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Study Objective To compare results of 3 original techniques of laparoscopically assisted colpopoiesis from the pelvic peritoneum. Design Prospective Level II study. Setting Department of Operative Gynecology, National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Ministry of Healthcare of Russia. Patients or Participants We recruited 226 patients with utero-vaginal aplasia (MRKH). Interventions We used colpopoiesis from the peritoneum of the pelvis, developed by Adamyan, as a treatment method for patients with uterine and vaginal aplasia (MRKH). Since 2012, neovagina creation has been undertaken utilizing three different methods: laparoscopic-perineal technique, total laparoscopic technique, and combined laparoscopic-perineal technique with ligatures used to lower the peritoneum. Measurements and Main Results A total of 81 patients underwent colpopoiesis using the laparoscopic-perineal technique, employing in 105 cases a total laparoscopic colpopoiesis technique and in employing in 40 case a laparoscopic-perineal technique with ligatures. Rudimentary uterine horns were found in 37 patients. 18 percent had kidney dystopia, of which 12% had a pelvic kidney, and 10% had kidney aplasia. There were no significant differences between the three types of colpopoiesis in terms of blood loss, the duration of surgery, the length of stay in the postoperative hospital, and the use of painkillers in the postoperative period. In terms of complications, there was 1 case of bladder injury, and 1 case of rectal injury in patients with prior fibrosis was diagnosed and repaired during surgery. Postoperative neovaginal stricture was observed in 5 cases, and dyspareunia in 11 cases, which improved with the expansion of the vagina within 1 month. Conclusion Laparoscopy Involving neovagina creation is an effective and safe operation, even in patients with unsuccessful previous neovagina attempts and radiation-induced fibrosis, which provides sufficient length of neovagina of 10-12 сm, functional aspects such as lubrication, epithelialization, extensibility, and sensitivity. However, such interventions, especially in complex cases, should be provided only in specialized medical centers.

To establish a porcine uterine horn adhesion model that mimicked laparoscopic procedures and use it to investigate the effect of a spray-type, novel dextrin hydrogel adhesion barrier (AdSpray; Terumo Corporation, Tokyo, Japan) on postsurgical adhesions.A single-blind randomized controlled trial (Canadian Task Force Classification I).A Certified animal research facility.Sixteen female pigs.All animals underwent laparoscopically assisted adhesion-inducing surgery. The uterine horns and the peritoneum of the pelvic sidewall were injured. In the experimental group, AdSpray was applied to the injured site, and the handling of the sprayer was assessed. At 28 ± 1 days after surgery, animals were sacrificed, and adhesions at the injured site were evaluated. Uterine horn suture sites were examined under a light microscope to assess healing of the incised wound, the inflammatory reaction, abscess, and the foreign body reaction to the surgical suture.The control group showed severe adhesions over the entire surface interface at the uterine horn suture sites and peritoneal resection site. Compared with the control treatment, AdSpray exhibited a higher percentage of adhesion-free sites (p .001) and reduced the total adhesion score (p .001). In the AdSpray group, no inflammation or abscess formation was observed on histopathological examination, and ideal healing of the suture sites was confirmed in all cases.Based on the results of the present study, the novel dextrin hydrogel shows excellent adhesion prevention and can be easily applied during laparoscopy using a dedicated sprayer.

Study Objective The objective of this video is to discuss and demonstrate a surgical approach to management of a deeply involved non-communicating left uterine horn. Design Case Study. Setting The patient was taken to the operating room for a planned procedure. Adequate general anesthesia was obtained. She was placed in the dorsal lithotomy position and prepped and draped in usual sterile fashion. Patients or Participants 21 y/o G0 presenting with 7 months of worsening dysmenorrhea. Interventions Patient underwent a Laparoscopic left uterine horn excision, left salpingectomy, chromotubation, treatment of endometriosis (excision and ablation). Measurements and Main Results A saline infusion sonogram was performed for further evaluation of dysmenorrhea which noted a possible uterine horn with endometrial lining. A subsequent MRI was ordered to further delineate anatomy and surgical planning. A non-communicating left uterine horn contiguous with the right unicornuate uterus was seen. The right unicornuate uterus was seen along the entire length communicating with the cervix. Pre-operative renal imaging was performed to assess for simultaneous renal abnormalities which was negative. In patients with mullerian anomalies, a thorough evaluation of the renal collecting system is essential. As high as 40% of patients with a unicornuate uterus are noted to have simultaneous renal anomalies. Pre-operative imaging with an ultrasound or an MRI is warranted to evaluate the kidneys, ureters and bladder. Obstruction is often associated with retrograde menses and hence endometriosis. Superficial scattered endometriosis lesions were noted in the pelvis of this patient. Surgical excision of the non-communications horn can provide symptomatic relief and eliminate reflux. Conclusion There are multiple types of mullerian anomalies. Ultrasound imaging is generally the first step in evaluation. if an ultrasound is unclear, an MRI can be ordered to further assess the complex anomaly. Evaluation of the renal collecting system is essential in these patients as the rate of renal anomalies can be high.

