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Consumer-based mobile meditation applications may help women self-manage stress and other mental health symptoms, especially during the coronavirus disease (COVID-19) pandemic., OBJECTIVE: To assess the effect of a consumer-based mobile meditation application (app) on wellness in outpatient obstetric and gynecology patients during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: We conducted a randomized controlled trial at a university outpatient clinic of obstetric and gynecology patients during the COVID-19 pandemic. Women were randomly assigned to the intervention group, who was prescribed a mobile meditation app for 30 days, or the control group, which received standard care. The primary outcome was self-reported perceived stress. Secondary outcomes included self-reported depression, anxiety, sleep disturbance, and satisfaction with the meditation app. A sample size of 80 participants (40 per group) was calculated to achieve 84% power to detect a 3-point difference in the primary outcome. RESULTS: From April to May 2020, 101 women were randomized in the study—50 in the meditation app group and 51 in the control group. Analysis was by intention-to-treat. Most characteristics were similar between groups. Perceived stress was significantly less in the intervention group at days 14 and 30 (mean difference 4.27, 95% CI 1.30–7.24, P=.005, d=0.69 and mean difference 4.28, 95% CI 1.68–6.88, P=.002, d=0.69, respectively). Self-reported depression and anxiety were significantly less in the intervention group at days 14 and 30 (depression: P=.002 and P=.04; anxiety: P=.01, and P=.04, respectively). Sleep disturbance was significantly less in the intervention group at days 14 and 30 (P=.001 and P=.02, respectively). More than 80% of those in the intervention group reported high satisfaction with the meditation app, and 93% reported that mindfulness meditation improved their stress. CONCLUSION: Outpatient obstetric and gynecology patients who used the prescribed consumer-based mobile meditation app during the COVID-19 pandemic had significant reductions in perceived stress, depression, anxiety, and sleep disturbance compared with standard care. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT04329533.

Purpose of review The purpose of this review is to summarize the most recent evidence-based interventions for perioperative pain management in minimally invasive gynecologic surgery. Recent findings With particular emphasis on preemptive interventions in recent studies, we found preoperative counseling, nutrition, exercise, psychological interventions, and a combination of acetaminophen, celecoxib, and gabapentin are highly important and effective measures to reduce postoperative pain and opioid demand. Intraoperative local anesthetics may help at incision sites, as a paracervical block, and a transversus abdominus plane block. Postoperatively, an effort should be made to utilize non-narcotic interventions such as abdominal binders, ice packs, simethicone, bowel regimens, gabapentin, and scheduled NSAIDs and acetaminophen. When prescribing narcotics, providers should be aware of recommended amounts of opioids required per procedure so as to avoid overprescribing. Summary Our findings emphasize the evolving importance of preemptive interventions, including prehabilitation and pharmacologic agents, to improve postoperative pain after minimally invasive gynecologic surgery. Additionally, a multimodal approach to nonnarcotic intraoperative and postoperative interventions decreases narcotic requirement and improves opioid stewardship.

Large vessel involvement and arterial aneurysms are not typically encountered in Granulomatosis with Polyangiitis (GPA), which is a small vessel disease. We report the case of a 70-year-old male presenting with a ruptured hepatic artery aneurysm and elevated Antineutrophil Cytoplasmic Autoantibody, Cytoplasmic (c-ANCA) titer, 9 months after the diagnosis of GPA, while on maintenance therapy with rituximab. The liver aneurysm was successfully treated with coiling and reintroduction of prednisone. Large and medium vessel aneurysms can be seen in the context of GPA, which warrants a low threshold for screening and prompt intervention to prevent life-threatening rupture.

