Surgical Tips for Robotic Assisted Laparoscopic Abdominal Cerclage: A Minimally Invasive Approach.

Preterm birth is the leading cause of perinatal and neonatal morbidity and mortality in the developed world. An important cause of preterm birth is cervical insufficiency, leading to membrane prolapse, premature rupture of membranes, and mid-trimester pregnancy loss. A cerclage can be placed vaginally or abdominally to treat cervical insufficiency. In cases of failed prior transvaginal cerclage (TVC), transabdominal cerclage (TAC) is the alternative. The procedure can be completed via laparoscopy or open approach. The suture is placed at the internal os giving greater structural support.1 In this article, we review the definition of cervical incompetence, we present the indications for TAC, we discuss the outcomes of minimally invasive TAC compared to open approach, and we review surgical tips and tricks for robotic assisted (RA) TAC placement that can be used prior to pregnancy or in early gestation. The included images delineate the surgical technique for safe placement of robotic assisted laparoscopic abdominal cerclage in the management of cervical insufficiency.

Society for Maternal-Fetal Medicine Consult Series #65: Transabdominal cerclage.

Cerclage is the mainstay of treatment for cervical insufficiency. Although transabdominal cerclage may have advantages over transvaginal cerclage, it is associated with increased morbidity and the need for cesarean delivery. In this Consult, we review the current literature on the benefits and risks of transabdominal cerclage and provide recommendations based on the available evidence. The following are Society for Maternal-Fetal Medicine recommendations: (1) we recommend that transabdominal cerclage placement be offered to patients with a previous transvaginal cerclage placement (history or ultrasound indicated) and subsequent spontaneous singleton delivery before 28 weeks of gestation (GRADE 1B); (2) we recommend maternal-fetal medicine consultation for counseling patients who may be candidates for transabdominal cerclage and those who have undergone transabdominal cerclage (Best Practice); (3) we suggest that both laparoscopic transabdominal cerclage and open transabdominal cerclage are acceptable and the decision of approach may depend on gestational age, technical feasibility, available resources, and expertise (GRADE 2B); (4) we suggest that transabdominal cerclage can be performed before pregnancy or in the first trimester of pregnancy with similar fetal outcomes. If a patient with an indication for transabdominal cerclage presents after the first trimester of pregnancy, transabdominal cerclage can still be considered before 22 weeks of gestation (GRADE 2C); (5) we recommend that routine transvaginal cervical length screening not be performed for patients with a transabdominal cerclage in situ (GRADE 1C); (6) we suggest that for individuals at risk of recurrent spontaneous preterm birth, including those with a transabdominal cerclage in situ, a risk-benefit discussion of supplemental vaginal progesterone be undertaken with shared decision-making (GRADE 2C); (7) we suggest that pregnancy loss be managed with dilation and curettage or dilation and evacuation with a transabdominal cerclage in situ or via usual obstetrical management after laparoscopic removal of the transabdominal cerclage, depending on gestational age and resources available (GRADE 2C); and (8) we suggest cesarean delivery between 37 0/7 and 39 0/7 weeks of gestation for patients with a transabdominal cerclage in situ (GRADE 2C).

Robot-Assisted Surgery for Endometriosis Current and Future Perspectives.

Successful resection of all visible lesions may effectively treat endometriosis-related infertility and pelvic pain. Minimally invasive surgery provides significant advantages, with lower rates of surgical complications such as surgical trauma, infection, postoperative pain, and hospital stay. Robotic surgery is shown to have similar perioperative outcomes to conventional laparoscopy; however, complex stage III and IV endometriosis, especially cases requiring significant resection such as deep infiltrating endometriosis, widespread peritoneal implants, and urologic and intestinal involvement, may benefit most from a robotic approach. There are certain aspects of endometriosis surgery where utilization of robotic technology might provide an additional benefit. These include (1) heterogeneity of lesions, and thus difficulty in identification; (2) difficulty in accurately predicting surgical complexity; and (3) prolonged operative time for complex cases. The objective of this review is to describe the current and future perspectives of robotic surgery as it pertains to endometriosis.

Use of low dose vaginal misoprostol in office hysteroscopy: a pre-post interventional study.

