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Diaphragm metastases in ovarian cancer can be safely resected robotically in selected patients. The technique is similar to laparotomy, whether it is a peritoneal or full-thickness excision. Trocar placement is very important for successful resection and is dependent on the location of the disease. Metastases involving the left diaphragm and the ventral aspect of the right diaphragm are accessed with trocars placed slightly cranial to the umbilicus. Metastases in the dorsal aspect of the right diaphragm are removed with trocars in the upper quadrants. Metastases located in the lateral portion of the right diaphragm are excised using an infrahepatic approach, and those in the medial aspect are removed using a suprahepatic approach. In peritoneal resection, monopolar instruments must be kept at 10 W to 15 W to prevent contraction of the diaphragm and pleural perforation. Intraoperative pleural decompression is performed via an aspirating catheter. A video of the technique described in this report is available online (Supplementary Video 1).

Study Objective To identify the clinical presentation, diagnostic evaluation, operative or medical management, and postoperative recurrence of umbilical endometriosis. Design A retrospective national survey. Setting Obstetrics and Gynecology and Plastic Surgery Departments at a teaching hospital in Japan. Patients Patients with umbilical endometriosis or malignant transformation. Interventions A national survey was conducted to identify and evaluate cases of umbilical endometriosis or malignant transformation documented between 2006 and 2016. Measurements and Main Results The following were evaluated for each patient: age at diagnosis, body mass index, medical history, presence of extragenital endometriosis, surgical history, symptoms, imaging modalities, surgical therapy, hormonal therapy, follow-up period, postoperative recurrence, and time to recurrence. Ninety-six patients were identified with pathologically diagnosed benign umbilical endometriosis. The patients frequently had swelling (86.5%), pain (81.3%), or bleeding (44.8%) in the umbilicus. Sensitivity was 87.1% for physical examination, 76.5% for transabdominal ultrasonography, 75.6% for computed tomography, and 81.8% for magnetic resonance imaging. The cumulative recurrence rate was 1.34% at 6 months, 6.35% at 12 months, and 6.35% at 60 months after surgery. Importantly, there was no recurrence after wide resection including of the peritoneum (0 of 37 cases). The efficacy of dienogest (an oral progestin), gonadotropin-releasing hormone agonists, and oral contraceptives was 91.7%, 81.8%, and 57.1%, respectively. Finally, 2 cases of malignant transformation were identified. Conclusion There was a low recurrence rate following surgery, and hormonal treatment is an option, although the current findings suggest surgical therapy as the first choice of treatment for umbilical endometriosis.

Study Objective To define vaginal cuff dehiscence, identify risk factors for dehiscence, understand steps needed for laparoscopic cuff revision, and review techniques for cuff closure. Design Vaginal cuff dehiscence, defined as a full thickness separation of the vaginal cuff, is a rare but morbid complication after hysterectomy. After a total laparoscopic hysterectomy, the incidence of vaginal cuff dehiscence is 0.7% (range 0.64 – 1.27%). Risk factors include poor vaginal cuff closure technique, smoking, low body mass index, conditions that cause poor wound healing such as infection, hematoma, prior radiation, or immunosuppression, and increased pressure on the vaginal incision line such as trauma, pelvic organ prolapse, or excessive valsalva. In this video we will demonstrate a laparoscopic repair of a vaginal cuff dehiscence. Setting Patients should be positioned in lithotomy position in the operating room. Standard GYN laparoscopic setup should be used. The authors prefer placing the camera via a 5mm trocar in the umbilicus, with 2 accessory 5mm ports laterally and a 5mm suprapubic port. Patients or Participants N/A. Interventions In this video we describe the 5 steps of a laparoscopic repair of a vaginal cuff dehiscence. We also discuss tips and tricks to optimize cuff closure. • Identify and normalize anatomy • Identify the vaginal cuff defect • Mobilize the cuff • Excise cuff edges • Close the cuff Measurements and Main Results N/A. Conclusion Although vaginal cuff dehiscence is rare, knowledge of safe and effective laparoscopic repair technique is crucial for the gynecologic surgeon, both for repair and for prevention of future cuff dehiscence.

