Laparoscopic Triple-tourniquet Constriction: A Convenient Way for Minimizing Blood Loss during Myomectomy.

STUDY OBJECTIVE: Although a pericervical tourniquet helped reduce blood loss in myomectomy [1], a technique of triple tourniquets was more influential in occluding the uterine vessel networks [2,3]. This video demonstrates the procedures of laparoscopic triple-tourniquet constriction with the number 1 suture around the uterine isthmic portion and bilateral infundibulopelvic ligaments [4] in a case of robotic myomectomy. DESIGN: A step-by-step, narrated video demonstration. SETTING: A university hospital. INTERVENTIONS: Robotic myomectomy was scheduled for a patient with menorrhagia. Magnetic resonance imaging revealed 8 uterine myomas; the maximal one was 9.1 × 8.4 × 8.6 cm in dimension. Our robotic settings included 3 ports: fenestrated bipolar in the left lower quadrant, spatula or mega needle holder in the right lower quadrant, and an umbilical glove port accessible for lens and assisted instruments. A number 1 Monocryl (Ethicon, Bridgewater, NJ) was introduced from the suprapubic area extracorporeally; then, the needle penetrated through bilateral avascular zones of broad ligaments at the isthmic level and with a sliding tie made anteriorly to the uterus. The isthmic tourniquet-we also named it as the hangman's tourniquet-was tightened by manually tensioning the suture extracorporeally and pushing down the knot intracorporeally. Bilateral infundibulopelvic tourniquets were placed by using sliding ties of 1-0 Monocryl as well. With the total occlusion of uterine vessel networks, the uterus should retain only minimal blood flow. During the enucleation of uterine myomas, the tourniquet may loosen because of newly developed, unoccupied space with increasing bleeding; therefore, the tourniquet should be tightened up regularly throughout the surgery. After the repair of all the uterine wounds, we removed the 3 tourniquets. CONCLUSION: The convenient and adjustable triple-tourniquet constriction is a safe and feasible laparoscopic technique to block the vessel networks temporally in uterine-preserving surgery.

Novel Neovaginoplasty Using Rudimentary Uterine Horn Serosa and Pelvic Peritoneum as a Graft in Müllerian Anomalies with Vaginal Agenesis.

STUDY OBJECTIVE: To study the outcome of a novel method of laparoscopic neovaginal reconstruction using rudimentary uterine horn serosa and the pelvic peritoneum as a graft. DESIGN: Canadian Task Force classification II-1. SETTING: A university hospital. PATIENTS: A retrospective study of 14 patients from 2000 to 2014 of patients with vaginal agenesis who underwent laparoscopic neovagina reconstruction using rudimentary uterine horn serosa and the pelvic peritoneum as a graft. INTERVENTION: Patients with vaginal agenesis associated with müllerian agenesis who requested surgery. Tertiary referral center and laparoscopic unit. The creation of a neovagina using rudimentary uterine horn serosa and the pelvic peritoneum as a graft via a combined laparoscopic and vaginal route. MEASUREMENTS AND MAIN RESULTS: Data were collected retrospectively including postoperative vaginal length and width, complications, stenosis or reoperations, dyspareunia, and sexual satisfaction. There were no major complications from the surgery with no rectal perforation or bladder or ureteric injury. The postoperative mean (±SD) vaginal length was 6.0±0.7 cm and a width of 2 fingerbreadths. The mean operation time was 142.7±45.9 min. Median blood loss was 100 ml (range: 10 to 300 mL). The mean duration of the hospital stay was 6.6±1.6 days. The follow-up period ranged from 3 to 84 months with a median follow-up of 11 months. CONCLUSION: Lee's method of neovaginoplasty using rudimentary uterine horn serosa and the pelvic peritoneum as a graft is a good method for neovagina creation with minimal morbidity, fast recovery, and minimal complications. This method results in good anatomic and functional outcome and can be a method that is widely used.

Effectiveness and appropriateness in the application of office hysteroscopy.

