Superior Hypogastric Plexus Nerve Block in Minimally Invasive Gynecology: A Randomized Controlled Trial.

STUDY OBJECTIVE: To assess the efficacy of a superior hypogastric plexus nerve block in reducing opioid requirements in the first 24 hours after minimally invasive gynecologic surgery. DESIGN: Patient-blinded randomized controlled trial. SETTING: Single-center academic institution (Sydney Women's Endosurgery Centre). Two surgeons administering the blocks in their own surgeries. PATIENTS: Patients undergoing either laparoscopic or robot-assisted laparoscopic hysterectomy or myomectomy for benign indications. INTERVENTIONS: Ropivacaine 10 mL (0.75%) infiltrated into the retroperitoneal space overlying the superior hypogastric plexus vs control of no block given at the completion of surgery. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the total opioid use in the first 24 hours after surgery, measured in morphine milligram equivalents (MME). Standardized fentanyl patient-controlled analgesia was given to all patients in the trial. The secondary outcome was pain measured on a visual analog scale (1 to 10) at 1, 2, 6, 12, and 24 hours after surgery. Fifty patients out of 56 approached for the study participated in, and completed, the study (89.2%). The patients were randomized over a 5-month period, March 2020 to July 2020. A total of 27 patients were randomized to receive a nerve block, and 23 were randomized to the control. There was a difference of -21.8 MME in the block group compared with the no-block group (95% confidence interval [CI], -38.2 to -5.5; p = .008). This correlated to a 38% reduction in opioid use in the block group. The mean opioid use in the patients in the block group was 33.1 MME (95% CI, 24.2-41.9) and in those in the no-block group 54.9 MME (95% CI, 40.7-69.1). For the block group, opioid use ranged from 1.0 to 76.5 MME, with an interquartile range of 37 (14-51). For the control group, the range was 7.5 to 113.5 MME, with a higher interquartile range of 60 (28-88). Pairwise comparisons of the mean pain scores over the 24 hours showed a lower pain score with a nerve block of 1.8 (95% CI, 1.5-2.1) compared with a no-block score of 2.6 (95% CI, 2.3-2.9) No adverse effects of local anesthetic toxicity, nerve injury, or bowel/vascular injury were noted in any patient. CONCLUSION: A superior hypogastric plexus nerve block is a simple technique for reducing postoperative opioid requirements and pain in the first 24 hours after minimally invasive gynecologic surgery.

Cultivating the Apprentice-Mentor Model for Minimally Invasive Gynaecology in the Era of Surgically Scarce Training: A Case Report of Laparoscopic Cornuostomy for Interstitial Ectopic Pregnancy by a Trainee.

Over the last few years, there is an apparent growing concern amongst O&G trainees of the inadequacy in exposure to minimally invasive gynaecology surgical training, which has been inadvertently compounded by the more stringent working hour regulations and disproportionately increasing number of trainees relative to surgical volume. Therefore, it is vitally important for trainees to maximise opportunities in the operating theatre and develop autonomy in carrying out more complex surgical procedures. This case report outlines the step-by-step approach of laparoscopic excision of a cornual ectopic pregnancy performed by a trainee under the supervision of a surgical mentor. This manuscript highlights key characteristic traits of a trainee that serve to foster surgical trust and simple but effective steps to foster surgical preparedness.

Long-term patient-reported outcomes after laparoscopic Burch colposuspension.

