Comparison of #Enzian classification and revised American Society for Reproductive Medicine stages for the description of disease extent in women with deep endometriosis.

STUDY QUESTION: How is endometriosis extent described by the #Enzian classification compared to the revised American Society for Reproductive Medicine (rASRM) stages in women undergoing radical surgery for deep endometriosis (DE)? SUMMARY ANSWER: The prevalence and severity grade of endometriotic lesions and adhesions as well as the total number of #Enzian compartments affected by DE increase on average with increasing rASRM stage; however, DE lesions are also present in rASRM stages 1 and 2, leading to an underestimation of disease severity when using the rASRM classification. WHAT IS KNOWN ALREADY: Endometriotic lesions can be accurately described regarding their localization and severity by sonography as well as during surgery using the recently updated #Enzian classification for endometriosis. STUDY DESIGN, SIZE, DURATION: This was a prospective multicenter study including a total of 735 women between January 2020 and May 2021. PARTICIPANTS/MATERIALS, SETTING, METHODS: Disease extent in women undergoing radical surgery for DE at tertiary referral centers for endometriosis was intraoperatively described using the #Enzian and the rASRM classification. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 735 women were included in the study. Out of 31 women with rASRM stage 1, which is defined as only minimal disease, 65% (i.e. 20 women) exhibited DE in #Enzian compartment B (uterosacral ligaments/parametria), 45% (14 women) exhibited DE in #Enzian compartment A (vagina/rectovaginal septum) and 26% (8 women) exhibited DE in #Enzian compartment C (rectum). On average, there was a progressive increase from rASRM stages 1-4 in the prevalence and severity grade of DE lesions (i.e. lesions in #Enzian compartments A, B, C, FB (urinary bladder), FU (ureters), FI (other intestinal locations), FO (other extragenital locations)), as well as of endometriotic lesions and adhesions in #Enzian compartments P (peritoneum), O (ovaries) and T (tubo-ovarian unit). In addition, the total number of #Enzian compartments affected by DE lesions on average progressively increased from rASRM stages 1-4, with a maximum of six affected compartments in rASRM stage 4 patients. LIMITATIONS, REASONS FOR CAUTION: Interobserver variability may represent a possible limitation of this study. WIDER IMPLICATIONS OF THE FINDINGS: The #Enzian classification includes the evaluation of DE in addition to the assessment of endometriotic lesions and adhesions of the ovaries and tubes and may therefore provide a comprehensive description of disease localization and extent in women with DE. STUDY FUNDING/COMPETING INTEREST(S): No funding was received for this study. All authors declare that they have no conflict of interest. TRIAL REGISTRATION NUMBER: N/A.

Assessment of Nerve Fiber Density and Expression of Hormonal Receptors Within Rectosigmoid Endometriosis Nodules.

STUDY OBJECTIVE: To assess nerve fiber density and expression of hormone receptors in bowel endometriosis. DESIGN: Cross-sectional study. SETTING: Private hospital. PATIENTS: Women with endometriosis undergoing laparoscopic segmental bowel resection (n = 54). INTERVENTIONS: Tissue samples were obtained from patients with surgically treated rectosigmoid endometriosis. MEASUREMENTS AND MAIN RESULTS: The rectosigmoid specimen containing the endometriosis nodule was manually sectioned and divided into 3 areas: core of the nodule, margin of the nodule, and healthy bowel tissue. The intensity of expression of estrogen and progesterone receptors was evaluated by immunohistochemistry and measured according to the Allred score. Nerve fibers were stained by immunohistochemistry using Protein Gene Product 9.5, and the density of nerve fillets was counted and expressed in number/mm². All glandular and stromal cells stained for estrogen; however, glandular cells stained more strongly than stromal cells (61.1% vs 35.2%; p = .01). Most of glandular and stromal cells stained strongly for progesterone receptors (90.7% vs 98.1%; p = .2). The density of nerve fibers was very high in the margin of the nodule (172.22±45.66/mm²), moderate in healthy bowel tissue (111.48±48.57/mm²), and very low in the core of the nodule (7.31±4.9/mm²); p = .01. CONCLUSION: Both glandular and stromal cells within the rectosigmoid endometriosis nodule express estrogen and progesterone receptors. Higher intensity of expression of estrogen receptors occurs in glandular cells. The density of nerve fibers is extremely high at the nodule margin and very low in the center of the nodule.

Peritoneal Retraction Pocket Defects and Their Important Relationship with Pelvic Pain and Endometriosis.

