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This study compares morbidity and mortality associated with retroperitoneal and transperitoneal para-aortic lymphadenectomy (PAAL) for pretherapeutic nodal staging of locally advanced cervical cancers (FIGO IB3–IVA). Pre-, per- and postoperative data of patients treated for locally advanced stage cervical cancer between 1999 and 2018 in 12 French referral centers (FRANCOGYN Study Group) were retrospectively collected. The study was conducted using a sample of 448 patients, of whom 223 (49,8%) underwent retroperitoneal (group 1) and 225 (50,2%) had transperitoneal PAAL (group 2). No differences were noted concerning clinical and histological characteristics between the two groups. Among these 448 patients, 23 (5,1%) had an intraoperative complication (9 (2,0%) in group 1 and 14 (3,1%) in group 2, p = 0.28) and 47 (10,5%) had a postoperative complication (22 (4,9%) in group 1 and 25 (5,6%) in group 2, p = 0.44), only one of which required revision surgery but the patient died. The length of hospital stay was significantly shorter in group 1 than in group 2 (3.97 versus 4.88 days, p < 0.001). There was no significant difference in mortality between the two groups; 34 of 223 patients in group 1 (15.3%) and 40 of 225 patients in group 2 (15.6%) died (HR = 0.968, 95% CI [0.591–1.585]). There was no significant difference in recurrence-free or overall survival between the two groups. Retroperitoneal PAAL appears as a valuable and safety surgical route for nodal staging in locally advanced cervical cancer compared with standard transperitoneal PAAL. [ABSTRACT FROM AUTHOR]

Radiological preoperative assessment of endometrial cancer (EC) is in some cases not precise enough and its performances improvement could lead to a clinical benefit. Radiomics is a recent field of application of artificial intelligence (AI) in radiology. To investigate the contribution of radiomics on the radiological preoperative assessment of patients with EC; and to establish a simple and reproducible AI Quality Score applicable to Machine Learning and Deep Learning studies. We conducted a systematic review of current literature including original articles that studied EC through imaging-based AI techniques. Then, we developed a novel Simplified and Reproducible AI Quality score (SRQS) based on 10 items which ranged to 0 to 20 points in total which focused on clinical relevance, data collection, model design and statistical analysis. SRQS cut-off was defined at 10/20. We included 17 articles which studied different radiological parameters such as deep myometrial invasion, lympho-vascular space invasion, lymph nodes involvement, etc. One article was prospective, and the others were retrospective. The predominant technique was magnetic resonance imaging. Two studies developed Deep Learning models, while the others machine learning ones. We evaluated each article with SRQS by 2 independent readers. Finally, we kept only 7 high-quality articles with clinical impact. SRQS was highly reproducible (Kappa = 0.95 IC 95% [0.907–0.988]). There is currently insufficient evidence on the benefit of radiomics in EC. Nevertheless, this field is promising for future clinical practice. Quality should be a priority when developing these new technologies. • Current preoperative staging may be inaccurate and underestimate disease extension. • Radiomics may improve preoperative radiological assessment of endometrial carcinoma. • Radiomics models should follow high-quality standards to ensure generalizability. • Evidence of benefit of these model remains insufficient to be part of clinical practice. [ABSTRACT FROM AUTHOR]

Study Objective: To compare a reusable hysteroscopic morcellator and standard resectoscopes in the hysteroscopic management of uterine polyps.Design: Single-center randomized prospective single-blind trial (resectoscope-morcellator study).Setting: Centre Médico-chirurgical Obstétrique teaching hospital, Strasbourg University Hospitals, France.Patients: All patients presenting with a single endometrial polyp of size 1 cm or larger.Interventions: After consent, the patients were randomized into 2 groups: hysteroscopic morcellation (HM) group or standard resection (SR) group. Office-based review hysteroscopy was performed 6 weeks to 8 weeks after surgery. Primary end point: time of morcellation or resection.Secondary Outcomes: total operating time (minutes), volume of fluid used (mL), fluid deficit (mL), number of morcellator or resectoscope insertions, operator comfort (visual analog scale: 0 to 10) and quality of vision (0 to 5), perioperative complications, completeness of resection, need to convert to another technique, pain assessment (visual analog scale), and length of hospitalization. At review hysteroscopy, we noted whether the resection or morcellation had been effective and if synechiae were present or absent. Statistical analyses followed Bayesian methods.Measurements and Main Results: Ninety patients were randomized: 45 in the HM group and 45 in the SR group. The average size of polyps at hysteroscopy was 13.3 mm. Morcellation time was lower than resection time (6.1 minutes vs 9 minutes; p [HM < SR] = .996). This also applied to total operating time (12.7 minutes vs 15.6 minutes; p [HM < SR] = .985), number of device insertions (1.50 vs 6; p [HM < SR] > .999), volume of fluid used (766.9 mL vs 1118.9 mL; p [HM < SR] = .994), and fluid deficit (60.2 mL vs 169.8 mL; p [HM < SR] = .989). Operator comfort was better in the HM group (8.4 vs 7.4; p [HM > SR] = .999) as was visualization (4 vs 3.7; p [HM > SR] = .911, highly probable). Operative complications were higher in the SR group (5 vs 0; p [HM < SR] = .989]. One patient in the SR group died after surgery owing to an anesthetic complication (anaphylactic shock complicated by pulmonary embolism). No differences were noted between the groups for pain assessment, length of hospitalization, and outcome on review hysteroscopy.Conclusion: The reusable morcellator is quicker, uses less fluid with less deficit and fewer introductory maneuvers, and offers better comfort and visualization than the resectoscope while being as effective for the hysteroscopic treatment of uterine polyps. [ABSTRACT FROM AUTHOR]