BACKGROUND: The negative media attention surrounding vaginal mesh procedures has seen a rise in demand for minimally invasive non-mesh options for the treatment of stress urinary incontinence (SUI). The laparoscopic Burch colposuspension (LBC) is a non-mesh alternative to synthetic midurethral slings (MUS) with similar short-term outcomes. However, long-term outcomes are not well established. AIMS: To evaluate the long-term outcomes of LBC for treatment of SUI in women. MATERIAL AND METHODS: One hundred and fifty-one cases of LBC were performed by a single surgeon over two private hospital settings between January 2010 and January 2016. Follow-up subjective outcomes were obtained in 137 cases (90.7%) utilising standardised questionnaires. Primary outcome was successful treatment of SUI, defined as subjective cure or significant improvement of stress incontinence symptoms. Secondary outcomes included new-onset or worsened symptoms of overactive bladder (OAB), voiding dysfunction, prolapse, and perioperative complications. RESULTS: One hundred and thirty-seven patients were analysed with a mean follow-up of 50.6 months (range: 13-89 months). Primary outcome of successful treatment was achieved in 90.5% of women. New-onset or worsened symptoms of OAB was reported in 10.2%, with a further 8.8% of women experiencing symptomatic voiding dysfunction. Sixteen patients (11.7%) reported new-onset or worsening symptoms of prolapse. There were no major surgical complications. CONCLUSIONS: LBC is a safe and effective long-term treatment for SUI, with low failure rates and minimal adverse outcomes. It is a suitable alternative for women with contraindications to mesh or those having concomitant laparoscopic procedures.

Surgical Management of Complete Procidentia in a Female Patient with Bladder Exstrophy-epispadias Complex: Case Report and Literature Review.

We herein describe the operative approach of a postmenopausal woman with a history of surgically corrected congenital bladder exstrophy-epispadias who presented with long-standing complete procidentia. The patient was initially treated by laparoscopic sacral colpopexy in conjunction with a modified Elevate mesh kit anterior vaginal repair with and posterior vaginal wall repair in the form of native tissue suture plication repair. Her prolapse recurred 8 months' later due to a detachment of the mesh at the level of the promontorium. During the second-look laparoscopy, a resuspension of this mesh was deemed unsatisfactory; therefore, with patients' consent, a successful colpocleisis was performed. This case report emphasizes the complexity of pelvic organ prolapse (POP) in the context of a bladder exstrophy-epispadias complex. These women are more likely to fail the more conventional current surgical treatments for POP, coercing to revert to colpocleisis.

Laparoscopic Myomectomy of a 4.2 kg Fibroid with Assistance of a Minilaparotomy.

The improved cosmesis and recovery from minimally invasive techniques has seen a dramatic rise in its popularity. Unfortunately, the laparoscopic myomectomy for large fibroids presents a unique challenge to the surgeon. It is reputed to be difficult and time consuming, with a high risk of conversion to laparotomy. As laparoscopic techniques improve, the laparoscopic myomectomy for larger fibroids is becoming more feasible. This article outlines the case of laparoscopic removal of a 4.2 kg fibroid with the assistance of a minilaparotomy.

The Sydney Contained In Bag Morcellation technique.