A pre-post interventional study of patients undergoing office hysteroscopy alone and in combination with endometrial biopsy was performed during October 2015-March 2018 to evaluate the effect of low dose vaginal misoprostol on patient's pain. Pain scores were assessed using the visual analog scale at the completion of the procedure. There were 646 patients included in the study. Of these, 462 had office hysteroscopy alone; 206 (44.6%) received 50 mcg of vaginal misoprostol the night prior to the procedure and the remaining 256 (55.4%) patients had no cervical ripening. The reported pain score following hysteroscopy was significantly lower among patients who received misoprostol [4(0-10) vs. 5(0-10); p=.001]. Most patients (78.2%) did not report any misoprostol related side effects. Of the 184 patients who underwent a combination of office hysteroscopy and endometrial biopsy, 97 (52.7%) received pre-procedure vaginal misoprostol while 87 (47.3%) did not. Post procedure pain was independent of pre-treatment with vaginal misoprostol (6.3 ± 2.7 vs. 6.6 ± 2.7; p = .54).Impact statementWhat is already known on this subject? Office hysteroscopy and endometrial biopsy is increasingly performed for evaluation of various gynaecologic conditions, however, patients' perceived pain at the time of procedure may lead to incomplete procedures. Various doses of misoprostol have been tested to reduce patients' pain, however none lower than 200 mcg vaginally, and at these doses, side effects are reported.What the results of this study add? To date, there is a scarcity of published data on the use of low dose misoprostol (50 mcg) in gynaecologic procedures. Our study found that the use of low dose vaginal misoprostol prior to office hysteroscopy is associated with lower reported pain and tenaculum utilisation during the procedure. However, vaginal misoprostol prior to successive office hysteroscopy and endometrial biopsy failed to decrease the reported pain, and the overall pain score was higher than hysteroscopy alone.What the implications are of these findings for clinical practice and/or further research? The use of low dose vaginal misoprostol (50 mcg) the evening prior to office hysteroscopy is associated with lower reported pain and tenaculum utilisation and is not associated with significant side effects. Therefore, 50 mcg of misoprostol could be used in clinical practice as a method to reduce patients' reported pain during office hysteroscopy.

Cost-effectiveness of a preoperative pelvic MRI in pelvic organ prolapse surgery.

OBJECTIVE: To investigate the cost-effectiveness of preoperative pelvic magnetic resonance imaging (MRI) in identifying women at high risk of surgical failure following apical repair for pelvic organ prolapse (POP). METHODS: A decision tree (TreeAgePro Healthcare software) was designed to compare outcomes and costs of screening with a pelvic MRI versus no screening. For the strategy with MRI, expected surgical outcomes were based on a calculated value of the estimated levator ani subtended volume (eLASV) from previously published work. For the alternative strategy of no MRI, estimates for surgical outcomes were obtained from the published literature. Costs for surgical procedures were estimated using the 2008-2014 National Inpatient Sample (NIS). A cost-effectiveness analysis from a third-party payer perspective was performed with the primary measure of effectiveness defined as avoidance of surgical failure. Deterministic and probabilistic sensitivity analyses were performed to assess how robust the calculated incremental cost-effectiveness ratio was to uncertainty in decision tree estimates and across a range of willingness-to-pay values. RESULTS: A preoperative MRI resulted in a 17% increased chance of successful initial surgery (87% vs. 70%) and a decreased risk of repeat surgery with an ICER of $2298 per avoided cost of surgical failure. When applied to annual expected women undergoing POP surgery, routine screening with preoperative pelvic MRI costs $90 million more, but could avoid 39,150 surgical failures. CONCLUSION: The use of routine preoperative pelvic MRI appears to be cost-effective when employed to identify women at high risk of surgical failure following apical repair for pelvic organ prolapse.

Association between Preoperative Adenomyosis Detection Rate during Pelvic Ultrasonography and the Specialty of the Reading Physician.