With the advances in miniature instruments, office hysteroscopy on conscious patients has been the standard to explore the intrauterine pathology, with the ability to perform some minor procedures concomitantly. Patients usually appreciate the efficient "see and treat" procedures with such minimal discomfort that exempt from the inconvenience of going into the operating room and the need for anesthesia. However, controversies exist in the appropriateness of its application in some clinical situations. Concerns include (1) the criteria for hysteroscopy applied in the vast number of patients suffering from abnormal uterine bleeding or subfertility, and (2) the frequency for repeated hysteroscopy on some kinds of patients, such as those of endometrial cancer with fertility-sparing treatment for monitoring the disease, or those of severe intrauterine adhesion who need adhesiolysis for subsequent conception, in whom the appropriate protocol of repeatedly applying hysteroscopy lacks consensus. This article reviews the literature to find the best available evidence on the effectiveness of office hysteroscopy in comparison with other clinical diagnostic tools, as well as the current opinions on such controversies in its application.

The Power Law of Learning in Transumbilical Single-Port Laparoscopic Subtotal Hysterectomy.

STUDY OBJECTIVE: To analyze the surgical outcomes and learning curve of transumbilical single-port laparoscopic subtotal hysterectomy, which requires sutures of the cervical stump. DESIGN: A prospective observational study (Canadian Task Force classification II-2). SETTING: A university-affiliated center. PATIENTS: From the first (July 2012) and consecutive patients of benign uterine disease scheduled for subtotal hysterectomy until October 2013. INTERVENTIONS: All single-port laparoscopies were performed using straight instruments by 1 gynecologist. An ancillary port was added whenever technical difficulties could endanger surgical quality. MEASUREMENT AND MAIN RESULTS: Seventy-five patients were recruited for intention-to-treat analysis with a mean (±SD) age of 44.7 ± 3.8 years and a body mass index of 24.2 ± 3.7 kg/m2. No major complication was noted. The mean uterine weight was 432.5 ± 344.0 g with 24 (32%) uteri ≧500 g. The patients' sequential order, or gradually increasing experience, was the determining factor in progressively decreasing operative time. Furthermore, most cases that required an additional ancillary port (67%) were clustered in the first 20 cases, whereas 4 were scattered after the 47th patient because of severe pelvic adhesion. The mean operative time decreased in the power law function of the patients' sequential order with a plateau achieved at the 20th patient. CONCLUSION: The patients' sequential order was identified as an independent factor of achieving purely single-port access, and the trend of decreasing operative time delineated the existence of a learning curve. Approximately 20 patients were needed for an experienced multiport laparoscopist to reach technical competency in the current series.

Pattern Recognition to Prognosticate Endometrial Cancer: The Science Behind the Art of Office Hysteroscopy-A Retrospective Study.

OBJECTIVE: This study aimed to evaluate a specific glomerular pattern for prognostication of endometrial cancer (EC). MATERIALS AND METHODS: The office hysteroscopy's picture and video of 4197 women were reviewed, 48 women who were suspected of type I EC were analyzed: 26 have glomerular pattern (group 1) and 22 without it (group 2). RESULTS: The histopathological grading after hysterectomy with glomerular pattern had grade 2 or grade 3 disease on final histology (n = 25; 96%). The sensitivity and specificity of this test were 84.6% and 81.8%, respectively, with a likelihood ratio of 4:6 in predicting and prognosticating those women who have high-grade tumor or invasive disease. CONCLUSIONS: This hysteroscopic picture might be used as a novel marker for risk stratification of EC.

Hysterectomy by transvaginal natural orifice transluminal endoscopic surgery (NOTES): a series of 137 patients.

STUDY OBJECTIVE: To evaluate the feasibility and safety of hysterectomy in benign disease using transvaginal natural orifice transluminal endoscopic surgery (NOTES). DESIGN: Prospective observational study (Canadian Task Force classification II-3). SETTING: Tertiary referral medical center. PATIENTS: From May 2010 to August 2011, consecutive patients who were scheduled to undergo laparoscopic hysterectomy and without virginity or suspected pelvic inflammation or cul-de-sac obliteration were included. INTERVENTION: Total hysterectomy via transvaginal NOTES. MEASUREMENTS AND MAIN RESULTS: The study included 137 patients, with mean (SEM) age 46.0 (0.4) years and body mass index 24.7 (0.4). Transvaginal NOTES was successfully performed in 130 patients (94.9%). Fifteen patients underwent concurrent adhesiolysis, and 17 underwent adnexal procedures. Mean (SEM) uterine weight was 450.0 (24.1) g; in 45 patients (34.6%), uterine weight was >500 g, and in 7 (5.4%) it was >1000 g. Operative time was 88.2 (4.1) minutes, with blood loss of 257.7 (23.9) mL. In 2 patients there was intraoperative hemorrhage or unintended cystotomy, and in another 5 transvaginal colpotomy failed because of a narrow vagina, cul-de-sac obliteration by bowel adhesions, or mass obstruction. Complications in these 7 patients (5.1%) were successfully managed via transabdominal laparoscopy. Five patients (3.6%) experienced postoperative urinary retention or febrile morbidity, and recovered uneventfully with conservative treatment. CONCLUSION: Transvaginal NOTES is a feasible technique for performance of hysterectomy and can be used in procedures that are difficult to complete via conventional vaginal surgery because posterior colpotomy is achievable. This procedure was not impeded by uterine volume, and had the advantage of no abdominal incision.