STUDY OBJECTIVE: To demonstrate a modification of the Shibley single-port technique suitable for morcellation of large myomatous uteri after total laparoscopic hysterectomy in a contained environment within the abdominal cavity [1]. DESIGN: Step-by-step explanation of the technique using descriptive text and an educational video. SETTING: In light of recent concern about the use of power morcellators and increasing the risk of disseminating occult leiomyosarcomatous myoma fragments throughout the abdominal cavity, we propose this new technique for management of morcellation of large myomatous uteri after total laparoscopic hysterectomy, to contain the morcellation process and minimize the risk. This technique, which we have coined "Sydney Contained in Bag Morcellation" involves introduction of a sterile plastic bag (Dual Drawstring Bag, 460 × 460 mm; Southern Cross Hospital Supplies, Northmead, NSW, Australia) before introducing an optical port and the power morcellator. Before insertion this bag is modified in several ways to facilitate bag opening and specimen retrieval. The dual drawstring is removed and replaced with a 150-cm length of PDS I (polydioxanone) suture material as the new drawstring, with its exit at the mouth of the bag in the 6 o'clock position. Five stay sutures are placed around the bag mouth, corresponding to the 12, 1, 5, 7, and 11 o'clock positions. This assists with opening the mouth of the bag intraabdominally and enables orientation to be maintained. The bag is then inserted in a McCartney tube (Gates Healthcare, Cheshire, UK). Corresponding slits are made in the tip of the tube to enable the end of the stay sutures to be securely held in place during tube insertion. These ends are then retrieved using atraumatic graspers and exteriorized and clipped alongside their corresponding port sites. After hysterectomy the uterus is placed in the bag, and the stay sutures maintain the mouth opening. The bag is closed and its mouth exteriorized onto the abdominal wall at the site of the umbilical trocar. The 12-mm umbilical trocar is then replaced within the bag, and pseudopneumoperitoneum is created. Once established, an optical trocar is introduced via one of the lower quadrant port sites using a balloon tip trocar (Kii; Applied Medical, Rancho Santa Margarita, CA). The insufflation tubing is attached to this trocar, and the umbilical trocar is replaced with the morcellator device. Morcellation is performed under direct vision in a contained environment. Once complete, all fragments are removed, and the bag is washed out. The original pneumoperitoneum is re-established. The bag is then removed during aspiration to encourage negative pressure relative to the re-established pneumoperitoneum, minimizing aerosolized fragment leakage. INTERVENTION: Contained in bag morcellation of a large myomatous uterus during total laparoscopic hysterectomy. This technique has been specifically developed to address the concerns of morcellating large myomatous uteri after hysterectomy. In the case of supracervical hysterectomy or myomectomy, in which there would be no vaginal conduit to exploit, we use an endocatch bag, inserted in the usual manner, with reintroduction of the umbilical trocar within the mouth of the bag to enable creation of pseudopneumoperitoneum. Again, an optical trocar would be introduced in a lower lateral port, and morcellation would be performed under direct vision. An article describing this technique has recently been published [2]. CONCLUSION: The Sydney Contained in bag Morcellation technique offers a possible solution to the risk of dissemination of benign morcellated and potentially leiomyosarcomatous myoma fragments. Certain aspects of the procedure are key to its success. The stay sutures are essential to facilitate orientation and opening of the bag mouth. The McCartney tube enables easier insertion of the flaccid bag into the vagina, and the suture-retaining slits enable the mouth of the bag to be opened quickly and easily. We have used this technique in 5 cases with uteri ranging in weight from 350 to 978 g. Recently, similar techniques have been described for use in single-port surgery and conventional laparoscopy [1,2]. Our technique is suitable for use with large uteri after total laparoscopic hysterectomy because the large capacity of the bag enables containment of uteri that would exceed the capacity of manually deployed specimen retrieval bags. This technique offers an alternative to vaginal morcellation, with the advantage of improved vision during morcellation and the ability to morcellate large uteri using a familiar instrument and view.

Sydney contained in bag morcellation for laparoscopic myomectomy.

STUDY OBJECTIVE: To demonstrate a new technique of contained in bag morcellation of a myoma after laparoscopic myomectomy. DESIGN: Step-by-step explanation of the technique in a narrated video. INTERVENTION: Contained In Bag Morcellation of myoma after laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: Recent controversy regarding the risk of disseminating occult leiomyosarcomatous tissue during morcellation means we need to revise our current approach to tissue extraction at laparoscopic myomectomy and morcellation in general. Herein we present a novel technique, conceived by Dr. Danny Chou, called the Sydney Contained In Bag Morcellation technique for laparoscopic myomectomy. In this technique an EndoCatch bag (EndoCatch II Auto Suture Specimen Retrieval Pouch; Covidien, Mansfield, MA) is introduced in the typical fashion, the myoma is retrieved, and the mouth of the bag is exteriorized onto the abdominal wall. A 12-mm trocar is then introduced within the bag, and pneumoperitoneum is created before introducing an optical balloon tip port (KII Balloon Blunt Tip System; Applied Medical, Rancho Santa Margarita, CA) and the power morcellator device. Morcellation is then performed within the bag, under direct vision. This technique may offer a safer approach to morcellation because the bowel is not within the morcellation field and there is lower risk of disseminating occult leiomyosarcomatous tissue during morcellation. Subsequent to the morcellation process, suctioning of the bag removes any aerosolized particles of myoma, further minimizing the risk of possible dissemination. CONCLUSION: This technique may enable a minimally invasive approach to myomectomy to continue as a viable option in the era since the warning by the US Food and Drug Administration.

Anterior approach to laparoscopic uterine artery ligation.