Study Objective: To demonstrate a systematic approach to the laparoscopic en bloc pelvic resection with rectosigmoid resection and anastomosis as part of ovarian cancer treatment in a tertiary gynecologic surgery referral center.Design: This video illustrates an en bloc pelvic resection performed par laparoscopy in 10 steps.Setting: A 56-year-old patient with an advanced high-grade serous ovarian cancer extending into the rectum was amenable to primary debulking surgery in accordance with the French guidelines [1]. In diagnostic laparoscopy, a bilateral adnexectomy was performed, and the pelvic carcinomatosis was considered primarily resectable. Histopathology of the subsequent en bloc resection was consistent with stage IIB high-grade serous ovarian cancer with an indication for adjuvant chemotherapy.Intervention: The Hudson's procedure revisited consists of a radical monobloc excision by way of a completely extraperitoneal dissection and total mobilization of the rectum. In this case, owing to rectal invasion, we achieved a laparoscopic radical resection including rectosigmoidectomy and primary anastomosis without the need for a defunctioning stoma [2].Conclusion: Traditionally, an en bloc pelvic resection with rectosigmoid resection and anastomosis was performed by laparotomy. The feasibility of performing laparoscopic optimal cytoreductive surgery in selected patients with advanced ovarian cancer was recently demonstrated without compromising survival in case of low residual disease. The prognosis depends rather on the resectability than on the operative access. However, the radicality and completeness of the cytoreduction, as well as the potential risk of tumor seeding, remain controversially discussed. Here, we demonstrate the minimally invasive approach following the same operative strategy as in open surgery. In this way, the radicality of the "en bloc resection" entailing avoidance of tumor rupture, less bleeding, and less urethral injury is combined with the benefits of a minimally invasive access. In expert hands, this procedure can be performed laparoscopically for other pelvic malignancies with peritoneal carcinomatosis. [ABSTRACT FROM AUTHOR]

Study Objective To report the clinical presentation and long-term issues of adolescent endometriosis. Design Retrospective cohort study. Setting Single private clinical center, Bordeaux, France. Patients Adolescents with a confirmed diagnosis of endometriosis. Interventions Surgical excision or ablation or lesions performed at laparoscopy. Measurements and Main Results Fifty-five adolescents, ages from 12 to 19 years (mean age 17.8), who were diagnosed with endometriosis from March 1998 to April 2013 were included in the study. Pain of various types was the leading symptom in all patients, except 2. Twenty-three patients had an adnexal mass identified preoperatively, and 5 had an associated infertility issue at the time of diagnostic laparoscopy. Four patients had an associated genital malformation. Fifty-one percent of the patients had a history of appendectomy. A familial history of endometriosis was reported by 19 patients (34.5%), with a first-degree relative affected in 14 cases (25.45%), and 47.3% of patients were smoking at least 5 cigarettes a day. Superficial implants was encountered in 31 cases (56.4%), endometriomas in 18 cases (32.72%), and deep infiltrating endometriosis (DIE) in 6 cases (10.90%). Sixty percent of patients were scored as stages I to II and 40% as stages III to IV. Five patients were lost to follow-up, and 37 had a follow-up ranging from 36 to 315 months (mean follow-up 125.5 months). Among the 50 patients not lost to follow-up, 13 (26%) had either no pain, or improved and had acceptable pain with medical treatment. Seventeen patients of the 50 adolescents not lost to follow-up (34%) underwent a repeat laparoscopy. A subsequent laparoscopic and/or magnetic resonance imaging scan was performed in 35 patients because of persistent pain. Among these, there was 12 endometriomas (7 recurrences) and 12 DIEs (3 recurrences), giving recurrence rates for endometriomas and DIEs of 36.84% and 50%, respectively. During the study, 18 patients wished to have a child. Thirteen had a delivery (72.2%), and 9 pregnancies occurred in patients who initially presented with stage I to II endometriosis. Of the 11 patients who had subfertility, 6 successfully conceived (54.5%). Conclusions Adolescent endometriosis is not a rare condition. In our study a familial history was reported in more than one-third of patients. Among those patients treated for DIE, there was a trend for higher rates of recurrences (symptoms or lesions) that required repeat laparoscopy. However, the impact on subsequent fertility appeared to have been limited. [ABSTRACT FROM AUTHOR]

