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Background: ArtiSential, a class of innovative laparoscopic instrument, has been developed to overcome the limitations of conventional laparoscopic surgery by enabling free, 360°-unrestricted movement of the wrist joint, as in robotic surgery., Objective: The aim of the present study was to describe the initial experiences with these devices in myomectomy and to report the surgical outcomes., Methods: A total of 77 women undergoing laparoscopic or robotic myomectomy between January 2021 and June 2022 were included in this multicenter prospective study. The ArtiSential instruments used by the surgeons were those chosen according to their respective preferences. The baseline characteristics, surgical outcomes, trocar placement options, and operator survey results were scrutinized., Results: The mean age of the patients was 39.9 ± 6.3, and the mean body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) was 22.4 ± 3.4 kg/m 2 ; 46.8% of the patients underwent robotic surgery, while 53.2% underwent laparoscopic surgery. The number of removed myomas was 3.3 ± 3.0, the size of the largest myoma was 7.1 ± 2.3 cm, and the operative time was 130.0 ± 54.0 min. No transfusions or laparotomy conversions were required. Other than one case of ileus, there were no postoperative complications. In most cases, the instruments were inserted through the umbilicus trocar, and the fenestrated forceps, needle holder, and bipolar fenestrated forceps, in that order, were frequently employed. According to a surgeon survey, 29.9% moderately or strongly agreed that the ArtiSential devices utilized were more convenient than conventional laparoscopic instruments, while only 9.7% moderately or strongly agreed that they were more convenient than robotic instruments., Conclusions: Myomectomy as performed with an ArtiSential instrument seems to be feasible and safe. Further studies are necessary in order to comparatively assess the outcomes and potential benefits of ArtiSential, robotic, and conventional laparoscopic myomectomy., (© 2024 International Federation of Gynecology and Obstetrics.)

Purpose: One of the most challenging tasks in laparoscopic gynecological surgeries is suturing. Knotless barbed sutures are intended to enable faster suturing and hemostasis. We carried out a meta-analysis to compare the efficacy and safety of V-Loc ™ barbed sutures (VBS) with conventional sutures (CS) in gynecological surgeries., Methods: We systematically searched PubMed and EMBASE for studies published between 2010 and September 2021 comparing VBS to CS for OB/GYN procedures. All comparative studies were included. Primary analysis and subgroup analyses for the different surgery and suturing types were performed. Primary outcomes were operation time and suture time; secondary outcomes included post-operative complications, surgical site infections, estimated blood loss, length of stay, granulation tissue formation, and surgical difficulty. Results were calculated as weighted mean difference (WMD) or risk ratio (RR) and 95% confidence intervals (CI) with a random effects model, and a sensitivity analysis for study quality, study size, and outlier results was performed. PROSPERO registration: CRD42022363187., Results: In total, 25 studies involving 4452 women undergoing hysterectomy, myomectomy, or excision of endometrioma. VBS were associated with a reduction in operation time (WMD - 17.08 min; 95% CI - 21.57, - 12.59), suture time (WMD - 5.39 min; 95% CI - 7.06, - 3.71), surgical site infection (RR 0.26; 95% CI 0.09, 0.78), estimated blood loss (WMD - 44.91 ml; 95% CI - 66.01, - 23.81), granulation tissue formation (RR 0.48; 95% CI 0.25, 0.89), and surgical difficulty (WMD - 1.98 VAS score; 95% CI - 2.83, - 1.13). No difference between VBS and CS was found regarding total postoperative complications or length of stay. Many of the outcomes showed high heterogeneity, likely due to the inclusion of different surgery types and comparators. Most results were shown to be robust in the sensitivity analysis except for the reduction in granulation tissue formation., Conclusion: This meta-analysis indicates that V-Loc ™ barbed sutures are safe and effective in gynecological surgeries as they reduce operation time, suture time, blood loss, infections, and surgical difficulty without increasing post-operative complications or length of stay compared to conventional sutures., (© 2023. The Author(s).)