Study Objective To demonstrate by video our surgical approach of the resection of a second trimester rudimentary horn ectopic pregnancy. Design Case Report Setting University hospital. Patient in dorsal lithotomy position. Patients or Participants A 22-year-old primigravida presented at 16 weeks gestation following two failed elective terminations, in the setting of a spontaneous pregnancy with a known uterine anomaly. The patient reported a prior diagnostic laparoscopy revealing a left unicornuate uterus. Outside ultrasounds reported an intrauterine pregnancy however MRI upon admission revealed a fetus located within a thin-walled structure separate from the main uterine cavity, consistent with a rudimentary horn pregnancy. Interventions A fetal intracardiac potassium chloride injection was completed by maternal fetal medicine to halt the growth of the pregnancy during pre-operative planning. Tranexamic acid was administered preoperatively to minimize blood loss. Ureteral stents were placed to safely identify the ureters with the knowledge that Mullerian anomalies are often associated with concomitant renal abnormalities. Robotic assisted laparoscopy was used to resect the rudimentary uterine horn containing the 16-week gestation with ipsilateral ureterolysis and uterine artery ligation. Measurements and Main Results Exam under anesthesia and diagnostic laparoscopy revealed a unicornuate uterus with a communicating rudimentary horn. The procedure was uncomplicated with an estimated blood loss of 100cc. The patient's hemoglobin remained stable from 11.7 preoperatively to 10.8 postoperatively. She was meeting all milestones and discharged home on postoperative day one. Conclusion Rudimentary uterine horn pregnancies are rare and best managed by a multidisciplinary team. Robotic-assisted surgery may decrease blood loss, length of stay and comorbidities from surgery in the setting of a rudimentary horn ectopic pregnancy. Rather than assuming infertility, long-acting reversible contraceptives should be offered to women to prevent recurrence.

Study Objective To describe the diagnostic challenge and surgical management of a noncommunicating uterine horn pregnancy. Design Clinical history, brief literature review, and video documentation. Setting Patient was placed in dorsal lithotomy for laparoscopic resection of a uterine horn pregnancy in a tertiary care center. Patients or Participants The patient was a 29 year old G1P0 female presenting with a live 11-week extrauterine pregnancy. Radiologic work-up with both pelvic ultrasound and MRI could not fully ascertain diagnosis. Differential diagnosis included tubal ectopic, horn pregnancy of a bicornuate uterus, interstitial pregnancy, and broad ligament pregnancy. Given this was a wanted pregnancy, intra-sac potassium chloride was not administered pre-operatively and the patient was consented for a diagnostic laparoscopy and possible removal of ectopic pregnancy. Interventions Laparoscopy Measurements and Main Results Diagnostic laparoscopy was undertaken where pelvic inspection revealed a right-sided normal appearing unicornuate uterus and a large left rudimentary noncommunicating horn distended by the pregnancy. The pregnancy was connected to the unicornuate uterus via a thick fibrous band. This confirmed a pregnancy in a Type II-B Mullerian anomaly as per the ASRM classification system. Such pregnancies are rare ranging from 1 in 75,000-150,000. Our video demonstrates a stepwise approach for the excision of such pregnancies including isolation of the ureter retroperitoneally, bladder dissection, use of peritoneal landmarks to ensure safe transection of the fibrous band, and use of hemostatic techniques such as vasopressin and advanced bipolar devices. In addition, we demonstrate a simple technique for oophoropexy where we stabilize a hypermobile ovary to the round ligament pedicle using a laparoscopic ligature device. Conclusion Rudimentary horn pregnancies are rare and pose a diagnostic challenge. Complications are common with >50% of such pregnancies presenting ruptured, thus resection is often recommended. We demonstrate that laparoscopy is a safe and feasible option to manage such pregnancies.