OBJECTIVE: The objective of this video is to demonstrate different clinical presentations of peritoneal defects (peritoneal retraction pockets) and their anatomic relationships with the pelvic innervation, justifying the occurrence of some neurologic symptoms in association with these diseases. DESIGN: Surgical demonstration of complete excision of different types of peritoneal retraction pockets and a comparison with a laparoscopic retroperitoneal cadaveric dissection of the pelvic innervation. SETTING: Private hospital in Curitiba, Paraná, Brazil. INTERVENTIONS: A pelvic peritoneal pocket is a retraction defect in the surface of the peritoneum of variable size and shapes [1]. The origin of defects in the pelvic peritoneum is still unknown [2]. It has been postulated that it is the result of peritoneal irritation or invasion by endometriosis, with resultant scarring and retraction of the peritoneum [3,4]. It has also been suggested that a retraction pocket may be a cause of endometriosis, where the disease presumably settles in a previously altered peritoneal surface [5]. These defects are shown in many studies to be associated with pelvic pain, dyspareunia, and secondary dysmenorrhea [1-4]. Some studies have shown that the excision of these peritoneal defect improves pain symptoms and quality of life [5]. It is important to recognize peritoneal pockets as a potential manifestation of endometriosis because in some cases, the only evidence of endometriosis may be the presence of these peritoneal defects [6]. In this video, we demonstrate different types of peritoneal pockets and their close relationship with pelvic anatomic structures. Case 1 is a 29-year-old woman, gravida 0, with severe dysmenorrhea and catamenial bowel symptoms (bowel distension and diarrhea/constipation) that were unresponsive to medical treatment. Imaging studies were reported as normal, and a laparoscopy showed a posterior cul-de-sac peritoneal pocket infiltrating the pararectal fossa, with extension to the lateral border of the rectum. Case 2 is a cadaveric dissection of a posterior cul-de-sac peritoneal pocket infiltrating the pararectal fossa, with extension to the pelvic sidewall. After dissection of the obturator fossa, we can observe that the pocket is close to the sacrospinous ligament, pudendal nerve, and some sacral roots. Case 3 is a 31-year-old woman, gravida 1, para 1, with severe dysmenorrhea that was unresponsive to medical treatment and catamenial bowel symptoms (catamenial bowel distention and diarrhea). Imaging studies were reported as normal and a laparoscopy showed left uterosacral peritoneal pocket infiltrating the pararectal fossa in close proximity to the rectal wall. Case 4 is a cadaveric dissection of the ovarian fossa and the obturator fossa showing the proximity between these structures. Case 5 is a 35-year-old woman, gravida 0, with severe dysmenorrhea that was unresponsive to medical treatment, referring difficulty, and pain when walking only during menstruation. A neurologic physical examination revealed weakness in thigh adduction, and the magnetic resonance imaging showed no signs of endometriosis. During laparoscopy, we found a peritoneal pocket infiltrating the ovarian fossa, with involvement in the area between the umbilical ligament and the uterine artery. This type of pocket can easily reach the obturator nerve. Because the obturator nerve and its branches supply the muscle and skin of the medial thigh [7,8], patients may present with thigh adduction weakness or difficulty ambulating [9,10]. Case 6 is a cadaveric dissection of the sacrospinous ligament and the pudendal nerve from a medial approach, between the umbilical artery and the iliac vessels. Case 7 is a 34-year-old woman, gravida 1, para 1, with severe dysmenorrhea and catamenial bowel symptoms as well as deep dyspareunia. The transvaginal ultrasound showed focal adenomyosis and a 2-cm nodule, 9-cm apart from the anal verge, affecting 30% of the bowel circumference. In the laparoscopy, we found a posterior cul-de-sac retraction pocket associated with a large deep endometriosis nodule affecting the vagina and the rectum. In all cases, endometriosis was confirmed by histopathology, and in a 6-month follow-up, all patients showed improvement of bowel, pain, and neurologic symptoms. CONCLUSION: Peritoneal pockets can have different clinical presentations. Depending on the topography and deepness of infiltration, they can be the cause of some neurologic symptoms associated with endometriosis pain. With this video, we try to encourage surgeons to totally excise these lesions and raise awareness about the adjacent key anatomic structures that can be affected.

Useful Pelvic Retroperitoneal Neuroanatomy for Benign Gynecologic Surgery: A Cadaveric Dissection.

OBJECTIVE: Knowledge of the retroperitoneal anatomy is particularly important to facilitate surgical procedure and reduce the number of complications. The objective of this video is to demonstrate pelvic neuroanatomic structures and their relationships in the pelvic sidewall and the presacral space in a laparoscopic cadaveric dissection. DESIGN: Case report (anatomic study). SETTING: Medical training center (AdventHealth Nicholson Center, Orlando, FL). INTERVENTIONS: The dissection started with the mobilization of the iliac vessels from the pelvic sidewall to identify the obturator nerve. The peritoneum of the ovarian fossa was opened, and the ureter was dissected up to the level of the uterine artery. The hypogastric nerve was identified. The close relationship between the ovarian fossa and the obturator nerve could be demonstrated. The deep dissection of the obturator fossa allowed for the identification of the lumbosacral trunk, S1, the sciatic nerve, S2, S3, S4, and the splanchnic nerves. Then, the ischial spine and the sacrospinous ligament were identified. The pudendal nerve and vessels could be observed passing below the sacrospinous ligament, entering the pudendal canal (Alcock's canal). The presacral space was dissected, and the hypogastric fascia was opened. S1 to S4 were identified coming from the sacral foramens. The laparoscopic dissection, using the cadaveric model, allowed for the development of the entire retroperitoneal anatomy, focusing on the dissection of the pelvic innervation. Anatomic relationships among the ureter, the hypogastric nerve, the uterosacral ligament, the splanchnic nerves, the inferior hypogastric plexus, and the organs (bowel, vagina, uterus, and bladder) could be demonstrated. CONCLUSION: A laparoscopic cadaveric dissection can be used as a resource to demonstrate and educate surgeons about the neurologic retroperitoneal structures and their relationships.

Diaphragmatic endometriosis minimally invasive treatment: a feasible and effective approach.