Although robotic single-site (RSS) surgery employing cross setup of semirigid instruments allows effective triangulation of instruments, it has some limitations in performing RSS transabdominal and transvaginal surgeries. We introduced the robotic glove port technique (RGPT) using parallel setup of endowristed rigid instruments in performing RSS transabdominal surgery and transvaginal surgery in July of 2017. Thirty-five patients underwent RSS surgery with RGPT. Twenty-one patients had RSS transabdominal reconstructive or fertility-preserving surgeries such as myomectomy (12 patients), adenomyomectomy (3 patients), and ovarian endometriosis cystectomy (6 patients). Fourteen patients underwent robotic transvaginal surgery for natural orifice transluminal endoscopic surgery (NOTES) hysterectomy. All procedures were successfully performed, and no postoperative complications were observed. In all patients, the median total operative time, console time, and docking time were 160 min (range 106-240), 120 min (range 65-180), and 10 min (range 4-25), respectively. There was no conversion to another type of surgery, such as conventional laparoscopy, laparotomy, or traditional multiport robotic surgery. The findings showed that RSS surgery via the RGPT is safe and feasible, using the parallel setup of endowristed rigid instruments is easily performed on transvaginal routes and transabdominal routes. Therefore, this procedure may be an important complement to gynecologic surgeons' armamentarium in the field of robotic reconstructive or fertility-preserving surgeries such as myomectomy, adenomyomectomy, ovarian cystectomy, and transvaginal surgery for NOTES hysterectomy. Nevertheless, further prospective controlled studies are needed to determine its full clinical application.

Objective: To introduce a new double-lumen intracervical cannula designed to allow a single-step hysteroscopic myomectomy with nonfragmented complete fibroid extraction after cold enucleation of submucosal type 2 fibroids, avoiding complications related to the use of energy and hypo-osmolar solutions., Design: Video article depicting the use of a new double-lumen intracervical cannula for single-step hysteroscopic cold myomectomy, according to our institutional care guidelines and after obtaining the patient's informed consent. (The publication of this video has been authorized by the Institutional Ethics Committee of CES University in Medellín, Colombia.) SETTING(S): Private infertility clinic., Patient(s): A 45-year-old woman with abnormal uterine bleeding consisting of polymenorrhea and hypermenorrhea, nonresponsive to medical treatment, caused by three type 2 (FIGO leiomyoma subclassification system) submucosal fibroids of 17, 15, and 13 mm with more than 80% of intramyometrial component., Intervention(s): Hysteroscopic enucleation of three submucosal fibroids performed by blunt dissection using the 30° Bettocchi hysteroscope's bevel under continuous observation of the avascular subcapsular plane of the fibroids. Once full enucleation was attained, cervical dilatation to 12 mm with Hegar plugs was performed followed by intracervical placement of a newly designed double-lumen intracervical cannula that allows the concomitant introduction of the Bettocchi diagnostic hysteroscope and a 5-mm laparoscopic tenaculum into the uterine cavity for complete nonfragmented fibroid extraction under direct visualization., Main Outcome Measure(s): Complete and unfragmented fibroid extraction in a single intervention, absence of surgical complications, and postoperative course., Result(s): Ambulatory hysteroscopic myomectomy of three submucosal type 2 fibroids was successfully performed by blunt enucleation and complete nonfragmented fibroid extraction using the double-lumen intracervical cannula. The total operative time was 32 minutes, and the total amount of distension media (normal saline) used was 800 mL with a liquid balance of 50 mL. No surgical or anesthesia-related complications occurred. In the postsurgical evaluation, the patient classified her pain as minimal, giving it a score of 1 on a pain scale of 1 to 5 (in which 1 is the lowest and 5 the highest pain perception). When asked about the level of satisfaction with the surgical procedure, the patient reported the highest degree of satisfaction with a score of 5 on a satisfaction scale of 1 to 5 (in which 1 is the lowest and 5 the highest satisfaction). The patient reported having postsurgical regular menstrual cycles every 28 days and 3 bleeding days without hypermenorrhea., Conclusion(s): An efficient hysteroscopic myomectomy of