Improved Exposure in Minimally Invasive Excision of Endometriosis with Temporary Ovarian Suspension Using Carter-Thomason CloseSure System, a Novel Technique.

STUDY OBJECTIVE: To describe a novel technique for temporary ovarian suspension using the Carter-Thomason CloseSure system (CooperSurgical, Inc., Trumbull, CT). DESIGN: A narrated, stepwise in vivo demonstration of surgical technique. SETTING: Academic tertiary care hospital (University of Louisville Hospital, Louisville, KY). INTERVENTIONS: Laparoscopic temporary ovarian suspension using the Carter-Thomason CloseSure system for improved exposure of deep pelvis during a laparoscopic excision of deep pelvic endometriosis (including demonstration of previously used techniques at this institution). CONCLUSION: We have developed and used this technique at our institution for the last several years, reviewing 20 cases between August 2018 and September 2019, with improved intraoperative visualization and no observed intraoperative or postoperative complications. This technique has replaced the use of other forms of ovarian suspension at our institution owing to the accessibility of the device, stability of the suspension, and ease of the procedure. The Carter-Thomason technique of ovarian suspension provides excellent retraction of ovarian tissue to provide improved views of the deep pelvis, with ease of use and low cost.

Total Laparoscopic Hysterectomy of a 7400 g Uterus.

OBJECTIVE: To demonstrate improved techniques and safety measures for total laparoscopic hysterectomy for a severely enlarged uterus. DESIGN: Technical video of the surgery, which demonstrates various techniques for improved visualization, hemostasis, and manipulation for total laparoscopic hysterectomy for a 7400 g uterus. SETTING: Academic tertiary care hospital, University of Louisville Hospital, Louisville, Kentucky. INTERVENTIONS: A 44-year-old woman, gravida 0, presented with a severely enlarged myoma uterus, class III obesity with a body mass index of 40.4 kg/m2, and hypertension seeking minimally invasive hysterectomy. Magnetic resonance imaging demonstrated a uterus measuring 26 × 26 × 17 cm with multiple myomas. The patient was counseled in detail regarding minimally invasive surgery. She underwent total laparoscopic hysterectomy, bilateral salpingectomy, right oophorectomy, and cystoscopy. The total operative time was 4 hours 12 minutes, and the estimated blood loss was 700 mL. Pre- and postoperative hemoglobin was 13.3 g/dL and 11.3 g/dL, respectively. A 4-cm minilaparotomy incision was created as an extension of the umbilical port, and the specimen was extracted by scalpel morcellation using the extracorporeal C-incision tissue extraction technique. The patient was discharged home on postoperative day 1 and recovered without any complications. CONCLUSION: There is an increasing trend in performing laparoscopic hysterectomy for large uteri, which has a lower incidence of overall complications than laparotomy [1,2]. In addition, a cost analysis has demonstrated the superiority of laparoscopic hysterectomy for myomatous uterus accounting for the rare incidence of leiomyosarcoma [3]. Our video demonstrates improved hemostasis and visualization techniques through the use of high-cephalad camera and assistant ports, generous traditional bipolar desiccation, blunt retraction with suction irrigator in the midline umbilical port, and surgical bed rotation. We also describe in detail the scalpel morcellation technique. To date, we believe this is the largest uterine size removed laparoscopically that has been reported in the literature. In the hands of an experienced surgeon and with the demonstrated techniques, a laparoscopic approach to hysterectomy of a very enlarged uterus is safe and feasible.

Latest Advances in the Laparoscopic Treatment of Uterine Fibroids.

INTRODUCTION: Fibroids are highly prevalent among reproductive-aged women and have a significant impact on their wellbeing. Myomectomy is a fertility-sparing option for these patients. MATERIALS AND METHODS: This paper is a comprehensive, evidence-based and updated review of literature regarding myomectomy techniques. RESULTS: This paper provides general recommendations for myomectomy techniques, including patient selection and surgical planning. Strategies to overcome intraoperative challenges and prevent blood loss are highlighted. In addition, recommendations are provided for tissue extraction and laparoscopic suturing. CONCLUSION: Myomectomy is a safe and feasible alternative to hysterectomy for patients who wish to bear children.

Emergency Undocking Curriculum in Robotic Surgery.

Introduction Traditional instruction for robotic surgery is typically devoid of training that addresses the delineation of interprofessional roles for operating room personnel. An emergency undocking scenario was developed for robotic surgeons with the objectives of improving time to access the patient, provider knowledge of and confidence in emergency undocking, completion of predetermined critical actions, and delineation of operating room personnel roles. Methods Over one month, participants joined in three sessions: Session 1 - formative, Session 2 - review, and Session 3 - summative. Embedded standardized participants (ESPs) represented members of the interprofessional team. Prior to entering the operating room for Sessions 1 and 3, trainees were asked to complete a confidence survey and multiple choice questionnaire (MCQ) for knowledge assessment. Participants were randomized to one of two cases and participated in the reciprocal case for the final session four weeks later. Following Session 1, participants underwent an educational intervention, including the proper technique for emergency undocking, emphasis on operating room personnel roles, and hands-on practice. Obstetrics and Gynecology (OBGYN) residents in post-graduate Years 2-4 and attending physicians with robotics privileges at Summa Health Akron Campus or Cleveland Clinic Akron General Medical Center were invited to participate. A total of 21 participants enrolled and finished the study. Results Among the 21 participants, there was a significant increase in the baseline level of knowledge (p-value=0.001) and in the confidence of surgeons when faced with an emergency undocking after the completion of our curriculum (p-value=0.003). Additionally, an improvement in the undocking times (p-value<0.001) and an increase in the critical actions performed (p-value=0.002) were observed. Conclusion The results of this study demonstrate that incorporating this curriculum into the training programs of robotic surgeons is an effective way to improve the surgical skill of emergency undocking.

Emergency Undocking in Robotic Surgery: A Simulation Curriculum.

The following is a training platform to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of a robotic system. In traditional robotic training for surgeons, a brief web based overview of performing an emergency undocking is provided during initial introductory training to the robotics system. During such a process, there is no training in delineation of interdisciplinary roles for operating room (OR) personnel. The training presented here uses formative simulation and debriefing followed by a lecture. For the simulation, a modified gynecologic simulator is draped in a steep trendelenburg position consistent with most gynecologic laparoscopic surgery. The training torso is modified using tubing hooked to pressure bags of red food colored IV fluid used to simulate a catastrophic vessel injury on demand. Positioned throughout the operating room setting is an interprofessional team consisting of embedded standardized persons (ESPs) to fulfill the roles of a circulating nurse, scrub nurse, anesthesiologist, and bedside assist surgeon. Robotic surgeons are presented a case scenario necessitating emergency undocking, and given control of the robotic instruments. The scenario is terminated following either successful completion of an emergency undock, or at five minutes due to the emergent nature of the case. A debriefing session with hands on training of the steps to emergency undocking, necessary equipment, troubleshooting techniques, and operating room personnel roles follows the simulation. The learners are presented with a short lecture reemphasizing the material presented in the debriefing for their own self-study. This training results in improved time accessing the patient, improved knowledge, confidence, and completion of critical actions, and can be replicated in most institutions. All robotic surgeons should be able to demonstrate competence in this crucial intervention. A limitation of the curriculum is ability to access the in-situ environment for training purposes.