grounds to prove professional conformity with specific guidelines and the unpredictability of an event.

Laparoscopic Myomectomy in 10 Steps.

STUDY OBJECTIVE: Laparoscopic myomectomy has the advantages of a minimally invasive approach for the surgical treatment of myomas. The standardization and description of the technique are the main objectives of this video. We described laparoscopic myomectomy in 10 steps, which could help make this procedure easier and safer [1]. SETTING: A French university tertiary care hospital. PATIENTS: Patients with indication for laparoscopic myomectomy. The local institutional review board ruled that approval was not required for this video article because the video describes a technique and does not report a clinical case. INTERVENTION: Standardized laparoscopic myomectomies were recorded to realize the video. MEASUREMENTS AND MAIN RESULTS: This video presents a systematic approach to myomectomy clearly divided into 10 steps: (1) prepare your surgery, make selection and prehabilitation of patient [2], provide a good cartography of the myoma(s), and plan the surgery [3,4]; (2) ergonomy and material; (3) preventive hemostasis: triple occlusion; (4) hysterotomy; (5) enucleation by fast dissection and traction; (6) bipolar hemostasis; (7) check for missing myomas; (8) suture; (9) extraction/morcellation; and (10) prevent adhesions [5]. CONCLUSION: Standardization of laparoscopic myomectomy could make this procedure easier and safer to perform. The 10 steps presented help to perform each part of surgery in logical sequence making the procedure ergonomic and easier to adopt and learn. Standardization of laparoscopic techniques could help to reduce the learning curve.

Perioperative Outcomes of Myomectomy for Extreme Myoma Burden: Comparison of Surgical Approaches.

STUDY OBJECTIVE: To describe the perioperative outcomes of various modes of myomectomy (abdominal [AM], laparoscopic [LM], or robotic [RM]) in cases of extreme myoma burden. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: A tertiary academic center in Boston, Massachusetts. PATIENTS: All women who underwent an AM, LM, or RM for extreme myoma burden, defined as representing the upper quartile for specimen weight (≥434.6 g) or myoma count (≥7 myomas), between 2009 and 2016. INTERVENTIONS: Baseline demographics and perioperative outcomes were collected from review of medical records, including estimated blood loss, operative time, length of stay, and complications. Univariate linear and logistic regression analyses were conducted. MEASUREMENTS AND MAIN RESULTS: During the study period 659 women underwent myomectomy for extreme myoma burden; 47.2% of cases were AM, 28.1% LM, and 24.7% RM. Overall myoma burden differed across the 3 routes and was greatest in the AM group (mean weight: 696.2 ± 784.5 g for AM vs 586.6 ± 426.1 g for LM and 586.6 ± 426.1 g for RM; mean number: 16.8 ± 15.0 for AM vs 7.2 ± 7.0 for LM and 6.7 ± 4.7 for RM; p <.001 for both). The 3 routes differed in operative time and length of stay, with RM having the longest operative time (mean, 239.7 minutes; p <.001) and AM the longest length of stay (mean, 2.2 ± .9 days; p <.001). Other perioperative outcomes were similar across the surgical approaches. Increasing myoma burden was associated with an increased risk of perioperative complications for all surgical approaches, with a threshold of 13 myomas associated with an almost 2-fold higher risk of perioperative complications (odds ratio, 1.77; 95% confidence interval, 1.17-2.70; p = .009). Cumulative incidence of perioperative complications with increasing specimen weight was greater in the RM cases as compared with AM (p = .002) or LM (p = .020), whereas the cumulative incidence of perioperative complications with increasing myoma count was lowest with AM compared with LM (p <.001) or RM (p <.001). CONCLUSION: Myomectomy for extreme myomas is feasible using an abdominal, laparoscopic, or robotic approach. Increased myoma burden is associated with an increased risk of perioperative complications. A threshold of 13 myomas was associated with an almost 2-fold higher risk of perioperative complications for all modes. Perioperative complication outcomes were more favorable in AM or LM over RM with increased myoma weight and AM over LM or RM with increased myoma number.