submucosal type 2 fibroids with deep intramyometrial component can be performed with complete and nonfragmented fibroid extraction in a single intervention by using a newly designed double-lumen intracervical cannula. This technique allows the completion of the surgery without the need of a resectoscope, electrosurgery, or hypo-osmolar uterine distension media, thus avoiding potential complications such as thermal-induced myometrial injury and hyponatremia; a second surgical intervention will not be required because the fibroid enucleation is complete. The procedure can be performed with the use of a diagnostic hysteroscope that is widely available in gynecologic practices. (Acknowledgment: The authors thank Dr. David Olive for the invaluable help and guidance with this surgical technique and video article.)., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Study Objective: To review pregnancy outcomes after laparoscopic myomectomy with the use of barbed suture., Design: Retrospective cohort study and follow-up survey., Setting: Single, large academic medical center., Patients: Patients who underwent laparoscopic myomectomy with the use of barbed suture for myometrial closure between 2008 and 2016., Intervention: Laparoscopic myomectomy and a follow-up survey regarding pregnancy outcome., Measurements and Main Results: A total of 486 patients met inclusion criteria and underwent a laparoscopic myomectomy between 2008 and 2016. Of the 428 with viable contact information, 240 agreed to participate (56%). Of those who responded to the survey, 101 (42%) attempted to get pregnant, and there were 4 unplanned pregnancies. There were 110 pregnancies among 76 survey respondents. In total, of the women attempting a postoperative pregnancy, 71% had at least 1 pregnancy. Comparing the women who did and did not conceive postoperatively, the group who got pregnant was on average younger, 33.8 ± 4.5 years vs 37.5 ± 6.5 years (p = .001); had fewer myomas removed, median = 2 (range 1-9) vs median = 2 (range 1-16) myomas (p = .038); and had a longer follow-up period, 30 months ( vs 30 (11-93 months) ± 20 (p <.001). The mean time to first postoperative pregnancy was 18.0 months (range 2-72 months). Of the 110 reported postoperative pregnancies, there were 60 live births (55%), 90% by means of cesarean section. The mean gestational age at birth was 37.8 weeks. In the cohort, there were 8 preterm births, 3 cases of abnormal placentation, 2 cases of fetal growth restriction, 3 cases of hypertensive disorders of pregnancy, and 2 cases of myoma degeneration requiring hospitalization for pain control. There were no uterine ruptures reported., Conclusion: According to our findings, pregnancy outcomes after laparoscopic myomectomy with barbed suture are comparable with available literature on pregnancy outcomes with conventional smooth suture., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: This study aimed to compare gasless single-port access (SPA) laparoscopic myomectomy using a J-shaped retractor and conventional SPA laparoscopic myomectomy., Study Design: The medical records of 60 patients who underwent laparoscopic myomectomy between January 2016 and August 2019 were reviewed. Thirty patients underwent gasless SPA laparoscopic myomectomy using a J-shaped retractor, and 30 patients underwent conventional SPA laparoscopic myomectomy. The 2 groups were compared in terms of surgical outcomes. In gasless laparoscopic myomectomy, closure of the uterine defect after myomectomy was performed using an extracorporeal suture technique with a Kelly clamp and knot pusher., Results: On comparing gasless SPA and conventional SPA laparoscopic myomectomy, no significant differences were observed in age, body mass index, parity, previous abdominal surgery, and size of the dominant uterine myoma. The median retraction setup time from skin incision was 8 minutes (range, 5 to 15 min) with gasless SPA laparoscopic myomectomy. The median total operation times were 105 minutes (range, 62 to 210 min) with gasless SPA myomectomy and 110 minutes (range, 60 to 270 min) with conventional SPA myomectomy, and there was no significant difference (P=0.251). There was no difference between the groups in terms of estimated blood loss. None of the patients experienced laparotomy conversion in both groups. No major complications, such as urologic, bowel, and vessel injuries, were found in both groups., Conclusion: Gasless SPA laparoscopic myomectomy using a J-shaped retractor is a safe and feasible approach, which allows for easy and convenient suturing of a uterine defect after myomectomy.