Study Objective: To describe the anatomy of the nerves during a laparoscopic retroperitoneal para-aortic lymphadenectomy with prioritization of their preservation.Design: Demonstration of a nerve-preserving para-aortic lymphadenectomy.Setting: A 65-year-old woman with no significant medical history underwent diagnostic laparoscopy for evaluation of a right ovarian mass. In the absence of peritoneal carcinomatosis, bilateral adnexectomy wasperformed with pathology revealing a high-grade tubo-ovarian serous carcinoma. In accordance with French Guidelines for management of ovarian cancer, operative staging including pelvic and para-aortic lymphadenectomy was recommended [1]. Final pathology following staging surgery was consistent with stage IA high-grade serous ovarian cancer prompting administration of adjuvant chemotherapy postoperatively.Interventions: We performed a lumbo-aortic lymphadenectomy with preservation of the following nerves: the superior hypogastric plexus, the lumbar splanchnic nerves and the sympathetic trunk.Conclusion: Although there are conflicting data as to the benefit of staging lymphadenectomy in women with presumed early stage high-grade serous ovarian cancer, current French Guidelines recommend its performance. When doing so, effort should be made to avoid injury to adjacent normal structures, and in doing so, minimize potential morbidity. The neural structures preserved in this case are part of the sympathetic contingent and participate in the innervation of the abdomen and pelvic viscera. The sympathetic contingent is responsible for the vasomotricity but is also involved in the contraction of the internal genitalia during orgasm and in the inhibition of the peristaltic contractions of the rectum. As such, its preservation may avoid certain postoperative complaints. When possible to do so without compromising essential elements of a cancer surgery, preservation of nerves should be considered. [ABSTRACT FROM AUTHOR]

Study Objective: To demonstrate how to treat bladder and ureteral deep pelvic endometriosis using a laparoscopic approach with partial cystectomy and resection and end-to-end anastomosis of the ureter.Design: Step-by-step explanation of the surgery using a video approved by the local institutional review board.Setting: University Hospital of Strasbourg, France.Patients: A 27-year-old nulliparous woman with severe endometriosis stage IV (revised American Fertility Society classification score >40) of the bladder and left ureter. On pelvic magnetic resonance imaging, we found dilatation of the left ureter and left hydronephrosis induced by a 17-mm endometriosis nodule. A JJ probe was placed on the left ureter before the surgery because of dilatation of the ureter and decreased renal function.Interventions: During the exploration, we found an abdominal cavity free of adhesion. There was an endometriosis implant in the bladder in front of the uterus and a large nodule of the left uterosacral ligament that was compressing the ureter. In the first step, we made a section of the round ligament to perform anterior ureterolysis and progressive dissection of the nodule surrounding the ureter. Once the nodule was resected, tight stenosis was observed approximately 1 cm from the bladder. The vesicouterine and vesicovaginal spaces were then dissected to pass under the nodule to the vagina. We opened the dome of the bladder using the thunderbeat (Olympus) and dissected the bladder to remove the transfixing nodule while staying away from the ureters. The closure of the bladder was performed by 2 lateral sutures and a running suture using a braided suture (V-Loc) 2-0, with good tightness as checked by a blue test. Ureteral resection was performed around the JJ probe in place to remove the stenotic zone; thereafter, we performed an end-to-end anastomosis of the ureter using 4 sutures of monofilament (Monocryl) 4-0 with a good anatomic result. Finally, an omentoplasty was fixed around the ureter using a 2-0 monofilament suture (Monocryl).Measurements and Main Results: The postoperative course was uneventful. A Foley catheter was left in place for 10 days, and the JJ probe was removed 6 weeks later. The operative time was 140 minutes. The step-by-step explanation technique was simple with minimal operative difficulty and a low rate of morbidity.Conclusion: This video shows how deep urinary endometriosis can be treated laparoscopically. Mastering suturing is essential to avoid complications. [ABSTRACT FROM AUTHOR]

Objective: To describe the different steps of the Davydov surgical technique for creating a neovagina, emphasizing visualization of the rectovesical cleavage and peritoneal-vaginal anastomosis by laparoscopic and vaginal approaches.Design: Production of a step-by-step surgical video tutorial with narrative video footage.Setting: Uterovaginal agenesis is a rare congenital defect, observed in 1 case per 4000 to 5000 newborn female infants [1]. Vaginal agenesis treatment can be performed by different nonsurgical and surgical techniques that are based on neocavity creation. The Davydov intervention uses the pelvic peritoneum as "covering" tissue for a neocavity and avoids the use of allogenic or autologous transplants, traction devices, or specialized surgical equipment. It is a minimally invasive technique that provides long-term functionality and anatomically satisfying results [2].Interventions: We treated an 18-year-old patient with Mayer-Rokitansky-Küster-Hauser syndrome who underwent the Davydov procedure after dissatisfaction with the Franck self-expansion method. We created a neovagina using peritoneal flaps that were obtained after rectovesical cleavage by laparoscopic approach and were then fastened to the introitus by vaginal approach. Finally, the vaginal vault was reconstructed laparoscopically, and an intravaginal dilator was left in place. The result after 1 year showed the transition from a narrow vaginal dimple 2 cm in length to a neovagina 10 cm in length, permeable, well epithelialized, and correctly healed without associated stenosis. Sexual intercourse is satisfying for both partners.Conclusion: The Davydov technique is less invasive than other surgical techniques and allows good outcomes [3,4] without the invasive use of sigmoidal grafts, cutaneous flaps, or prostheses. It should be proposed to patients experiencing failure with the Franck nonsurgical method. [ABSTRACT FROM AUTHOR]