Background Cardiovascular disease, one of the main Non-Communicable Disease (NCD), is the first cause of death in the world representing 30% of global mortality. Their prevention, early detection, reduction of risk and progression are major daily challenges. Success depends on patient adherence which is the most enigmatic and difficult challenge for the physician to assess. Our objective was to better understand Patients' Experience, including their behavior and knowledge of the risks and benefits of their treatment, as well as their perception of therapeutic adherence and iatrogenic risk. Purpose This real-world study conducted on patients affected by cardiovascular diseases, identified their views on iatrogenic risk and compliance with their condition and treatment intake. Method An online survey was conducted on the Carenity platform among adult patients affected by cardiovascular disease (CV) between February 14th and May 15th, 2020. A multiple correspondence analysis (MCA) was performed on a dataset of French patients with CV disease using a hierarchical cluster analysis. Results 403 patients (women 54%) mean age 60,6 YO with High Blood Pressure (56,6%), diabetes (28,3%), heart attack (26%), hypercholesterolemia (22%), arrythmia (19,6%), stroke (14%). Mean number of medications per day was 5,1 and 6,1 of pills. 3 groups of patients were identified as per MCA. The group 1 “at risk” (n=168) concerns the least compliant patients, mostly women. They visit more often their doctor (83%), whom they are afraid to disappoint. 46% deliberately deviate from initial prescription even if they feel compliant (73%). They consider they are less likely to have received explanation on treatment benefits (73%). They seem to be more worried about incompatibility with daily life (33%) and frequency of administration (40%). 34% are more likely to be afraid of becoming dependent and 49% lacking efficacy. 76% discuss about constraints and risks with someone. The group 2 “tolerant” (n=90) includes patients less aware with interactions with other treatments (73%) and with alcohol (64%). They do not think it is necessary to inform their doctor about compliance issues (76%). The group 3 “reporters” (n=145) concerns patients, mostly men, who feel more compliant (90%) than others. They feel informed (84%), they use practical solutions to be compliant (63%) and they are aware of treatment interactions such as tobacco (37%). Conclusion These results from the Patient Experience, suggest new patient behaviors and profiles. They focus on coping mechanisms and solutions they develop to manage their relationship with treatment. These identified profiles should be included in the Therapeutic Patient Education approach. The objective is to improve overall management by increasing compliance and reducing the iatrogenesis risk. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Pfizer PFE France, a Viatris company

We review the main results of our investigations motivated by the tadpole potentials of ten-dimensional strings with broken supersymmetry. While these are at best partial indications, it is hard to resist the feeling that they do capture some lessons of String Theory. For example, these very tadpole potentials lead to weak-string-coupling cosmologies that appear to provide clues on the onset of the inflation from an initial fast roll. The transition, if accessible to us, would offer a natural explanation for the lack of power manifested by the CMB at large angular scales. In addition, the same tadpole potentials can drive spontaneous compactifications to lower-dimensional Minkowski spaces at corresponding length scales. Furthermore, the cosmological solutions exhibit an intriguing "instability of isotropy" that, if taken at face value, would point to an accidental origin of compactification. Finally, symmetric static AdS x S solutions driven by the tadpole potentials also exist, but they are unstable due to mixings induced by their internal fluxes. On the other hand, the original Dudas-Mourad solution is perturbatively stable, and we have gathered some detailed evidence that instabilities induced by internal fluxes can be held under control in a similar class of weak-coupling type-IIB compactifications to Minkowski space., Invited contribution to the special issue of Letters in High Energy Physics (LHEP) on "Swampland and String Theory Landscape", edited by I. Antoniadis, K. Benakli and E. Dudas

Background: Cervical insufficiency is one cause of preterm birth and its associated neonatal outcomes. Transabdominal cerclage is an option for women with cervical insufficiency and a hist...

The objectives of the study were to compare the cephalad migration of two patient positioning pads used in robotic gynecologic surgery and to determine if any correlation exists between cephalad movement and time in Trendelenburg position or body mass index. This was a prospective randomized controlled open-label trial (Canadian Task Force classification I). Sixty women undergoing robotic-assisted laparoscopic gynecologic surgery were randomized to the Pink Pad® system or egg-crate foam pre-operatively. Patients were placed under general anesthesia and then positioned in dorsal lithotomy. The locations of the iliac crest, acromion process, and buttock were marked on the table before and after surgery to calculate cephalad migration during surgery. The primary outcome was centimeters of cephalad migration at the three anatomic landmarks. Comparing the Pink Pad® (n = 24) to the egg-crate group (n = 26) revealed similar mean cephalad migration at the iliac crest (4.8 cm vs 4.3 cm, p = 0.56) and the shoulder (4.6 cm vs 3.9 cm, p = 0.39), and less cephalad migration at the buttock (median 3.0 cm vs 2.0 cm, p = 0.041). The total time in Trendelenburg was not correlated with cephalad migration at any anatomic landmark. Body mass index was positively correlated with cephalad migration only at the iliac crest (p = 0.032) regardless of pad type. The egg-crate foam resulted in less cephalad migration at all anatomic sites and significantly less migration at the buttocks compared to the Pink Pad®. This suggests that the less-costly egg-crate foam is noninferior to the Pink Pad® system and trends at superiority.

