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To show how obturator internus endometriosis can safely be managed with laparoscopic resection. Stepwise demonstration of the technique with narrated video footage. Endometriosis is a common disease that can affect the pelvic organs as well as distal structures. It can rarely be found invading into the muscles surrounding the pelvis. We present the case of a 46-year-old with a known history of endometriosis who had left hip pain and was found to have a nodule on the left obturator internus muscle on MRI concerning for an endometriosis implant. This space is not commonly entered during gynecologic surgery but with thorough anatomical knowledge and careful surgical technique the endometriosis implant can be safely removed laparoscopically. Laparoscopic resection of left obturator internus endometriosis implant with the following key steps: 1. Left ureterolysis is performed. 2. The external iliac artery is followed to the psoas muscle and then the obturator muscle. 3. The obturator nerve is identified and then dissected to the level of the obturator foramen. 4. The left uterine artery is dissected at its origin and ligated. The obturator artery is identified and spared. 5. The bladder is backfilled to confirm the nodule does not invade into the bladder wall. 6. The obturator internus nodule is fully isolated and excised. Pathology confirmed endometriosis in all excised nodules and the patient had significant symptomatic improvement at 4 weeks postop. Endometriosis lesions in the obturator internus muscle can cause significant symptoms and surgical resection with laparoscopy is safe with thorough anatomical knowledge and careful surgical technique. [ABSTRACT FROM AUTHOR]

Objective: To determine if higher-volume, fixed-dose administration of vasopressin further reduces blood loss at the time of minimally invasive myomectomy.Design: Randomised multicentre clinical trial.Setting: Tertiary-care academic centres in the USA.Population: Women undergoing conventional laparoscopic or robot-assisted laparoscopic myomectomy.Methods: All participants received the same 10-unit (U) dose of vasopressin, but were randomly assigned to one of two groups: (i) received 200 ml of diluted vasopressin solution (20 U in 400 ml normal saline), and (ii) received 30 ml of concentrated vasopressin solution (20 U in 60 ml normal saline).Main Outcome Measures: The primary study outcome was estimated blood loss; the study was powered to detect a 100-ml difference.Results: A total of 152 women were randomised; 76 patients in each group. Baseline demographics were similar between groups. The primary outcome of intraoperative blood loss was not significantly different, as measured by three parameters: surgeon estimate (mean estimated blood loss 178 ± 265 ml and 198 ± 232 ml, dilute and concentrated groups respectively, P = 0.65), suction canister-calculated blood loss, or change in haematocrit levels. There were no vasopressin-related adverse events.Conclusion: Both dilute and concentrated vasopressin solutions that use the same drug dosing demonstrate comparable safety and tolerability when administered for minimally invasive myomectomy; however, higher volume administration of vasopressin does not reduce blood loss.Tweetable Abstract: This randomised trial failed to show benefit of high-volume dilute vasopression. [ABSTRACT FROM AUTHOR]

The article presents case studies of four women diagnosed with caesarean scar ectopic pregnancy who were treated using laparoscopic technique. Results reveal that the laparoscopic approach is a safe treatment option for caesarean ectopic pregnancy without complications. Also mentioned is the advantage of the technique compared to other methods.

Study Objective: To explore attitudes and hysterectomy practices among gynecologists in the United States and to identify potential barriers to offering minimally invasive hysterectomies.Design: Mixed-mode (online and on-paper) survey of a random sample of 1500 practicing obstetrician-gynecologists.Setting: Nationwide survey in the United States.Participants: Nonretired obstetrician-gynecologists identified through a physician list from the American Medical Association.Interventions: Postal and online survey. MEASUREMENTS & MAIN RESULTS: We received a response from 376 physicians (25.8% response rate). The average age of respondents was 47.9 years, and 87% were generalists. Participants performed on average 4 surgical cases per week and 32 hysterectomies per year, most of which were abdominal hysterectomies. When asked for preferred mode of access for themselves or their spouse, 55.5% chose vaginal hysterectomy (VH), 40.6% chose laparoscopic hysterectomy (LH), and 8% chose abdominal hysterectomy (AH). Younger physicians (<40) and high surgical volume physicians were significantly more likely to chose a laparoscopic approach and identified significantly fewer barriers for performing LH. The main barriers to performing VH were technical difficulty, potential for complications, and caseload of VH. The main barriers for performing LH were training during residency, technical difficulty, personal surgical experience and operating time. The majority of gynecologists wanted to decrease their AH rates and increase their LH rates. The most significant identified contraindications to VH were prior laparotomy, a uterus larger than 12 weeks, narrow introitus, adnexal mass, and minimal uterine descent.Conclusions: While a large majority of gynecologists would prefer a VH or LH for themselves or their spouse, AH remains the most common hysterectomy method in the United States. A generation gap appears to be brewing with younger gynecologist more in favor of the laparoscopic approach. More emphasis should be placed on training gynecologists in performing minimally invasive hysterectomies, given their desire to change their surgical mode of access. [ABSTRACT FROM AUTHOR]