The present review aims to analyse the current data available on the feasibility, safety and effectiveness of the minimally invasive surgical (MIS) treatment of diaphragmatic endometriosis (DE). Through the use of PubMed and Google Scholar database, we conducted a literature review of all available research related to diagnosis and treatment of DE, focussed on the minimally invasive techniques. The studies were selected independently by two authors according to the aim of this review. DE is an under-diagnosed disease affecting between 0.1% and 1.5% of fertile women. It is predominantly multiple, asymptomatic and highly associated with pelvic disease in about 50-90%. MIS techniques seems to be safe, effective and feasible in tertiary advanced endometriosis centre, offering definitive advantages in terms of hospital stay, post-operative pain and return to normal activity by using several surgical techniques as hydro-dissection plus resection, laser CO2 vaporisation, electrical fulguration, Sugarbaker peritonectomy, partial (shaving) and full-thickness diaphragmatic resection. Symptoms control range from 85% to 100%, with less than 3% of conversion, peri-operative complications and recurrence rate. All cases must be performed by multidisciplinary teams including at least a gynaecologist, thoracic surgeon and anaesthetist. The lack of prospective evaluation of DE interferes with the understanding about the natural history of disease and treatment results. Therefore, the development of adequate evidence-based recommendations about diagnosis, management and follow-up is difficult at this moment.

Laparoscopic Variants of Temporary Uterine Artery Ligation.

OBJECTIVE: Laparoscopic uterine artery ligation may be performed during myomectomy or other uterine invasive procedures to reduce the amount of blood loss during surgery. In this video, the authors describe 3 different laparoscopic techniques to approach the uterine artery. DESIGN: Step-by-step video demonstration of 3 different surgical techniques. SETTING: Private hospital in Curitiba, Paraná, Brazil. INTERVENTIONS: The main steps of uterine artery ligation are described in detail as well as different laparoscopic variants to this procedure. ANTERIOR APPROACH: The impression of the uterine vessels can usually be seen anteriorly and laterally to the uterine cervix. After identification of the path of the uterine arteries, the peritoneum of the anterior cul-de-sac is opened over the vessels and the uterine artery is carefully dissected next to the lateral border of the uterine cervix. This dissection must be performed with extreme caution because the uterine veins are very close to the artery. Venous bleeding at this point of the dissection can be very difficult to control without ligating the vessels. After circumferential dissection of the artery, temporary occlusion is conducted using 2-0 polyester suture. POSTERIOR APPROACH, LATERAL TO THE INFUNDIBULOPELVIC LIGAMENT: For ligation of the uterine artery posteriorly to the uterus and laterally to the pelvic infundibulum, opening of the peritoneum of the broad ligament should start immediately below the round ligament, parallel and medial to the external iliac vessels toward the base of the pelvic infundibulum. The avascular space is dissected by blunt dissection (traction and countertraction), identifying the lateral (external iliac vessels) and medial (pelvic infundibulum and the ureter attached to the peritoneum of the ovarian fossa) landmarks. The external iliac artery is dissected cranially to find the bifurcation of the common iliac artery and the internal iliac artery. The first medial branch of the anterior division of the internal iliac usually is the uterine artery. After circumferential dissection of the uterine artery, it may be ligated according to the same technique described above. MEDIAL APPROACH: For the medial approach, the peritoneum should be opened medial to the infundibulopelvic ligament. The assistant grasps the infundibulopelvic ligament, creating a peritoneal tent. Immediately after broad ligament opening, anatomic landmarks are identified. First, the ureter is identified and medialized. For the identification of vascular anatomy, movement of the obliterated umbilical artery is made active, which reduces the risk of error to ligate the uterine artery. After circumferential dissection of the artery, it may be ligated according to the same technique described above. CONCLUSION: Laparoscopic uterine artery ligation may be performed during laparoscopic myomectomy to reduce intraoperative blood loss. According to the position of the myomas within the uterus as well as the uterine volume, the surgeon may choose among 1 of the above-mentioned techniques to perform. This technique could also be applied to other types of invasive uterine procedures to reduce blood loss. Standardization of these techniques could help to reduce the laparoscopic learning curve.

Combined Laparoscopic-Hysteroscopic Isthmoplasty Using the Rendez-vous Technique Guided Step by Step.

OBJECTIVE: To demonstrate the surgical technique of Rendez-vous isthmoplasty for the treatment of symptomatic cesarean scar defect. In this video, the authors show the complete procedure in a step-by-step manner to standardize and facilitate the comprehension and performance of the procedure in a simple and safe way. DESIGN: Step-by-step video demonstration of the surgical technique. SETTING: Private hospital in Curitiba, Paraná, Brazil. INTERVENTIONS: The patient is a 36-year-old woman without any comorbidities, G3 C3, and with radiologic transvaginal ultrasound diagnosis of isthmocele grade 3 (over 25 mm) identified in the superior third of the cervical canal. The main steps of combined laparoscopic-hysteroscopic isthmoplasty using the Rendez-vous technique are described in detail. A combined laparoscopic-hysteroscopic approach was performed. Under general anesthesia, the patient was placed in 0° supine decubitus, with her arms alongside her body. Operative setup included 15 mm Hg pneumoperitoneum, created using the closed Veress technique, and 4 trocars: a 10-mm trocar at the umbilicus for a 0° laparoscope, a 5-mm trocar in the right iliac fossa, a 5-mm trocar in the left iliac fossa, and a 5-mm trocar in the suprapubic area. The procedure begins after a systematic exploration of the pelvic and abdominal cavities. Step 1: Identification of key anatomic landmarks and exposure of the operation field. Step 2: By carrying out blunt and sharp dissection with cold scissors or a harmonic scalpel, the visceral peritoneal layer over the isthmus area is opened, a vesicouterine space is developed, and the bladder is pushed down at least 2 cm from the lower edge of the isthmocele. Step 3: Final Phrase: By hysteroscopic exploration of the cervical canal using the vaginoscopic approach, identification and delimitation of the isthmocele its performed by recognizing the diverticular mucosal hyperplasia, and then the hysteroscopic light is pointed directly toward the cephalic limit of the scar defect. Step 4: Laparoscopic lights are decreased in intensity and the "Halloween sign" is identified (hysteroscopic transillumination). The light of the hysteroscope is pointed to the top of the cesarean scar defect allowing the laparoscopist to identify the upper and lower edges of the scar. Step 5: Laparoscopic resection of all scar tissue, excision of all the edges of the pseudo cavity. Step 6: Adequate intracorporeal suturing technique, with a 2-layer myometrial repair using intracorporeal running and interrupted stitches of polydioxanone 2-0, is done, while ensuring preservation of the cavity by not including the endometrial tissue in the myometrial suture [1-3]. Step 7: Installation of the methylene blue dye to locate any leakage. The surgery ended without any intraoperative complications and within 60 minutes. The patient was discharged on the first day postoperatively and became pregnant 6 months after surgery, with a final C-section delivery of a healthy term newborn at 39-weeks gestational age. CONCLUSION: Combined Rendez-vous isthmoplasty is feasible, safe, and effective in experienced hands, giving the surgeon a comprehensive evaluation of the anatomy of the isthmocele, and increasing the odds of a complete resection and restoration of the anatomy [4-7]. In this patient, the procedure was uneventful, without any intra- or postoperative complications, and the symptoms were completely controlled.

