Single-Use Energy Sources and Operating Room Time for Laparoscopic Hysterectomy: A Randomized Controlled Trial.

STUDY OBJECTIVES: To compare the intraoperative direct costs of a single-use energy device with reusable energy devices during laparoscopic hysterectomy. DESIGN: A randomized controlled trial (Canadian Task Force Classification I). SETTING: An academic hospital. PATIENTS: Forty-six women who underwent laparoscopic hysterectomy from March 2013 to September 2013. INTERVENTIONS: Each patient served as her own control. One side of the uterine attachments was desiccated and transected with the single-use device (Ligasure 5-mm Blunt Tip LF1537 with the Force Triad generator). The other side was desiccated and transected with reusable bipolar forceps (RoBi 5 mm), and transected with monopolar scissors using the same Covidien Force Triad generator. The instrument approach used was randomized to the attending physician who was always on the patient's left side. Resident physicians always operated on the patient's right side and used the converse instruments of the attending physician. MEASUREMENTS AND MAIN RESULTS: Start time was recorded at the utero-ovarian pedicle and end time was recorded after transection of the uterine artery on the same side. Costs included the single-use device; amortized costs of the generator, reusable instruments, and cords; cleaning and packaging of reusable instruments; and disposal of the single-use device. Operating room time was $94.14/min. We estimated that our single use-device cost $630.14 and had a total time savings of 6.7 min per case, or 3.35 min per side, which could justify the expense of the device. The single-use energy device had significant median time savings (-4.7 min per side, p < .001) and total intraoperative direct cost savings ($254.16 per case). CONCLUSIONS: A single-use energy device that both desiccates and cuts significantly reduced operating room time to justify its own cost, and it also reduced total intraoperative direct costs during laparoscopic hysterectomy in our institution. Operating room cost per minute varies between institutions and must be considered before generalizing our results.

Delayed presentation of a paracytic myoma fragment after laparoscopic supracervical hysterectomy requiring small bowel resection. A case report.

BACKROUND: Uterine myomas are commonly treated with laparoscopic myomectomy or hysterectomy. Morcellation is often required to evacuate tissue through the laparoscopic incisions using a designated morcellator or through extension of a port site with self-retaining retractor and a cold scalpel. Both techniques carry a risk of inadvertently leaving tissue fragments behind. CASE: We present a case of a parasitic fragment of morcellated uterus that became adherent to the small bowel, resulting in severe abdominal pain and requiring exploratory laparotomy and small bowel resection 5 months later. CONCLUSION: Gynecologic surgeons should be aware of possible delayed postoperative complications that can result from parasitic myoma fragments inadvertently left behind followinig morcellation.

Direct injection of vasopressin during hysteroscopic myomectomy: a case report.

BACKGROUND: Hysteroscopic myomectomy is the ideal procedure for symptomatic women with submucosalfibroids who desire to preserve their fertility. Vascular myomas can limit visualization when a mechanical morcellator is used. Injection of a dilute vasopressin solution has been shown to decrease blood loss during laparoscopic myomectomy. To date, direct injection of a dilute vasopressin during hysteroscopic myomectomy has not been described. CASE: Our first patient's hysteroscopic myomectomy of a vascular submucosal myoma had to be terminated before complete resection due to impaired visualization and maximum fluid overload. During a subsequent patient's procedure, direct injection ofa dilute vasopressin through the operative port decreased intraoperaftve bleeding and enabled complete resection. CONCLUSION: Injecting a dilute vasopressin solution directly into a vascular submucosal myoma during hysteroscopic resection can assist with hemostasis and visualization, enabling complete resection.

Surgical evaluation and treatment of the patient with chronic pelvic pain.

Treatment of patients with chronic pelvic pain is assisted by detailed history, physical examination, pain diary, and ultrasonography. The possibility of other contributing systems (eg, gastrointestinal, genitourinary, musculoskeletal) should also be addressed and treatment initiated if present. A diagnostic surgical procedure is helpful in patients for whom medical management or whose severity of pain warrants an urgent diagnosis. Limited evidence exists to support adhesions, endometriosis, ovarian cysts, ovarian remnants, and hernias as being causes of chronic pelvic pain. In select patients, ovarian cystectomy, excision of endometriosis and ovarian remnants, adhesiolysis, hysterectomy, hernia repair, and presacral neurectomy may provide relief.

Massive delayed vaginal hemorrhage after laparoscopic supracervical hysterectomy.

Background. A known complication of supracervical hysterectomy is cyclical bleeding from the retained cervix when functioning endometrial tissue is not totally removed. We present a rare case of delayed postoperative vaginal hemorrhage after supracervical hysterectomy. Case. A 44-year-old woman presented on postoperative day 15 after laparoscopic supracervical hysterectomy with massive vaginal hemorrhage requiring emergent re-operation. Her bleeding was controlled with vaginally placed sutures. Ultrasound confirmed no intraperitoneal free fluid. The etiology was thought to be induced by postoperative tissue necrosis from cautery applied to the endocervical canal during the original surgery. Conclusion. Delayed vaginal hemorrhage from a retained cervix is a rare complication of laparoscopic supracervical hysterectomy. Caution should be exercised when cauterizing the endocervical canal as induced tissue necrosis may increase the risk of postoperative bleeding.