Video Objective To demonstrate new idea of laparoscopic unification of functional non – communicating horn with hemi-uterus instead of removal to improve obstetric outcome in future. Setting an academic tertiary care hospital. A 14-year-old girl presented with complaints of pain in lower abdomen, on and off for 2 months. Her previous 2 cycles were regular; she had cyclic dysmenorrhoea since her menarche which was now become intolerable and continuous. Secondary sexual characteristic was normal. hormone profile normal and on local examination normal external genitalia found. A thin dilator passed into vagina to confirm patent vagina. ultrasound suggested a unicornuate hemi uterus and right non communicating horn with a turbid collection. MRI also confirm the same. Interventions On Hysteroscopy a small right uterine cavity with only one ostium on right. Cervical canal was normal with normal crypts. vagina also normal and spacious. On diagnostic laparoscopy: A unicornuate right hemi- uterus with a non-communicating left horn was noted on the right side of the round ligament, tube and ovary were seen normal with small hemi-uterus. On the left, small uterine horn seen with absent tube but normal ovary and round ligament attachment. First, we were planned resection of non-communicating horn as described in literature but after assessing the anatomical proximity and good size of horn and small size of hemi-uterus we decided for unification of both. After injecting diluted inj. vasopressin, linear medial incision given in full thickness of myometrium with monopolar energy and opening the cavity with scissors. Both the walls sutured together first posteriorly and then anteriorly in double layer with no. 1 polyglactin 910 suture. Conclusion Good normal size, shape and contour of uterus appreciated after completion of procedure. After surgery patient had one normal menses without any pain suggest success of surgery.

Video Objective Review noncommunicating uterine horns; incidence, diagnosis and surgical management. Demonstrate the steps needed to safely remove this type of horn using our 4 quadrant laparoscopic approach. Setting A 21 year old nulligravid female with severe dysmenorrhea and acute worsening pain, found to have a uterine malformation. MRI confirming a unicornuate uterus with American Fertility Society class II b malformation. Interventions A 4 quadrant laparoscopic approach, combining retroperitoneal dissection with myomectomy techniques, to safely remove the noncommunicating functional horn. Conclusion Even though rare, uterine abnormalities must be ruled out as a cause of continued female pelvic pain. Once a noncommunicating functional horn is diagnosed, principles used in laparoscopic hysterectomy and myomectomy can be combined to safely remove it. Our 4 quadrant laparoscopic technique allows both surgeon and assistant to actively participate in most minimally invasive gynecologic surgery in an ergonomic fashion.

Video Objective This video demonstrates the laparoscopic management of a surgical emergency due a non-communicating herniated rudimentary uterine horn and ipsilateral torsed adnexa. Setting NA. Interventions This case is a 36-year-old healthy woman undergoing elective oocyte cryopreservation with normal baseline pelvic ultrasounds. On day 7 of oocyte stimulation, an enlarging inguinal mass was identified associated with severe inguinal pain; an incarcerated ovary was suspected. She was taken to the operating room for surgical management. The diagnosis of a Mullerian anomaly was made laparoscopically, noting that she had a right unicornuate uterus with associated normal-appearing right adnexa and ureter. Notably, the left non-communicating rudimentary uterine horn was found herniated through the deep inguinal ring, drawing with it a portion of the left tube and ovary, torsed around its associated pedicle. A left ureter could not be visualized. After decompressing and de-torsing the left inguinal mass, the rudimentary horn, fallopian tube, and necrotic portion of the left ovary were excised using a bipolar sealing device; the inguinal hernia was repaired. The viable left ovarian tissue was retained. A postoperative renal ultrasound confirmed left renal agenesis. Two months later, she successfully underwent oocyte cryopreservation with eggs aspirated from both ovaries. Conclusion Hernia uterus inguinale is a rare condition in which uterine tissue and occasionally adnexa herniate through the inguinal ring. It can present as an asymptomatic palpable mass or rarely as pelvic pain. Most reports have focused on its association with persistent Mullerian duct syndrome, which affects phenotypically male infants. While there are few reports of hernia uterus inguinale occurring in adult females, this case highlights the importance of keeping it in the differential in a patient with an inguinal mass and recognizing the potential for its associated morbidity and the ability to manage it surgically, if needed, through a minimally invasive approach.