Laparoscopic Reverse Technique for Posterior Rectovaginal Deep Endometriosis Nodule Step by Step.

STUDY OBJECTIVE: To demonstrate the application of the so-called reverse technique to approach deep infiltrating endometriosis nodules affecting the retrocervical area, the posterior vaginal fornix, and the anterior rectal wall. In Video 1, the authors describe the complete procedure in 10 steps in order to standardize it and facilitate the comprehension and the reproduction of such a procedure in a simple and safe way. DESIGN: A case report. SETTING: A private hospital in Curitiba, Paraná, Brazil. PATIENT: A 32-year-old woman was referred to our service complaining about cyclic dysmenorrhea, dyspareunia, chronic pelvic pain, and cyclic dyschezia. Transvaginal ultrasound with bowel preparation showed a 2.4-cm endometriotic nodule at the retrocervical area, uterosacral ligaments, posterior vaginal fornix, and anterior rectal wall, infiltrating up to the muscularis 10 cm far from the anal verge. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: Under general anesthesia, the patient was placed in the dorsal decubitus position with her arms alongside her body and her lower limbs in abduction. Pneumoperitoneum was achieved using a Veress needle placed at the umbilicus. Four trocars were placed according to the French technique as follows: a 10-mm trocar at the umbilicus for the 0 degree laparoscope; a 5-mm trocar at the right anterosuperior iliac spine; a 5-mm trocar in the midline between the umbilicus and the pubic symphysis, approximately 8 to 10 cm inferior to the umbilical trocar; and a 5-mm trocar at the left anterosuperior iliac spine. The entire pelvis was inspected for endometriotic lesions (step 1). The implants located at the ovarian fossae were completely removed (step 2). The ureters were identified bilaterally, and both pararectal fossae were dissected, preserving the hypogastric nerves (step 3). The lesion was separated from the retrocervical area, and the posterior vaginal fornix was resected (reverse technique), leaving the disease attached to the anterior surface of the rectum (step 4). The lesion was shaved off the anterior rectal wall using a harmonic scalpel (step 5). The anterior rectal wall was closed using X-shaped stitches of 3-0 polydioxanone suture in 2 layers (step 6). The specimen was extracted through the vagina (step 7). The posterior vaginal fornix was reattached to the retrocervical area using X-shaped sutures of 0 poliglecaprone 25 (step 8). A pneumatic test was performed to check the integrity of the suture (step 9). At the end of the procedure, hemostasis was controlled, and the abdominal cavity was irrigated using Lactate ringer solution (step10). CONCLUSION: The laparoscopic reverse technique is an alternative approach to face retrocervical or rectovaginal nodules infiltrating the anterior rectal wall. In this technique, the separation of the nodule from the rectal wall is performed at the end of the surgery and not at the beginning as performed within the traditional technique. This enables the surgeon to perform a more precise dissection of the endometriotic nodule from the rectal wall because of the increased mobility of the bowel. The wider range of movements serves as an ergonomic advantage for the subsequent dissection of the lesion from the rectum, allowing the surgeon to decide the best technique to apply for the treatment of the bowel disease (rectal shaving or discoid or segmental resection).

Laparoscopic Transabdominal Cerclage for Cervical Incompetence: A Feasible and Effective Treatment in 10 Steps.