Uterine Fibroids - Current Trends and Strategies.

Fibroids are the most common benign tumors in women of childbearing age and can be found in almost 80-90% of all women by age 50 years. They can cause pain, excessive menstrual bleeding or infertility. The development of fibroids increases with age. Since the age of women in industrial countries who are trying to conceive is generally increasing, there has been a growing demand for minimally invasive and uterine-sparing surgical treatment of fibroids. Whereas the main focus of previous surgical techniques for the treatment of fibroids was enucleation of the tumour with subsequent closure of the uterine incision, modern devices developed over the past decade can destroy fibroids by using ultrasound or radio-frequency without incising the uterine wall. Thus, there is no uterine scar, which would impart a risk of rupture during labour or pregnancy. This article provides an overview of the latest techniques and devices used for uterine-sparing surgical treatment of fibroids. While laparoscopic myomectomy is still the gold standard, novel laparoscopic and transcervical radiofrequency ablation techniques use low-voltage and alternating current to induce heat in the uterine tissue, which triggers necrosis in fibroids. This enables the removal of multiple fibroids without the need for large incisions in the uterine wall. In addition, we address the benefits and potential risks, as well as the impact on fertility and pregnancy, of the different surgical approaches used for the treatment of uterine fibroids.

Six-year survival of patients with unsuspected uterine malignancy after laparoscopic versus laparotomic myomectomy: An 11-year national retrospective cohort study.

OBJECTIVE: The primary objective was to compare the overall survival of women with unsuspected uterine malignancy (UUM), including sarcomas and adenosarcomas, diagnosed after laparotomic versus laparoscopic myomectomy. The secondary objective was to determine the incidence of UUM diagnosed after myomectomy. METHODS: We analyzed the national health insurance database, which covers almost the entire Korean population, between 2006 and 2010 to calculate the incidence and mortality of UUM diagnosed after myomectomy. Diagnosis and procedure codes were used to identify women with or without UUM. RESULTS: During the study period, 78,826 patients who underwent myomectomy among women in the database (23 million per year) were enrolled. The women were divided into a laparotomic myomectomy group (n = 56,213) and a laparoscopic myomectomy group (n = 22,613). The incidence of UUM diagnosed after myomectomy was 0.08% in both groups (47/56,213 and 18/22,613 women, respectively). There was no difference in mean age, socioeconomic status, diagnostic code, UUM incidence at 5-year intervals, survival rate, or mean survival time. The 5-year survival rates of women with UUM were 95.7% and 88.9% in the laparotomic and laparoscopic groups, respectively. A Kaplan-Meier survival analysis showed no difference in the overall survival rates according to the surgical method (P = 0.447). CONCLUSIONS: The incidence of UUM after myomectomy was 0.08% after laparotomic or laparoscopic myomectomy. Although morcellator use does not reduce the overall survival rate, clinicians should explain the risks of intraperitoneal tumor dissemination to patients and do their best to prevent tumor spillage when using this tool.

Hysteroscopic myomectomy: a comparison of techniques and review of current evidence in the management of abnormal uterine bleeding.

PURPOSE OF REVIEW: Submucosal uterine leiomyomas are a common benign pelvic tumor that can cause abnormal uterine bleeding and may contribute to infertility and miscarriage. Hysteroscopic myomectomy is the treatment of choice to alleviate bleeding from these myomas and to normalize the uterine cavity. This review discusses the techniques and recent evidence for hysteroscopic myomectomy and examines the two primary surgical tools employed today: the bipolar resectoscope and hysteroscopic mechanical morcellator. RECENT FINDINGS: Hysteroscopic myomectomy has been a popular treatment for symptomatic submucosal fibroids for decades; it is a minimally invasive, low-cost, low-risk procedure, and is associated with high patient satisfaction. There have been rapid advances in the surgical technology available for this procedure. Both the bipolar resectoscope and the hysteroscopic mechanical morcellator are appropriate tools to remove submucosal myomas. Although the hysteroscopic morcellators have been associated with shortened operative time and a decreased learning curve, the data are limited for their use on type 2 fibroids. The strength of the bipolar resectoscope lies in its ability to resect deeper type 2 fibroids. SUMMARY: The evidence suggests that no one technique should be used for all patients, but rather a choice of technique should be taken on a case-by-case basis, depending on the myoma number, size, type, and location. Gynecologists must become knowledgeable about each of these techniques and their associated risks to safely offer these surgeries to their patients.