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. 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. 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. 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. N/A. 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. 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. [ABSTRACT FROM AUTHOR]

Video presentation showing retroperitoneal dissection and deep pelvic side wall anatomy. Case presentation. Tertiary medical center. 74-year-old female with history of type 2 diabetes, hypertension, and a vaginal hysterectomy with left sacrospinous ligament suspension nine years ago, presented with fever and found to have bacteremia. Abdominal and pelvic MRI showed a presacral and precoccygeal loculated collections, sacral osteomyelitis, and fistula from the left superior vaginal vault to one of the presacral collections. Laparoscopic resection of sacrospinous fistula tract. The patient showed significant improvement in her symptoms with resolution of low back pain, vaginal discharge and bleeding. Gentle dissection with maintained hemostasis, creating windows, and starting from less distorted anatomy are key points in retroperitoneal dissection. [ABSTRACT FROM AUTHOR]

To demonstrate the feasibility of excision of a transmural rectal endometriosis nodule and repair of the rectal defect. 26yo Gravida-0 with pelvic pain, cyclic hematochezia, and dyschezia presented with biopsy-proven rectal endometriosis. Pelvic MRI revealed a 2.3 × 2.0 × 1.8cm an endometriotic implant extending from the mesorectal fascia into the mucosa. There was also an adjacent 2.5cm endometrioma. Laparoscopic local excision was offered since the lesion was <3cm in greatest diameter, too large for discoid excision, and the procedure offered an alternative to bowel resection. Intraoperative findings were notable for an obliterated posterior cul de sac. There was a firm, 2-3cm nodule in the anterior rectum with an adjacent endometrioma. The case begins with mobilization of the ureters and the rectum bilaterally. The ultrasonic scalpel is used to dissect the rectovaginal septum and subsequently drain the endometrioma. The rectum overlying the nodule is injected with dilute vasopressin to maintain hemostasis. Cold scissors are used to open the rectal serosa, and the ultrasonic scalpel is then used to fully excise the transmural rectal nodule. Once the nodule is completely detached, it is removed through the rectal defect within in a laparoscopic specimen bag. The remaining rectal defect is closed in three layers, which involves reapproximation of the mucosa, an imbricating layer, and reinforcement of the serosa. Copious warm irrigation is performed, and a medium EEA sizer is passed through the area of the repair to ensure normal caliber. An air-leak test is negative. At her postoperative visit, the patient endorsed complete resolution of her hematochezia and dyschezia. Transmural rectal endometriotic nodules less than 3cm in size may be amenable to resection with primary repair in select patients. Preoperative bowel prep is not recommended. After closure, checking for an air-tight closure and adequate lumen caliber is essential. [ABSTRACT FROM AUTHOR]

To assess the feasibility of outpatient laparoscopic management of apical pelvic organ prolapse along with indicated vaginal repairs and anti-incontinence procedures. Retrospective cohort study. Tertiary-care academic center, Boston, MA. 112 patients seen in the Minimally Invasive Gynecologic Surgery (MIGS) and Urogynecology clinics with symptomatic pelvic organ prolapse. Laparoscopic hysterectomy, sacro (cervico- or colpo-) pexy along with vaginal prolapse and anti-incontinence procedures as indicated from 2013-2017 at Brigham & Women's Hospital and Brigham & Women's Faulkner Hospital performed by a MIGS and Urogynecology team. Of the 112 patients, 52 were outpatient and 60 were admitted (median stay in admission group = 1 day; range 1-3). Patient baseline characteristics, ASA class, and POP-Q stage were similar between the outpatient and admitted cohorts. Most patients underwent hysterectomy at the time of the sacropexy (65.4% outpatient vs 73.3% admitted, p=.08). Concomitant AP repair was more common in the outpatient group (98.1% vs 85%, p =.02). The proportion of outpatient procedures increased from 17% in 2013 to a peak of 70% in 2016. OR time was shorter for the outpatient cohort (103.9 mins vs 115.5 mins, p =.04), but other peri-operative outcomes were similar. There were no intra-operative complications. Post-operative complications, readmission and re-operations were low and similar between outpatient and admitted cohorts. No factor was predictive of admission on regression analysis. Laparoscopic apical prolapse repair with concomitant vaginal repairs can be performed safely as an outpatient procedure. A unique team approach may foster a shorter, more efficient procedure without compromising short term outcomes. [ABSTRACT FROM AUTHOR]