High-risk pregnancy stratification and the use of Progesterone and prophylactic cerclage based on prior obstetrical outcomes and cervical length screening have been successful in curbing the impact of preterm birth. However, a large number of women will still suffer from preterm delivery even with optimal management. Experts agree that a transabdominal cerclage is the next best option for women who fail a transvaginal cerclage in a prior pregnancy. Our primary objective with this study is to assess the obstetric benefits and feasibility of robotic-assisted transabdominal cerclage in high-risk women projected to have poor obstetric outcomes.A multicenter retrospective cohort analysis of consecutive patients undergoing a robotic-assisted transabdominal cerclage (RA-TAC) for obstetric indications at two urban teaching university hospital and one academically affiliated community hospital. High-volume gynecologic surgeons performed all transabdominal cerclage procedures (N = 68). To assess whether the transabdominal cerclage had any effect on subsequent pregnancies, we categorized gestational age into ordinal variables and used a two-proportion z-test to compare pregnancy outcomes and neonatal survival pre (n = 200) and post (n = 59) abdominal cerclage placement.A total of 68 consecutive patients undergoing a RA-TAC for obstetric indications were selected. We compared 200 pregnancies pre-robot-assisted cerclage to 59 pregnancies post-robot-assisted cerclage. The odds of delivering after 34 and 37 weeks gestational age was 4.0 and 3.6 times greater post-robot-assisted cerclage, respectively (P 0.001). The RA-TAC also had a significant effect on neonatal survival. The odds of neonatal survival was 12.6 times greater after RA-TAC placement when compared to prior pregnancy outcomes. Surgical outcomes were also favorable with no conversions to laparotomy or perioperative pregnancy loss.The RA-TAC influences an increase in gestational age and improves neonatal survival in women projected to have poor pregnancy outcomes. The robot-assisted transabdominal cerclages provide excellent obstetric outcomes without the morbidity of a laparotomy or the technical challenges associated with a conventional straight-stick laparoscopy. This procedure is not intended to replace any other minimally invasive modality for cerclage placement but rather increase awareness of a less technically challenging option for transabdominal cerclage placement to help propagate the procedure to more patients.

Study Objective To investigate the impact of retained cystoscopy fluid after laparoscopic hysterectomy on time to spontaneous void, time to discharge, urinary retention, bladder discomfort, and patient satisfaction. Design Single-blind randomized controlled trial. Setting An academic medical center. Patients One hundred and twenty patients who underwent laparoscopic hysterectomy with universal cystoscopy for benign indications, excluding pelvic organ prolapse and urinary incontinence indications. Interventions From October 10, 2018, to October 17, 2019, we compared 200 mL retained cystoscopy fluid and complete bladder emptying after laparoscopic hysterectomy with universal cystoscopy. Measurements and Main Results A total of 120 patients were enrolled and randomized (59 in the retained cystoscopy fluid group and 61 in the emptied fluid group). The primary outcome was time to first spontaneous void. The secondary outcomes were time to discharge, urinary retention rates, bladder discomfort, and patient satisfaction. A sample size of 120 was calculated to detect a 57-minute difference in time to spontaneous void. There were minimal differences in baseline demographics and surgical characteristics between the groups. There was an apparent, although not significant, difference in time to void of 25 minutes (143 minutes vs 168 minutes, p = .20). Time to discharge and urinary retention rates did not differ (199 minutes vs 214 minutes, p = .40, and 13.6% vs 8.2%, p = .51, respectively). There was no difference in postoperative bladder discomfort and patient satisfaction. Conclusion Retained cystoscopy fluid after laparoscopic hysterectomy did not significantly affect time to first spontaneous void, time to discharge, urinary retention, bladder discomfort, or patient satisfaction.