Study Objective To investigate the efficacy, feasibility, and safety of cold scissor ploughing technique in hysteroscopic adhesiolysis for intrauterine adhesions. Design Retrospective cohort study. Setting University-affiliated hospital. Patients or Participants A total of 179 intrauterine adhesion (IUA) patients who had undergone hysteroscopic adhesiolysis (HA) at the Third Xiangya Hospital of Central South University were enrolled in this study from January 2016 to October 2017. They were divided into three groups according to the surgical technique used. The groups were: cold scissors ploughing group (PG) (n=81); traditional group (TG:) (n=42); and, electrosurgical group (EG) (n=56). Interventions PG: use cold scissors to dissect the adhesion and cut the scar tissue using a ploughing technique; TG: use cold scissors to dissect the adhesion, but not deal with the scar tissue; and, EG: use resectoscope to dissect the adhesion with an energy L-hook electrode. Measurements and Main Results American Fertility Society (AFS) scores, along with adhesion types and areas; visible uterine horn and tubal ostia; menstrual recovery; pregnancy rates and live birth rates were evaluated to determine surgical efficacy. Feasibility was evaluated by technique replacement rates. Safety was evaluated by intra- and post- operative complication rates. Neither patient pre-operation history or adhesion rates were significant (P>0.05). There were significant differences between PG and TG, as well as PG and EG in: postoperative AFS scores; IUA reverse rates; reduced adhesion areas; pregnancy rates and live birth rates (P Conclusion Cold scissor ploughing is effective, feasible, and safe for HA, which is worth further study.

Study Objective We present an uncomplicated robotic resection of a uterine horn in a teenage patient to highlight a minimally invasive approach, emphasize the importance of preoperative imaging, discuss potential areas for intraoperative complications, and address the possibility of trial of labor. Design N/A Setting Academic Medical Center - The patient was a 14-year-old nulligravida who presented to the Emergency Room for cyclic, right sided abdominal four months after menarche. The patient was found to have a unicornuate uterus with a functional, non-communicating rudimentary right uterine horn as demonstrated by an MRI obtained with and without contrast. The MRI included examination of the renal system, which was normal in this patient. Patients or Participants N/A Interventions Robotic resection of a non-communicating uterine horn with right salpingectomy. Measurements and Main Results N/A Conclusion Uterine malformations do not always occur in isolation. Given the high incidence of renal tract malformations associated with Mullerian duct anomalies, specifically unicornuate uterus, it is imperative that you obtain preoperative imaging to confirm a normal or abnormal renal system. As far as we are aware, there is not a standardized approach to removal of uterine horns. A minimally invasive approach, whether laparoscopic or robotic, should be the standard of care. Although this case was without complications, due to the unpredictability of these anomalies, a skilled surgeon should be involved with the case, especially one who is prepared to deal with a variety of complications. Additionally, we propose that patients with a history of a non-communicating uterine horn resection without entry in the uterine cavity be given the option for a trial of labor, with caution, similar to myomectomies.

Study Objective We present the case of a utero-paravaginal fistula noted in a patient with primary infertility and a history of a bicornuate uterus who had previously undergone multiple gynecologic surgical procedures. Design Case report. Setting A tertiary care center. Patients or Participants N/A Interventions N/A Measurements and Main Results A 28 y/o G0 with primary infertility associated with a bicornuate uterus presented to our office for evaluation after obtaining an ultrasound and MRI which showed a normal left hemiuterus but a right cystic pelvic mass consistent with a distended uterine horn with extensive blood within it. She had previously undergone several surgical procedures in Brazil, one of which was labeled a Strassman procedure. She was taken to the OR for hysteroscopy and laparoscopy where hysteroscopy revealed a small uterine septum but otherwise normal appearing endometrial cavity and laparoscopy revealed a normal appearing uterus and endometriosis that was resected. She subsequently developed a pelvic abscess in what appeared to be the lower uterine segment suggestive of an isthmocele. Pelvic abscess was drained, and subsequent CT hysterosalpingogram was performed which revealed a utero-paravaginal fistula. Three months after her infection, she returned to the OR for utero-paravaginal fistula repair. Postoperatively she did well and sonohystogram performed 3 months post-operatively has shown no residual defect. Conclusion This is the only case in the literature we could find where this type of utero-paravaginal fistula is described. Given her extensive surgical history, it is likely this is a result of previous surgical intervention. We highlight the use of CT hysterosalpingogram to document the nature of the fistula and aid us in subsequent repair.

Video Objective Learn the preoperative investigation and retroperitoneal dissection required for safe surgical resection of a rudimentary uterine horn associated with unicornuate uterus. Setting 19 year old female with increasing right gluteal pain subsequently found to have a cavitary rudimentary uterine horn with concomitant renal anomaly. Interventions Robotic assisted laparoscopic dissection of retroperitoneal spaces and resection of rudimentary uterine horn. Conclusion Unicornuate uterus can be associated with rudimentary uterine horns and renal anomalies. A surgical approach which incorporates retroperitoneal dissection is necessary for safe resection of rudimentary uterine horn.