Herein is described an anterior approach to uterine artery ligation during laparoscopic myomectomy and total laparoscopic hysterectomy. The anterior leaf of the broad ligament is opened and the uterine artery is clipped lateral to its crossing over the ureter. Outcome measures were completion of the procedure laparoscopically and the need for transfusion postoperatively. Thirty-eight myomectomies and 28 difficult total laparoscopic hysterectomies (primarily uteri with large myomas) were performed, with 1 conversion to laparotomy during myomectomy and 1 during hysterectomy, and 1 transfusion after total laparoscopic hysterectomy. The anterior approach to uterine artery ligation is an alternative method for treatment of uterine artery occlusion during laparoscopic myomectomy or hysterectomy performed to treat large myomas.

Bowel resection for iatrogenic parasitic fibroids with preoperative investigations suggestive of malignancy.

OBJECTIVE: To describe a case in which a midline laparotomy for two presumed malignant masses instead revealed parasitic fibroids. DESIGN: Case report. SETTING: Tertiary-level private hospital. PATIENT(S): Woman with 7- and 13-cm abdominopelvic masses 3 years after a total laparoscopic hysterectomy for fibroids. INTERVENTION(S): Midline laparotomy, bilateral salpingooophorectomy, infracolic omentectomy, appendicectomy, para-aortic lymph node dissection, and high rectosigmoid resection with primary anastomosis. MAIN OUTCOME MEASURE(S): Histology of masses showed adenomyoma. RESULT(S): There was no evidence of malignancy. CONCLUSION(S): Morcellation of the fibroids during a total laparoscopic hysterectomy likely left fragments that formed iatrogenic parasitic fibroids, which led to the subsequent laparotomy and bowel resection for potential malignancy.

Purse-string suture technique to enable laparoscopic management of the interstitial gestation of a heterotopic pregnancy.

OBJECTIVE: To describe the laparoscopic management of an interstitial gestation of a heterotopic pregnancy. DESIGN: Case report and technique description. SETTING: Tertiary-level private practice. PATIENT(S): Woman with a 6-week gestation spontaneous heterotopic twin pregnancy: one twin intrauterine, one interstitial. INTERVENTION(S): A purse-string suture was applied to the proximal portion of the interstitial heterotopic pregnancy. MAIN OUTCOME MEASURE(S): To enable a cornual resection to be performed with minimal bleeding and without recourse to laparotomy. RESULT(S): At 8 weeks gestation an ultrasound scan confirmed a viable singleton intrauterine pregnancy, but a scan at 12 weeks showed a missed miscarriage. CONCLUSION(S): The embedding of the suture into the uterine serosa prevents slipping of the ligature that could occur with a pretied loop.

Uterine perfusion following laparoscopic clipping of uterine arteries at myomectomy.

Laparoscopic clipping of uterine arteries facilitates laparoscopic myomectomy with minimal blood loss. This paper shows the return to normal myometrial perfusion following this procedure with literary evidence of the safety and efficacy of this technique.

Is hysterectomy necessary for laparoscopic pelvic floor repair? A prospective study.

