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Background An ectopic pregnancy is a nonviable pregnancy located outside of the endometrial cavity of the uterus, which can be managed medically or surgically. Case A 35-year-old woman with a prior ectopic pregnancy, who reported tubal surgery of unknown location and extent, presented with a recurrent ectopic pregnancy. Ultrasound imaging showed a complex cystic lesion adjacent to the ovary, moderate complex free fluid, and no intrauterine pregnancy. She underwent an urgent diagnostic laparoscopy. Chromopertubation was performed to demonstrate absence of the left fallopian tube. The ectopic pregnancy was incidentally noted to be mobile and was expelled from the right fallopian tube. Conclusion Chromopertubation offers a minimally invasive technique for management of ectopic pregnancy that may reduce injury as a result of less surgical manipulation of the fallopian tube.

Background. Heterotopic pregnancy occurs when two pregnancies occur simultaneously in the uterus and an ectopic location. Treatment includes removal of the ectopic pregnancy with preservation of the intrauterine pregnancy. Treatment is done laparoscopically with either a Laparoendoscopic Single-Site Surgery (LESS) or a multiport laparoscopic surgery. Case. We present a case of a first trimester heterotopic pregnancy in a 42-year-old gravida 5, para 0-1-3-1 female with previous history of left salpingectomy, who underwent laparoscopic right salpingectomy and lysis of adhesions (LOA) via Single-Incision Laparoscopic Surgery (SILS). Conclusion. Although LESS for benign OB/GYN cases is feasible, safe, and equally effective compared to the conventional laparoscopic techniques, studies have suggested no clinically relevant advantages in the frequency of perioperative complications between LESS and conventional methods. No data on the cost effectiveness of LESS versus conventional methods are available. LESS utilizes only one surgical incision which may lead to decreased pain and better cosmetic outcome when compared to multiport procedure. One significant undesirable aspect of LESS is the crowding of the surgical area as only one incision is made. Therefore, all instruments go through one port, which can lead to obstruction of the surgeon’s vision and in some cases higher rate of procedure failure resulting in conversion to multiport procedure.

Endometrial ablation is a minimally invasive surgical option to treat abnormal uterine bleeding. Here, we summarize the evidence regarding patient optimization prior to endometrial ablation and the long-term outcomes of this procedure. Patient optimization includes preoperative planning, patient selection, and preoperative predictors of postoperative failure. Long-term outcomes include postoperative bleeding patterns, frequency of additional procedures for treatment failure, patient satisfaction, risk of endometrial cancer, and pregnancy outcomes. Endometrial ablation is a safe procedure to treat abnormal uterine bleeding in high- and low-risk surgical patients. A prior low transverse cesarean section is not a contraindication to the procedure. Young age at ablation (less than 30–45 years of age) is the most significant risk factor for treatment failure. Preoperative dysmenorrhea, large uterine size, fibroids, and prior tubal ligation may also be risk factors for failure. Reduction in menstrual bleeding and patient satisfaction achieved at 12 months usually persist for 5–10 years. There is a 17–25% risk of subsequent hysterectomy that usually occurs within the first 5 years. Endometrial ablation does not appear to increase the risk for developing endometrial cancer. Lastly, outcomes of post-ablation pregnancy are poor, and preoperative counseling should include a discussion about reliable post-ablation contraception. Endometrial ablation can effectively reduce menstrual blood loss and improve patient satisfaction with effects sustained for years after the procedure and is appropriate to use in high-risk surgical candidates. Younger women should be counseled preoperatively about the risk of treatment failure and need for additional procedures in the future.

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.

Background. Endometriosis usually occurs in the pelvis and often involves the ovaries, the uterosacral and broad ligaments, and the pelvic peritoneum. In rare instances, it can occur in the vasculature of the pelvis. Patients with endometriosis present with abnormal pain, menstrual cycle disruption and infertility. Management of endometriosis is usually surgical with excision of the tissue via laparoscopic means. Case. A 42-year-old Gravida 5, Para 2-0-3-2 patient with a 22 year history of endometriosis, who had had multiple laparoscopic endometriosis resections, total abdominal hysterectomy, and an exploratory laparotomy with bilateral salpingo-oophorectomy, presented with left pelvic pain when standing, dyspareunia, and a 3.7 cm cyst on ultrasound. The patient underwent laparoscopic vessel endometriosis resection and excision of endometriotic nodules from external iliac vessels. Final pathology report showed evidence of old endometriosis in all locations. On interval follow-up, the patient reported sustained relief from pain. Conclusion. Complete resection of endometriosis from large vessels can be successfully achieved laparoscopically by a well-experienced surgeon with delicate, proper techniques.