This report describes a simple technique using conventional instrumentation for the placement of Seprafilm, a sodium hyaluronate or carboxymethylcellulose absorbable barrier for adhesion prevention. A total of 378 women with uterine myomas undergoing laparoscopic myomectomies had 737 Seprafilm pieces placed. Seprafilm sheet was softened through exposure to room air for 5 minutes, cut into 4 pieces (length, 5-10 mm), rolled up alongside a plastic sheet cut from a camera drape cover, and gently placed at the right paracolic gutter. The Seprafilm pieces unfolded semiautomatically on release and were then placed on the uterus. The median time to apply per Seprafilm piece was 1 (range: 0.8-3.5) minute. We failed to place 16 pieces (16 of 737, 2.2%) in 11 patients. Virginal status, myoma weight, and the number of removed myomas were the risk factors of failed placement. Our technique for Seprafilm placement during laparoscopic myomectomy is simple and safe., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To demonstrate a novel technique to surgically treat certain vaginal conditions., Design: Technical video demonstrating 2 cases in which the technique is used., Setting: Gynecological Minimally Invasive and Robotic Surgery Unit at Clínica Universitaria (private clinic), Concepción, Chile., Interventions: Local institutional review board was consulted, and this study was exempted from approval. Institutional ethics committee approved the study and publication of these data. A 35-year-old woman with a bicornuate unicollis uterus presented with dyspareunia. Her examination revealed an incomplete longitudinal vaginal septum. Her right hemivagina was slightly wider than the left one. With the patient under spinal anesthesia, we performed a complete resection of the septum using the single-port/pneumovagina technique (SPPT). A 36-year-old woman who was nulligravida presented with dyspareunia. On clinical exam she had a 3-cm leiomyoma in the proximal vaginal third. Doppler-powered pelvic ultrasound ruled out any vascular communication with the cervix. We performed a vaginal myomectomy using the SPPT under spinal anesthesia. In this particular case we used a fourth trocar in the gel cap to use a myoma screw. With this technique we created a pneumovagina occluding the introitus with the aid of a single-port device (GelPoint Path; Applied Medical, Rancho Santa Margarita, CA). We selected this particular device, designed for transanal surgery, because its access channel avoids gas leakage after applying gentle pressure on the cap. The working cannel is 4 × 4.5 cm, and up to 4 trocars can be inserted in the gel cap. We use 12 mm Hg of pressure to create the pneumovagina and 5 L/min flow to maintain it. Similar approaches have been described for treating eroded and/or infected sacrocolpopexy mesh [1-3]. One could question the utility of this approach over conventional vaginal surgery, and in this sense we believe it provides both the surgeon and surgical assistant a much more comfortable and ergonomic position while performing surgery. It also improves the view of anatomic structures for the surgical team, which in conventional vaginal surgery is limited only to the surgeon. Both procedures were uneventful. The operation time for the first patient was 5 minutes, and the patient was discharged 4 hours later. The operation time for the second patient lasted 35 minutes, and she was discharged 12 hours later., Conclusion: The creation of a pneumovagina with the application of a single-port device provides an excellent view of vaginal structures and allows the application of laparoscopic techniques to perform vaginal surgeries in a much more ergonomic fashion compared with conventional vaginal surgery., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To develop a preoperative calculator to predict the total operative time (TOT) for robotic-assisted laparoscopic myomectomy (RALM)., Design: Retrospective cross-sectional study., Setting: University medical center., Patients: Women who underwent RALM performed by 3 high-volume surgeons at a single institution between January 2014 and December 2017., Interventions: Demographic characteristics, indication for surgery, surgical history, myoma burden on imaging, and TOT were collected. RALM operative time was classified as <3 hours, 3 to 5 hours, and >5 hours. We identified preoperative characteristics predictive of increased operative time and developed a preoperative calculator to estimate TOT., Measurements and Main Results: A total of 126 women underwent RALM during the study period, with a mean TOT of 213 minutes ± 66 minutes. The mean total weight of myomas removed was 264 g ± 236 g, and mean largest myoma diameter was 8.5 cm ± 2.6 cm. Overall, mean number of myomas removed was 2.5 ± 2.4, and estimated blood loss (EBL) was 215 ± 212 mL. Five patients (4.0%) received a blood transfusion, and 4 patients (3.2%) underwent conversion to laparotomy. Preoperative factors significantly associated with TOT included patient age, personal history of diabetes mellitus, uterine volume, number of myomas, number of myomas >3 cm, diameter of the dominant myoma, and surgeon experience. The mean uterine volume was 282 cm 3 for procedures with a TOT <3 hours, 461 cm 3 for procedures with a TOT of 3 to 5 hours, and 532 cm 3 for procedures with a TOT >5 hours (p = .004). Body mass index, personal history of hypertension, previous abdominal/pelvic surgery, surgical indication, location of dominant myoma (anterior, posterior, or fundal) and classification of dominant myoma (submucosal, intramural, subserosal, or other) were not associated with TOT. Our preoperative calculator correctly predicted TOT category in 88% of the patients and estimated TOT within a 1-hour margin in 80% of patients., Conclusion: RALM is becoming a more popular surgical approach for the management of uterine myomas. Preoperative radiographic evaluation and a thorough patient history may enhance patient counseling and surgical planning. Uterine volume and myoma number and size appear to be more predictive of TOT compared with myoma location., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To introduce an effective approach using a self-made retrieval bag during laparoscopic myomectomy to contain tissue extraction., Design: Step-by-step video explanation of the surgical procedure with still pictures and surgical video clips to demonstrate the detailed technique, approved by the Shengjing Hospital of China Medical University., Setting: University hospital., Patient(s): A 32-year-old woman diagnosed with a uterine myoma (diameter, 6 cm). She had endured 5 years of intermittent lower abdominal pain and 2 years of infertility., Intervention(s): A self-made retrieval bag during laparoscopic myomectomy was used (consists of four steps) to contain tissue extraction. 