Study Objective: Although the standard technique is currently based on laparoscopic promontofixation, the standard vaginal technique for the treatment of uterine prolapse is sacrospinofixation according to Richter [1-3]. Described by Kurt Richter in 1968, this intervention corrects the middle floor and consists of fixing the vaginal dome (after hysterectomy or not) on the sacrospinous ligament(s) [4,5]. The technique includes a wide dissection of the pararectal fossa using several Breisky valves to grip the sacrospinous ligament under strict visual control. This crucial step of the intervention implies optimal visual control for the operator but does not allow visual access to the operative assistants, which is regrettable for the purpose of teaching [2,4-6]. The aim of this surgical video is to describe the different stages of the sacrospinofixation surgical technique, showing sacrospinous ligaments during the crucial step thanks to a laparoscopic camera.Design: A step-by-step explanation of the surgery using a video (an instructive video [Video 1]) approved by the local ethics committee.Setting: Gynecological Surgery Unit, University Hospital of Strasbourg, Strasbourg, France.Patients: A 70-year-old woman with multicompartment pelvic organ prolapse.Interventions: Installation in the conventional gynecologic position with 2 operating assistants on both sides of the operator. The steps are as follows: step 1, posterior colpotomy; step 2, rectovaginal dissection and opening of the pararectal fossa; step 3, dissection of the sacrospinous ligament; and step 4, gripping of the sacrospinous ligament. The following 4 steps are realized bilaterally: step 5, suspension of the vaginal dome; step 6, beginning of vaginal closure; step 7, tightening the spinofixation threads; and step 8, ending the closure of the vaginal colpotomy.Measurements and Main Results: The operative time was 60 minutes. The operation was simple and shows precisely the sacrospinous ligaments. There were no intraoperative complications. The vaginal mesh urinary catheter was removed on day 1, and the patient was discharged on day 3.Conclusion: Thanks to a laparoscopic column, this video of the surgical technique of sacrospinofixation using the Richter procedure is an original approach to show sacrospinous ligaments. The latter is a crucial step of this surgery, which remains the reference vaginal technique for the treatment of a uterine prolapse. [ABSTRACT FROM AUTHOR]

Study Objective: To show how pudendal neurolysis can be managed safely with a laparoscopic approach.Design: Stepwise demonstration of the technique with narrated video footage.Setting: The pudendal nerve is formed from spinal roots at levels S2, S3, and S4. It passes through the pelvis parallel to the pudendal vein and artery. This nerve exits the pelvis between the sacrospinous and sacrotuberous ligaments then passes through Alcock's canal. It can be compressed and responsible for pain in the gluteal and perineal regions. After confirmation of the diagnosis by positive analgesic block with computed tomography infiltration of the pudendal nerve, surgical decompression may be considered. The usual access procedures are the transglutal and transischiorectal ways.Interventions: This video shows a total laparoscopic approach for a right pudendal neurolysis. It is a step-by-step didactic video. This technique of decompression of the right pudendal nerve by laparoscopy by means of dissection of the ischiorectal fossa along the right internal obturator muscle, after visualization of the obturator vessels and identification of the pudendal nerve, allowed the section of the right sacrospinous ligament and complete removal with repositioning of the nerve in its path. The nerve was followed until it passed freely through Alcock's canal. The procedure went well and without complications, with clinical improvement on waking up.Conclusion: Pudendal nerve neurolysis by laparoscopic technique is a reproducible and safe method for treating pudendal neuralgia, allowing good visualization and dissection of the entire pelvis toward the ischiorectal fossa. [ABSTRACT FROM AUTHOR]

Study Objective: To describe a 10-step strategy to treat severe endometriosis with a frozen pelvis by laparoscopy.Design: Educational video.Setting: University Hospital of Strasbourg, France.Interventions: The patient was a 33-year-old nulliparous woman suffering from endometriosis. Because of pain and a desire for pregnancy, she was scheduled for surgery. After setting the patient in gynecologic position, we used a uterine manipulator to facilitate exposure. We assessed the global situation and discovered a frozen pelvis. To treat the myoma, the surgeon should use traction and countertraction as much as possible. We started with the caecum and sigmoid detachment. Then we performed a bilateral ureterolysis. Once the ureters were identified, we could perform safely the adhesiolysis of the bowel from the uterus. The adnexas could be freed and suspended with a T-Lift device to facilitate exposure. After identifying the utero sacral ligament, we opened the para rectal fossa, leading to the opening of the recto vaginal space. The anatomy was then restored, and we could define the specific surgical strategies.Conclusion: Frozen pelvis is a situation where anatomy is distorted. The surgeon should find anatomic landmarks to restore anatomy and to establish specific strategies adapted to the patient. [ABSTRACT FROM AUTHOR]