Background The incidence of adnexal masses in pregnancy is estimated to be Surgical intervention is required particularly in the setting of potential malignancy ovarian torsion or direct mass affect on the pregnancy Single incision laparoscopic surgery SILS averts the potential morbidity of multiple trocar insertions as it is associated with less bleeding pain and better cosmetics and tissue retrieval We describe the use of SILS technique in a week pregnancy complicated by a cm left adnexal cystic mass that was managed with a single incision laparoscopic left salpingectomy with cystectomy Case The patient was a year old pregnant Gravida Para with gestational diabetes and morbid obesity Body Mass Index of Her only pregnancy ended as a spontaneous abortion She initially presented to our clinic at weeks for further evaluation of a large x x cm maternal abdominal cystic mass which had been detected on prenatal ultrasound She was managed by Single Incision diagnostic laparoscopy and Single incision laparoscopic left salpingectomy and left paratubal cystectomy at weeks Pathologic examination of the paratubal cyst revealed the mass to be a benign mullerian serous cystadenofibroma Her recovery was uncomplicated with discharge on the first postoperative day Conclusion In summary removal of this patient s adnexal mass in pregnancy was warranted to avert potential complications The patient s paratubal cyst was drained without leakage and then removed intact through the umbilical incision Single incision laparoscopic cystectomy for large ovarian and paratubal cysts in pregnancy is not only feasible but has also been shown to result in better outcomes There were no complications in this patient intraoperatively postoperatively or in a subsequent pregnancy

Introduction This series of cases was an investigation of the safety and feasibility of robotic laparoendoscopic single-site surgery (R-LESS) as a method of performing sacrocolpopexy. Case presentation This is a retrospective series of 15 cases of R-LESS sacrocolpopexy with the V-Loc (Medtronic, Minneapolis, Minnesota, USA) suture and a retroperitoneal tunneling technique performed by a single surgeon, combined with a literature review. Patient demographic information and perioperative data were analyzed. The standard robotic sacrocolpopexy steps were followed, but the surgeon used a combined technique of V-Loc suture and retroperitoneal tunneling to simplify the procedure. No additional ports were necessary in any of the patients. Management and outcome Using the pelvic organ prolapse quantification (POP-Q) scoring method, the mean preoperative C-point of the 15 patients was +1.16 compared to the mean immediate postoperative C-point, which was -5.5. The mean total sacrocolpopexy time was 74.7 (range, 50-99) minutes and mean mesh anchoring time was 22.60 ± 3.85 minutes. The mean sacral promontory fixation and tunneling and mesh position times were 11.87 ± 3.02 and 5.80 ± 2.14 minutes, respectively. All 15 cases were performed without perioperative or long-term complications. Discussion R-LESS in combination with the V-Loc suture and the retroperitoneal tunneling technique can be safely and feasibly performed, especially in sacrocolpopexy and, potentially, in other POP surgeries. With adequate and systematic training, surgeons can acquire the necessary skills to perform this complex surgical procedure.

Objective To demonstrate how a transvaginal natural orifice transluminal endoscopic surgery (NOTES) tubal reanastomosis is a novel route for tubal surgery. The surgical technique is a combination of traditional vaginal surgery with single-site surgical skills. Design The surgical technique is explained in a stepwise fashion with the use of surgical video footage. The video uses a surgical case to demonstrate the specific techniques necessary to perform a NOTES tubal reanastomosis. Setting Teaching university. Patient(s) A 42-year-old female G2P2 with a history of tubal ligation 11 years before presentation requesting a tubal recanalization. Intervention(s) Transvaginal NOTES tubal reanastomosis was initiated with a posterior colpotomy. A single-site gelport was placed. The fallopian tubes were hydrodissected, the blocked portion of each tube was removed, an epidural catheter was threaded through each lumen, and the two remaining segments of each tube were sutured together in an end-to-end fashion using single-site suturing skills. Main Outcome Measure(s) Transvaginal NOTES tubal reanastomosis as an alternative route for tubal reanastomosis. Result(s) The bilateral fallopian tubes were recanalized with bilateral tubal patency. This was confirmed 8 weeks postoperatively with a three-dimensional sonohystogram, which showed patency of the bilateral fallopian tubes. Conclusion(s) The current preferred technique for reversal of a tubal sterilization is to perform a minimally invasive surgery with an end-to-end anastomosis. This gives the patient a 60%–90% intrauterine pregnancy rate postoperatively. NOTES has the benefits of a fast recovery, no abdominal incisional pain, and an extremely cosmetic outcome. Current research has shown a 0%–3.1% range for the risk of pelvic infection in transvaginal NOTES if prophylactic antibiotics are administered during the surgery. The NOTES tubal reanastomosis combines the traditional vaginal surgery technique of creating a posterior colpotomy with single-site surgical skills like suturing and knot tying. The surgery is completed through a single transvaginal port without an abdominal incision. In the hands of a skilled minimally invasive surgeon, transvaginal NOTES tubal reanastomosis is a feasible and alternative route for this procedure.