1. Self-made retrieval bag using a sterile medical bag. 2. Inspect the pelvic cavity, evaluate and determine the location and number of myomas. 3. Resect the myoma. 4. Morcellate the myoma into pieces inside the retrieval bag using laparoscopic power morcellation., Main Outcome Measure(s): Value and feasibility of using a self-made retrieval bag in laparoscopic myomectomy., Result(s): The myoma was successfully and completely resected by laparoscopy using a self-made retrieval bag to contain tissue extraction. Operative time was 93 minutes. In the follow-up period, the patient did not report any symptom of iatrogenic parasitic myoma. The woman had a pregnancy at month 26 after operation and underwent a cesarean section. This resulted in a full-term baby., Conclusion(s): Our surgical approach demonstrated a number of noteworthy advantages. The use of retrieval bag to contain tissue extraction during laparoscopic morcellation can avoid the risk of iatrogenic parasitic myoma. The retrieval bag is self-made using a sterile packing bag, which is cost free and also reduces operative expenses., (Copyright © 2019 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Study Objective: To determine the ability of tissue containment systems to prevent leakage of cancer cell surrogates when subjected to forces encountered during power morcellation procedures., Design: In vitro study., Setting: Medical device research laboratory., Interventions: Samples from 7 different legally marketed tissue containment bags (1 of which is indicated for power morcellation) were subjected to dye and bacteriophage penetration tests at pressures ranging from 0.5 to 50 times the insufflation pressure. The minimum pressure required to cause bag leakage was measured. Subsequently, the morcellation leakage safety factor for each bag was determined as the ratio of the minimum leakage pressure of the bag to the total pressure contributed from insufflation pressure and mechanical forces acting during the power morcellation procedure., Measurement and Main Results: The leakage performance of the bags varied markedly from brand to brand. No correlation was found between leakage pressure and the bag material or the total bag thickness. The leakage pressures ranged from 26 mmHg to >1293 mmHg for the 7 bags, and safety factors ranged from 1 to 50 when only the insufflation pressure was considered. However, if the morcellation forces were included in the calculation, the safety factor dropped by 6-fold for all brands and dropped below 1, indicating likelihood of leakage, for 2 of the 7 brands., Conclusion: This study provides a mechanism for more realistically simulating the conditions experienced by containment bags during morcellation and quantifying the level of safety provided by the bags., (Published by Elsevier Inc.)

Power morcellation in laparoscopic surgery enables specialists to carry out minimally invasive procedures such as hysterectomies and myomectomies by cutting specimens into smaller pieces using a rotating blade and removing pieces through a laparoscope. Unexpected uterine sarcoma treated by surgery involving tumor disruption could be associated with poor prognosis. The current study aims to shed light on power morcellation from a medicolegal perspective: the procedure has resulted in adverse outcomes and litigation, and compensation for plaintiffs, as published in various journals cited in PubMed and MEDLINE, Cochrane Library, EMBASE, and GyneWeb. Considering the claims after the US Food and Drug Administration warnings on morcellation, the current study broadens the scope of research by including search engines, legal databases, and court filings (DeJure, Lexis Nexis, Justia, superior court of New Jersey, and US district court of Minnesota) between 1995 and 2019. Legal records show that courts determine professional responsibility regarding complications, making it essential to document adherence to safety protocols and specific guidelines, when available. Sound medical practices and clearly stated institute best practices result in better patient outcomes and are important when unfavorable clinical outcomes occur; adverse legal decisions can be avoided if there are grounds to prove professional conformity with specific guidelines and the unpredictability of an event., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: Intrauterine adhesion after hysteroscopic myomectomy contributes to infertility, recurrent miscarriages, menstrual irregularities, and hinders pregnancy outcomes. The aim of this study was to apply the indwelling Malecot catheter in prevention of intrauterine adhesion after hysteroscopic myomectomy and to further evaluate the effectiveness of this approach with reported live birth rates in infertile patients who underwent subsequent infertility treatment., Materials and Methods: Seventeen patients with FIGO Classification System PALM-COIEN Type 0 or 1 submucous myoma that received hysteroscopic myomectomy were recruited in this retrospective analysis. Post-operative insertion of the Malecot catheter via the aid of the uterine sound was performed and the catheter was left in place for seven days., Results: The mean duration of TTP (time to pregnancy) was 15.6 months after hysteroscopy. Within three years after the operation, 10 out of 17 infertility patients achieved ongoing pregnancy over 12 weeks. Ongoing pregnancy rate was 58.8% (10/17). Eight patients achieved live birth (seven singletons, one twin pregnancy) with mean gestational age of 38 weeks. Live birth rate was 47.1% (8/17)., Conclusion: The Malecot catheter is an inexpensive, easy-to-operate, and effective physical barrier method for preventing IUA in infertile patients undergoing hysteroscopic myomectomy with high live birth rate and no obvious visible post-operative adhesions., Competing Interests: Declaration of Competing Interest All authors declare no potential conflicts of interest with respect to the research, authorship, and publication of this article., (Copyright © 2020. Published by Elsevier B.V.)