Study Objective: To describe a laparoscopic technique for the transplantation of a cryopreserved ovarian cortex.Design: Educational video.Setting: University Hospital of Strasbourg, France.Interventions: A 28-year-old nulliparous woman presented with anaplastic T lymphoma and was then treated with chemotherapy. Before the treatment, the ovarian cortex was collected by laparoscopy to preserve fertility. Remission was achieved, but the patient suffered from premature ovarian failure. At the age of 32 years, she wished to become pregnant. The patient was thus included in the research protocol Development of Ovarian Tissue Autograft in Order to Restore Ovarian Function, and the transplantation site was chosen accordingly. The cortex was stored in liquid nitrogen at -196°C after slow congelation. To restore ovarian function and because of pregnancy desire, we transplanted the cryopreserved ovarian cortex in the right ovary and inside a pocket of the peritoneum of the left ovarian fossa. The first step included adhesiolysis to treat small adhesions developed after the first surgery. On the right, the ovarian cortex was opened by an antimesial incision with cold scissors. The cryopreserved ovarian cortex was placed through the cortex of the right ovary and fixed with stitches. On the left side, the peritoneum of the ovarian fossa was opened, and a subperitoneal pocket was dissected. The cortex was inserted. It was then closed with absorbable sutures or with a hemostatic pad. Six months after her surgery, the patient had natural cycles. We monitored an ovulation of both the sides. She underwent 3 in vitro fertilizations but with failures of embryo transfer. She conceived spontaneously a year after the surgery. She gave birth to a healthy child weighing 3300 g.Conclusion: For patients who have suffered from premature ovarian failure owing to chemotherapy, ovarian cortex transplantation can restore the ovulatory function, allow in vitro fertilization, and permit, as in our case, a spontaneous pregnancy. [ABSTRACT FROM AUTHOR]

Study Objective: Lumboaortic lymphadenectomy is frequently performed in the surgical management of different gynecologic pelvic malignancies: cervical endometrial and ovarian cancer. The retroperitoneal access presents a real advantage, allowing direct access to vascular axes, thus avoiding bowel segments. The use of a vessel-sealing device could facilitate the technique by providing an ergonomic alternative to conventional tools such as a bipolar grasper and scissors. Here the surgical technique of laparoscopic retroperitoneal lumboaortic lymphadenectomy using a vessel-sealing device in 10 steps is described.Design: Educative video (Canadian Task Force classification III).Setting: Tertiary referral center in Strasbourg, France.Patients: Women undergoing lumboaortic lymphadenectomy.Intervention: Laparoscopic retroperitoneal lumboaortic lymphadenectomy using a vessel-sealing device. The local institutional review board approved the video.Measurements and Main Results: The surgeon and assistant are positioned on the left of the patient and the column is placed in front. After peritoneal exploration 3 trocars are introduced in the left flank according to a very precise arrangement. We use a camera scope with a zero-degree view angle. After development of the extraperitoneal space and identification of the vascular landmarks, lymphadenectomy using a vessel-sealing device involves several steps in an anticlockwise direction starting from the left common iliac group. We first start with the lateroaortic group of lymph nodes. We then continue with the preaortic, interaorticocaval, and precaval supramesenteric group. After that, we perform the inframesenteric dissection of lymph nodes, the bifurcation of the aorta, and finally the right common iliac group. At the end of the procedure, in the absence of signs of metastatic lymph nodes, we open the peritoneum.Conclusion: Retroperitoneal lumboaortic lymphadenectomy using a vessel-sealing device is useful because of better ergonomics of the multitasking instrument, avoiding alternating between scissors and bipolar forceps. The surgeon will be able to use both hands for exposure and for surgery. The presence of a metastatic ganglion is an important and decisive factor in the choice of adjuvant or neoadjuvant management of cancers, especially for cervical cancer. [ABSTRACT FROM AUTHOR]

Study Objective: To demonstrate a technique of laparoscopic management of a rudimentary horn in a 12-year-old girl.Design: A step-by-step explanation of the surgery using a video (instructive video) approved by the local institutional review board.Setting: A university hospital (University Hospital of Strasbourg, Strasbourg, France).Patient: A 12-year-old girl with a uterine rudimentary horn.Intervention: We describe a case of a 12-year-old girl who had no medical history. She had her first menstruation at 11 years old with major left pelvic pain occurring each month. Ultrasonography showed a duplication of the uterus with a liquid collection on the left side; this type of malformation is called an accessory and cavitated uterine mass. Medical treatment was initiated with progestin. Magnetic resonance imaging showed a left noncommunicating rudimentary horn with a unicornuate uterus. No other malformation was present, particularly in the kidneys. A primary vaginal endoscopy was performed showing a single cervix without vaginal malformation. It was decided to perform a laparoscopic excision of the left rudimentary horn. We placed a 10-mm optical port into the umbilicus and 3 accessory 5-mm trocars. Evaluation of the abdominal cavity showed 2 normal adnexas with normal ovaries. We decided to start with a left salpingectomy using the Ligasure device (Medtronic, Minneapolis, MN), staying close to the tube to preserve ovarian vascularization. The remnant fimbria must be removed to avoid cancerization. Then, the vesicouterine septum was divided until we reached the cervix to dissect the bladder from the rudimentary horn. The broad ligament was fenestrated in order to push the left ureter laterally .The utero-ovarian pedicle was transected with the Ligasure device; the left ovary was preserved and vascularized by the left infundibulopelvic ligament. We then dissected the left uterine artery. The posterior peritoneum was opened. The resection of the rudimentary horn was performed by means of a monopolar hook. The dissection was performed slowly with selective coagulation until we reached the cavity of the horn, with old blood flowing out. The entire cavity was removed, and we confirmed the absence of communication with the other part of the uterus. Uterine reconstruction was performed with inverted separated stiches of a 2-0 braided suture, and, finally, an antiadhesion barrier was placed.Conclusions: Laparoscopic management of a uterine rudimentary horn is feasible with satisfactory uterine reconstruction. This is not the first case of this surgery performed by laparoscopy. A similar case has been published in 2015 [1], and recently another video [2] has been published describing 2 other cases. [ABSTRACT FROM AUTHOR]