Objective To show 3 different techniques for achieving an endobag morcellation without adding extra-time and cost to the surgery. Design Stepwise demonstration of the 3 techniques with narrated video footage. Setting Morcellation is a useful procedure for fragmenting and extracting specimens during laparoscopic surgery without the need to perform a laparotomy. In this sense, patients that otherwise would not be eligible for minimally invasive surgery (i.e. large uterus or fibroids) could benefit from laparoscopic advantages. However, morcellation has a major limitation: the risk of dissemination of unsuspected malignancies. In 2017 the Food and Drugs Administration (FDA), released an updated assessment of the use of laparoscopic power morcellators for treatment of leiomyomas. A total of 23 studies were included in the analysis, and 20 studies (90,910 women) contributed to the estimated prevalence of leiomyosarcoma at the time of surgery for presumed leiomyomas. Depending on the modeling methodology used the estimated prevalence of uterine sarcoma was 1 in 305 to 1 in 360 women, and for leiomyosarcoma the estimated prevalence was 1 in 570 to 1 in 750 women. [1] Currently available evidence suggests that if an undiagnosed uterine malignancy is intraabdominally morcellated, there is risk of intraperitoneal dissemination of the disease. [2] Therefore, European Society of Gynecological Oncology (ESGO) emitted a statement in 2016 recommending avoiding morcellation if there is any suspicion of sarcoma and using endobag containers for morcellation of surgical removed uterine fibroids [3]. Additionally, in the United States, the FDA recommends performing laparoscopic power morcellation for myomectomy or hysterectomy only with a tissue containment system, legally marketed in the U.S. [4] INTERVENTIONS: There are several techniques described in the literature for contained uterine fibroids morcellation [5]. In this video, we present 3 of them: First, indirect view morcellation is described. In this technique we place the fibroid in the bag and exteriorize it through one of the trocars. Once outside the abdomen we will place the morcellator through the bag opening and do the morcellation inside the bag while checking through the umbilicus camera. Special attention must be paid in order to avoid any damage to the bag, as the visualization is limited in this technique. Second, direct view technique is described, where we exteriorize the opening of a 15mm bag through the suprapubic trocar and a closed end of the bag through the umbilicus. A hole must be made in the umbilicus end of the bag and we should introduce the camera trocar through it. Once done, we introduce the morcellator trough the opening and the camera in the umbilicus port. Third, single-port contained morcellation is explained. The bag is exteriorized through the umbilicus, and a skin retractor is placed. A glove is placed outside the retractor to isolate the bag. Once placed, two of the fingers are opened and used as trocars (one for the morcellator a the other for a 30-degree camera). After using this technique, the scope should be replaced in order to minimize the risk of contamination. The limitations of each technique could be the next: in the indirect view technique, due to the limited visualization, the surgeon must pay special attention to avoid bag tearing while morcellating the specimen. In the single port technique, the surgeon must have previous experience in this type of approach, minimizing the risk of contamination by changing the scope after the morcellation process. Finally, in the third method, the surgeon needs to ensure the proper closure of the bag before removing it from the abdomen to avoid possible dissemination risk. Conclusion Laparoscopic power morcellation may provide several benefits for our patients, when performing a hysterectomy or a multiple myomectomy. We present 3 different and feasible techniques for laparoscopic power morcellation using an endobag container.

Study Objective To review preoperative evaluation of a patient presenting with an abdominopelvic mass. To discuss methods of drainage and spill prevention during surgical management of large abdominopelvic masses and to demonstrate an efficient laparoscopic method for extraction of large adnexal masses. Design N/A Setting In the operating room with patient in dorsal lithotomy position with both arms tucked. Five-millimeter ports were placed in the umbilicus, the right lower quadrant and the left mid-abdomen. The specimen was extracted through an 8 mm port in the left lower quadrant. Patients or Participants 27-year-old female with a 15 × 13 cm abdominopelvic mass who presented with right lower quadrant and low back pain and mild right hydronephrosis. She had a benign appearing cyst on ultrasound and her tumor markers were negative. Interventions We employ a morcellation method we refer to as apple-peeling to cut the cyst into a long strip of 1 inch width to allow easy removal through an 8 mm laparoscopic port without spill or struggle. Measurements and Main Results N/A Conclusion Large abdominopelvic masses can be managed via laparoscopic approach with proper pre-operative work-up to ensure benign status. The apple-peeling morcellation technique demonstrated in this video allows efficient extraction of abominopelvic masses > 10 cm through small laparoscopic ports (8mm)

Study Objective Our objective is to review the anatomic course, sensory and motor functions, and approach to dissection of important pelvic nerves encountered during advanced gynecologic laparoscopy. Design Using annotated intraoperative footage, we illustrate surgical approaches to safe dissection of the following pelvic nerves: Ilioinguinal, iliohypogastric, lateral femoral cutaneous, femoral, genitofemoral, obturator, sciatic, hypogastric and pudendal nerves, lumbosacral trunk and sacral nerve roots. Setting Patients were placed in dorsal lithotomy position with legs in Yellowfin stirrups. The umbilicus was used for camera port placement, and three accessory ports were placed (in the bilateral lower quadrants and a second to the left of the umbilicus). Patients or Participants Patients requiring dissection of the aforementioned nerves for surgical treatment of deep infiltrating endometriosis, adhesiolysis, or treatment of pudendal neuralgia were selected. Interventions N/A. Measurements and Main Results N/A. Conclusion Surgeons must have a comprehensive understanding of pelvic anatomy and comfort operating in deep pelvic spaces in order to minimize risk of inadvertent nerve injury. A systematic approach to nerve dissection enables adequate exposure of the operative field and safe space for lysis of adhesions, excision of endometriosis, and surgical treatment of pelvic pain syndromes.

Study Objective The incidence of ureteral injury with laparoscopic hysterectomy reported in the literature is 0.78%. The objective of this study was to evaluate the rates of ureteral injury at the time of laparoscopic hysterectomy among high-volume fellowship-trained surgeons. Design We performed a retrospective chart review, evaluating gynecologic surgery cases between January 2009 and May 2019 performed exclusively by fellowship-trained surgeons in the Minimally Invasive Gynecologic Surgery (MIGS) Department at Harvard Medical School teaching hospitals in Boston. The rate of ureteral injury was assessed. Setting Patients were positioned in dorsal lithotomy with legs in Allen stirrups. A central (typically umbilical) camera port was placed along with bilateral lower quadrant ports and a third ipsilateral port to the left of the umbilicus. Patients or Participants A total of 5,160 cases were performed by MIGS surgeons between 2009-2019 at Brigham & Women's Hospital and Brigham & Women's Faulkner Hospital. Patients undergoing laparoscopic hysterectomy were selected for this review. Interventions N/A. Measurements and Main Results Out of the 5,160 MIGS cases, 2,396 laparoscopic hysterectomies were performed. Only 1 ureteral injury was noted intraoperatively (0.04%). No additional delayed ureteral injuries were observed. Conclusion Ureteral injury is associated with significant patient morbidity and high economic burden. Despite taking on medically and surgically complex cases at our tertiary referral center, we observed very low rates of ureteral injury at the time of laparoscopic hysterectomy. Putting this into context given that approximately 600,000 hysterectomies are performed annually in the US; the literature-reported ureteral injury rate would result in approximately 4,680 injuries versus an estimated 240 injuries in a high-volume center. This study highlights the benefits of fellowship-training and high-volume practice on patient outcomes.