STUDY OBJECTIVE: To demonstrate the surgical technique of laparoscopic cerclage (LAC) in nonpregnant women with a clinical diagnosis of cervical incompetence. In this video, the authors describe the complete procedure in 10 steps to standardize and facilitate the comprehension and performance of the procedure in a simple and safe way. DESIGN: Step-by-step video demonstration of the surgical technique. SETTING: Private hospital in Curitiba, Paraná, Brazil. INTERVENTIONS: The patient was 32 years old (gravidity and parity, G3A3; late progressive miscarriage), had no comorbidities, and had a radiologic diagnosis of cervical incompetence. The main steps of LAC are described in detail. A complete laparoscopic approach was performed. Under general anesthesia, the patient was placed in the 0-degree supine decubitus position with arms alongside her body. The operative setup included a 15-mm Hg pneumoperitoneum created using the closed Veress technique and 4 trocars: a 10-mm trocar at the umbilicus for a 0-degree laparoscope; a 5-mm trocar in the right iliac fossa; a 5-mm trocar in the left iliac fossa; and a 5-mm trocar in the suprapubic area. After systematic exploration of the pelvic and abdominal cavities, the procedure began. Step 1 involved identification of anatomic key landmarks and exposure of the operation field. Step 2 involved opening of the anterior peritoneum. The anterior peritoneal reflection was opened over the peritoneum uterovesicalis and then extended laterally until the uterine artery could be clearly identified on both sides. Step 3 involved dissection of the avascular space on each side of the uterus. The vesical-cervical avascular space was created, and the bladder was pushed down, away from the isthmus area. Step 4 involved preparation for a perfect stitch placement. A 5-mm Mersilene suture (Ethicon, Somerville, NJ) with a straight needle was introduced by a suprapubic trocar into the abdominal cavity before a complete identification of uterine vessels at both the sides using atraumatic graspers. Step 5 involved identification of the perfect space in the posterior aspect for Mersilene suture placement. Step 6 was to make a perfect anterior stitch. For this, the needle was grasped at the proximal portion in a 90-degree angle. In posterior position and when helped by a cranial and posterior uterine mobilization, the needle passed through the right, broad ligament in the avascular space created on the anterior leaf and medially from the uterine artery until the tip of the needle was seen on the posterior face above the uterosacral ligament. All steps were possible by synchronic uterine mobilization. Step 7 was to make a perfect posterior stitch. The procedure was then repeated contralaterally following the same anatomic and technical precepts but from posteriorly to anteriorly. Step 8 involved correct positioning and orientation of the Mersilene suture far away from the ureter and medial to the uterine arteries 2 cm over the uterosacral ligaments. Step 9 involved fixation of the Mersilene suture with an adequate blocking sequence. Step 10 involved fixation of the Mersilene suture and reperitonealization. The tape was knotted with an adequate blocking intracorporeal suturing sequence at the cervicoisthmic junction, and a Monocryl 2-0 stitch (Ethicon, Somerville, NJ) was made to fix the knot and left it horizontally. Finally, the procedure was ended with anterior reperitonealization, covering all the plica uterovesicalis and mesh, leaving it completely extraperitoneal. The surgery ended without any intraoperative complications and within 30 minutes. Patient was discharged on the first day postoperatively and became pregnant 6 months after surgery, with a C-section delivery of a healthy term newborn at 39 weeks of gestational age. CONCLUSION: LAC in nonpregnant women with a diagnosis of cervical incompetence is safe and feasible in experienced hands, adding all the intrinsic advantages of minimally invasive surgery and providing better obstetric outcomes. In this patient, the procedure was performed without any intra- or postoperative complications, and the patient had an uneventful term pregnancy in the follow-up period. We must remember that adequate standardization of surgical procedures will help reduce the learning curve.

Which Knots Are Recommended in Laparoscopic Surgery and How to Avoid Insecure Knots.

STUDY OBJECTIVE: To investigate why security of identical knot sequences is variable and how to avoid occasionally insecure knots. DESIGN: A factorial design was used to assess factors affecting the security of half knot (H) and half-hitch (S) knot combinations. The effect of tying forces and the risk factors to transform H knots into S knots were investigated. The risk factors evaluated were as follows: starting with an H1 or H2 instead of an H3 knot, inexperience, short sutures, and monomanual knot tying. Security of transformed knots, S2S1 and S2S2 knots, and their recuperation with 2 additional half hitches, SSb or SbSb, were evaluated. SETTING: Training center for laparoscopic suturing. PATIENTS: Not applicable. INTERVENTIONS: Security of knots was evaluated in vitro. MEASUREMENTS AND MAIN RESULTS: The forces that caused knot combinations to open before breaking of the suture were used to calculate the risk of opening with low forces. Tying more strongly increased the security of half knots (H2H1sH1s) (p <.02) and half hitches (p <.001). The forces needed to transform an H3 into an S3 are higher than those for an H2 (p <.001), and the risk increases when the surgeon is inexperienced (p <.001), when sutures are short (p <.001), and when monomanual knot tying (p <.001) is used. Inadvertently made S2S1 and S2S2 knots are dangerous, with the exception of the symmetric S2S2, which is stable. Unstable knots such as S2S1a and S2S2a knot combinations improve with 2 additional blocking half hitches (SbSb), but S2S2aSbSb remains occasionally insecure. CONCLUSION: To reduce the risk of accidentally transforming a first H into an S knot, it is recommended to start with an H3, tie with force, avoid short sutures, and use bimanual suturing. This permits the recommendation to use preferentially H3H2 knots or 5 half hitches (SSSbSbSb). When in doubt, half knot combinations should be secured with at least 2 blocking half hitches.

Vesico-Vaginal Fistula: Nature and Evidence-Based Minimally Invasive Surgical Treatment.