Study Objective: Laparoscopic transperitoneal lymphadenectomy has a few advantages. First, it is a minimally invasive approach, and the transperitoneal approach is also the best option when intra-abdominal surgery is indicated. Although the procedure was described more than 2 decades ago, there is a lack of diffusion of the technique. The main objective of this video is standardization and a simple description of the technique. We described this procedure in 10 logical steps, which should help to understand and perform this procedure.Methods: This video presents a systematic approach to transperitoneal lumboaortic lymphadenectomy, which is clearly divided in 10 steps ordered in a counterclockwise direction.Results: The 10 steps are as follows: step 1, retroperitoneal access; step 2, creating a space for subsequent lymphadenectomy and identification of anatomic landmarks; step 3, left common iliac lymph node dissection; step 4, right common iliac lymph node dissection; step 5, presacral lymph node dissection; step 6, lateroaortal lymph node dissection; step 7, laterocaval lymph node dissection; step 8, aortocaval lymph node dissection; step 9, vaginal extraction of bags with specimens; and step 10, vaginal suture.Conclusions: Laparoscopic transperitoneal access to lumboaortic lymph nodes is an effective method of lymphadenectomy, which may bring benefits to a patient and physician. The presented 10 steps help to perform each part of surgery in a logical sequence, making the procedure ergonomic and easier to adopt and learn. Standardization of laparoscopic techniques could help to reduce the learning curve. [ABSTRACT FROM AUTHOR]

Study Objective: Laparoscopy using a single port improves morbidity while keeping the same level of requirement. This technique has been evaluated in gynecology for salpingectomy, ovarian surgery, and hysterectomy. Here, the authors illustrate a new use of a single port using the transvaginal approach.Design: Case report (Canadian Task Force classification III).Setting: Tertiary referral center in Strasbourg, France.Patient: Woman age 59 years.Intervention: Single-port platform used in the transvaginal approach for resection of sacrocolpopexy mesh. The local institutional review board approved the video.Measurements and Main Results: A 59-year-old woman suffering from insulin-dependent diabetes and a tobacco user had 2 laparoscopic sacrocolpopexies for recurrent rectocele, the first in 2007 and the second in 2012. The sequences were marked by mesh erosion and granuloma in the vagina, requiring its surgical excision in 2016. The patient was then symptomatic, with an increasingly foul-smelling vaginal discharge with recurrent mesh erosion. Magnetic resonance imaging showed an abscess formation along the length of the mesh to the promontory. The patient then underwent surgery, realized under probabilistic antibiotic therapy, consisting of complete excision of the sacrocolpopexy mesh by the transvaginal approach. After putting the single-port trocar (GelPoint; Applied Medical, Rancho Santa Margarita, CA) into the vagina and obtaining distension with the insufflator (AirSeal; Conmed, Utica, NY), classic laparoscopic instruments were introduced by the single-port trocar. The mesh was entirely resected in the retroperitoneal space. Mesh was again used because the exposed space is almost always surrounded by loose granulation tissue that facilitates dissection and also prevents injury to adjacent structures such as bladder, rectum, and peritoneum. Moreover, the opening of adjacent structures will manifest gas leaks and, consequently, loss of the pneumovagina. At the end of procedure, the vagina is not closed to permit optimal drainage with a multitubular drain in the dissection space. The surgery lasted 60 minutes. The mesh excision was completed with relative ease, and there was no blood loss. Bacteriologic examination revealed the presence of Streptococcus anginosus, Klebsiella pneumoniae, and Bacteroides fragili. The operating suites were simple with great cicatrization after 6 weeks. The principal difficulties of this surgery were obtaining a good seal by the creation of cutaneous sutures. Finally, there are less conflicts between the instruments inside the single-port trocar used in transvaginally because of a more limited dissection space. Indeed, the rate of mesh erosion reached 2.4% and, in case of infection, justifies this excision.Conclusion: The transvaginal use of a single-port trocar represents a good alternative, allowing easy resection of the sacrocolpopexy mesh while remaining in the retroperitoneal space. [ABSTRACT FROM AUTHOR]