Video Objective In this video we present the surgical management of a fused non communicating, rudimentary uterine horn with significant myometrial invasion. The objectives of this video are to review the diagnostic imaging features that are suggestive of surgical complexity with non communicating fused rudimentary horn resections. And review the steps involved in their resection. Setting A 12 year old previously healthy female presenting with 8 months of progressively worsening, severe dysmenorrhea. Onset 5 months post menarche. Her pain was not alleviated with ibuprofen, naproxen or acetaminophen. Initial Abdominal & Pelvic US: possible uterine fibroid, unremarkable kidneys. A Repeat US suggestive of a unicornuate uterus with an obstructed left rudimentary horn. She was started on menstrual suppression with a continuous combined oral contraceptive. A MRI was done confirming the presence of a left fused, non communication rudimentary horn, with significant myometrial invasion. Interventions A laparoscopic left uterine horn resection was performed. The surgery was divided into four steps. These include to perform a anatomical survey to confirm the patients anatomy, lateral isolation of hemi-uterus, division of the myometrial connection and finally, myometrial reconstruction. Conclusion In summary, the surgical steps in the management of a fused non communicating rudimentary uterine horn with significant myometrial connection include: To perform a anatomical survey to confirm the patients anatomy, lateral isolation of hemi-uterus, division of the myometrial connection and finally, myometrial reconstruction. A non-communicating functional fused rudimentary horn with significant myometrial invasion can present as a surgical challenge to gynecologists. It is important to do a pre-operative MRI in adolescents or with complex anomalies to assess the complexity of anticipated surgery. Post operative imaging with a MRI can assess for any residual endometrium from the resected horn.

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

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.

Study Objective To demonstrate surgical techniques utilized during uterine-sparing laparoscopic resections of accessory cavitated uterine masses (ACUMs). ACUMs represent a rare uterine entity observed in premenopausal women suffering from dysmenorrhea and recurrent pelvic pain. The diagnosis is made when an isolated extra-cavitated uterine mass is resected from an otherwise normal appearing uterus with unremarkable endometrial lumen and adnexal structures. Pathologic confirmation requires an accessory cavity lined with endometrial epithelium (and corresponding glands and stroma) filled with chocolate-brown fluid. Adenomyosis must be absent. Although the origin of ACUMs is currently unknown, the most common presentation is a 2-4 cm lateral uterine wall mass at the level of the insertion of the round ligament. Hence it has been hypothesized that gubernaculum dysfunction may be responsible for duplication or persistence of paramesonephric tissue leading to ACUM formation as a new Mullerian anomaly. Design A stepwise surgical tutorial describing 2 laparoscopic ACUM resections using a narrated video (Canadian Task Force classification III). Setting An academic tertiary care hospital. Patients In this video, we present 2 patients who underwent uterine-sparing laparoscopic resections of their ACUM in order to preserve fertility (Case 1) or avoid the complications and surgical recovery time of a total laparoscopic hysterectomy (Case 2). Case 1 is a 19-year-old, gravida 0, para 0 woman with dysmenorrhea and recurrent pelvic pain who presented for multiple emergency room and outpatient evaluations. Transvaginal ultrasonography was unremarkable except for a 28×30×26mm left lateral uterine mass with peripheral vascular flow that was initially felt to be a leiomyoma or rudimentary uterine horn. MRI imaging, however, demonstrated this mass to be more consistent with an ACUM. This was based on the lack of communication between the lesion and the main uterine cavity exhibited by high T2 signal (compatible with endometrial tissue) surrounding low T2/high T1 signal in the dependent aspects (representing blood products). After counseling regarding treatment options including medical management with hormonal contraception, the patient elected for definitive fertility preserving laparoscopic resection. In contrast, case 2 is a 39-year-old, gravida 3, para 3 woman with a 2 month history or left lower quadrant pain following her last vaginal delivery. Transvaginal ultrasonography showed a 23×18×19mm cystic structure within the left uterine wall, which was confirmed to represent an ACUM on MRI. Although she had no desire for fertility preservation, the patient elected for surgical resection of the mass as opposed to a hysterectomy in order to minimize complications and recovery time. Interventions Laparoscopic resection of ACUMs in patients desiring uterine preservation. Measurements and Main Results Laparoscopic resection of the ACUMs was performed utilizing 2 different techniques. In both cases, dilute vasopressin was injected with a modified butterfly or spinal needle along the uterine-ACUM serosal interphase to aid with hemostasis. In patients desiring to preserve fertility (case 1) monopolar energy is utilized to make an incision along the ACUM serosa to help facilitate dissection. ACUM enucleation is then commenced in a circumferential manner along the ACUM and uterine myometrial interphase utilizing bipolar energy. In contrast to leiomyomas where dissection advances along the pseudocapsule, ACUM have poorly delineated borders with disorganized muscular fibers making dissection particularly difficult. A variety of instruments can be utilized to help in the sequential circumferential dissection in addition to a bipolar device including a single-tooth tenaculum, myoma hook, suction device or fine-needle grasper. Ultimately, the ACUM is transected off its uterine-myometrial attachment and hemostasis is obtain before closing the uterine defect in at least 2 layers using a 2-0 barbed V-Loc (Medtronic, Minneapolis, MN). If fertility preservation is no longer desired, the dissection can greatly be expedited by performing a salpingectomy and skeletonizing the ACUM from the leaves of the broad ligament (case 2). A monopolar L-hook can then be used to transect the ACUM from the remaining uterine body. While difficult, these cases can be completed laparoscopically in approximately 2 hours with minimal blood loss. Conclusions ACUMs are hypothesized to represent a previously under recognized Mullerian anomaly linked to gubernaculum dysfunction that occurs in premenopausal women with dysmenorrhea and chronic pelvic pain. Uterine and fertility sparing laparoscopic resection is possible but challenging due to poorly defined planes.

