Robot-Assisted Vaginal Natural Orifice Transluminal Endoscopic Surgery for Frozen Pelvis.

STUDY OBJECTIVE: To show feasibility and techniques used to perform a total hysterectomy, bilateral salpingectomy, endometriosis resection, and ovarian reconstruction in a patient with a frozen pelvis secondary to a history of ruptured tubo-ovarian abscess. DESIGN: Narrated step-by-step video demonstration. SETTING: Single academic institution. INTERVENTIONS: In patients with a history of multiple abdominal surgeries, abdominal mesh, or in the case of this patient, a history of a ruptured tubo-ovarian abscess, a vaginal approach may be safer. Immediate access to the uterine pedicles through the vagina bypasses the need for extensive enterolysis and adhesiolysis when compared to an abdominal approach. With the use of indocyanine green injected into bilateral ureters, we highlight the benefits of immediate identification of the ureters allowing for safer and more efficient dissection. We show rotational uterine maneuvers to aid in rectosigmoid-to- posterior-uterus dissection in a limited space due to dense pelvic adhesions. Lastly, we demonstrate ovarian reconstruction and oophoropexy for the purpose of easier ovarian identification in future surgeries to possibly reduce the risks of ovarian remnant syndrome. CONCLUSION: This video highlights the feasibility and strategies used to perform robot-assisted vaginal natural orifice transluminal endoscopic surgery on a patient with a frozen pelvis.

Robot-Assisted Vaginal Natural Orifice Transluminal Endoscopic Surgery (RvNOTES) With Total Hysterectomy for Management of Stage IV Endometriosis With/Without Complete Cul-de-Sac Obliteration: 23-Case Pilot Feasibility Study.

STUDY OBJECTIVE: To show feasibility and short-term outcomes of robot-assisted vaginal NOTES (RvNOTES) for the treatment of stage IV endometriosis during total hysterectomy with/without complete cul-de-sac obliteration. DESIGN: Retrospective case series. SETTING: Single academic tertiary care hospital in Houston, Texas, USA. PATIENTS: Twenty-three adult women with stage IV endometriosis. INTERVENTIONS: RvNOTES with total hysterectomy for excision of severe endometriosis. MEASUREMENTS AND MAIN RESULTS: Patients were assessed for various metrics including total operative time, robot dock time, robot console time, hysterectomy time, estimated blood loss, perioperative pain using the Visual Analogue Scale (VAS), and complications. The mean total operative time was 224.3 minutes. The study also found that patients with complete cul-de-sac obliteration had significantly longer operative times and higher estimated blood loss compared to those with partial or no obliteration. Postoperative VAS pain scores showed a significant reduction over a 6-week period. Complications included one case of complete ureteral transection, pelvic hematoma with infection, vaginal abscess, urinary tract infection, and pneumonia. CONCLUSION: Our findings suggest that RvNOTES may be a feasible surgical approach in expert hands for treating stage IV endometriosis, even in cases with complete obliteration of the cul-de-sac.

The Evolution of Transvaginal Robot-Assisted Surgery in Gynecology.

Laparoscopy has advanced over the last three decades with residency training programs focusing on trans-abdominal laparoscopic techniques whether conventional or robotic. Despite attempts over many years to adopt vaginal surgery as the preferred method of hysterectomy, traditional vaginal surgery has largely fallen out of favor. Vaginal natural orifice transluminal endoscopic surgery (vNOTES) has gained popularity with patients and promises to provide an attractive option, but the surgical skills of many gynecologists have limited its widespread adoption. We explore the use of robot-assisted vNOTES (RA-vNOTES), which offers improved ergonomics, visualization, and wristed instruments for more precise surgery. Robotic vNOTES, was originally performed in Taiwan by Dr. Chyi-Long Lee in 2014.1 Our center has used the robotic vaginal approach for hysterectomy, myomectomy, sacrocolpopexy, adnexal surgery, endometriosis excision, and more. We have also shown feasibility in performing surgery on patients with a completely obliterated posterior cul-de-sac, long been thought to be a contraindication for the transvaginal approach. Enhancements have been made to improve safety and efficiency, such as the use of indocyanine green to visualize the ureters. There are some limitations on instrument maneuverability and reach with the current da Vinci® Xi (Intuitive Surgical, Sunnyvale, California) platform. However, with over 300 cases logged in our center, these limitations may be overcome with the new da Vinci® SP (Intuitive Surgical, Sunnyvale, California). We are eager to share our experience and hope that more gynecologic surgeons will choose this innovative approach for the benefit of our patients.

Recurrent Paravaginal Abscess: An Unusual Presentation of a Distal Ectopic Ureteral Remnant.

Introduction: Obstructed hemivagina ipsilateral renal agenesis (OHVIRA) is a rare syndrome with limited data on both treatment and postoperative sequelae, specifically of ectopic ureters to the vagina. Case Description: This case study describes a 22-year-old patient with OHVIRA syndrome presenting with pelvic pain and drainage from a chronic vaginal abscess secondary to a remnant distal ectopic ureter after nephrectomy and proximal ureterectomy. Imaging was significant for a right paravaginal abscess. Previously, the patient was treated with conservative therapy and on presentation her evaluation confirmed a right paravaginal abscess. She subsequently underwent a robot-assisted incision and drainage of the paravaginal abscess and excision of the remnant distal ectopic ureter. She did well postoperatively without recurrence. Discussion: We discuss the successful surgical technique used to identify and excise a paravaginal abscess. We also highlight the unique anatomy of a patient with OHVIRA syndrome. Lastly, we underline the importance of a complete resection of an ectopic ureter to the vagina at the time of nephrectomy, given the potential risk of ascending chronic infection and recurrent abscess formation.

Applications of In Vivo Functional Testing of the Rat Tibialis Anterior for Evaluating Tissue Engineered Skeletal Muscle Repair.

Despite the regenerative capacity of skeletal muscle, permanent functional and/or cosmetic deficits (e.g., volumetric muscle loss (VML) resulting from traumatic injury, disease and various congenital, genetic and acquired conditions are quite common. Tissue engineering and regenerative medicine technologies have enormous potential to provide a therapeutic solution. However, utilization of biologically relevant animal models in combination with longitudinal assessments of pertinent functional measures are critical to the development of improved regenerative therapeutics for treatment of VML-like injuries. In that regard, a commercial muscle lever system can be used to measure length, tension, force and velocity parameters in skeletal muscle. We used this system, in conjunction with a high power, bi-phase stimulator, to measure in vivo force production in response to activation of the anterior crural compartment of the rat hindlimb. We have previously used this equipment to assess the functional impact of VML injury on the tibialis anterior (TA) muscle, as well as the extent of functional recovery following treatment of the injured TA muscle with our tissue engineered muscle repair (TEMR) technology. For such studies, the left foot of an anaesthetized rat is securely anchored to a footplate linked to a servomotor, and the common peroneal nerve is stimulated by two percutaneous needle electrodes to elicit muscle contraction and dorsiflexion of the foot. The peroneal nerve stimulation-induced muscle contraction is measured over a range of stimulation frequencies (1-200 Hz), to ensure an eventual plateau in force production that allows for an accurate determination of peak tetanic force. In addition to evaluation of the extent of VML injury as well as the degree of functional recovery following treatment, this methodology can be easily applied to study diverse aspects of muscle physiology and pathophysiology. Such an approach should assist with the more rational development of improved therapeutics for muscle repair and regeneration.