Dysregulated expression of GATA2 and GATA6 transcription factors in adenomyosis: implications for impaired endometrial receptivity.

OBJECTIVE: To study the effect of adenomyosis on the localized expression of the GATA binding proteins 2 and 6 (GATA2 and GATA6) zinc-finger transcription factors that are involved in proliferation of hematopoietic and endocrine cell lineages, cell differentiation, and organogenesis, potentially leading to impaired endometrial implantation. DESIGN: Laboratory based experimental study. SETTING: Academic hospital and laboratory. PATIENTS: Human endometrial stromal cells (HESCs) of reproductive age patients, 18-45 years of age, with adenomyosis were compared with patients with no pathology and leiomyomatous uteri as controls (n = 4 in each group, respectively). Additionally, midsecretory phase endometrial sections were obtained from patients with adenomyosis and control patients with leiomyoma (n = 8 in each group, respectively). INTERVENTIONS: GATA2 and GATA6 immunohistochemistry and H-SCORE were performed on the midsecretory phase endometrial sections from adenomyosis and leiomyoma control patients (n = 8 each, respectively). Control and adenomyosis patient HESC cultures were treated with placebo or 10-8 M estradiol (E2), or decidualization media (EMC) containing 10-8 M E2, 10-7 M medroxyprogesterone acetate, and 5 × 10-5 M cAMP for 6 and 10 days. Additionally, control HESC cultures (n = 4) were transfected with scrambled small interfering RNA (siRNA) (control) or GATA2-specific siRNAs for 6 days while adenomyosis HESC cultures (n = 4) were transfected with human GATA2 expression vectors to silence or induce GATA2 overexpression. MAIN OUTCOME MEASURES: Immunohistochemistry was performed to obtain GATA2 and GATA6 H-SCORES in adenomyosis vs. control patient endometrial tissue. Expression of GATA2, GATA6, insulin-like growth factor-binding protein 1 (IGFBP1), prolactin (PRL), progesterone receptor (PGR), estrogen receptor 1 (ESR1), leukemia inhibitory factor (LIF), and Interleukin receptor 11 (IL11R) messenger RNA (mRNA) levels were analyzed using by qPCR with normalization to ACTB. Silencing and overexpression experiments also had the corresponding mRNA levels of the above factors analyzed. Western blot analysis was performed on isolated proteins from transfection experiments. RESULTS: Immunohistochemistry revealed an overall fourfold lower GATA2 and fourfold higher GATA6 H-SCORE level in the endometrial stromal cells of patients with adenomyosis vs. controls. Decidual induction with EMC resulted in significantly lower GATA2, PGR, PRL and IGFBP1 mRNA levels in HESC cultures from patients with adenomyosis patient vs. controls. Leukemia inhibitory factor and IL11R mRNA levels were also significantly dysregulated in adenomyosis HESCs compared with controls. . Silencing of GATA2 expression in control HESCs induced an adenomyosis-like state with significant reductions in GATA2, increases in GATA6 and accompanying aberrations in PGR, PRL, ESR1 and LIF levels. Conversely, GATA2 overexpression via vector in adenomyosis HESCs caused partial restoration of the defective decidual response with significant increases in GATA2, PGR, PRL and LIF expression. CONCLUSION: In-vivo and in-vitro experiment results demonstrate that there is an overall inverse relationship between endometrial GATA2 and GATA6 levels in patients with adenomyosis who have diminished GATA2 levels and concurrently elevated GATA6 levels. Additionally, lower GATA2 and higher GATA6 levels, together with aberrant levels of important receptors and implantation factors, such as ESR1, PGR, IGFBP1, PRL, LIF, and IL11R mRNA in HESCs from patients with adenomyosis or GATA2-silenced control HESCs, support impaired decidualization. These effects were partially restored with GATA2 overexpression in adenomyosis HESCs, demonstrating a potential therapeutic target.