Study Objective To compare the perioperative outcomes of the robotic single-port myomectomy (RSPM) using the new da Vinci SP® surgical system with those of the robotic multi-site myomectomy (RM) using the da Vinci Xi® surgical system. Design Multicenter retrospective case-controlled study. Setting A university tertiary care hospital. Patients or Participants A total of 101 patients were enrolled. 67 patients underwent RSPM and 34 patients underwent RM at November 2018 to May 2020 were included. Interventions All patients underwent robotic myomectomy who diagnosed uterine myoma with target size that the instrument could operate by entering the umbilicus. The choice of surgical modality was not influenced by the patient's history of previous abdominal surgery, body mass index, uterus size, location or type of myoma, or myoma size. Measurements and Main Results RSPM vs. RM patients demographics had no difference significantly in mean age, BMI, maximal diameter of myoma and total number of myomas. In terms of surgical outcomes, RSPM and RM has comparable in EBL (50 mL vs. 150 mL, p Conclusion Robotic single-port myomectomy using new da Vinci SP® surgical system is feasible surgical modality as like as multi-site myomectomy. Further studies are needed to confirm these preliminary results and to determine the proper indications for the surgery.

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, Parana, 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).

Study Objective To educate surgeons on the advantages of robotic techniques in hysteroscopic-assisted single-site resection of cesarean scar defect. Design A step-by-step video presentation detailing the complete surgical procedure. Setting University Hospital, Baylor College of Medicine, Houston, Texas. Patients The first patient was a 34-year-old G2P2002 who complained of dysmenorrhea and menorrhagia, with an expressed desire for a single-site cesarean scar defect correction. Her surgical history included 2 cesarean deliveries, in 2012 and 2014. The second patient was a 34-year-old G4P3013 who complained of dysmenorrhea and a persistent mucus vaginal discharge, with an expressed desire for a cesarean scar defect correction in anticipation of conception. Her surgical history was notable for 3 previous cesarean deliveries. Neither patient's ultrasound report showed adenomyosis or any other pathologies. Interventions In both patients, hysteroscopic-assisted robotic single-site resection of the cesarean scar defect was performed, using a monopolar hook, wristed needle drivers, cold scissors, and a diagnostic vs operative hysteroscope. Entry was made through the umbilicus with a 15-mm incision and carried down through the subcutaneous tissue until the fascia was grasped and entered using Mayo scissors. The abdomen was inspected. The bladder was carefully disected off of the lower uterine segment and then backfilled to aid identification of the correct plane for dissection. Once the bladder was adequatetly dissected off of the uterus, the suspected defect could be identified. The monopolar hook was used to incise the defect, and the tip of the hysteroscope was placed through the defect to fully delineate it. The edges were trimed with cold scissors (Endoshears) in the first surgery and the monopolar hook in the second surgery. The uterine defect was closed with 2 layers of countinuous running V-Loc suture. The peritonium was closed with an additional V-Loc suture in a running fashion. Finally, hysteroscopy was performed. The closure was noted to be watertight, verifying successful repair of the defect. In the second case, an intercede was placed over the defect to help prevent future adhesive disease. In addition, after consulting with experts in cesarean scar repair, an energy device was recommended, and thus the monopolar hook over cold scissors was used for the second case due to its superior cutting effect. In both cases, the pelvis was inspected, and hemostasis was observed throughout. Measurements and Main Results The 2 cases had similar outcomes, with successful repair of the cesarean scar defect and resolution of the patient's symptoms. The thickness of the residual myometrium in cesarean scar defect was 2.8 mm in the first case and 2.3 mm in the second case. This video is exempt from Institutional Review Board review. In the first case, the surgery was completed in 90 minutes with only 15 mL of blood loss. The patient was discharged home on the day of surgery and denied any postoperative complications at her follow-up appointment. In the second case, the surgery was completed in 85 minutes with only 10 mL of blood loss. The patient was discharged home on the day of surgery. At her follow-up appointment, she had a positive pregnacy test and denied any postoperative complications. When contacted at a later date, she revealed that she was 15 weeks pregant. Conclusion Hysteroscopic-assisted single site resection of a cesarean scar defect is a feasible method for the resection of cesarean scar defect. Use of the robot makes the difficult surgical techniques required for this operation easier and more accessible.

To determine whether the location of the superior and inferior epigastric vessels (deep epigastric vessels) change with abdominal insufflation.Descriptive study (Canadian Task Force classification III).Tertiary care academic institution.Patients undergoing gynecologic laparoscopic surgery were recruited. A total of 35 subjects were enrolled.Subjects underwent color Doppler ultrasound assessment of deep epigastric vessel location preoperatively and intraoperatively following abdominal insufflation. The deep epigastric vessels were identified at 5 points along the abdomen (pubic symphysis, anterior superior iliac spine [ASIS], umbilicus, xiphoid, and midpoint from umbilicus to xiphoid), with the distance from vessels to midline measured. Paired t tests and split-plot analysis of variance were used as appropriate.The mean patient age was 45.6 ± 16.5 years, and mean BMI was 29.8 ± 7.2. A significant difference between vessel location in the resting abdomen and insufflated abdomen was noted bilaterally at the ASIS, umbilicus, and midpoint from the umbilicus to the xiphoid. At each of these points, the deep epigastric vessels were found more laterally after insufflation on average, ranging from 0.6 ± 0.9 cm (p .001) more laterally at the midpoint between the umbilicus and xiphoid to 1.1 ± 0.8 cm (p .001) more laterally at the umbilicus. The most lateral location of the deep vessels after insufflation was seen at the ASIS (10.6 cm) and the umbilicus (10.9 cm). In a subanalysis of subjects grouped by body mass index (obese vs nonobese), deep epigastric vessels were more lateral in the insufflated abdomen of obese subjects compared with that of nonobese subjects at the ASIS, umbilicus, and midpoint from umbilicus to xiphoid (p .05 for each point bilaterally).The deep epigastric vessels shift laterally with abdominal insufflation, and may be found as far as 10.9 cm from the midline; this is more lateral than previously described and is clinically significant. Obesity is associated with a more lateral location of the deep epigastric vessels.

