Search

Show strategies to minimize blood loss in minimally invasive laparoscopic myomectomy. Case report of perioperative strategies. Laparoscopic myomectomy in a a tertiary hospital. A 33-year-old nulliparous woman, with abnormal uterine bleeding and dysmenorrhea, not responsible to medical treatments and desiring future pregnancy. The MRI shows a myometrial transmural nodule in the cervical and anterior uterine wall, measuring 8.3 x 8.2 x 8.1 cm with restricted weighted diffusion and areas of hyaline and cystic degeneration, suggestive of atypical leiomyoma. Preoperative vaginal use of 400mcg of misoprostol, one hour prior to the laparoscopic procedure. Intraoperatively, the uterine arteries were bilaterally identified laterally to the ureters, after opening the posterior leaf of the large ligament and clamped. Both utero-ovarian ligaments and round ligaments were also clipped, reducing uterine blood supply. Diluted Vasopressin was injected into the anterior myometrium. A transverse incision was performed with careful identification of leiomyoma pseudo-capsule and cauterization of its vessels. After myomectomy, a hemostatic 2.0 barbed suture closure was performed, and a oxidized regenerated cellulose hemostatic barrier was applied covering the incision. Clips were removed. The surgery lasted 200 minutes with a total blood loss of 255 ml. Hemoglobin dropped from 12,9 g/dL to 11,8 g/dL. The nodule measured 14,5 cm and histological analysis reported a typical leiomyoma. The patient was discharged the following day Laparoscopic myomectomy is associated with longer operating hours and more intense blood loss than hysterectomy. Misoprostol, temporary uterine artery clamping, and intramyometrial vasopressin injection are associated with lower blood loss. Barbed suture decreases operative time. Our case shows how the combination of strategies contributes to a successful post-operative result. [ABSTRACT FROM AUTHOR]

Objective: Knowledge of the retroperitoneal anatomy is particularly important to facilitate surgical procedure and reduce the number of complications. The objective of this video is to demonstrate pelvic neuroanatomic structures and their relationships in the pelvic sidewall and the presacral space in a laparoscopic cadaveric dissection., Design: Case report (anatomic study)., Setting: Medical training center (AdventHealth Nicholson Center, Orlando, FL)., Interventions: The dissection started with the mobilization of the iliac vessels from the pelvic sidewall to identify the obturator nerve. The peritoneum of the ovarian fossa was opened, and the ureter was dissected up to the level of the uterine artery. The hypogastric nerve was identified. The close relationship between the ovarian fossa and the obturator nerve could be demonstrated. The deep dissection of the obturator fossa allowed for the identification of the lumbosacral trunk, S1, the sciatic nerve, S2, S3, S4, and the splanchnic nerves. Then, the ischial spine and the sacrospinous ligament were identified. The pudendal nerve and vessels could be observed passing below the sacrospinous ligament, entering the pudendal canal (Alcock's canal). The presacral space was dissected, and the hypogastric fascia was opened. S1 to S4 were identified coming from the sacral foramens. The laparoscopic dissection, using the cadaveric model, allowed for the development of the entire retroperitoneal anatomy, focusing on the dissection of the pelvic innervation. Anatomic relationships among the ureter, the hypogastric nerve, the uterosacral ligament, the splanchnic nerves, the inferior hypogastric plexus, and the organs (bowel, vagina, uterus, and bladder) could be demonstrated., Conclusion: A laparoscopic cadaveric dissection can be used as a resource to demonstrate and educate surgeons about the neurologic retroperitoneal structures and their relationships., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To investigate why security of identical knot sequences is variable and how to avoid occasionally insecure knots., Design: A factorial design was used to assess factors affecting the security of half knot (H) and half-hitch (S) knot combinations. The effect of tying forces and the risk factors to transform H knots into S knots were investigated. The risk factors evaluated were as follows: starting with an H1 or H2 instead of an H3 knot, inexperience, short sutures, and monomanual knot tying. Security of transformed knots, S2S1 and S2S2 knots, and their recuperation with 2 additional half hitches, SSb or SbSb, were evaluated., Setting: Training center for laparoscopic suturing., Patients: Not applicable., Interventions: Security of knots was evaluated in vitro., Measurements and Main Results: The forces that caused knot combinations to open before breaking of the suture were used to calculate the risk of opening with low forces. Tying more strongly increased the security of half knots (H2H1sH1s) (p <.02) and half hitches (p <.001). The forces needed to transform an H3 into an S3 are higher than those for an H2 (p <.001), and the risk increases when the surgeon is inexperienced (p <.001), when sutures are short (p <.001), and when monomanual knot tying (p <.001) is used. Inadvertently made S2S1 and S2S2 knots are dangerous, with the exception of the symmetric S2S2, which is stable. Unstable knots such as S2S1a and S2S2a knot combinations improve with 2 additional blocking half hitches (SbSb), but S2S2aSbSb remains occasionally insecure., Conclusion: To reduce the risk of accidentally transforming a first H into an S knot, it is recommended to start with an H3, tie with force, avoid short sutures, and use bimanual suturing. This permits the recommendation to use preferentially H3H2 knots or 5 half hitches (SSSbSbSb). When in doubt, half knot combinations should be secured