Indications for morcellation in gynecologic surgery.

PURPOSE OF REVIEW: Minimally invasive gynecologic procedures, in particular laparoscopic hysterectomy and myomectomy, often require tissue morcellation. RECENT FINDINGS: Whether morcellated or not, myometrial cells can be found in the abdomen and pelvis after either laparoscopic or open myomectomy. Following morcellation, careful inspection for and removal of tissue fragments and copious irrigation and suctioning of fluid can remove residual tissue and cells without the use of containment bags. The dogma of not 'cutting-through' cancer is not correct for many surgical specialties and irrelevant with regards to leiomyosarcoma (LMS) and minimally invasive gynecologic surgery. Eliminating residual disease in the pelvis and abdomen should be the goal of myomectomy or hysterectomy. SUMMARY: Morcellation of excised tissue is necessary for many women with symptomatic fibroids who choose to undergo laparoscopic myomectomy or hysterectomy. LMS is an uncommon disease, with a poor prognosis due to early hematogenous metastasis to lung, bone and liver. Preoperatively, it is often difficult to differentiate from benign fibroids. LMS has a high propensity for local recurrence despite performance of total hysterectomy. Efforts to remove all tissue and cells from the pelvis and abdomen should be the goal of minimally invasive surgery with morcellation.

Economics of gynecologic morcellation.

PURPOSE OF REVIEW: As the Food and Drug Administration raised concern over the power morcellator in 2014, the field has seen significant change, with patients and physicians questioning which procedure is safest and most cost-effective. The economic impact of these decisions is poorly understood. RECENT FINDINGS: Multiple new technologies have been developed to allow surgeons to continue to afford patients the many benefits of minimally invasive surgery while minimizing the risks of power morcellation. At the same time, researchers have focused on the true benefits of the power morcellator from a safety and cost perspective, and consistently found that with careful patient selection, by preventing laparotomies, it can be a cost-effective tool. SUMMARY: Changes since 2014 have resulted in new techniques and technologies to allow these minimally invasive procedures to continue to be offered in a safe manner. With this rapid change, physicians are altering their practice and patients are attempting to educate themselves to decide what is best for them. This evolution has allowed us to refocus on the cost implications of new developments, allowing stakeholders the opportunity to maximize patient safety and surgical outcomes while minimizing cost.

Advantages of Single-Port Laparoscopic Myomectomy Compared with Conventional Laparoscopic Myomectomy: A Randomized Controlled Study.

STUDY OBJECTIVE: To compare operative outcomes of single-port laparoscopic myomectomy (SP-LM) vs conventional laparoscopic myomectomy (CLM), including subjective and objective cosmetic aspects. DESIGN: Prospective randomized controlled trial (Canadian Task Force classification I). SETTING: University hospital. PATIENTS: Women with uterine myoma scheduled for laparoscopic myomectomy. INTERVENTIONS: Sixty-six women were assigned at random to either the SP-LM or CLM group. Surgical outcomes, including patient and observer scar assessments, were evaluated between the groups according to the intention-to-treat principle. MEASUREMENTS AND MAIN RESULTS: There were no significant differences in demographic characteristics and properties of myomectomy between the groups. There also were no differences in surgical outcomes, such as operation time, estimated blood loss, and complications, between the 2 groups. The mean total score of the Observer Scar Assessment Scale was lower in the SP-LM group at 1 week (13.0 ± 3.2 vs 18.3 ± 4.8; p < .001) and 8 weeks (9.9 ± 3.2 vs 14.3 ± 3.8; p < .001) after discharge. Similar results were obtained for the Patient Scar Assessment Scale at 1 week (11.6 ± 7.2 vs 18.5 ± 12.8; p = .024) and 8 weeks (9.5 ± 6.0 vs 18.8 ± 9.1; p < .001) after discharge. Postoperative pain and analgesic consumption did not differ between the groups, except in patient-controlled analgesia consumption at 6 hours after operation, which was lower in the SP-LM group (12.7 ± 6.3 mL vs 16.4 ± 6.2 mL; p = .039). Operative outcomes were similar in the 2 groups. CONCLUSION: SP-LM is associated with more favorable cosmetic outcomes and better patient satisfaction compared with CLM. There were no differences in operative outcomes and complications between the 2 modalities.