Study Objective To study the feasibility of a non umbilical first blind entry port in patients with BMI less than 18.5. Design Retrospective study assessing the laparoscopic entry in patients operated during the study period from January 2011 to December 2019. Setting Patients were operated under general anesthesia. Patients or Participants Selection criteria was patients of BMI less than 18. Out of the total 7398 patients in which laparoscopic entry was done by the left lateral port,398 patients met the selection criteria.70 thin patients had history of previous surgeries. Interventions In the study group veress needle and first primary port was introduced through a left lateral paraumbilical port about 10 cm lateral to the umbilicus. This point is located on a straight line drawn 2.5cm medial to the ASIS at the level of umbilicus. During veress needle and primary 5mm trocar entry the abdominal wall is not lifted up and veress needle insertion is done in one straight vertical line without changing the direction to 45 degree. Under vision of first 5mm telescope the 10mm port and then accessory ports are inserted. This port placement is aimed at avoiding the major vessel injury. 5 mm port also optimizes the 10mm telescope port entry as is needed in cases with large masses and cases with previous surgery. This port then continues as main ergonomic ipsilateral working port. Measurements and Main Results All 398 cases were entered safely without any major complication or conversion to laparotomy. First blind entry was well delineated due to good muscle tone in thin patients. No long term sequelae noted. Conclusion Left lateral paraumbilical port is a safe alternate first blind non - umbilical port in thin patients with advantage of avoiding major vascular injury and avoiding adhesions in previous surgery cases.

Study Objective My objective in making this video is to share how we approach laparoscopic myomectomy in a patient with large uterine leiomyoma. Design Video presentation. Setting Hospital, operating room. Patients or Participants Laparoscopic myomectomy case was presented. Interventions Myomectomy. Measurements and Main Results N/A Conclusion I present a case of laparoscopic myomectomy, demonstrating myomectomy and suturing techniques, as well as leiomyoma morcellation through the umbilicus.

Study Objective To show that Laparoscopic approach is beneficial for surgical repair of uterine inversion cases. Design A case report. Setting Pandit Hospital and Laparoscopy centre, Ahmednagar, India. Patients or Participants A 26 year female presented with subacute uterine inversion in January 2020. Interventions Laparoscopic Haultain's repair for subacute uterine inversion. Measurements and Main Results Although in modern era, endoscopy has replaced abdominal or vaginal surgeries, there is hardly any case report of laparoscopic management of uterine inversion. Here, we report a case of successful management of subacute uterine inversion by Laparoscopic approach by Haultain's technique, which is done for the first time as per our knowledge and no such case of laparoscopic repair is been mentioned in the literature. A 26 year old P2L2, presented on seventh day postpartum with complaints of continuos bleeding per vaginum and fever. Patient was febrile with temperature of 99 F with tachycardia. On per abdominal examination, uterus was much below the umbilicus and indentation was felt at the level of fundus. On per speculum examination, endometrium was seen protruding outside, so inversion of uterus was suspected which was confirmed on ultrasonography of pelvis. Before going for the Laparoscopy, manual reposition of uterus was tried under general anaesthesia but was not successful. During Laparoscopic Haultan's repair, posterior wall of uterus was incised at the rim. By continuous upward traction on bilateral round ligament, inversion was corrected. Uterine incision was closed in double layer. Patient was asymptomatic on discharge and on fallow up examination after seven days and one month. Conclusion Uterine inversion cases can be managed laparoscopically without any harmful effects and with added benefits of laproscopic route as for any other procedure.

Study Objective To review surgical principles that can be used to approach the obliterated anterior cul-de-sac. Additionally, to demonstrate application of these principles during total laparoscopic hysterectomy Design N/A Setting This procedure took place in a hospital-based operating room. Four laparoscopic ports were utilized, including a camera at the umbilicus, right and left lower quadrant ports and a suprapubic port. Patients or Participants The patient is a 46 year old female with complex chronic pelvic pain. Her surgical history included a prior Cesarean delivery. Ultrasound showed small 8 wk uterus with likely adenomyosis Interventions This video demonstrates a laparoscopic management of an obliterated anterior cul-de-sac as performed during total laparoscopic hysterectomy and bilateral salpingectomy. Measurements and Main Results N/A Conclusion Prior cesarean delivery can complicate laparoscopic hysterectomy. However, reliance on sound surgical principles can help ensure success. These include: Isolation and control of blood supply prior to adhesiolysis; Understanding and identifying safe spaces where anatomy is not altered by adhesive disease; Maintaining forward progress; Restoring anatomy