To assess the efficacy of a superior hypogastric plexus block (SHPB) for pain relief following laparoscopic hysterectomy. Multi-center, single-blind, randomized controlled trial. Brigham and Women's Hospital, Boston, MA, University of North Carolina Medical Center, Chapel Hill, NC, and George Washington University Hospital, Washington, D.C. 100 patients undergoing laparoscopic hysterectomy for benign indications were recruited between January 2018 and February 2019. Patients were randomized to receive a SHPB (n = 50) or no block (n = 50) at the start of laparoscopic hysterectomy. The block contained 10 mL of 0.25% bupivacaine injected in the presacral space. The proportion of patients with a mean VAS (visual analogue scale) pain score less than 4 within 2 hours postoperatively was defined a priori as the primary outcome and compared between the groups. An intention to treat analysis was performed. Patients in the SHPB group were 1.6-times more likely to have a mean VAS < 4 within 2 hours postoperatively compared to women in the no block group (52.0% of women in the block group compared to 40.0% in the no block group), however this did not reach statistical significance (OR 1.63, 95% CI 0.74 to 3.59). Patients in the SHPB group were significantly more likely to have a mean VAS < 4 within 1 hour postoperatively (OR 2.90, 95% CI 1.29 to 6.53). Total postoperative opioid use within four hours postoperatively, total recovery unit time, and hospital length of stay were no different between the two groups. Mean daily VAS pain scores were also no different for one week postoperatively. SHPB reduces immediate postoperative pain after laparoscopic hysterectomy however this effect does not extend to two hours postoperatively. SHPB does not impact opioid consumption, long-term pain, or recovery unit time. [ABSTRACT FROM AUTHOR]

The objective of this video is to review the utility of patient-specific 3D printed models of the uterus in surgical planning and as an intraoperative visual aid in laparoscopic myomectomy. Patients undergoing a laparoscopic myomectomy with the Minimally Invasive Gynecologic Surgery department at Brigham and Women's Hospital were prospectively identified. Women with three or more fibroids and a preoperative MRI for their planned laparoscopic myomectomy were approached for the study, and verbal consent was obtained. Models were printed for three patients in the series, and one case is reviewed in detail in this video. MRI of the pelvis was acquired for each patient. The DICOM images resulted from the MRI were converted to Standard Tesselation Language (STL), using image segmentation and postprocessing software (Mediprint, Chester, NY). The STL file was printed using a 3D printer (PolyJet J750; Stratasys, Eden Prairie, MN). The models are printed in a clear polymer with fibroids selectively colorized. Transverse slices allow visualization of the intramural extent of fibroids. The models were provided to surgeons for preoperative planning and were also available to the surgeon intraoperatively. Intraoperatively, the models were manipulated outside the sterile field by the research assistant. 3D printing is a developing technology with potential for use in surgery. In laparoscopic myomectomy, patient-specific 3D models present an additional tool for preoperative and intraoperative planning. Primary uses include planning of hysterotomies, assessment of the depth of myometrial involvement and proximity to the uterine cavity, and intraoperative identification of fibroids which are not visible or palpable laparoscopically. Additionally, the 3D model can serve as an educational tool for patients and trainees. Currently cost and the time to print 3D models are limiting factors for widespread use. As this technology develops, 3D printing may become a more promising surgical tool. [ABSTRACT FROM AUTHOR]

Since the 2014 Food and Drug Administration warnings regarding the use of power morcellation, gynecologists have adopted multiple alternative tissue extraction strategies. The objective of this study is to investigate the current techniques used by minimally invasive gynecologic surgeons for tissue extraction following minimally invasive hysterectomy for fibroids. Web-based survey. N/a Current AAGL members were sent a link to access the survey, which was available from March 26, 2019 to April 17, 2019. N/a. 420 respondents completed the survey. The most common methods of tissue extraction were manual morcellation through the colpotomy (72.4%) and mini-laparotomy (66.9%). 31.7% of all participants endorsed the use of power morcellation. Intact specimen removal through a laparotomy was reported by 10% of respondents. Other methods of tissue extraction, such as intra-abdominal manual morcellation with a laparoscopic scalpel, were reported by 1.4%. Use of containment bags was reported by 43.4% during vaginal morcellation, 83.6% during mini-laparotomy, and 56.8% during power morcellation. Mini-laparotomies were on average 3.5cm and most commonly located at the umbilicus. Geographic differences were seen with respect to power morcellation, with 18.4% of US-based surgeons reporting its use compared to 56.9% of non-US-based surgeons. Minimally invasive gynecologic surgeons are currently employing a variety of tissue extraction strategies for hysterectomy for fibroids. A large majority of practitioners are performing manual morcellation through the colpotomy and/or mini-laparotomy; use of containment bags is more common with during mini-laparotomy than via colpotomy. Power morcellation is still in use, less commonly in the United States than in other countries, and usually within a containment system. [ABSTRACT FROM AUTHOR]