Study Objective: To illustrate a laparoscopic technique for the resection of cesarean scar ectopic pregnancy, associated with isthmocele repair.Design: Case report (Canadian Task Force classification III).Setting: A tertiary referral center in Strasbourg, France.Background: Cesarean scar pregnancy is a rare form of ectopic pregnancy. The major risk of this type of pregnancy is the early uterine rupture with massive, sometimes life-threatening, bleeding. Thus, active management of these pregnancies starting immediately after diagnosis is crucial. Therapeutic options can be medical, surgical, or a combination. Numerous case reports or case series can be found in the literature, but there are few clinical studies, which are difficult to conduct because of case rarity and inconclusiveness. A 2016 meta-analysis that included 194 articles published between 1978 and 2014 (126 case reports, 45 cases series, and 23 clinical studies) concluded that hysteroscopy or laparoscopic hysterotomy seems to be the best first-line approach to treating cesarean scar ectopic pregnancy, with uterine artery embolization reserved for significant bleeding and/or a high suspicion index for arteriovenous malformation [1]. There is no consensus on the treatment of reference, however.Patient: The case involves a 38-year-old primiparous women who underwent a cesarean section delivery in 2010 and who was diagnosed by ultrasound scan at 7 weeks gestation with cesarean scar ectopic pregnancy, which was confirmed by pelvic magnetic resonance imaging. The patient initially received medical treatment with 2 intramuscular injections of methotrexate and one local intragestational injection of KCl. Her initial human chorionic gonadotropin (hCG) level was 82 000 IU/L. Rigorous weekly biological and ultrasound monitoring revealed an involution of the ectopic pregnancy associated with decreasing hCG. No bleeding or infectious complications occurred during this period. After 10 weeks of monitoring, her hCG had stabilized at 300 IU/L, and a residual image persisted next to the cesarean scar, and thus surgical treatment was considered.Intervention: This video illustrates the laparoscopic resection of a cesarean scar ectopic pregnancy associated with isthmocele repair. The originality of this video lies in the fact that it is the first demonstration of the laparoscopic treatment of total caesarean scar dehiscence.Measurements and Main Results: The total operative time was 180 minutes. First, hysteroscopic evaluation revealed the cesarean scar dehiscence and the posterior pole of the ectopic pregnancy. Then the diagnosis of cesarean scar ectopic pregnancy was confirmed laparoscopically. The utero-ombilical truncs were clamped bilaterally. Complete enucleation of pregnancy was achieved after dissection of the vesicouterine peritoneum. Isthmocele repair was performed with closure in 2 planes. A blue dye test confirmed the tightness of the stitches. The utero-ombilical truncs were unclamped, and antiadhesion gel was applied to the new uterine scar [1]. The operation was performed successfully without complications. Intraoperative blood loss was <100 mL. The patient was discharged on postoperative day 3. No immediate complications were noticed. At 1 month after the intervention, ultrasound was normal.Conclusion: Surgical management of caesarean scar ectopic pregnancy with total dehiscence of hysterotomy can be performed safely and efficiently under laparoscopy. [ABSTRACT FROM AUTHOR]

Study Objective: To illustrate laparoscopic sacral colpopexy for pelvic organ prolapse, a new method using a simplified mesh fixation technique, with only 6 fixing points.Design: Step-by-step explanation of the surgery using video (educative video). The video was approved by the local institutional review board.Setting: University Hospital of Strasbourg, France (Canadian Task Force Classification III).Patients: Women with multicompartment prolapse.Intervention: We first dissected the promontorium and vertically incise the posterior parietal peritoneum on the right pelvic sidewall up the pouch of Douglas. We then dissect the rectovaginal septum up to the anal cap, laterally exposing the puborectalis muscle on each side. Middle rectal vessels can be coagulated and cut without increasing the risk of digestive disorders (especially constipation), but it is preferable to conserve them if the space is sufficient for suture. Then, we dissect the vesicovaginal space and realized the subtotal hysterectomy. Finally, we realized the fastening of the anterior and posterior meshes. The particularity is that we performed only 6 points for fixing the meshes: 1 on the puborectalis muscle on each side without tension (to reduce the risk of mesh contracture, dyspareunia, and chronic pelvic pain), 1 for the fixing of the anterior mesh on the anterior vaginal wall at the level of the bladder neck, and 1 on each side of the cervix for the reconstitution of the pericervical ring gathering together the anterior mesh, the pubocervical fascia, and the insertion of the uterosacral ligament at the level of the cervix and the posterior mesh. The sixth stitch fastened 1 of 2 meshes to the anterior paravertebral ligament at the level of the sacral promontory. We finished with the peritonization.Main Results: The duration of surgery lasts approximately 120 minutes in well-experienced hands. Based on our experience the 6-point technique was relatively simple (few laparoscopic stiches) with few operative difficulties and was also associated with a low rate of reintervention.Conclusion: Surgical management of middle compartment prolapse could be performed quickly and efficiently under laparoscopy with the "6-points" technique. [ABSTRACT FROM AUTHOR]