Study Objective To demonstrate a step by step surgical hysteroscopy technique in a patient with asymmetric uterine septum and transverse uterine septum that was not previously described in the literature. Design Resection of an asymmetric uterine septum by laparoscopy and ultrasound-guided hysteroscopy (Canadian Task Force classification III). The video was assumed exempt from official review by our institutional review board. Setting A septate uterus is defined as the uterus in which the uterine cavity is longitudinally divided by the septum [1] . The most common uterine anomaly, septate uterus has a spectrum of configurations ranging from complete septate to incomplete septate uterus. Asymmetric uterine septum was reported only as case reports in the literature and is described as Robert's uterus [2] . This unique malformation is described as a septate uterus with a noncommunicating hemicavity, composed of a blind uterine horn usually with unilateral hematometra, and a contralateral unicornuate uterine cavity. The external uterine shape is normal. The asymmetric septum with transverse uterine septum in the present case has not yet been reported in the literature. Patient A 29-year-old woman presented to our clinic with primary amenorrhea, cyclic pelvic pain, and the desire to have pregnancy. She previously had failed 2 laparoscopy and hysteroscopy procedures for fertility treatments. Hysterosalpingography previously had been failed. The patient previously underwent magnetic resonance imaging. The magnetic resonance imaging report states there was no connection between the uterus and cervix. On external genital organs assessment, there was no abnormal sign. Ultrasonography revealed 2 uterine cavities and hematometra. Both ovaries were in normal view. Interventions In view of her examination findings, the patient was scheduled for laparoscopy and hysteroscopy. Laparoscopy revealed extensive adhesions on both the pelvis and upper abdomen. Initially, the uterus and ovaries were not visualized. Adhesiolysis was performed, and normal anatomy was restored. After this step, the operation was continued by laparoscopy and ultrasound-guided hysteroscopy. Under ultrasound and laparoscopy guidance, the transverse uterine septum at the level of uterine isthmus was incised and the left endometrial cavity was observed with hysteroscopy. The asymmetric uterine septum was then incised, and the right-sided endometrial cavity was then accessed. Finally, the uterine septum was completely incised and both sides of the endometrial cavities were merged. The patient had an uncomplicated postoperative course and was discharged 24 hours after surgery. She returned for follow-up examination in the second month after surgery. She had regular menstrual cycles, and her pain was cured. Conclusion Hysteroscopy and laparoscopy combined with ultrasound is a useful method for the diagnosis and treatment of asymmetric uterine septum. The skill and experience of the laparoscopic surgeon is another important factor to identify and manage unusual uterine malformations.