Single-port laparoscopic myomectomy: initial operative experience and comparative outcome.

OBJECTIVE: To present the initial operative outcome and comparative data among patients undergoing single-port laparoscopic myomectomy (SPLM). MATERIALS AND METHODS: A prospective, observational study of all patients who underwent SPLM was performed. The demographic and operative data, including age, body mass index, operative indications, operative time, estimated blood loss, complications, and postoperative hospital stay were recorded. A match cohort of patients undergoing traditional LM was also retrospectively compared. RESULTS: SPLM was successfully performed in all ten patients from April 2010 to October 2010. The two groups (SPLM and traditional LM) were matched by age, body mass index, size, and weight of fibroids. The median operating time (196.5 vs. 82.5 min, P < 0.001) and length of hospitalization (3 vs. 2 days, P = 0.042) were significantly longer in SPLM group than in traditional LM group. The median operative blood loss was not significantly different. No patients in either group had serious complications. CONCLUSION: Despite the increased operating time, SPLM is feasible and offers comparable surgical outcomes and superior cosmesis compared with traditional LM.

Origami Box Folding Exercise: A laparoscopic box simulation training and assessment method in facilitating laparoscopic psychomotor skills with minimal preparation.

OBJECTIVE: Laparoscopic box simulation training is widely recognized as an assessment tool to facilitate psychomotor skills especially for novice surgeons. However, current commercialized training modules including pegs, gauze, clips, pins etc. are generally costly and relatively inaccessible. We introduce a simple and pioneer surgical training drill, the Origami Box Folding Exercise (OBFE), based on the validated evaluating system of objective structured assessment of technical skills (OSATS) constructed with the scoring system of procedure-specific checklist (PSC) and global rating scale (GRS). MATERIALS AND METHODS: Face and content validation of the OBFE and OSATS are evaluated by five endoscopic experts from two medical centers in Taiwan. This is a prospective observational study analyzing the pre-test/post-test result of OBFE from 37 participants in two individual workshops as training and evaluating method for laparoscopic psychomotor skills. Both the pre and post tests are video recorded with a time limit of 5 min graded by two independent evaluators based on the OSATS scoring system. RESULTS: The reliability of PSC, GRS, and intergroup value between PSC and GRS were 0.923, 0.926 and 0.933, respectively. Inter-rater reliability of PSC, GRS, and both were 0.985, 0.932 and 0.977, respectively. Construct validity of PSC and GRS were statistically significant, with p-value 0.006 and 0.001, respectively. CONCLUSION: OBFE enhances laparoscopic psychomotor skills with requirement of a single piece of paper. The associated OSATS tool for a 5-min OBFE test was validated. OBFE training is an efficient training and assessment system to promote psychomotor skills in laparoscopic box simulation drill which requires simple and economical preparation.

Improving the diagnosis of endometriosis in Asia-Pacific: Consensus from the Asia-Pacific Endometriosis Expert Panel for Endometriosis.

Endometriosis should be diagnosed as early as possible in the continuum of care; but substantial delays of approximately 6-8 years between symptom onset and endometriosis diagnosis have been widely reported. With the purpose of improving the prompt diagnosis of endometriosis, the Asia-Pacific Endometriosis Expert Panel (APEX) sought to address the reasons for diagnostic delays across the region, and formulate a multi-pronged approach to overcoming these challenges. In the first instance, clinical diagnosis is preferable to surgical diagnosis, in order to facilitate earlier empirical treatment and minimize the negative sequelae of undiagnosed/untreated disease. There should be a high clinical index of suspicion in women presenting with cyclical symptoms, including those involving extrapelvic organs. Diagnostic delays in Asia-Pacific countries are attributable to a variety of patient, physician, and healthcare factors, including poor awareness, normalization/trivialization of pain, individual/cultural attitudes toward menstruation, default use of symptom-suppressing treatments, misdiagnosis, and a lack of diagnostic resourcing or adequate referral pathways in some areas. Suggested initiatives to reduce diagnostic delays are geared toward improving public awareness, improving clinical diagnostic skills, streamlining multidisciplinary care pathways for timely referral, updating and implementing diagnostic guidelines, lobbying policymakers and insurance companies for endometriosis support, and increasing efforts to bridge data gaps and perform further research in this field. Formulating specific action plans and gathering traction are the responsibility of individual countries within local parameters. The APEX group advocates for any initiatives and policies that support the unmet needs of women with endometriosis, to improve patient experience and outcomes.