The present review aims to analyze the current information available on the pathophysiology, clinical presentation and treatment of vesico-vaginal fistulas (VVF), with particular focus on the safety and efficacy of minimally invasive surgical (MIS) techniques. Through the use of the PubMed and Google Scholar databases, we conducted a literature review of all available studies related to MIS treatment of VVF, focusing on laparoscopic techniques. After abstracts were read to identify pertinent studies, full manuscripts were reviewed by two authors according to the aim of the review. Vesico-vaginal fistula is defined as an abnormal passage that connects the bladder to the vagina and affects over 3 million women worldwide. It can be classified according to its complexity (simple or complex) and mechanism (obstetric-related or iatrogenic). Laparoscopic treatment of VVF started in 1994 and is currently the gold-standard approach for this pathology. No differences in terms of efficacy or safety have been reported between MIS (laparoscopy, robotic-assisted laparoscopy and laparoscopic single-site) using extra-vesical and trans-vesical approaches, with success rates of 80% to 100%, and low rates of conversion (1.9%), recurrence (less than 1%) and intra- or post-operative complications (3%). Surgical principles for fistula repair, described independently by Angioli and Couvelaire, must always be followed. A bladder fill and integrity test with at least 300 mL should be performed before ending surgery, since this increases the success rate by about 6%. Other interventions such as flap interposition, number of layers in closure and expectant management (spontaneous closure with a Foley catheter alone) remain controversial. To date, no differences have been seen among the laparoscopic surgical techniques. The lack of prospective evaluations has hindered a better understanding of the natural history of the disease and the development of evidence-based recommendations regarding diagnosis, management and follow-up. Since no differences were found compared to a trans-vesical approach, extra-vesical repair is recommended to avoid bladder bi-valving.

Different Blocking Sequences Performed by Laparoscopy.

STUDY OBJECTIVE: To demonstrate the application of different knot blocking sequences in laparoscopic surgery. DESIGN: A step-by-step demonstration of different blocking sequences performed by laparoscopic surgery (Canadian Task Force classification III). SETTING: Private hospital in Curitiba, Paraná, Brazil. INTERVENTION: The correct placement of one knot over the other is rarely taught in the surgical literature. Laparoscopic knot-tying techniques may be performed using one hand (monomanual technique) or alternating both hands (bimanual technique). Rotation of the needle holders around the thread (clockwise or counterclockwise rotation) is very important to have a symmetric or an asymmetric configuration of the knot, which affects the stability of the entire knot sequence. The monomanual knot-tying technique needs to alternate the rotation of the needle holder, and the bimanual technique does not when performing half knots (square or flat knots). The half hitch is an asymmetric knot that is obtained when the surgeon makes asymmetric traction on one thread (passive thread) and place the knot using the other thread (active thread). To block 2 half hitches, the surgeon needs to change the active and the passive threads. Beginners in laparoscopy commonly make mistakes tying knots, leading to an insecure knot sequence that may slip and/or open under minimal forces. In this video, we demonstrate different types of blocking sequences performed by laparoscopy applied in different surgical procedures. Ethics Committee approval was obtained for this video. CONCLUSION: Knot-tying is a basic surgical skill that must be mastered by all laparoscopists.

What is the Best Surgeon's Knot? Evaluation of the Security of the Different Laparoscopic Knot Combinations.

STUDY OBJECTIVE: To investigate the security of various knot combinations in laparoscopic surgery. DESIGN: Prospective nonrandomized trial (Canadian Task Force classification II). SETTING: Storz Training Centre, Sao Paulo, Brazil. INTERVENTION: Different knot combinations (n = 2000) were performed in a laparoscopic trainer. Dry or wet 2.0 polyglycolic acid or dry 2-0 poliglecaprone 25 was used. The tails were cut at 10 mm, and the loops were tested in a dynamometer. The primary endpoints were the forces at which the knot combination opened or at which the suture broke. Resulting tail lengths were measured. MEASUREMENTS AND MAIN RESULTS: Surprisingly, the combination of a 2-throw half knot (H2) and a symmetric 1-throw half knot (H1s) (a surgical flat knot) opened at <1 Newton (N) in 2.5% of tests and at <10 N in 5% of tests. This occasional opening at low forces persisted after 1 or 2 additional H1s knots. A sequence of an H2 or a 3-throw half knot (H3) followed by a H2, either symmetric or asymmetric (H2H2 or H3H2), resulted in 100% secure knots that never opened at forces below 30 N. Other safe combinations were H2H1s followed by 2 blocking half hitches, and a sequence of 5 half hitches with 3 blocking sequences. CONCLUSION: A traditional surgical knot (H2H1s) occasionally opens with little force and thus is potentially dangerous. Safe knots are H2H2 and H3H2 combinations, a sequence of 5 half hitches with 3 blocking sequences, and H2H1s together with 2 blocking half hitches.

Treatment of heterotopic caesarean scar pregnancy complicated with post termination increase in size of residual mass and morbidly adherent placenta.

We report a case of a secundipara with heterotopic cesarean scar pregnancy (HCSP) treated with potassium chloride injection into the ectopic embryo followed by sac aspiration. The remaining "mass" increased in size threefold and was surrounded by a rich vascular network. An arteriovenous malformation was suspected; however, appropriate treatment was precluded because of the viability of the ectopic gestation. Sonographic examination revealed a morbidly adherent placenta, and attempt to resect the mass laparoscopically was complicated by bleeding that required hysterectomy. This case illustrates a complication of the intervention performed to preserve the intrauterine gestation in case of HCSP. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 46:227-230, 2018.

Laparoscopic Double Discoid Resection With a Circular Stapler for Bowel Endometriosis.