Colorectal involvement represents 90% of bowel endometriosis. The best surgical approach must consider the patient's clinical symptoms, preoperative imaging, and correlation with surgical findings. For patients with severe pain who either have failed medical treatment or contraindications to hormonal treatment and have a single bowel lesion3 cm that involves the inner muscularis, disc resection is the preferred approach to treat bowel endometriosis [1,2]. Therefore, here we describe the surgical principles for disc resection for deep bowel endometriosis.Step-by-step video illustration of our surgical technique with clarification of surgical principles.Tertiary care center.A mechanical bowel preparation is given before surgery. A 10-mm port is placed in the umbilicus, and 3 other 5-mm auxiliary ports are placed in the right and left iliac fossa and in the suprapubic region. Dissection starts with development of both medial pararectal spaces. The retrocervical region is approached, and the bowel lesion is isolated. A suture is placed into the endometriosis bowel lesion to facilitate invagination into the stapler. A circular stapler is inserted into the rectum, and the anvil is opened at the level of the endometriosis lesion. Each end of the suture held by 2 graspers are pushed dorsally, whereas the stapling device is gently pushed ventrally, imbricating the delineated area. The stapler is closed, including the endometriosis area. After reassuring that the posterior part of the mesentery is free, the device is fired, excising only the anterior wall of the rectum.Disc resection is the technique of choice to treat a focal bowel endometriosis lesion3 cm.

Video Objective To demonstrate the surgical steps of the laparoscopic appendectomy for a deep endometriosis nodule using endoloops. Setting Endometriosis affect between 6%-10% of patients in reproductive age. Furthermore, gastrointestinal tract is involved between 3% to 34% of the cases, and specifically the appendix is invaded in about 2.8% to 5%. Appendiceal endometriosis encompass a wide range of manifestations including acute and chronic appendicitis, cyclic lower quadrant pain, melena, rectorrhagia, cecal intusception and intestinal perforation.Laparoscopic appendectomy is widely performed in nowadays and include several techniques as stapler, endoloops and hand-made loops. Specific steps of the procedure must be know and understand. Here we present a laparoscopic appendectomy using 2 base endoloops in a 38 years old patient with clinical history of dysmenorhheia, dayspareunia and cyclic rectorhhagia. Pelvic Ultrasound and MRI were negative for appendiceal endometriosis. Interventions A completely laparoscopic approach to the pelvic and bowel endometriosis was performed. Under general anesthesia, the patient was placed in 0 degrees dorsal decubitus with her arms alongside her body. Operative set-up include 15 mmhg pneumoperitoneum created using the closed-Veress technique and four trocars: a 10-mm trocar at the umbilicus for a zero-degree laparoscope; a 5-mm trocar in the right-iliac fossa; a 5-mm trocar in left-iliac fossa; and a 12-mm trocar in the suprapubic area. Using blunt and sharp dissection with cold scissors, bipolar grasper and ultrasonic energy, complete resection of pelvic deep endometriosis was done followed by appendectomy using 2 endo-loops (Vicryl 2-0) at their base. Specimen extraction was done using an endobag and fascial defect was closed by delayed-absorbable 1-0 . Patient was discharge in the second day postoperative without any complications. Conclusion Appendectomy is a part of the global treatment of endometriosis and must be removed when involved.Laparoscopic resection using endoloops is feasible, safe and effective.

Study Objective The study objective is to assess the safety and effectiveness of LESS for management of non-obstetric, gynecological disease processes in pregnant patients. Design A case series of 11 pregnant women [23-42 years] who underwent LESS for various gynecological pathology is presented. If permitted, patients were followed until delivery of the fetus. Setting Surgeries were performed in two institutions between 2015 and 2018. Patients or Participants Patients were selected if laparoscopic intervention was indicated. Interventions The cases include four ovarian cystectomy, three salpingo-oophorectomy, one myomectomy, one salpingectomy, one cerclage, and one paratubal cyst. LESS was performed at the umbilicus. For cases involving simple cysts at the umbilicus, cysts were drained and removed from the single site, and laparotomy was performed without extending the incision. Measurements and Main Results Data including surgical/obstetric history, gestational age at surgery, ultrasound results were collected; and operative duration, intraoperative bleeding, postoperative symptoms, fetal monitoring, pathologic findings, conversion and pregnancy outcomes were measured. Three cases were performed in the first trimester and seven in the second trimester with surgeries lasting between 109 to 298 minutes. Estimated blood loss ranged from 5 to 300 mL, and postoperative symptoms of pelvic or abdominal pain were reported. There was one surgery requiring additional ports but no open surgery conversions or complications. Fetal heart rates were between 136 and 175 bpm. Six patients agreed to follow-up and had successful deliveries. Conclusion LESS can be safely performed by experienced surgeons on pregnant patients requiring a variety of gynecological surgery. Most notably, an open surgical technique can be used through the single-site incision in suitable situations. However, further case studies at multiple centers with large sample sizes are needed for further utilization of this technique.

Study Objective Extra-genital endometriosis is rare, with umbilical endometriosis accounting for 0.4-4% of cases. Primary umbilical endometriosis (PUE) is even more uncommon and is not associated with prior surgery. The pathogenesis of this disease is unknown but may be secondary to hematogenous/lymphatic spread or coelomic metaplasia. Here we describe the presentation, diagnosis, and management of a case of PUE presenting along with a 19cm multi-fibroid uterus. Design Case report/literature review. Setting Academic affiliated gynecology practice. Patients or Participants 41yo G0 presented with a 2 year history of increasing pain at her umbilicus associated with odor. Symptoms progressed to cyclic bleeding during menses and gradual disfiguration of umbilicus. Biopsy revealed normal benign tissue. Patient also complained of heavy menstrual bleeding. She had no previous surgical history and medical history was significant for endometrial hyperplasia treated with progesterone. Exam revealed a brown firm, tender, multinodular mass measuring 2cm associated with the umbilicus. MRI showed a T1 hypointense contrast-enhancing 2.4 × 2.1cm mass of the umbilicus extending into the subcutaneous tissue as well as a 19 × 13 × 19cm multi-fibroid uterus. Interventions The umbilicus and margin of subcutaneous tissue were excised by general surgery. Laparoscopic survey did not identify pelvic endometriosis. Robotic assisted hysterectomy was performed with tissue extraction through the umbilical defect. Fascia was repaired with 0 PDS and incision was closed to create a cosmetic umbilical appearance. Measurements and Main Results Umbilical endometriosis was confirmed on pathology. The uterine tissue weighed 1444 grams with benign leiomyoma and secretory endometrium. There was no pelvic endometriosis. There were no perioperative complications. Post-operatively she had relief of umbilical pain and bleeding. Conclusion PUE is a rare condition that should be considered in premenopausal women presenting with painful masses of the umbilicus especially if associated with bleeding at time of menses. Primary umbilical endometriosis can be successfully treated with surgical excision with favorable cosmetic outcome and relief of symptoms.