Resume Introduction La chondrocalcinose est un rhumatisme microcristallin provoque par la presence de cristaux de pyrophosphate de calcium dans l’articulation. Nous rapportons une observation exceptionnelle de pseudo-abces musculaire microcristallin mimant une infection osteo-musculaire de hanche. Observation Un homme de 92 ans etait hospitalise pour l’exploration de douleurs inguinales gauches subaigues. A l’examen clinique, le patient presentait une douleur inguinale et un psoitis. Le bilan biologique montrait un syndrome inflammatoire. L’imagerie mettait en evidence plusieurs collections au sein des muscles iliopsoas et petit gluteal associees a une arthrite de hanche gauche. La ponction des collections rapportait un liquide inflammatoire sterile. L’analyse anatomopathologique revelait des cristaux de pyrophosphate de calcium, confirmant le diagnostic de pseudo-abces aseptique lie a une chondrocalcinose, probablement consequence d’une bursite de hanche. Le traitement medical associe au drainage radioguide etait partiellement efficace, le patient recidivant sous la forme de bursites multiples. Conclusion L’atteinte de chondrocalcinose de hanche est rare, et son association a une atteinte musculaire est exceptionnelle, avec a notre connaissance seule 4 autres cas publies dans la litterature. Le mecanisme le plus probable est une infiltration par contiguite avec formation d’un pseudo-abces aseptique musculaire. Un mecanisme primitif par neoformation musculaire de microcristaux est egalement discute. Une revue des cas publies dans la litterature montre une evolution favorable mais parfois au prix d’un drainage chirurgical. Cette atteinte doit etre connue et distinguee des abces musculaires d’origine infectieuse.

Study Objective The objectives of this film are to review pelvic anatomy and levels of pelvic support, present a technique for uterosacral ligament suspension done robotically at the time of hysterectomy, and discuss suture choices for long-lasting support. We discuss important points to consider when performing the procedure, and suggest a technique that results in a reliable outcome. Design N/A. Setting Operating room with patient in reverse Trendelenburg and Da Vinci Xi robot docked. Patients or Participants N/A. Interventions Uterosacral Ligament Suspension with barbed delayed absorbable suture and serpentine stitches. Measurements and Main Results The correction of an apical defect can be accomplished with uterosacral ligament suspension, which can also decrease the severity of cystocele and rectocele. Starting with a peritoneal releasing incision can mobilize the ureter and avoids kinking of the ureter when tugging on the ligament. Suture choices include barbed delayed absorbable sutures and permanent sutures. Barbed delayed absorbable suture dissolves in 180 days, which is enough time to form scar tissue that will continue to support the suspension. Serpentine stitches along the ligaments are made and tightened to shorten the ligament, which fixes it to the vagina allowing for elevation of the apex. A McCall's culdoplasty can be done with the same suture, reducing enterocele. Finally, plicating the uterosacral ligaments at the end brings them to the midline and strengthens the suspension. Conclusion In conclusion, uterosacral ligament suspension at the time of robotic hysterectomy can correct uterovaginal prolapse. Barbed delayed absorbable suture is a viable alternative to permanent sutures due to scar formation. Peritoneal releasing incisions between the ureter and uterosacral ligament protect the ureter from kinking. Serpentine bites around the uterosacral ligaments result in secure cinching of the tissue, which contributes to a reliable suspension.

Study Objective To demonstrate our technique of vertical cuff closure. Design Video presentation. Setting Academic Medical Center. Patients or Participants N/A. Interventions Robotic Vertical Vaginal Cuff Closure. Measurements and Main Results N/A. Conclusion Vertical cuff closure is a reasonable alternative to horizontal cuff closure.

Depuis le debut de l’annee 2020, le monde a ete bouleverse par une pandemie virale dont les effets depassent largement le strict cadre de la Sante. Ce nouveau virus a concentre au cours de cette periode une large partie des ressources de soins, mais egalement de recherche, afin de proposer le plus rapidement possible des solutions preventives et therapeutiques permettant de diminuer le fardeau des maladies qu’il provoquait. D’une maladie que certains croyaient purement virale, les soignants et les chercheurs ont pu rapidement evoluer pour rapprocher les formes graves de l’infection de ce qui avait ete observe dans d’autres pathologies, infectieuses ou non, a savoir une reponse excessive de l’hote a l’infestation virale. Celle-ci prend la forme biologique d’un orage cytokinique qui est rapidement devenu la cible preferentielle des therapeutiques commencant a prouver leur efficacite chez ces patients graves, au contraire des approches antivirales. De facon concomitante, la survenue d’accidents thrombotiques graves, parfois atypiques, a la fois arteriels et veineux, a fait prendre conscience de l’existence d’une endothelite et d’une coagulopathie excessive responsables a elles seules d’une proportion significative des deces en reanimation, en salle, comme tres probablement a domicile ou en EHPAD. Les medecins vasculaires ont souvent ete en premiere ligne au chevet des patients, pour depister et traiter les complications thrombotiques des cas les plus graves. Des lors, il apparaissait evident au comite scientifique d’organiser cette session lors de ce congres afin de presenter les connaissances epidemiologiques, pathophysiologiques et therapeutiques acquises au cours des 6 derniers mois a travers l’experience d’infectiologues, de medecins vasculaires, d’internistes et de dermatologues. Une large place sera laissee aux questions de l’auditoire, afin de repondre au maximum des interrogations que cette maladie suscite.