STUDY OBJECTIVE: To demonstrate the technique of laparoscopic double discoid resection with a circular stapler for bowel endometriosis. DESIGN: Case report (Canadian Task Force classification III). SETTING: Private hospital in Curitiba, Paraná, Brazil. PATIENT: A 33-year-old woman was referred to our service complaining about cyclic dysmenorrhea, dyspareunia, chronic pelvic pain, and cyclic dyschezia. Transvaginal ultrasound with bowel preparation showed a 6-cm endometriotic nodule at the retrocervical area, uterosacral ligaments, posterior vaginal fornix, and anterior rectal wall, infiltrating up to the submucosa, 5 cm far from the anal verge. INTERVENTIONS: Under general anesthesia, the patient was placed in the dorsal decubitus position with her arms alongside her body and her lower limbs in abduction. Pneumoperitoneum was achieved using a Veres needle placed at the umbilicus. Four trocars were placed: a 10-mm trocar at the umbilicus for the zero-degree laparoscope; a 5-mm trocar at the right anterosuperior iliac spine; a 5-mm trocar in the midline between the umbilicus and the pubic symphysis, approximately 8 to 10 cm inferior to the umbilical trocar; and a 5-mm trocar at the left anterosuperior iliac spine. The entire pelvis was inspected for endometriotic lesions, and all implants in the anterior compartment of the pelvis were resected. The lesions located at the ovarian fossae were completely removed. The ureters were identified bilaterally, and both para-rectal fossae were dissected. The right hypogastric nerve was released from the disease laterally. The lesion was separated from the retrocervical area, and the posterior vaginal fornix was resected (reverse technique), leaving the disease attached to the anterior surface of the rectum. The lesion was shaved off the anterior rectal wall using a harmonic scalpel. A x-shaped stitch was placed at the anterior rectal wall using 2-0 mononylon suture. A 33-mm circular stapler was placed transanally under laparoscopic control, and once it reached the area to be resected, it was opened. A gap was created between the envil and the stapler. The anterior rectal wall was placed inside this gap with the aid of the stitch at the anterior rectal wall. The stapler was fired, and a piece of the anterior rectal wall was resected. The same procedure was performed using a 29-mm circular stapler, which allowed for the complete removal of the lesion. We usually perform the second discoid resection using a 29-mm circular stapler to allow an easy progression of the stapler through the rectum beyond the first stapler line, so not to put too much pressure on it. In our experience, the first discoid resection removes most of the disease, and the second discoid resection is only needed to remove a small amount of residual disease, along with the first staple line. MEASUREMENTS AND MAIN RESULTS: The procedure took 177 min, and the estimated blood loss was 100 mL. The patient started clear liquids 6 hours after the procedure, and was discharged 19 hours after that [1]. Pathological examination of the 2 strips of the anterior rectal wall revealed infiltration of the bowel wall by endometriotic tissue. She had an uneventful postoperative course, and was able to re-start sexual intercourse 50 days after surgery. Between January 2010 and January 2015, 315 women underwent laparoscopic surgery for the treatment of bowel endometriosis in our service. Among them, 16 (5.1%) were operated on by using the double discoid resection technique. Median age of the patients was 34 years, and median body mass index was 25.9 kg/m(2). Median preoperative cancer antigen-125 level was 26.5 U/mL (normal value is <35 U/mL). Median size of the rectosigmoid nodule was 35 mm (range: 30-60), and median distance from the anal verge was 10.5 cm (range: 5-15 cm). Median surgical time was 160 min (range: 54-210 min). Concomitant procedures included hysterectyomy (n = 5), partial cystectomy (n = 3), resection of the posterior vaginal fornix (n = 4), and appendectomy (n = 1). Median estimated intraoperative bleeding was 32.5 mL (range: 30-100), and median time of hospitalization was 19 hours (range: 10-41). Median American Fertility Society score was 46 (10-102). Two minor complications (12.5%) occurred in this initial series: 1 patient required bladder catheterization for urinary retention; and 1 patient developed a urinary tract infection that required oral antibiotic treatment. One major complication (6.2%) was observed; the patient developed fever and abdominal pain on the fourth postoperative day. She was re-operated, and the intraoperative diagnosis was pelviperitonitis. The abdominal cavity was inspected for any dehiscence of the bowel and then washed. She was discharged on the second day after re-operation with oral antibiotic therapy. In our daily practice, we are used to discharging our patients soon in the postoperative setting (19 hours for rectal shaving or discoid resection and 28 hours for segmental bowel resection) [1] because the rate of postoperative fistula seems to be low [2]. Because we still have not seen any fistulas after conservative surgery (rectal shaving, discoid resection, and double discoid resection), we usually prefer to perform this type of surgery compared with segmental bowel resection, when possible. CONCLUSIONS: Laparoscopic double discoid resection with circular stapler may be an alternative to segmental bowel resection in selected patients with bowel endometriosis.

Fast-track surgery in intestinal deep infiltrating endometriosis.

STUDY OBJECTIVE: To evaluate the length of hospital stay (LOS) and the readmission rate in patients undergoing laparoscopic surgery to treat intestinal deep infiltrating endometriosis (DIE) with application of the concepts of fast-track surgery. DESIGN: Retrospective study of women undergoing laparoscopic treatment of intestinal DIE (Canadian Task Force classification II-3). SETTING: Tertiary referral private hospital. INTERVENTIONS: We evaluated 161 women who underwent laparoscopic surgery between January 2010 and April 2013 for complete treatment of intestinal DIE, via either conservative surgery (rectal shaving, mucosal skinning, or anterior disk resection) or radical surgery (segmental bowel resection). After surgery, all specimens were sent for pathologic examination to confirm the presence of endometriosis. MEASUREMENTS AND MAIN RESULTS: Patients were divided into 2 groups according to type of surgery (conservative [n = 102] or radical [n = 59]), and LOS and readmission rate were measured in both groups. Median LOS was shorter in the conservative group compared with the segmental bowel resection group (19 vs 28 hours; p < .001). Ninety-two patients (90.2%) in the conservative surgery group were discharged to home on the first postoperative day, compared with only 38 patients (64.4%) in the segmental bowel resection group. Overall, the readmission rate was low (3.1%): 6.8% in the segmental bowel resection group and 1% in the conservative group (p = .04; odds ratio, 7.34; 95% confidence interval, 0.8-67.3); however, the need for repeat operation was similar in both groups (3.4% vs 1%; p = .28; odds ratio, 3.54; 95% confidence interval, 0.31-39.95). CONCLUSION: Implementation of fast-track concepts in the laparoscopic treatment of intestinal DIE resulted in a short LOS and low readmission rate in both the segmental bowel resection and conservative surgery groups.