with at least 2 blocking half hitches., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: 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 lesion <3 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., Design: Step-by-step video illustration of our surgical technique with clarification of surgical principles., Setting: Tertiary care center., Intervention: 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., Conclusion: Disc resection is the technique of choice to treat a focal bowel endometriosis lesion <3 cm., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To demonstrate the application of different knot blocking sequences in laparoscopic surgery., Design: A step-by-step demonstration of different blocking sequences performed by laparoscopic surgery (Canadian Task Force classification III)., Setting: Private hospital in Curitiba, Paraná, Brazil., Intervention: The correct placement of one knot over the other is rarely taught in the surgical literature. Laparoscopic knot-tying techniques may be performed using one hand (monomanual technique) or alternating both hands (bimanual technique). Rotation of the needle holders around the thread (clockwise or counterclockwise rotation) is very important to have a symmetric or an asymmetric configuration of the knot, which affects the stability of the entire knot sequence. The monomanual knot-tying technique needs to alternate the rotation of the needle holder, and the bimanual technique does not when performing half knots (square or flat knots). The half hitch is an asymmetric knot that is obtained when the surgeon makes asymmetric traction on one thread (passive thread) and place the knot using the other thread (active thread). To block 2 half hitches, the surgeon needs to change the active and the passive threads. Beginners in laparoscopy commonly make mistakes tying knots, leading to an insecure knot sequence that may slip and/or open under minimal forces. In this video, we demonstrate different types of blocking sequences performed by laparoscopy applied in different surgical procedures. Ethics Committee approval was obtained for this video., Conclusion: Knot-tying is a basic surgical skill that must be mastered by all laparoscopists., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Study Objective: To investigate the security of various knot combinations in laparoscopic surgery., Design: Prospective nonrandomized trial (Canadian Task Force classification II)., Setting: Storz Training Centre, Sao Paulo, Brazil., Intervention: Different knot combinations (n = 2000) were performed in a laparoscopic trainer. Dry or wet 2.0 polyglycolic acid or dry 2-0 poliglecaprone 25 was used. The tails were cut at 10 mm, and the loops were tested in a dynamometer. The primary endpoints were the forces at which the knot combination opened or at which the suture broke. Resulting tail lengths were measured., Measurements and Main Results: Surprisingly, the combination of a 2-throw half knot (H2) and a symmetric 1-throw half knot (H1s) (a surgical flat knot) opened at <1 Newton (N) in 2.5% of tests and at <10 N in 5% of tests. This occasional opening at low forces persisted after 1 or 2 additional H1s knots. A sequence of an H2 or a 3-throw half knot (H3) followed by a H2, either symmetric or asymmetric (H2H2 or H3H2), resulted in 100% secure knots that never opened at forces below 30 N. Other safe combinations were H2H1s followed by 2 blocking half hitches, and a sequence of 5 half hitches with 3 blocking sequences., Conclusion: A traditional surgical knot (H2H1s) occasionally opens with little force and thus is potentially dangerous. Safe knots are H2H2 and H3H2 combinations, a sequence of 5 half hitches with 3 blocking sequences, and H2H1s together with 2 blocking half hitches., (Copyright © 2018 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Study Objective: To show a step-by-step laparoscopic approach for excision of an ovarian endometrioma following surgical principles for safety and maximal preservation of ovarian function., Design: Video. Medical management of ovarian endometriomas is not recommended. Operative laparoscopy is the treatment of choice. Although considered a simple procedure, ovarian cystectomy requires a precise and correct technique in order to preserve ovarian function., Setting: A private hospital., Patient: An asymptomatic, 27-year-old woman with ultrasound imaging suggesting a 6.2 × 5.4 cm left endometrioma. Additional findings of endometriotic implants were noted in the posterior aspect of the left broad ligament, retrocervical region, Douglas pouch, and left round ligament., Interventions: After trocar insertion, standard inspection of the pelvic cavity with identification of endometriosis lesions and adhesions was performed. The endometrioma was drained with direct trocar puncture to avoid spillage of the endometriotic contents. Cyst aspiration and saline cleaning were executed. After drainage, a cold cut was performed at the puncture site for better identification of the cyst capsule. Through gentle traction and countertraction, the capsule was peeled from the ovarian cortex, preserving as much ovarian tissue as possible followed by careful hemostasis with a bipolar instrument. The ovary is fixed, anatomy re-established, and concomitant pelvic endometriosis resected. We aim for complete surgical excision in order to avoid leaving disease behind. The ovarian edges were reapproximated using simple interrupted stitches., Measurements and Main Results: The total procedure time was 40 minutes., Conclusion: Laparoscopic endometrioma stripping offers an effective option for ovarian endometriosis treatment, reducing recurrence and being reproducible by gynecologic surgeons after proper training., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)