STUDY OBJECTIVE: To compare the detection rate of adenomyosis when ultrasound is performed by a radiologist compared with a gynecologic expert sonologist. DESIGN: A retrospective, single-center study. SETTING: A university teaching hospital. PATIENTS: All women above 18 years of age with a positive histopathology diagnosis of adenomyosis obtained in a hysterectomy specimen from October 1, 2011, to October 1, 2017, were screened for inclusion. Cases without a preoperative pelvic ultrasound report, those with coexisting premalignant/malignant conditions, and patients presenting to the clinic with symptoms other than abnormal uterine bleeding, dysmenorrhea, or abdominal pain were excluded. A total of 412 cases were included in the final analysis. MEASUREMENTS AND MAIN RESULTS: The preoperative ultrasound was performed by a radiologist in 241 patients (59%) and by an expert gynecologic sonologist in 171 patients (42%). Patients' age, body mass index, race, ethnicity, parity, and history of prior cesarean section were comparable between the 2 groups. The adenomyosis detection rate was significantly higher in the expert gynecologic sonologist group compared with radiologists (95 [56%] vs 29 [12%], p <.01). After controlling for patients' race, body mass index, prior cesarean sections, and presence of myomas using multivariable logistic regression, gynecologic expert sonologists were 7.8 times more likely to detect adenomyosis than radiologists (odds ratio = 7.84; 95% confidence interval, 4.58-13.44). Regardless of medical specialty, the presence of myomas significantly decreased the detection of adenomyosis compared with the absence of myomas (odds ratio = 0.23; 95% confidence interval, 0.13-0.39). CONCLUSION: The detection rate of adenomyosis was significantly higher when ultrasound was performed by expert gynecologic sonologists compared with radiologists. The presence of myomas significantly decreased detection rates regardless of specialty. Ultrasound evaluation for detecting adenomyosis should be preferentially performed by gynecologic expert sonologists.

Robotic Surgery for Urologic Deep Infiltrating Endometriosis: A Review and Case Presentations.

Urologic involvement is seen in 1.2-3.9% of women with endometriosis. The bladder (84%) is the most common location of urinary tract endometriosis and the retro-trigone and dome of the bladder are the most frequently affected sites. Ureteral involvement is commonly extrinsic and leads to compression and fibrosis of peri-ureteral tissue, leading to obstruction. Robotic-assisted laparoscopy provides additional advantages of 3D visualization, shorter learning curve compared to conventional laparoscopy, improved dissection in tight pelvic spaces, and facilitation of suturing techniques. In this review, we present the multidisciplinary management of four cases of deep infiltrating endometriosis of the urinary tract in a tertiary referral center of expertise and a review of the literature.

Laparoscopic Entry Technique Using a Veress Needle Insertion with and without Concomitant CO2 Insufflation: A Randomized Controlled Trial.

STUDY OBJECTIVE: To compare the time and number of attempts needed for successful Veress needle entry during laparoscopic surgery using concomitant versus subsequent CO2 insufflation approaches. DESIGN: Randomized controlled trial. SETTING: University teaching hospital. PATIENTS: One hundred consecutive patients scheduled for laparoscopic surgery by 2 high-volume laparoscopic surgeons were screened and randomized, and 95 of these were included in the final analysis. Ninety (45 in each group) was the precalculated priori number of patients needed to detect a 50% difference in the time (seconds) to obtain adequate insufflation with 90% power and alpha of 5%. INTERVENTIONS: Patients were randomized to either Veress needle entry with concomitant (Con) or subsequent (Sub) CO2 insufflation. MEASUREMENTS AND MAIN RESULTS: Forty-six patients were randomized to the Con group and 49 to the Sub group. Patient age, body mass index, prior surgical history, presence of adhesions, and type of procedure performed were similar between both groups. The median time required for adequate insufflation in the Con group was 103.5 seconds (Q1-Q3, 80.0-130.0) compared with 113.0 seconds (Q1-Q3, 102.0-144.0) in Sub group (p = .16). Approximately 89% (95% confidence interval, 80.1%-98.1%) of patients in Con group achieved successful entry in the first attempt compared with only 67% (95% confidence interval, 54.2%-80.0%) in Sub group (p = .01). The incidence of preperitoneal insufflation and failed entry was comparable between the 2 groups. No patient developed solid organ, visceral, or vascular injuries; gas embolism; or case conversion to laparotomy in relation to the Veress needle entry technique. CONCLUSION: Veress needle entry with concomitant CO2 insufflation was associated with a higher rate of successful entry during the first attempt of Veress needle insertion. The total time required for insufflation and rates of complications between the 2 techniques were similar.

Minimally Invasive Surgery for the Obese Patient Among the Spectrum of Gynaecologic Surgery-A Surgical Viewpoint.