Surgical results of pelvic exenteration in the treatment of gynecologic cancer.

BACKGROUND: Our aim in the present study was to evaluate surgical outcomes and complications of pelvic exenteration in the treatment of gynecologic malignancy and to compare surgery-related complications associated with different types of exenteration. METHODS: We performed a retrospective analysis of patients who underwent pelvic exenteration for the treatment of gynecologic cancer between January 2008 and August 2011. Patients were divided into two groups for comparison: total pelvic exenteration (TPE) and nontotal pelvic exenteration (NTE, including anterior pelvic exenteration (APE) posterior pelvic exenteration (PPE)). Outcomes are reported according to the modified Clavien-Dindo Classification of Surgical Complications. RESULTS: Twenty-eight patients were included in the analysis. Eighteen had cervical cancer (64.3%). The prevalence of stage IIIB cervical cancer was 55%. Primary treatment with radiotherapy was performed in 53.3% of patients. Fifty percent of patients underwent TPE, 25% had APE and 25% underwent PPE. Patients who underwent TPE had worse outcomes, with a mean operative time of 367 minutes, use of blood transfusion in 93% of patients, ICU stay of 4.3 days and total hospital stay of 9.4 days. The overall mortality rate was 14.3%, and the surgical site infection rate was 25%. In the TPE group, 78.6% of patients experienced surgical complications. One-fourth of the total patient sample required reoperation, and the leading cause was urinary fistula (57.1%). Urinary leakage occurred in 22.7% of urinary reconstruction patients. Wet colostomy was the most common form of reconstruction with 10% of leakage. CONCLUSIONS: Postoperative urinary and infectious complications accounted for 75% of all causes of morbidity and mortality after pelvic exenteration. TPE is a more complex and morbid procedure than NTE.

Retrocervical deep infiltrating endometriotic lesions larger than thirty millimeters are associated with an increased rate of ureteral involvement.

STUDY OBJECTIVE: To estimate the presence of ureteral involvement in deep infiltrating endometriosis (DIE) affecting the retrocervical area. DESIGN: Retrospective study of women undergoing laparoscopic treatment of DIE affecting the retrocervical area. DESIGN CLASSIFICATION: Canadian Task Force classification II-3. SETTING: Tertiary referral private hospital. PATIENTS: We evaluated 118 women who underwent laparoscopy for the treatment of retrocervical DIE lesions between January 2010 and March 2012. INTERVENTIONS: All women underwent laparoscopic surgery for the complete treatment of DIE. After surgery all specimens were sent for pathologic examination to confirm the presence of endometriosis. MEASUREMENTS: Patients with pathologically-confirmed retrocervical DIE were divided into 2 groups according to the size of the lesion (group 1: lesions ≥ 30 mm; group 2: lesions < 30 mm) and the rate of ureteral endometriosis was compared between both groups. MAIN RESULTS: Ureteral involvement was present in 17.9% (95% confidence interval [CI] 10%-29.9%) of women with retrocervical lesions ≥ 30 mm whereas in only 1.6% (95% CI 0.4%-8.5%) of those with lesions <30 mm (odds ratio = 13.3 [95% CI 1.6-107.3]). CONCLUSION: Patients undergoing surgery for retrocervical DIE lesions ≥ 30 mm in diameter have a greater risk of having ureteral involvement (17.9%).

Laparoscopic Surgery: A Systematic Review of Loop and Knot Security, Varying with the Suture and Sequences, Throws, Rotation and Destabilization of Half-Knots or Half-Hitches.

Surgical knots are sequences of half-knots (H) or half-hitches (S), defined by their number of throws, by an opposite or similar rotation compared with the previous one, and for half-hitches whether they are sliding (s) or blocking (b). Opposite rotation results in (more secure) symmetric (s) knots, similar rotation in asymmetric (a) knots, and changing the active and passive ends has the same effect as changing the rotation. Loop security is the force to keep tissue together after a first half-knot or sliding half-hitches. With polyfilament sutures, H2, H3, SSs, and SSsSsSs have a loop security of 10, 18, 28, and 48 Newton (N), respectively. With monofilament sutures, they are only 7, 16, 18, and 25 N. Since many knots can reorganize, the definition of knot security as the force at which the knot opens or the suture breaks should be replaced by the clinically more relevant percentage of clinically dangerous and insecure knots. Secure knots with polyfilament sutures require a minimum of four or five throws, but the risk of destabilization is high. With monofilament sutures, only two symmetric+4 asymmetric blocking half-hitches are secure. In conclusion, in gynecology and in open and laparoscopic surgery, half-hitch sequences are recommended because they are mandatory for monofilament sutures, adding flexibility for loop security with less risk of destabilization.