Transvaginal natural-orifice transluminal endoscopic surgery (NOTES) in adnexal procedures.

From August 2010 to June 2011, 10 consecutive patients underwent transvaginal NOTES of the adnexa, including tubal sterilization in 3, salpingectomy because of ectopic pregnancy in 3, and ovarian tumor enucleation in 4. The mean (SD; 95% CI) age of the patients was 34.8 (9.7; 27.9-41.8) years, and their body mass index was 21.6 (2.8; 19.4-23.8). In 9 of the 10 patients, the procedure was completed. The 3 tubal sterilization procedures were completed in 18 to 30 minutes, with negligible blood loss. Operative time for the 3 salpingectomies because of ectopic pregnancy was 62 to 116 minutes. One of these procedures included management of 2000 mL hemoperitoneum. Three of the 4 attempts at ovarian enucleation were successfully completed within 64 to 162 minutes, with estimated blood loss ≤ 50 mL. One NOTES procedure failed because of a misdiagnosed peritoneal mucinous tumor located anterior to the uterus and inaccessible, leading to subsequent conversion to transabdominal laparoscopy. Our preliminary results show that purely transvaginal NOTES is feasible and safe for use in performing uterine adnexal procedures in selected patients. However, the procedure cannot be used in patients with cul-de-sac disease, and could have limited use in treating lesions located anterior to the uterus.

Outcome of laparoscopic repair of ureteral injury: follow-up of twelve cases.

STUDY OBJECTIVE: To review the feasibility of laparoscopic repair in cases of ureteral injuries occurring during gynecologic laparoscopy. DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: Institution-specific retrospective review of data from a tertiary referral medical center. PATIENTS: Patients suffering from iatrogenic ureteral injuries diagnosed during or after surgery, and cases with deliberate ureteral resection and repair because of underlying disease. MEASUREMENTS AND MAIN RESULTS: We conducted a retrospective review of all (10 345) laparoscopic gynecologic surgeries performed in our institute between February 2004 and November 2008. Twelve cases (median: 45.5 years, range: 27-63) of ureter transections were diagnosed and repaired laparoscopically by endoscopists. Of these, 10 had previous surgeries, pelvic adhesions, or a large pelvic-abdominal mass. One patient had undergone a segmental resection and laparoscopic ureteroureterostomy for deep infiltrative endometriosis. Of the remaining 11 iatrogenic ureteral transections, 10 were repaired via laparoscopic ureteroureterostomy, whereas 1 had undergone a laparoscopic ureteroneocystostomy. One injury was recognized on the second postoperative day, but intraoperative recognition was attained in 11 cases. The median duration of double J stenting was 73 days. Three patients had development of strictures (between 42 and 79 days after surgery) treated with restenting, but 1 had to undergo an ureteroneocystostomy for ureter disruption when trying to restent. One patient had development of leakage of the anastomotic site but recovered with a change of the double J stent. Only 1 case required another laparotomy for ureteroneocystostomy. Laparoscopic primary repair of ureteral injury was successful for 11 of 12 patients. All the patients were well and symptom free at the conclusion of the study period. CONCLUSION: Early recognition and treatment of ureteral injuries are important to prevent morbidity. Laparoscopic ureteroureterostomy could be considered in transections of the ureter where technical expertise is available. To the best of our knowledge, this is the largest series, to date, of ureteral repairs via laparoscopy.

Vaginal natural orifice transvaginal endoscopic surgery (vNOTES) surgical staging for endometrial carcinoma: The feasibility of an innovative approach.

OBJECTIVE: This study aims to describe the feasibility of treating early-stage endometrial cancer with hysterectomy, bilateral salpingo-oophorectomy, sentinel lymph node biopsy, and bilateral pelvic lymphadenectomy by vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES). MATERIALS AND METHODS: A longitudinal study of prospectively registered patients was conducted at an academic tertiary care center. 15 patients who underwent vNOTES surgical staging of early endometrial carcinoma between January 2014 and December 2020 were included in the study. RESULTS: 15 patients between 20 and 80yrs of age with histologically proven Stage1 Gr1-2 endometrial cancer underwent vNOTES surgical staging. The mean age of the study population was 52.8 years (Standard Deviation [SD] 6.8) and the mean BMI was 27.8 kg/m2 (SD 6.4). The average operative time was 231.4 min (SD 41.0) with the mean estimated blood loss of 122.0 mL (SD 104.4). A total of 12 (80%) patients underwent SNL biopsy with ICG guided system, whereas 3 (20%) had pelvic lymph node dissection. There was one case with the surgical complication of bladder injury requiring conversion to conventional laparoscopy. CONCLUSION: With this study, we studied the feasibility of vNOTES surgery for early-stage endometrial cancer with minimal complications and the best long-term surgical outcome. The surgeries were performed by a single skilled endoscopist surgeon with previous experience with vNOTES surgery for adnexal tumors and hysterectomy. Our results showed the practicality of vNOTES in staging surgery for early-stage endometrial cancer. However, application to a larger cohort is required for more extensive surgical outcome studies.