The prevalence of obesity has increased, achieving an epidemic status. Obesity has surgical and medical implications on the health of a woman. A minimally invasive surgical approach has several advantages and is considered the preferred approach for various procedures in obese women. The spectrum of gynaecologic surgical care spans over three main domains: benign gynaecologic surgery, reconstructive pelvic surgery, and gynaecologic cancer surgery. In this viewpoint, we chose a signature procedure for each main domain to compare minimally invasive surgery (MIS) trends for obese patients across all domains. Discrepancy was found in minimally invasive surgical trends for obese patients across different gynaecologic surgical domains. Fellowship training or maintaining high surgical volume might help to bridge this gap in the domain of benign gynaecologic surgery and improve quality care offered to obese patients.

Contemporary management of adnexa at the time of benign hysterectomy: a review of the literature.

Ovarian cancer is the leading cause of Gynecological cancer related mortality in the USA. Due to the absence of an effective screening method, concomitant adnexal management during hysterectomy or other pelvic surgeries is a prime consideration. Bilateral salpingo-oophorectomy (BSO) offers the benefit of eliminating the risk of ovarian cancer however it leads to surgical menopause with unfavourable overall health outcomes. With the latest verification that serous tubal intraepithelial carcinoma detected in the distal fimbriated end of the fallopian tube being the precursor of Type 2 ovarian cancers, there is an increased trend of performing bilateral salpingectomy (BS) as a risk reduction strategy for ovarian cancer. Women with a high risk for ovarian cancer due to familial or genetic mutations and those diagnosed with endometriosis need particular attention while planning adnexal management during hysterectomy. Physician and patient's shared decision-making regarding adnexal management during benign hysterectomy taking into consideration the route of hysterectomy is an important portion of pre-operative planning. The objective of this article is to understand the current trends of BSO and BS during benign hysterectomy and appreciate the pros and cons to aid in pre-operative counselling of patients.

National rates, trends and determinants of inpatient surgical management of tubal ectopic pregnancy in the United States, 1998-2011.

AIM: To describe the frequency and temporal trends of inpatient hospitalization for tubal ectopic pregnancy as well as patients' characteristics, determinants and the current national trends in surgical management of ectopic pregnancy. METHODS: We conducted a retrospective, cross-sectional analysis of patients who were treated for tubal ectopic pregnancy in an inpatient hospital setting in the United States from 1998 to 2011 using data from the Nationwide Inpatient Sample databases. National frequency and significant changes in the rate of surgical management of tubal ectopic pregnancy in the inpatient setting are described. RESULTS: The study included 334 639 tubal ectopic pregnancies for women aged 18-50 in the United States from 1998 to 2011. The rate of tubal ectopic pregnancy (per 10 000 maternal admissions) decreased from 77.2 in 1998 to 40.5 in 2011. The proportion of tubal ectopic pregnancies for which salpingostomy was performed decreased from 17.0% in 1998 to 7.0% in 2011, while the rate of salpingectomy increased from 69.3% in 1998 to 80.9% in 2011. The temporal change in surgical choice was not different in states with comprehensive in vitro fertilization insurance mandates. CONCLUSION: The rate of tubal ectopic pregnancy managed in the inpatient setting in the United States decreased 5% annually between 1998 and 2011. The rate of salpingectomies performed annually increased whereas that of salpingostomy decreased over time. The surgical approach selected for the management of tubal ectopic pregnancies was not influenced by a state's in vitro fertilization mandate status.

Total Laparoscopic Hysterectomy in the Setting of Prior Bilateral Renal Transplant, a Case Report and Review of the Literature.

In recent years, more women are undergoing renal transplantation as a treatment for end-stage renal disease. Women with kidney transplants are prone to certain gynecologic issues which might necessitate hysterectomy. Laparoscopic hysterectomy can safely be performed in patients with prior unilateral or bilateral renal transplantation. Laparoscopy offers magnification of anatomy, decreased wound-related problems, and continuation of immunosuppression therapy. We present a case report and review of the literature for total laparoscopic hysterectomy and bilateral salpingectomy for a patient with prior bilateral renal transplant.

The Association Between Hospital Surgical Volume and the Uptake of Minimally Invasive Surgical Approach and Outpatient Setting for Hysterectomy.