Study Objective Abdominal wall anatomy can be altered after transverse rectus abdominis myocutaneous flap (TRAM) procedure in patient with breast cancer and the umbilicus may be distorted. For this reasons, laparoscopic gynecologic surgery is difficult procedure including proper port placement, the knowledge of the residual blood supply to the abdominal wall and umbilicus. We present our experience performing single port access total laparoscopic hysterectomy and bilateral salpingo-oophorectomy (SPA-TLH BSO) on a woman after TRAM surgery. Design N/A Setting N/A Patients or Participants N/A Interventions 53 years old woman who were diagnosed with breast cancer got left modified radical mastectomy followed by the breast mound reconstruction with contralateral pedicled TRAM flap three years ago. she took two cycles of chemotherapy after surgery. Since then, she has been taking tamoxifen and referred to Gynecologic oncology department for growing uterine myoma. 8 × 7 cm sized uterine myoma on transvaginal sonography was observed. The patient was recommended with hysterectomy and bilateral salpingo-oophorectomy. Transumbilical SPA TLH and BSO were performed after confirming the pathway of the vessel of pedicle by Abdominal-pelvic CT. Measurements and Main Results After making of altered anatomy of abdominal muscle flap, self designed single port system was made using the wound retractor and a surgical glove on umbilicus. We did not make additional port placement to avoid damage of abdominal wall with previous TRAM procedure. patient underwent successful SPA TLH and BSO transumbilical incision for single port placement. There was no complication during operation. Conclusion Single port access laparoscopic surgery is feasible in women after TRAM reconstruction. Knowledge of anatomic and physiologic variations related to the TRAM procedure is necessary in planning a safe operation.

Video Objective In approximately 0.6 % of cases, ectopic endometrium has been found in extrapelvic sites, such as the umbilicus, skin, upper abdominal peritoneum and organs (liver, spleen), diaphragm, pleural cavity, lungs, and pericardium. The prevalence of diaphragmatic endometriosis has been reported in up to 0.19 % of lesions. No guidelines exist about treatment of diaphragmatic endometriosis, and this rare condition is still a matter of debate because it raises several diagnostic and treatment challenges. We present a case of patient affected by diaphragmatic endometriosis who was treated by laparoscopy. Setting Case study, University hospital in Korea. Interventions A 41-year-old woman was referred to our department because of dyspareunia and dysmenorrhea. Laparoscopic finding showed left ovarian cyst adherent to peritoneum, cul-de-sac partial obliteration and endometriotic nodule on right diaphragm. We performed laparoscopic adhesiolysis, right ureter peritonectomy and diaphragmatic resection of endometriosis. An accidental diaphragmatic injury was occurred during the laparoscopic diaphragmatic resection. We performed successful laparoscopic primary repair of diaphragm and then chest tube was also inserted. The patient was uneventfully discharged home 4 days later. Conclusion Laparoscopic primary repair after resection of diaphragmatic endometriosis is feasible.

Study Objective To describe the experience of robotic-assisted single port supracervical hysterectomy with bilateral salpingectomy on a giant uterine leiomyoma using the da Vinci SP surgical system. Design A Case report. Setting Robot Surgery Center of Ewha Womans University Hospital. Patients or Participants A 45-year old virgin woman with huge uterine leiomyoma sized about 26 × 23cm2. Interventions Robotic-assisted single port SCH with BS using the da Vinci SP surgical system. Measurements and Main Results The recently introduced da Vinci SP surgical system include a fully wristed camera which can offer an easy movement of camera and instruments to 360 degree at once. Therefore this surgical system has an advantage on the surgery which requiring procedures both below and above the umbilicus with only the single incision inside the umbilicus. We present a case of huge uterine leiomyoma of intramural type measured about 26 × 23cm2 which is successfully performed the SCH with BS using the da Vinci SP system. Total operative time was 145 minutes and the estimated blood loss was 250 mL. The hospital stay was 2.5 days. No operative or postoperative complications occurred. To the best of our knowledge, this is the largest leiomyoma case of robotic-assisted single port SCH using the da Vinci SP system and we have known the advantage of the da Vinci SP® surgical system on the huge intraabdominal mass requiring procedures above the umbilicus level as in this case. Conclusion The da Vinci SP surgical system enables easy rotation of camera and instruments at once and this make it easy to perform the procedures which are performed above the umbilicus for the huge uterine leiomyoma reaching the diaphragm.