Pediatric Foley Catheter Placement After Operative Hysteroscopy Does Not Cause Ascending Infection.

STUDY OBJECTIVE: To determine the incidence of postoperative ascending infection without antibiotics with the use of a pediatric Foley catheter (PFC) after operative hysteroscopy for intrauterine pathology. DESIGN: Retrospective case series (Canadian Task Force classification III). SETTING: University-affiliated outpatient medical center. PATIENTS: Patients who underwent operative hysteroscopy for uterine septum, arcuate uterine anomaly, or multiple submucosal myomas between 1992 and 2015. INTERVENTIONS: In all patients, a PFC was placed in the endometrial cavity at the conclusion of operative hysteroscopy and left in place for 7 days to reduce intrauterine adhesion formation. MEASUREMENTS AND MAIN RESULTS: A total of 1010 patients who underwent operative hysteroscopy for uterine septum (n = 479), arcuate uterine anomaly (n = 483), or multiple submucosal myomas (n = 48) were studied. All patients presented with infertility, recurrent pregnancy loss, or excessive uterine bleeding (in patients with submucous myomas). In all patients, a PFC was placed at the conclusion of the procedure and left in place for 7 days. An 8Fr PFC was used after hysteroscopic division of uterine septum or arcuate uterine anomaly, and a 10Fr PFC was used after hysteroscopic myomectomy. Patients with a history of pelvic inflammatory disease were excluded. Following PFC placement, patients were prescribed estrogen for 6 weeks and progestogen for the last 10 days of the estrogen course. No prophylactic antibiotic therapy was provided. All patients were discharged to home on the same day. Postoperative pain was well controlled with oral pain medication in 98.5% of the patients. There were no reported postoperative infections, and all patients had an uneventful recovery. CONCLUSION: In 1010 consecutive operative hysteroscopies followed by temporary (7-day) PFC placement, no clinically significant uterine infection was observed.

Preclinical safety testing for morcellation and extraction for an endobag with sealable ports: in vitro pilot study.

BACKGROUND: Electromechanical power morcellation is an important tool of modern laparoscopy. Recent reports on the spread of previously undetected malignancy by power morcellation indicate the need for additional protective devices to reduce this risk. We conducted a study to obtain the first data concerning the safety of an endobag with three closable ports during morcellation and subsequent bag extraction under in vitro conditions, mimicking the settings in our operating theater. The second purpose of the study was to establish a minimal width of the skin incision necessary to safely extract the sealed bag after morcellation. METHODS: The morcellation test was carried out on 11 stained porcine muscle tissue samples with one additional sample as a control. The insufflation pressure was set at 12 mmHg. After filling the endobag with blue dye solution, an additional extraction test was conducted by pulling the closed bag through a template with apertures of various diameters. For each opening, a series of ten bag extractions was carried out. RESULTS: No loss of solid material or fluid was recorded during the morcellation test. The extraction test showed a loss of fluid for template openings smaller than 18 mm. The force necessary to extract the bag was inversely related to the width of the aperture. CONCLUSIONS: The data suggest that under the evaluated conditions, the use of a closable morcellation bag can considerably improve the patient's safety during morcellation. Further studies are necessary to evaluate the influence of the bag on operating time, intervention costs and complications.

Feasibility of Reduced-Port Robotic Surgery for Myomectomy with the da Vinci Surgical System.