BACKGROUND: There are large variations in the use of minimally invasive surgery (MIS), and outpatient hysterectomy (OP) among Medicare patients according to hospital surgical volume and geographical distribution. OBJECTIVE: To explore the changing trend in OP and MIS hysterectomy in the United States. STUDY DESIGN: We used all Medicare fee-for-service claims data for 2012 and 2014 to determine the incidence of OP and MIS hysterectomy according to hospital surgical volume and geographical distribution. MIS included both laparoscopy and robotic surgery. OP procedures included only same-day discharge hysterectomies. RESULTS: A total of 55,562 and 53,054 hysterectomies were performed in the years 2012 and 2014, respectively. OP rate in 2014 in high-volume centers (16,828 [47.1%]) exceeded low-volume centers (136 [16%]) by 31.1% (p<0.001). Time trends between 2014 and 2012 show that a rise in OP rate was 17.7% and 7% for high- and low-volume hospitals (p<0.001), respectively. High-volume hospitals showed an increase of 3.1% (p=0.003) in MIS hysterectomy rate in 2014 (69%) as compared to 2012 (65.9%). There was no change in MIS rate among low-volume hospitals. CONCLUSION: In the Medicare population, the rate of OP and MIS hysterectomy for high-volume centers is significantly different form low-volume centers. Over the years, outpatient hysterectomy is being practiced widely but an increase in MIS rate is limited to high-volume centers.

Demonstration of a box-stitch technique for laparoscopic uterosacral ligament suspension.

AIM: We demonstrate a novel box stitch technique of laparoscopic post-hysterectomy uterosacral ligament suspension for apical prolapse in restorative pelvic reconstructive surgery. MATERIAL AND METHODS: We present a case of a 58yo female with symptomatic stage III pelvic organ prolapse with a history of a total abdominal hysterectomy 30 years prior. She strongly desired the usage of no synthetic or biologic mesh for her restorative surgical repair. This video provides a step-by-step guide on how to perform a laparoscopic box stitch as a technique for uterosacral ligament suspension as an apical native tissue option for patients with the need for post hysterectomy apical prolapse. CONCLUSION: This video demonstrates a novel box-stitch technique of laparoscopic post-hysterectomy uterosacral ligament suspension as a native tissue option for minimally invasive reconstructive surgery. The procedure is a reasonable option to address apical prolapse in patients who do not desire or who are unable to have synthetic or biologic mesh placed for restorative reconstructive prolapse surgery.

A Simplified Novel Approach for Total Laparoendoscopic Single-Site (LESS) Hysterectomy.

Total laparoendoscopic single-site (LESS) hysterectomy is a technically challenging minimally-invasive gynecologic procedure. Multiple technological innovations assist surgeons to overcome the challenges that are usually encountered during this advanced approach. Simplifying the steps of this advanced surgery is an invaluable addition in overcoming associated challenges with this procedure. We present our novel technique for a total laparoscopic hysterectomy that will optimize a single-site approach (LESS) for surgeons.

Trends of Bilateral Salpingectomy During Vaginal Hysterectomy With and Without Laparoscopic Assistance Performed for Benign Indications in the United States.

STUDY OBJECTIVE: To estimate the recent temporal trends of concurrent bilateral salpingectomy (BS) during vaginal hysterectomy (total vaginal hysterectomy [TVH] and laparoscopic-assisted vaginal hysterectomy [LAVH]) in the United States. DESIGN: A cross-sectional analysis was conducted using data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, including all female patients 18 years and older whose inpatient discharge record indicated a TVH or LAVH performed for benign indications between January 1, 1998, and December 31, 2011. Joinpoint regression was used to identify statistically significant changes in overall and subgroup temporal trends of TVH and LAVH as well as concomitant BS during the 14-year study period (Canadian Task Force Classification II). SETTING: Not applicable. PATIENTS: All patients who underwent TVH and LAVH from 1998 to 2011 registered in the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: Regarding TVH, between 1998 and 2001, there was a steep negative trend with an annual percentage change of -5.2 (95% confidence interval [CI], -8.8 to -2.2). From 2001 to 2011, the negative trend was still observed but with a more gradual 2% annual decrease (95% CI, -2.4 to -1.3). Conversely, the rate of LAVH increased at a rate of 4.4% each year (95% CI, 3.7-5.0). From 1998 to 2004, the national rate of BS during TVH increased sharply with an annual increase of 42.8% (95% CI, 22.7-66.3). Beginning in 2004, the BS rate during TVH decreased and remained stable. During LAVH, the rate of concomitant BS increased an estimated 15% each year during the entire study period (95% CI, 11.9-17.8). CONCLUSION: The proportion of annual LAVH with concomitant BS procedures performed across the nation is on the rise while TVH is declining with a stable rate of concomitant BS.