Hysteroscopic removal, with or without laparoscopic assistance, of first-trimester cesarean scar pregnancy.

OBJECTIVE: To demonstrate the implementation and potential benefits of hysteroscopic removal, with or without concomitant laparoscopic assistance, of first-trimester cesarean scar pregnancies (CSPs). DESIGN: Patients with prior cesarean deliveries may have scar formation at the muscular wall of the uterine isthmus, resulting in a cesarean scar defect (CSD), also known as an isthmocele or diverticulum. When implantation of a trophoblast occurs at the CSD, a CSP develops, and with progression onto higher gestational age, it carries risks for serious complications, such as placenta previa spectrum, life-threatening bleeding, uterine rupture, and cesarean hysterectomy. Therefore, early termination is often recommended. Given that the chorionic frondosum only penetrates the decidual basalis layer during the first trimester and does not invade the distal myometrial segment until early second trimester, operative hysteroscopy can be a reliable and efficient treatment modality for early intervention. This narrated video features the systematic approach and surgical management for patients with first-trimester CSPs. SETTING: Academic tertiary hospital. PATIENT(S): Three multiparous women between 34 and 38 years of age diagnosed with CSPs within the first trimester. INTERVENTION(S): Initial assessment with transvaginal ultrasonography and color Doppler flow identifies the site of implantation and measures the residual myometrial thickness (RMT), which are important parameters for classifying the CSPs into type I or type II. Type I CSPs often present at an earlier gestational age, have a thicker RMT, and grow toward the uterine cavity, while type II CSPs are frequently noted at a higher gestational age, have a thinner RMT, demonstrate obvious scar dehiscence, and often invade toward the bladder. The patients received either operative hysteroscopy alone or with concomitant laparoscopic assistance and repair of CSD dehiscence. For all hysteroscopic operations, misoprostol (200 µg) was given 4 hours before the procedure while oxytocin (20 U in 1000 mL isotonic solution, intravenous infusion) was infused immediately after removal of the placental tissue. For laparoscopic excision and repair of the dehiscent scar, local injection of 5 mL terlipressin acetate (1 mg) was added before the initiation of laparoscopic CSD excision. MAIN OUTCOME MEASURE(S): Appraisal of the parameters used for preoperative assessment, the efficacy of the surgical procedures, and the intention to minimize the associated risks and morbid sequalae were evaluated. RESULT(S): Most of the type I CSPs or type II CSPs with gestational age <8 weeks and RMT >3 mm can be successfully treated with operative hysteroscopy alone. In contrast to blind dilatation and curettage, operative hysteroscopy offers direct visualization to ensure complete removal of the chorionic villi, which can occasionally be buried deep within the concavity of the CSD. It is worth noting that gently sweeping the decidua basalis from the myometrium with the loop resectoscope is more than enough to separate the chorionic villi within and completely displace the placental tissues without causing massive hemorrhage. For type II CSPs in late first-trimesters showing distended CSDs and diminished RMT, laparoscopy can be established before the hysteroscopic procedure for better surveillance and to prevent inadvertent myometrial perforation. Then, hysteroscopic removal of CSP can further induce uterine contractions to help reduce blood loss during subsequent laparoscopic repair of CSD. CONCLUSION(S): Accurate diagnosis and timely management of CSPs during the first trimester are crucial for preventing significant morbidities associated with advanced gestational age. Operative hysteroscopy offers the benefit of direct visualization for competent detachment of the decidua basalis of the CSP from the steep concavity of the CSD. Furthermore, the employment of laparoscopy for type II CSPs helps avoid inadvertent complications related to the thin RMT and allows concomitant repair of the extensive dehiscence.