Study Objective To investigate the feasibility and safety of single-port laparoscopic hysterectomy with 5mm mini incision. Design The clinical data of 5 patients who underwent 5mm mini-incision single-port laparoscopic hysterectomy were retrospectively analyzed. Setting Department of Obstetrics and Gynecology, C the Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University. Patients or Participants 5 patients who underwent 5mm mini-incision single-port laparoscopic hysterectomy. Interventions The median longitudinal incision of the umbilicus is about 5mm long, and the subcutaneous sneak expansion space is 3-5mm. The 40/50 small abdominal retractor expands and retracts the incision approach, using small lenses such as pediatric surgical laparoscopy, cystoscopy or hysteroscopy. Place the operating instrument to perform the operation. Measurements and Main Results Five patients in this group were successfully operated. No other channels were added during the operation, and no laparotomy was performed. The operation time is 100-195 min, in which the puncture establishes the surgical access part for 5-10 min, and the umbilical hole reconstruction part 3-5 min; The intraoperative blood loss was 50-100 ml, the body temperature was 36.5°C to 37.5°C after 1 day, and the anus exhaust time was 1.0-1.5 days. The patient was discharged from hospital for 6-7 days. The postoperative umbilical wounds healed well, almost no surgical scars were seen, and no postoperative umbilical hernia and other serious complications occurred. Conclusion Under the premise of mature laparoscopic technique, it is safe and effective to perform a 5mm mini incision laparoscopic hysterectomy.

The umbilicus is viewed as a portal by the laparoscopic surgeon, a doorway to the real business at hand. However, the umbilicus itself may be the site of a variety of lesional conditions. Some of these may be iatrogenic, caused by prior surgical interventions, such as endometriosis or seeding of a malignant neoplasm. Some may be the initial presenting complaint. This review discusses umbilical lesions that may be encountered by the minimally invasive gynecologic surgeon.

Study Objective Fifty percent of laparoscopic bowel and vascular injuries occur at the time of entry. These serious complications can lead to significant morbidity and even mortality. This video demonstrates 3 techniques that have been developed to minimize the risk of these injuries during entry. Design Step-by-step description of 3 techniques that can be used as a highly reliable and safe method of obtaining intraperitoneal entry during laparoscopy. Measurements and Main Results Caudal displacement of the umbilicus before insertion of the veress needle allows for a median displacement of 6 cm between the site of entry and the common iliac vessels. An entry pressure of less than 9 mm Hg is suggestive of successful intraperitoneal entry. The left upper quadrant should be used in specific cases instead of the umbilicus as the point of entry for the veress needle. The use of a visualized trocarless cannula instead of a conventional primary trocar for entry after insufflation allows for real-time recognition of injury and converts linear penetrating force to radial torque. Conclusion These 3 techniques can help decrease the risk and improve intraoperative recognition of serious bowel and vascular injuries during laparoscopy.

To estimate whether variability in the size and ratios of the lower and upper abdomen exist in women undergoing robotic gynecologic surgery and whether demographic variables are significantly associated, and to determine the association between abdominal wall dimensions and supraumbilical robotic port placement.Prospective cohort study (Canadian Task Force classification II-2).University teaching hospital.Seventy-eight women undergoing robotic surgery between May 2008 and March 2009.Measurements from the symphysis pubis to the umbilicus (lower abdomen), umbilicus to the xyphoid process (upper abdomen), and distance between the anterior superior iliac crests were obtained at surgery. A multiple linear regression model was created to determine the relationships between abdominal wall measurements, demographic variables, and need for supraumbilical robotic port placement.Fifty-six white and 22 black women were enrolled. Mean lower abdominal length was significantly affected by body mass index (BMI) (p.001) and race (p = .006), with white women having longer measurements (17.1 cm vs 15 cm). Mean lower abdominal width was independent of age (p = .95) or race (p = .98), but was significantly correlated with BMI (p.001). Mean upper abdominal length correlated with BMI (p.001) and age (p = .03) but not race (p = .13). Ratios of bottom to top were significantly affected by race (p = .002) and age (p = .008) but not BMI (p = .07). Adjustments to port placement above the umbilicus were made in 44 of the 74 women (59.5%). Those who required supraumbilical port placement had a significantly shorter mean (SD) distance between the symphysis pubis and the umbilicus (14.99 [1.36] vs 18.55 [2.21]; p.001).Significant variability in abdominal wall anatomy exists in women undergoing robotic gynecologic surgery, and the need for supraumbilical robotic port placement is common.

Since most gynecologists use the Veres/trocar entry, and because the Veres intraperitoneal (VIP) pressure appears to be the most reliable indicator of correct Veres needle placement, the objective of this study was to determine the effect of height, weight, body mass index (BMI), parity, and age on the initial Veres intraperitoneal CO2 insufflation pressure during laparoscopic access in women.Prospective observational cohort study (Canadian Task Force classification II-1).University affiliated teaching hospital.We prospectively collected data on 356 women undergoing laparoscopy for a variety of indications by the senior author (G.A.V.). The median and (range) for height, weight, BMI, parity, and age were 1.64 m (1.45-1.85 m), 65 kg (40-120 kg), 24.3 kg/m2 (16-47 kg/m2), 1 (0-5) and 34 years (18-87 yrs), respectively.Under general endotracheal anesthesia including muscle relaxants and with the patient in appropriate stirrups in the horizontal position, a nondisposable Veres needle was inserted at the umbilicus or left upper quadrant (Palmer's point) with CO2 flowing at 1 L/min. The initial Veres intraperitoneal insufflation pressure was recorded once the Veres needle was believed to be in the peritoneal cavity.The mode and the median VIP pressure was 4 mm Hg with a range of 2 to 10 mm Hg. With multivariate analysis, the VIP pressure correlated positively with the weight (r = 0.518, p.001) and BMI (r = 0.545, p.001) and negatively with the parity (r = -0.179, p.001) of women. The correlation of the VIP pressure with height and age was r = 0.029 (p = .591) and r = -0.044 (p = .411), respectively.A VIP pressureor =10 mm Hg indicates intraperitoneal placement of the Veres needle. The VIP pressure correlates positively with the weight and BMI and negatively with the parity of women. There is no correlation of the VIP pressure with women's height and age.