Study Objective: To describe 2 different surgical techniques for Essure removal on the same patient: the hysteroscopic and laparoscopic techniques.Design: An educational video approved by the local institutional review board (Canadian Task Force classification III).Setting: A university hospital (University Hospital of Strasbourg, Strasbourg, France).Patient: A 46-year-old woman with many symptoms after Essure device implantation. An ultrasound found a right implant in the uterine cavity and a left intratubal implant.Interventions: The first step was the hysteroscopic removal of the right implant. We viewed the 2 internal and external spirals, allowing the gripping of the whole device without risking any fragmentation or tubal lesion. The second step was bilateral salpingectomy with resection of the left interstitial tubal portion. We longitudinally incised the antimesial edge of the fallopian tube 2 to 3 cm from the tubal serous to the implant contact. A circumferential incision was performed at the uterine horn to circumscribe the interstitial tubal portion. The implant was released from the surrounding tissue. It was gently pulled to completely extract it and avoid spiral fragmentation. Then, we performed a bilateral total salpingectomy. An X-ray of the implants and pelvis was performed to ensure complete removal of the device. We made an X-stitch in the uterine horn to avoid the risk of fistula.Conclusion: More and more patients are asking for the removal of their implants. The surgical technique has to be adapted to the location of the implants and has to allow their complete removal to avoid leaving fragments that can cause the persistence of side effects. [ABSTRACT FROM AUTHOR]

Study Objective: Radical trachelectomy has emerged as a valuable fertility-preserving treatment option for young women with early-stage cervical cancer [1]. Laparoscopic radical trachelectomy performed by trained surgeons can be a feasible and safe therapeutic option as a fertility-sparing surgical technique [2,3]. To the best of our knowledge, this is the first time the total laparoscopic approach of radical trachelectomy is being published. In this video, rather than the description of the technique step by step, we show how to conserve uterine arteries even if the importance of such conservation is questionable.Design: A case report.Setting: A tertiary referral center in Strasbourg, France.Patient: A 37-year-old patient with no medical history who presented with stage IB1 invasive epidermoid cervical cancer.Intervention: In this video, we describe the fertility-sparing surgical procedure consisting of type B total laparoscopic radical trachelectomy with uterine artery preservation. The procedure consists of the following 10 steps: step 1, bilateral pelvic lymphadenectomy and opening of the para vesical fossa; step 2, opening of the pararectal fossa in between the ureter and the internal iliac artery on each side; step 3, ureteric dissection up to the ureteric canal; step 4, opening of the vesicouterine space and section of the vesicouterine ligament; step 5, posterior dissection with division of the uterosacral ligament approximately 20 mm from the uterine insertion; step 6, section of the descending branch of the uterine artery and skeletonization of the ascending branch up to the uterine isthmus level; step 7, trachelectomy with a monopolar hook; step 8, laparoscopic isthmovaginal stitches; step 9, laparoscopic cerclage; and step 10, peritoneal closure.Measurements and Main Results: The operative time was 420 minutes. The intraoperative blood loss was <200 mL. The operation was performed successfully with no intraoperative complications. The resection margins were safe. The patient was discharged on day 4. After 2 months, no late complications or recurrence were detected, and the patient had normal menstruation.Conclusion: Type B laparoscopic radical trachelectomy with uterine artery preservation appears to be a safe option for women who intend to maintain their desire for a future pregnancy. [ABSTRACT FROM AUTHOR]

Background: Clinical assessment of fetal head station is difficult and subjective; it is mandatory before attempting operative vaginal delivery.Objective: The principal objective of our study was to assess whether measurement of the perineum-to-skull ultrasound distance was predictive of a difficult operative vaginal delivery. Secondary objectives included evaluation of the interobserver reproducibility of perineum-to-skull ultrasound distance and comparison of this measurement and digital examination in predicting a difficult operative delivery.Study Design: This was a prospective cohort study including all cases of operative vaginal deliveries in singleton pregnancies in cephalic presentation >34 weeks' gestation, from 2012 through 2015. All data were entered prospectively in a medical record system specially devised to meet the requirements of this study.Results: Of the 659 patients in whom perineum-to-skull ultrasound distance was measured prior to operative vaginal delivery, 120 (18%) met the composite criterion for a difficult extraction. Perineum-to-skull ultrasound distance measurement of ≥40 mm was significantly associated with the occurrence of a difficult extraction based on the composite criterion, after adjustment for parity, presentation type, and fetal macrosomia (odds ratio, 2.38; 95% confidence interval, 1.51-3.74; P = .0002). The intraclass correlation coefficient between the perineum-to-skull ultrasound distance measured by the first operator and that measured by the second operator was 0.96 (95% confidence interval, 0.95-0.97; P < .0001). Based on the receiver operating characteristic curve analyses, perineum-to-skull ultrasound distance was a more accurate predictor of difficult operative delivery than digital vaginal examination (P = .036).Conclusion: Measurement of the perineum-fetal skull ultrasound distance is a reproducible and predictive index of the difficulty of instrumental extraction. Ultrasound is a useful supplementary tool to the usual clinical findings. [ABSTRACT FROM AUTHOR]