STUDY OBJECTIVE: To present our initial experience with reduced-port robotic surgery (RPRS) for myomectomy using the Octo-Port system (DalimSurgNet, Seoul, Korea). DESIGN: Prospective and noncomparative study (Canadian Task Force classification II-3). SETTING: University hospital. PATIENTS: Nineteen consecutive patients with symptomatic uterine myomas desiring conservative minimally invasive robotic surgery from October 2015 to December 2016. INTERVENTIONS: An 8.5-mm or 12-mm robotic camera cannula was inserted through 1 of the Octo-Port channels and an 8-mm conventional robotic port was inserted into a 10-mm channel of the Octo-Port through a 3-cm transumbilical incision. An additional 8-mm conventional robotic port was inserted into a typical robotic port site in the patient's right abdomen. MEASUREMENTS AND MAIN RESULTS: Feasibility and operative outcomes of RPRS myomectomy. The median docking time and console time were 10 minutes (range, 4-22) and 90 minutes (range, 29-198). The largest myoma was located on the anterior uterine wall in 11 patients (57.9%). The median myoma size and weight were 7.2 cm (range, 4.1-10.5) and 141 g (range, 42-590), respectively. Median operative blood loss and change in hemoglobin were 100 mL (range, 30-700) and 2.6 mg/dL (range, .1-3.8), respectively. The procedure was successfully performed via RPRS in 89.5% of patients; 2 patients required placement of 1 to 2 additional robotic ports, resulting in a return to traditional multiport robotic surgery. There were no major postoperative complications or postoperative hernias. CONCLUSION: Our experience demonstrated the feasibility of RPRS for myomectomy using the Octo-Port system in selected patients.

Laparoscopic Myomectomy for a Plethora of Submucous Myomas.

STUDY OBJECTIVE: To demonstrate a laparoscopic myomectomy technique for the removal of multiple submucous myomas. DESIGN: A step-by-step demonstration of the surgical procedure (Canadian Task Force classification III-C). SETTING: In cases of multiple submucous myomas, hysteroscopic resection of myomas might not be a viable option, especially in cases requiring fertility preservation. It may cause significant damage to the endometrial surface, leading to the formation of endometrial synechiae [1]. The procedure is technically challenging and requires prolonged operating time owing to impaired visibility and the need for repeated specimen removal. This can lead to complications, such as fluid overload and, rarely, air embolism [2]. Thus, laparoscopic myomectomy may be a better option in such cases [1]. INTERVENTIONS: A 30-year-old nulligravida presented with a 3-year history of heavy menstrual bleeding and dysmenorrhea. She had received no symptom relief with hormonal medications and magnetic resonance-guided focused ultrasound. On examination, she was anemic, and her uterus was enlarged to 16-weeks gravid size. Ultrasonography revealed an intramural fundal myoma of 6 × 4.2 cm and numerous submucous myomas of 1 to 3.2 cm. During hysteroscopy, multiple submucous myomas of varying sizes ranging from type 0 to type 1 were seen. On laparoscopy, an incision was made on the uterine fundus with an ultrasonic device after injecting vasopressin (20 U in 200 mL dilution), and the fundal myoma was enucleated. The incision was then extended to open the endometrial cavity for the removal of the submucous myomas. Most of the myomas were removed with mechanical force, along with the minimal use of ultrasonic energy. A total of 46 myomas were removed, and the myometrium was closed in 2 layers. The duration of the surgery was 210 minutes, and estimated blood loss was 850 mL. The patient did not require blood transfusion, but was advised to take hematinics. At a 6-month follow-up, the patient reported significant improvement in her symptoms. A repeat hysteroscopy revealed moderate synechiae in the midline and 2 small submucous myomas near the internal os. The synechiae were incised with hysteroscopic scissors, and the submucous myomas were resected with a bipolar resectoscope. The patient was advised to attempt conception after 2 months. CONCLUSION: Laparoscopic myomectomy is an alternative to hysteroscopic resection for multiple submucous myomas. A repeat hysteroscopy is useful for identifying any residual myomas and synechiae.