Objectifs Les antagonistes de la vitamine K (AVK) representent la premiere classe pharmacologique en termes de iatrogenie medicamenteuse en partie due a la difficulte de maintenir le patient dans sa fourchette therapeutique. Le risque d’hemorragie augmente considerablement lorsque l’INR est ≥ 5. L’objectif principal de ce travail a ete d’evaluer la faisabilite de l’exploitation des donnees medicales informatisees sur la problematique du surdosage en AVK en milieu hospitalier tous services confondus. Methode Ce travail descriptif monocentrique a interroge la base numerique d’un hopital parisien sur 21 275 dosages d’INR realises entre janvier 2013 et octobre 2018 (6813 sejours), chez les patients hospitalises. Un premier travail a consiste a extraire de maniere informatisee les INR ≥ 5 a j2 de l’hospitalisation afin d’etudier la prevalence du surdosage en AVK. Une analyse manuelle des dossiers a par la suite etudie la conformite de la prise en charge du surdosage selon les recommandations de la HAS. Resultats Un surdosage en AVK avec un INR ≥ 5 a j2 a ete retrouve au cours de 350 (6 %) sejours hospitaliers (331 patients). L’âge moyen de cette population de patients etait de 85 ans et 57 % etaient des femmes ; 23 (7 %) patients ont presente une complication hemorragique, dont 11 etaient des complications hemorragiques graves prises en charge medicalement. Quinze deces intra hospitaliers (4 %) ont ete rapportes sans permettre de faire un lien avec le surdosage. L’infection et la decompensation cardiaque etaient les motifs d’hospitalisation les plus frequemment retrouves. La prise en charge du surdosage en AVK n’etait pas conforme aux recommandations dans 42 % des cas. L’analyse informatisee a par la suite etudie les caracteristiques cliniques/biologiques/comorbidites associees (PMSI)/prescriptions medicamenteuses selon l’existence ou non d’un surdosage au cours des 6813 sejours permettant d’identifier les facteurs de risque associes. Conclusion L’etude informatisee de ces donnees medicales permet d’identifier des profils de patients a risque de surdosage au cours de leur prise en charge hospitaliere. Une amelioration de la pharmacovigilance en est attendue. L’exploitation de ces donnees informatisees sur la problematique du surdosage en AVK en milieu hospitalier servira a terme a proposer des outils d’aide pour une prise en charge personnalisee des patients, comme par exemple la creation de systeme d’alerte lors de la prescription informatisee.

Study Objective To investigate the impact of a consistent anesthesiologist for laparoscopic hysterectomy on time to discharge and same-day discharge. Design A retrospective cohort study. Setting An academic medical center. Patients or Participants Two hundred and twenty patients who underwent laparoscopic hysterectomy for benign indications. Interventions Outpatient laparoscopic or robotic-assisted hysterectomy between 2018 and 2019. Measurements and Main Results A total of 220 patients were included in the study with 99 patients who had a single consistent anesthesiologist and 121 patients who had inconsistent anesthesiologists from a large anesthesia provider group. Demographic and preoperative characteristics between groups were similar, except patients with an inconsistent anesthesiologist were more likely to be tobacco users (p = .005). Surgery variables not controlled by the anesthesiologist were similar between groups including operative time, uterine weight, urine output, and estimated blood loss. Variables which are controlled by the anesthesiologist at our institution included intraoperative and recovery room opioids, NSAIDS, and intravenous (IV) fluids. The consistent anesthesiologist gave intraoperative and recovery room fentanyl more frequently than morphine and hydromorphone, gave more IV ketorolac, and gave less IV fluids (500mL versus 1000mL, p Conclusion The presence of a single consistent anesthesiologist significantly shortened the time to discharge and improved the success of same-day discharge after outpatient laparoscopic hysterectomy.

