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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 investigate the advantages of using robotic assistance in tubal reanastomosis surgery. Design A narrated instructional video. Setting University Hospital, Baylor College of Medicine, Houston, Texas (Canadian Task Force Classification III). Patient A 33-year-old woman, G2P2003, who regretted her prior tubal ligation; she continued to request for a tubal reversal with a desire to conceive in the near future. A single-site approach was decided on when she expressed concern for the cosmetic aftermath of multiport surgery. Interventions Robotic single-site tubal reanastomosis. Measurements and Main Results We performed robotic single-site tubal reanastomosis on the patient. We used the energy instruments of the monopolar hook and the bipolar slotted grasper. Entry was performed in the umbilicus, after which an abdominal survey was conducted to determine and locate the blocked fallopian tubes. A cold scissor, to avoid additional damage to the tubes, was used to resect the portion of the right blocked tube, and a neonatal feeding tube was inserted though both sections of the tube to ensure proper alignment during the repair. Additionally, a figure of eight suture was placed in the mesosalpinx to reduce the amount of tension during the tubal reanastomosis. We used 4 interrupted 5-0 PDS sutures, with 2 wristed needle drivers, to establish and precisely align the 2 sections of tube, first in the mucosal layer and then in the serosal layer, to achieve proper retention. Upon successful chromopertubation with methylene blue dye, the process was repeated on the left side. A successful tubal reanastomosis was completed and chromopertubation clearly demonstrated that the tubes were patent. Total operation time was approximately 100 minutes, resulting in a successful surgery. Estimated blood loss was only 20 mL. At 2 months after surgery a fluoroscopic hysterosalpingogram was conducted to verify the patency of the tubes. We concluded that both tubes were patent. Conclusions The single-site robotic approach provides a potent and valuable method for tubal reanastomosis, rendering difficult surgical techniques more accessible.

STUDY OBJECTIVE To compare postoperative pain in patients using an abdominal binder with a control group after laparoendoscopic single-site (LESS) surgery. DESIGN A randomized controlled trial (Canadian Task Force classification level 1). SETTING An academic gynecologic surgeon's practice. PATIENTS Private patients undergoing surgery performed by a fellowship-trained minimally invasive gynecologic surgeon between April 2016 and April 2017. INTERVENTIONS Ninety total patients were selected for this study, with 60 randomized to receive an abdominal binder after surgery and 30 patients randomized to the control group without a binder. MEASUREMENTS AND MAIN RESULTS Using a 10-point verbal analog scale, patients recorded pain levels for 3 weeks postoperatively on a variety of measures, including overall and incisional pain. They recorded results on postoperative days 0, 1, 2, 3, 4, 7, 14, and 21. On average, the association between time and the overall pain score did not differ with binder use (p = .37). The overall pain decreases significantly over time (p

Study Objective Transvaginal surgery is the most minimally invasive surgery for a gynecologic procedure, but it has the limitation of lack of exposure and limited surgical space when using traditional vaginal surgical instrumentation, such as in a hysterectomy for a uterus without descent or for a myomectomy. Transvaginal natural orifice transluminal endoscopic surgery (NOTES) offers similar benefits of traditional vaginal surgery but also expands the horizon of transvaginal surgery by allowing the surgeon to perform procedures that are typically limited to an abdominal approach. The advantages of NOTES may include no incisional pain as well as a better cosmetic outcome. These benefits help outweigh the obstacle of learning this novel approach. Our objective is to demonstrate the transvaginal NOTES technique as a combination of traditional vaginal surgical skill with single-site surgical skill. Design Stepwise demonstration of the transvaginal NOTES technique for myomectomy with narrated video footage (Canadian Task Force classification III). Setting Academic tertiary care hospital. Patient A 42-year-old woman. Interventions Transvaginal NOTES myomectomy with combined transvaginal surgical and single-site surgical skills. Measurements and Main Results A 42-year-old woman (gravida 2 para 2) with a preoperative transvaginal ultrasound diagnosis of a 6-cm left anterior myoma requested myoma removal with uterine preservation. She presented with a 2-year history of left pelvic pain and menorrhagia. The myoma was removed with minimal blood loss, and pathology revealed a necrotic myoma. The patient had resolution of her left-sided pelvic pain. Conclusions Combined with traditional transvaginal anterior colpotomy, single-site surgical skills allow the surgeon to access the entire abdomen and perform myomectomy through a transvaginal single port. Transvaginal NOTES myomectomy is not only possible but allows myomectomy to be performed with no abdominal incision.

Background and objectives With advances in laparoscopic surgery, the goal of surgeons and patients is to minimize pain to allow for faster recovery and return to normal daily activities. One of these advances is single-site surgery. In this study, we compared postoperative pain in laparoendoscopic single-site surgery (LESS) to that in traditional multiple-incision hysterectomy. Methods Seventy patients were selected for this prospective cohort study, with 35 undergoing multiple-incision and 35 undergoing LESS hysterectomy. All patients were included who were undergoing hysterectomy with the primary surgeon. All multiport hysterectomies were performed laparoscopically. Six patients underwent LESS hysterectomy and 29 underwent robotic single-site surgery (rLESS). Patients recorded pain levels for 3 weeks after surgery on a variety of measures, including overall and incisional pain. Linear mixed effects models for repeated measures were used for all multivariate analyses, with an unstructured covariance matrix accounting for correlation between time points. Results Overall, across all time points, there was an average reduction in pain by 1.26 (SD 0.69) points in the single-site group (P = .06). Days 3 and 14 had a marginally significant reduction in pain (P = .06 and 0.058, respectively). On days 4 and 7 there was a significant reduction in overall pain (P = .04 and .04, respectively). Conclusion Based on the results, it is likely that single-site hysterectomy leads to less postoperative pain and achieves a lower pain score faster than multiport surgery. A randomized control trial is necessary to confirm these results before accepting them in clinical practice.