Pregnancy in a rudimentary uterine horn is a rare and potentially lethal condition. The highest risk of rupture is reported to be during the late first and second trimester. The risk of rupture correlates with the thickness of the myometrium surrounding the fetal pole. In 2005, a 20-year-old woman was incompletely diagnosed by imaging studies and laparoscopy to have an absent right kidney, a bicornate uterus with a right rudimentary uterine horn and a single cervix, a transverse vaginal septum with hematocolpos, and endometriosis caused by reflux menstruation. The transverse vaginal septum was excised, and the surgeon observed a single cervix. Oral contraceptives were prescribed as complementary treatment for the endometriosis and associated dysmenorrhea. In 2009, magnetic resonance imaging confirmed resolution of hematocolpos and revealed a right cervix connected to the right horn of a uterus didelphys and covered by a partial longitudinal vaginal septum. The patient had a contraception failure and presented in 2010 at 9 6/7 weeks' gestation. By ultrasonography and subsequent magnetic resonance imaging, the pregnancy was in the right uterus and the corpus luteum was on the left ovary. The myometrium was thinned to 2 to 3 mm atop the gestational sac. Using the Harmonic ACE, laparoscopic excision of the right fallopian tube and a supracervical right hysterectomy with an intact pregnancy was performed. This case supports the Acien hypothesis that the vagina forms from both Mullerian and Wolffian duct elements, and it illustrates the risk for uterine rupture when pregnancy forms in a rudimentary structure; presumed transperitoneal migration of an ovum that was captured by the opposite fallopian tube; and surgical management of the in situ pregnancy by laparoscopic supracervical excision of the rudimentary uterine body.

Uterine diverticula and rudimentary horns are rare forms of uterine anomalies that occur during embryogenesis. They can communicate with the endometrial cavity and may have the potential to develop pathology. This case report presents an obese, anovulatory adolescent with polycystic ovarian syndrome who was admitted with acute abdominal pain and found to have radiological findings that were concerning for a ruptured mass contiguous with the uterine cavity, which was likely a uterine horn or diverticulum. Further evaluation revealed simple hyperplasia without atypia on endometrial sampling, supporting the surgical resection and subsequent medical management of this young patient.

Herein is presented the case report of a patient who had severe dysmenorrhea since menarche, known right unicornuate uterus with a left rudimentary horn, and recurrent hematometra. Previous hysteroscopic drainage of the hematometra temporarily alleviated the symptoms. At subsequent hysteroscopy, 3 cavities were identified, 2 corresponding to the uterine horns and the other to a cervical diverticulum. Hysteroscopic metroplasty with drainage of the rudimentary horn hematometra provided long-term relief of the symptoms. The diagnosis was verified at diagnostic laparoscopy.

The aim of these case reports is to present the feasibility of isthmo-neovagina anastomosis after Davydov's colpopoiesis in patients with Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH) with a rudimentary uterine horn. Ten MRKH patients were treated surgically with laparoscopic Davydov's vaginoplasty between 2006 and 2012. Two of these patients were found to have a functional rudimentary uterine horn. These patients underwent a 2-step surgical intervention: (1) Davydov's colpopoiesis with a combined laparoscopic and perineal approach and (2) isthmo-neovagina anastomosis with laparotomy in the 2 cases with a uterine horn in a second surgical step 4 and 6 months after the initial procedure, respectively. The main outcome measures were the perioperative and postoperative details, the vaginal length during follow-up, the postoperative initiation of intercourse, and the postoperative menstrual function. Isthmo-neovagina anastomosis was uneventful, and there were no early postoperative complications. The mean hospitalization duration was 9.5 days. Anastomosis was successful in both patients. The mean follow-up was 42 months, and the mean vaginal length was measured 9.5 cm; both patients reported normal intercourse and normal menstrual function. Anatomic restoration of the genital tract in these patients appears to have been successful and led to functional menstruation and restitution of the patients' sex life.

A 40-year-old, nulliparous woman with a known case of Mayer-Rokitansky-Kuster-Hauser syndrome had a 3-month history of cyclic and progressively increasing lower abdominal pain. At laparoscopy, the ovarian fossa, the ovaries, and the uterosacral ligaments were covered with endometriotic lesions bilaterally. Both the ovaries were free and had endometriomas of 3 to 4 cm in size. The fallopian tubes were free and turgid with normal healthy fimbriae. There were 2 horns of the uterus, the right being 5 ! 3 ! 3 cm, and the left being 3.5 ! 2 ! 2 cm. They were not communicating with the vagina, and had evidence of a functional endometrium and adenomyosis, resulting in small hematometra bilaterally. A bilateral (Fig.1 and 2) laparoscopic resection of the rudimentary uterine horns with bilateral salpingo-oophorectomy was undertaken using a harmonic scalpel and bipolar coagulation. The uterine arteries were both identified and were coagulated and resected close to the uterine horns. Both the angles of the vaginal vault were sutured using intracorporeal sutures to the respective round ligaments. Several biopsy specimens of various lesions were taken. The specimens were delivered through the extended left port. The blood loss was 100 mL. A cystoscopy with retrograde ureteral catheterization showed patent ureters bilaterally.