Objective This study aimed to report the case of a patient who developed an iliopsoas abscess after a dilation and evacuation for a midtrimester fetal demise. Materials and methods This is a case report of a 35-year-old woman who underwent a dilation and evacuation at 17 weeks' gestation because of a preterm premature rupture of membranes and fetal demise. Four days later, she presented with fevers, chills, malaise, and right lower back, hip, and thigh pain. Magnetic resonance imaging of the abdomen and pelvis revealed a 2.3 × 1.6-cm right iliopsoas abscess. Results The patient underwent computed tomography-guided drainage of the abscess and made an uneventful recovery after completion of an antibiotic course and physical therapy. Conclusions An iliopsoas abscess should be considered in the differential diagnosis of any woman presenting with fevers, chills, and unilateral lower back, hip, and thigh pain in a radicular pattern after a recent dilation and evacuation.

Background Transvaginal surgery is the most minimally invasive surgery for a gynecologic procedure but can be challenging for many to perform as evidenced by its declining rate. Vaginal removal of the adnexal structures can be difficult because of poor visualization. Factors such as abnormal pathology, incidental finding of early-stage endometriosis or adhesions from previous cesarean section or surgery, and obesity may further complicate the procedure. Transvaginal natural orifice transluminal endoscopic surgery (NOTES) may be performed during vaginal surgery using basic laparoscopic single-site skills as a “rescue” procedure for the complete removal of the adnexae. This allows the surgeon to complete the procedure vaginally without requiring conversion or addition of abdominal incisions. The combination of total vaginal hysterectomy (TVH) with NOTES as a “rescue” procedure may be a useful tool for gynecologic surgeons for removal of the adnexae and performance of other pelvic procedures. Study Objective To demonstrate various common pelvic procedures that can be performed by transvaginal NOTES after completion of TVH. Design Variety demonstrations of the transvaginal NOTES technique as a “rescure” for total vaginal hysterectomy with narrated video footage (Canadian Task Force classification III). Setting Academic tertiary care hospital. Patients Patients with various surgeries including prophylactic bilateral salpingectomy, salpingo-oophorectomy, adhesiolysis, and incidental finding of superficial endometriosis resection. This video is exempt from institutional review board review at our institution. Interventions Transvaginal NOTES adnexal surgery and other procedures using basic laparoscopic single-site surgical skills. Measurements and Main Results Salpingectomy, oophorectomy, lysis of adhesions, and resection of endometriosis can be performed using NOTES at the time of vaginal hysterectomy. Conclusion NOTES allows the surgeon to survey the pelvis for pathology and to complete other pelvic procedures transvaginally during TVH with no additional abdominal incisions. Transvaginal NOTES can be considered a “rescue” approach and can be a helpful tool for the pelvic surgeon.

Study Objective To investigate the safety and feasibility of robotic single-site for surgical resection of stage I to IV endometriosis in chronic pelvic pain patients. Design A retrospective cohort study via chart review collected data. All procedures were performed by a single surgeon between January 2015 and April 2019. Setting An academic university hospital. Patients or Participants A total of 272 patients with chronic pelvic pain and pathology confirmed endometriosis were managed with surgical resection via the robotic single-site laparoscopy. All of the patients were chronic pelvic pain who incurred symptoms of dysmenorrhea, menorrhagia, deep dyspareunia, although other symptoms may be present such as dysphasia, lower back pain, urinary, or intestinal symptoms. Interventions All procedures were completed successfully with robotic single-site resection; however, an additional port was added in fourteen cases due to deep infiltrating endometriosis with colorectal, urinary tract involvement and extensive pelvic adhesion. Measurements and Main Results The median operative time was 110 min (range, 45-480 min), and the median blood loss was 50 mL (range, 15-300 mL). The length of hospital stay was less than 24 hours for 90.8% of patients (247/272). The incidence of complication was 5.9% (16/272). All but two surgeries had no severe complications, which included eight wound infection, one vaginal cuff dehiscence, four urinary tract infection and pelvic abscess. One patient with symptomatic bowel endometriosis nodule developed in the right abdominal wall and perineal hematoma after lower anterior bowel resection. The other patient, who had undergone a double ureteral malformation, ureteral endometriosis, and severe adhesion, had injured the left ureteral ten days after extensive pelvic and bladder nodule endometriosis resection. Conclusion Robotic single-site laparoscopic resection of endometriosis surgery appears to be a reasonably safe and feasible method for the surgical management of women with endometriosis. Adding a port is a good alternative if challenging cases encountered.