STUDY OBJECTIVE: To evaluate whether the addition of hysterectomy to laparoscopic pelvic floor repair has any impact on the short-term (perioperative) or long-term (prolapse outcome) effects of the surgery. DESIGN: A controlled prospective trial (Canadian Task Force classification II-1). SETTING: Private and public hospitals affiliated with a single institution. PATIENTS: A total of 64 patients with uterovaginal prolapse pelvic organ prolapse quantification system stage 2 to 4 had consent for laparoscopic pelvic floor repair from January 2005 through January 2006 (32 patients in each treatment arm). Patients self-selected to undergo hysterectomy in addition to their surgery. INTERVENTIONS: Patients were divided into group A (laparoscopic pelvic floor repair with hysterectomy) or group B (laparoscopic pelvic floor repair alone). All patients had laparoscopic pelvic floor repair in at least 1 compartment, whereas 52 patients had global pelvic floor prolapse requiring multicompartment repair. Burch colposuspension and/or additional vaginal procedures were performed at the discretion of the surgeon in each case. MEASUREMENTS AND MAIN RESULTS: Symptoms of prolapse and pelvic organ prolapse quantification system assessments were collected preoperatively, perioperatively, and at 6 weeks, 12 months, and 24 months postoperatively. Validated mental and physical health questionnaires (Short-Form Health Survey) were also completed at baseline, 6 weeks, and 12 months. No demographic differences occurred between the groups. Time of surgery was greater in group A (+35 minutes), as was estimated blood loss and inpatient stay, although the latter 2 results had no clinically significant impact. No difference between groups was detected in the rate of de novo postoperative symptoms. At 12 months, 4 (12.9%) patients in group A had recurrent prolapse as did 6 (21.4%) patients in group B. At 24 months these figures were 6 (22.2%) and 6 (21.4%), respectively. These differences were not statistically significant (p=.500 at 12 months and .746 at 24 months). In the group not having hysterectomy, 4 (14.3%) of 28 patients had cervical elongation or level-1 prolapse by the 12-month assessment. CONCLUSION: The addition of total laparoscopic hysterectomy to laparoscopic pelvic floor repair adds approximately 35 minutes to surgical time with no difference in the rate of perioperative or postoperative complications or prolapse outcome. Leaving the uterus in situ, however, is associated with a risk of cervical elongation potentially requiring further surgery. Laparoscopic pelvic floor repair is successful in 80% of patients at 2 years.

Major complications arising from 1265 operative laparoscopic cases: a prospective review from a single center.

STUDY OBJECTIVE: To identify the volume and type of laparoscopic surgery being performed. To review the incidence, nature of associated complications, and reasons for conversion to laparotomy. DESIGN: A multicenter, prospective case load analysis and chart review, identifying operations performed by 6 advanced laparoscopic surgeons over a 12-month period (1/1/05 to 12/31/05). SETTING: Surgical cases were performed in 5 hospitals in Sydney, New South Wales. PATIENTS: One thousand two hundred sixty-five women underwent a variety of major and advanced operative procedures. MEASUREMENTS AND MAIN RESULTS: A total of 1265 major and advanced laparoscopic procedures were performed. Laparoscopic hysterectomy accounted for 364 cases (28.8%), pelvic floor repair and Burch colposuspension 280 cases (22.2%), excisional endometriosis surgery 354 cases (28%), adnexal surgery 177 cases (13.9%), adhesiolysis 75 cases (5.9%), and miscellaneous cases 15 (1.2%). Overall major complications in terms of bowel, urologic, or major vessel injuries accounted for 8 cases (0.6%). There were 4 injuries of the bowel, 2 injuries to the bladder, and 2 injuries to ureters. There were no major vessel injuries. There were no injuries associated with primary trocar or Veres needle insertion. The most common perioperative morbidity reported was the requirement for blood transfusion (11 cases [0.9%]), and the second most common was venous thromboembolism (4 patients [0.3%]). Six (0.5%) cases were converted to laparotomy, 2 as a result of a complication and 4 for technical reasons. Six of the 8 complications were managed laparoscopically, and a multidisciplinary input was sought only in 4 of the 8 complications. CONCLUSIONS: Despite the advanced nature of laparoscopic procedures performed by our group, the complication rate and conversion to laparotomy remain low. There is an increasing feasibility to perform traditional open operations laparoscopically. An increasing number of these complications are now being managed laparoscopically by the gynecologist.

Total laparoscopic hysterectomy: a tried and tested technique.

Gynecologists are increasingly adopting total laparoscopic hysterectomy as their preferred method for performing a hysterectomy. The laparoscopic approach offers a superior view of the anatomy, facilitates meticulous hemostasis, enables the surgeon to perform adnexal surgery and pelvic reconstructive surgery, and reduces morbidity associated with large abdominal incisions. During the last 10 years, the surgeons at the Sydney Women's Endosurgery Centre (SWEC) have developed a laparoscopic technique using the same well-known steps as in the open abdominal approach. The ovarian pedicles are ligated, the uterine pedicles and vaginal vault are sutured laparoscopically, and some novel time-saving maneuvers are adopted.