Study Objective To compare the effects of 2 nonsteroidal antiinflammatory drugs of different chemical classes (meloxicam and dexketoprofen) on postoperative intraabdominal adhesion formation in a rat model. Design Experimental study (Canadian Task Force classification I). Setting Center for research and development. Animals Thirty female Wistar albino rats. Interventions The animals were randomly assigned to 1 of 3 groups (10 rats per group) and received intramuscular injections of 0.5 mg/kg dexketoprofen (group 1), 0.5 mg/kg meloxicam (group 2), or 1 mL sterile saline solution (control; group 3) daily for 2 days. Laparotomy was performed, and 1 of the uterine horns was damaged via monopolar electrocautery, whereas an incision was made in the other horn using a scalpel and was sutured to promote adhesion formation. The surgeons were blinded to the treatment method. Drug administration was continued for 5 days. The animals were euthanized at 14 days after surgery. Measurements and Main Results Intraperitoneal macroscopic and microscopic adhesions were assessed using standard adhesion scoring systems. Macroscopic adhesion scores were similar among the 3 groups in each horn (p > .50). The total histologic score was significantly lower in the meloxicam group than in the control group (8.0 vs 15.5; p = .006). Dexketoprofen did not significantly affect the total histologic score (11.0 vs 15.5; p = .09) or individual items (i.e., inflammation, fibroblastic activity, foreign body reaction, collagen formation, and vascular proliferation) compared with the control group (p > .02). Meloxicam significantly inhibited inflammation and collagen formation compared with the control group (p Conclusion Although meloxicam did not affect clinical adhesion formation, it significantly decreased histologic scores compared with those of the control group. Therefore, meloxicam may be suitable in reducing postoperative intraabdominal adhesion formation.

To compare adhesion formation and ease of use of barbed vs traditional suture during myometrial closure in a sheep model.Randomized trial using each subject as its own control (Canadian Task Force classification I).Certified animal research facility.Twenty-three nonpregnant ewes.The Harmonic scalpel was used to create a myometrial incision in each uterine horn, and the incisions were randomly allocated to be closed using either polyglactin 210 (Vicryl) or barbed suture. Each animal served as its own control, with 1 horn sutured using barbed suture and the other horn sutured using Vicryl suture. Ease of use was evaluated by comparing closure times. Adhesion formation was compared at necropsy 3 months later using a standardized adhesion-formation scoring system. The evaluator of the adhesion score was blinded to the exposure at surgery.Mean total procedure time was 13.3 minutes. Myometrial closure was significantly faster using barbed vs traditional suture (126.5 seconds vs 272.6 seconds; p.001). At necropsy 3 months later, adhesions were observed in 12 uterine horns (52.2%) in the barbed suture group vs 10 uterine horns (43.5%) in the Vicryl group (p = .62). The mean (SD) adhesion score was not significantly different between the barbed suture group (3.78 [3.92]) vs the Vicryl group (3.04 [3.75]) ( p = .16).Barbed suture significantly facilitates myometrial closure and is associated with adhesion formation and adhesion severity that is not different from that using Vicryl in an animal model.

Hernia uterine inguinale is a rare condition often presenting within the first few years of life as an asymptomatic palpable mass in the inguinal/groin area. This type of hernia contains uterine tissue and may contain oviducts, ovaries, and rarely the bladder. We report a case of a woman with a history of pelvic pain, found to have a rudimentary uterine horn herniating through the internal inguinal ring. A 24-year-old woman presented with noncyclic pelvic pain and irregular menses. Imaging revealed a solid 6- × 2-cm mass posterolateral to the ascending colon at the level of the pelvic brim in addition to absent right kidney and suspected unicornuate uterus. Laparoscopy with excision of the pelvic mass and appendectomy was performed. Surgical findings revealed a right rudimentary uterine horn herniating through the internal inguinal ring, attached to an elongated ovary/and an oviduct tightly tethered to the pelvic side wall. The result of pathologic study was consistent with rudimentary uterine horn, ovary with multiple cortical cysts, normal oviduct, and normal appendix. Hernia uterine inguinale is a rare condition and an even more uncommon cause of pelvic pain, instead presenting as an asymptomatic palpable groin mass early in life. This has been reported most commonly in the literature as both persistent mullerian duct syndrome and male pseudohermaphroditism. It is most often seen in a phenotypically normal male infant having both testes and uterine tissue present. Few cases have been documented to occur in the female sex, the adult patient, or as a cause of pelvic pain. Abdominal and pelvic imaging is useful in the diagnosis of this condition because it may aid in identifying patients with coexisting mullerian malformations. This subset may be at higher risk for hernia uterine inguinale, and, if presenting with complaints of pain or inguinal mass, it should likewise be considered in the differential diagnosis.