To compare obstetric and surgical outcomes of transabdominal cerclage (TAC) via laparotomy (TAC-LAP) versus robotic-assisted (TAC-RA) approaches.Retrospective cohort study.An academic medical center.Sixty-nine women with acquired or congenital cervical insufficiency.All women underwent TAC either by laparotomy or robotic-assisted approaches by 2 primary surgeons between January 2003 and July 2018. Women with a preconceptional TAC without a subsequent pregnancy were excluded.A total of 69 women met inclusion criteria in the 15-year study period with 40 in the historical TAC-LAP group and 29 in the TAC-RA group. Gestational age at delivery was similar in the 2 groups (36 weeks 3 days vs 37 weeks; median difference -1 day, 95% confidence interval [CI] -6 to 2, p = .36). There were no differences in birth weight, Apgar scores, neonatal intensive care unit admission, or neonatal survival. Estimated blood loss and length of stay were significantly greater in the TAC-LAP group (50 mL vs 20 mL; median difference 25, 95% CI 5-40, p = .007 and 76 hours vs 3 hours; median difference 71, 95% CI 65-75, p.001, respectively). Operative time was significantly shorter in the TAC-LAP group (65 minutes vs 132 minutes; median difference -64.7, 95% CI -79 to -49, p.001). There was one intra-operative complication and 4 minor postoperative complications in the TAC-LAP group and none observed in the TAC-RA group. All outcomes were similar when comparing postconceptional TAC alone, except there was no longer a difference in blood loss. When comparing pre- versus postconceptional robotic TAC, there were no differences in surgical outcomes.Robotic TAC has similar favorable obstetric outcomes to traditional laparotomy and is associated with reduced blood loss and shorter hospital stays. Despite longer operative times, the robotic group did not experience any intra-operative or postoperative complications, which speaks to the benefits of this minimally invasive approach to TAC.

Resume Objectif L’enquete FLAHS 2015 a cherche des determinants du controle de l’HTA chez les sujets traites par antihypertenseurs en France metropolitaine. Methode Envoi d’auto-questionnaire par courrier a un panel representatif de la population vivant en France metropolitaine (base Metascope, TNS SOFRES, France). Un sujet declarant une prise actuelle d’antihypertenseur est considere hypertendu traite. Une automesure sur 3 jours a ete demandee chez ceux disposant d’un tensiometre et la moyenne de 18 mesures a ete calculee. Resultats Un total de 6379 sujets âges de 55 ans et plus ont ete inclus dont 2814 (44,1 %) traites par antihypertenseurs. Une automesure est obtenue chez 1455 sujets et montre une PAS/PAD a 129,3 ± 13,5/75,5 ± 9,0 mmHg. La PA est plus elevee chez les traites dans chaque categorie d’âge. Une PA 30 ; 63,1 %/46,1 %). Chez les 80 ans et plus, une PAS Conclusion Le controle de l’HTA evalue par automesure sur une population representative vivant en France metropolitaine est estime entre 44,3 % et 74,7 % et plusieurs determinants font varier le controle de la pression arterielle dont l’âge, le sexe et le BMI.

Study Objective Demonstrate the construction and use of very low-fidelity simulation to practice advanced laparoscopic skills in gynecologic surgery. Design Educational demonstration using affordable materials and a basic laparoscopic box trainer. Setting N/A Patients or Participants N/A Interventions N/A Measurements and Main Results N/A Conclusion Laparoscopic surgical training is an important aspect of OB/GYN residency and successful completion of the Fundamentals of Laparoscopic Surgery is now required. A laparoscopic box trainer provides a platform for practicing basic and advanced laparoscopic skills. Very low-fidelity models can be quickly created using inexpensive material to simulate more advanced skills such as vaginal cuff closure, cystotomy repair, myomectomy closure with baseball stitch of the serosa, bowel serosa repair, ovarian cystectomy, and peritoneal biopsy.