Study Objective To show that in selected cases transvaginal NOTES can be a frugally innovative approach for adhesiolysis and that it can be performed in a low-cost setting. Design Step-by-step explanation of the technique using videos and pictures (educative video). Patients and Measurements A 51-year old (para 2, gravida 2) presented with meso- and hypogastric pain. Two years before, an umbilical hernia had been repaired using a Proceed Ventral Patch mesh. The diagnosis of pain caused by adhesions was made, and laparoscopic adhesiolysis was planned. On ultrasound, a small left ovarian fibroma was visualized. Because of the suspected umbilical location of the adhesions, we decided to use a transvaginal NOTES approach to perform adhesiolysis and left adnexectomy. Pathological examination confirmed a small benign papillary serous adenofibroma of the ovary. Interventions A transvaginal NOTES approach to perform adhesiolysis combined with left adnexectomy using only standard reusable laparoscopic instruments and a low-cost self-constructed NOTES port. Main Results The procedure and postoperative recovery were uneventful. No minor or major complications occurred. The patient has been cured of her pain. Conclusion Transvaginal NOTES is a novel approach that requires further validation. This case report shows that transvaginal NOTES can be used to perform adhesiolysis for abdominal pain and that it can be performed in a low-cost setting without the need for expensive ports or disposable instruments.

Laparoendoscopic single-site (LESS) surgery has gained increased acceptance among surgeons in various specialties. The universal nature of port placement in the umbilicus during LESS surgery may enable concomitant procedures to be performed in these surgical specialties via this single incision. This case report presents a 37-year-old woman who underwent concomitant LESS cholecystectomy and hysterectomy to treat a symptomatic fibroid uterus and symptoms of cholelithiasis. The surgical procedure was performed in approximately 3 hours without any complications, and the patient was discharge to home 18 hours after the procedure. This case demonstrates that increasingly complex concomitant procedures can be performed using a LESS surgical approach.

We report a case of umbilical endometriosis externa and systematically review the literature regarding this finding. In our case report, a 47-year-old woman with cyclic umbilical bleeding, pelvic pain, and no previous umbilical surgery developed a spontaneous umbilical endometrioma, cured by surgical resection and bilateral salpingo-oophorectomy. In our review, 122 patients with documented umbilical endometriomas from 1966 to the present and 109 cases reported before 1953 were analyzed. Procedures used for diagnosis and/or therapeutic intervention included umbilical biopsy or resection, abdominal wall repair, diagnostic and/or operative laparoscopy, adhesiolysis, hysterectomy, and bilateral salpingo-oophorectomy. Variables included patient age; race; medical and surgical history; past use of oral contraceptives; history of umbilical pain, bleeding, or swelling; duration of signs and symptoms; size and color of the lesion; diagnostic evaluations; and medical or surgical management. Mean age of the study population was 37.7 +/- 0.98 years. Up to 40% of patients with extrapelvic endometriosis present with umbilical endometriomas, with symptoms occurring an average of 17.8 +/- 3.9 months before presentation. Lesions averaged 2.3 +/- 0.2 cm in diameter; were predominantly brown (19.1%), blue (13.2%), or purple (10.3%); and patients frequently had with pain (77.93%), cyclical bleeding (47.1%), and swelling (88.2%). Most patients had no history of endometriosis (73.1%), and laparoscopic, umbilical trocar-related seeding was identified in only 5 patients. Three patients received medical management, and surgical management was invariably curative, though 1 patient required repeat surgical therapy. Umbilical endometriosis is a common manifestation of external endometriosis, representing primary or secondary endometriosis, with a typical presentation that has little variation. Laparoscopic endometrioid tissue excision can result in iatrogenic seeding to the umbilicus. Historical and physical findings are pathognomonic, thus justifying a formal name--Villar's nodule, after the initial reporting physician. Surgical intervention is recommended, but medical therapy may result in long-term symptom control with minimal malignancy risk.

Surgeons performing sophisticated endoscopic operations must be well versed in alternate laparoscopic access methods to address evolving patient expectations and safety requirements. The safety of left upper quadrant laparoscopic entry in patients with prior surgeries and abdominal adhesions was evaluated. Laparoscopic surgery was performed for various indications on patients with prior surgical scars and anticipated risk of adhesions at the primary umbilical port site. All laparoscopies performed from July 1998 through June 2004 were analyzed. Of the 918 laparoscopies, 504 patients (54.9%) were found to have involvement of their umbilicus with adhesions that could have affected the traditional umbilical primary port entry. Left ninth intercostal space was used for Veres needle entry, and the primary trocar was placed in the left upper quadrant space. Of the 504 potentially risky entries, there were two (0.39%) Veres-needle related and zero trocar-related injuries. All surgical procedures were accomplished laparoscopically, and all entries were accomplished by the left upper quadrant entry technique. Therefore left upper quadrant entry technique is a safe and easily learned alternate access technique.

h p a h n s s f l r t l t F o Richter’s hernia occurs when there is a strangulated ernia involving part of the circumference of the bowel all. It does not affect the passage of bowel contents hrough the bowel lumen. Hence, despite strangulation, here is an absence of intestinal obstruction. A 54-year-old woman underwent ambulatory laparocopic adnexectomy because of ovarian cystic complex foration. First a 10-mm intraumbilical trocar was placed in a tandard closed technique, with a 12-mm trocar in the left ide and a 5-mm EndoTIP (Karl Storz, Tuttlingen, Gerany) in the right side. The left fascial defect was sutured, nd the umbilical fascia was not closed.