Study Objective The purpose of this video is to review a case of severe pelvic congestion and uterine arteriovenous malformations (AVMs) that was managed operatively with uterine artery embolization followed by immediate hysterectomy. Our objectives include: • Review the risk factors, diagnosis, and treatment of uterine arteriovenous malformations. • Describe the clinical course of a patient referred to our MIGS clinic for uterine artery embolization and hysterectomy. • Consider postoperative expectations for a patient after embolization and hysterectomy for pelvic congestion syndrome and AVMs. Design This is a case report. Setting Interventional radiology operating room and robotic operating room. Patients or Participants 41yo patient referred to our clinic from an interventional radiologist for surgical treatment of severe pelvic congestion syndrome with an intrauterine arteriovenous malformation. Interventions Uterine artery embolization and robotic-assisted total laparoscopic hysterectomy Measurements and Main Results N/A Conclusion Our case report emphasizes that uterine artery embolization before hysterectomy can help decrease blood loss for severe pelvic congestion syndrome and known AVMs. To achieve these favorable outcomes, coordination with interventional radiology, anesthesia, and the OR staff is necessary.Postoperatively, patients may have a fever due to the uterine artery embolization. Additionally, pelvic fluid collections may be due to inflammation and increased blood flow to the area due to the known pelvic congestion. These postoperative changes may present similarly to a pelvic abscess, but our patient was successfully managed expectantly.

Study Objective To demonstrate the steps of transabdominal cerclage (TAC) placement and removal. The video addresses timing of removal at time of cesarean section versus interval laparoscopic removal and reviews tips and tricks for both approaches. Design The video describes a needle-less technique to TAC placement which avoids penetration into the cervical stroma, prevents scarring, and facilitates removal. Additionally, we describe tips and tricks to utilize while performing cerclage removal and highlight the advantages and disadvantages of TAC removal at the time of cesarean section. Setting The patient was placed in either dorsal lithotomy and/or supine position for the videos. Patients or Participants In this surgical video we present a case of a gravid woman with cervical insufficiency who required placement of a TAC. The pregnancy was uncomplicated and she had a scheduled cesarean section, tubal ligation, and TAC removal. Interventions Robotic-assisted TAC placement for cervical insufficiency followed by removal at time of cesarean section. Interval laparoscopic removal is also demonstrated. Measurements and Main Results Successful removal of TAC during cesarean section delivery was accomplished. If TAC removal at the time of cesarean section is precluded, it can be deferred to interval laparoscopic removal. Conclusion In placement of transabdominal cerclage, a minimally invasive approach is safe and effective. Removal of TAC at either time of cesarean delivery or with an interval laparoscopic removal is possible utilizing these surgical tips and tricks.

Study Objective To demonstrate the steps of a robotic-assisted resection and revision of a uterine scar defect with hysteroscopic guidance and review tips and trips for this rare surgical procedure. Design This video describes the step by step approach to a robotic resection and revision of a uterine scar defect using hysteroscopic guidance to identify the target anatomy. Additionally, we describe tips and tricks to utilize while performing this rare surgical procedure to facilitate identification of the uterine scar laparoscopically, resect the defect in its entirety, improve hemostasis, and place a supportive suture for revision. Setting The patient was placed in dorsal lithotomy position in preparation for both hysteroscopic and robotic access. Patients or Participants In this surgical video, we present a case of a women with secondary infertility and a uterine scar defect in the setting of a history of prior cesarean delivery. She was referred by an REI physician due to history of aborted embryo transfers with abnormal fluid collections in the uterine defect. Interventions Robotic-assisted resection and revision of the uterine scar defect with hysteroscopic guidance. Measurements and Main Results Complete resection and reapproximation of the defect was visualized both laparoscopically and hysteroscopically without evidence of leakage of hysteroscopic fluid through the incision. Conclusion A minimally invasive approach to uterine scar defects can utilize simultaneous robotic-assisted laparoscopy and hysteroscopic guidance to identify the defect for resection and revision in symptomatic women or for fertility indications.

Study Objective The purpose of this video is to present an uncommon liver laceration complication with Palmer's Point entry and describe considerations for laparoscopic entry in the obese patient. Design In this surgical video, we present a case report of a liver laceration during laparoscopic entry with Palmer's Point on an obese patient with a body mass index of eighty-seven. Given this patient's super obesity, both her external and internal anatomy were distorted contributing to our surgical complication. Additionally, we describe strategies and considerations for laparoscopic entry in the obese patient with specific emphasis on the consideration of hepatomegaly due to fatty liver disease. Finally, we discuss the management of liver lacerations as recommended by the American Association for the Surgery of Trauma. Setting Operating room. Patients or Participants 34-year-old patient with super obesity presenting to our emergency room department with a large pelvic mass. Interventions Laparoscopic cystectomy. Measurements and Main Results N/A Conclusion A diagnosis of hepatomegaly must be considered in the super obese patient prior to planning laparoscopic entry using Palmer's point.