Study Objective: To demonstrate a technique of temporary ligation of the uterine artery at its origin., Design: A step-by-step demonstration of the surgery in an instructional video., Setting: A private hospital in Mumbai, India., Intervention: The peritoneum over the pelvic side wall was dissected bilaterally to expose the uterine arteries at their origins. Using a polyglactin absorbable suture, a double thread loop was used to create a removable "shoelace" knot (Video 1). Both uterine arteries were ligated in this manner. The myomectomy was completed uneventfully, and the myoma bed was sutured in 2 layers using polyglactin sutures. Once suturing was completed, the shoelace knot was untied by simply pulling one end of the thread to restore blood supply to the uterus. Intraoperative blood loss was 30 mL, and the total operation time was 120 minutes., Conclusion: Laparoscopic ligation of the uterine arteries at their origin is known to reduce intraoperative blood loss [1,2]. However, in patients desiring future fertility, the effect of permanent ligation of these vessels bilaterally remains under study [3-5]. The removable "shoelace" knot is a low-cost, readily available alternative to metallic titanium clips that requires no special surgical expertise to implement., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: Laparoscopic myomectomy has the advantages of a minimally invasive approach for the surgical treatment of myomas. The standardization and description of the technique are the main objectives of this video. We described laparoscopic myomectomy in 10 steps, which could help make this procedure easier and safer [1]., Setting: A French university tertiary care hospital., Patients: Patients with indication for laparoscopic myomectomy. The local institutional review board ruled that approval was not required for this video article because the video describes a technique and does not report a clinical case., Intervention: Standardized laparoscopic myomectomies were recorded to realize the video., Measurements and Main Results: This video presents a systematic approach to myomectomy clearly divided into 10 steps: (1) prepare your surgery, make selection and prehabilitation of patient [2], provide a good cartography of the myoma(s), and plan the surgery [3,4]; (2) ergonomy and material; (3) preventive hemostasis: triple occlusion; (4) hysterotomy; (5) enucleation by fast dissection and traction; (6) bipolar hemostasis; (7) check for missing myomas; (8) suture; (9) extraction/morcellation; and (10) prevent adhesions [5]., Conclusion: Standardization of laparoscopic myomectomy could make this procedure easier and safer to perform. The 10 steps presented help to perform each part of surgery in logical sequence making the procedure ergonomic and easier to adopt and learn. Standardization of laparoscopic techniques could help to reduce the learning curve., (Copyright © 2019. Published by Elsevier Inc.)

Study Objective: To describe the perioperative outcomes of various modes of myomectomy (abdominal [AM], laparoscopic [LM], or robotic [RM]) in cases of extreme myoma burden., Design: Retrospective cohort study (Canadian Task Force classification II-2)., Setting: A tertiary academic center in Boston, Massachusetts., Patients: All women who underwent an AM, LM, or RM for extreme myoma burden, defined as representing the upper quartile for specimen weight (≥434.6 g) or myoma count (≥7 myomas), between 2009 and 2016., Interventions: Baseline demographics and perioperative outcomes were collected from review of medical records, including estimated blood loss, operative time, length of stay, and complications. Univariate linear and logistic regression analyses were conducted., Measurements and Main Results: During the study period 659 women underwent myomectomy for extreme myoma burden; 47.2% of cases were AM, 28.1% LM, and 24.7% RM. Overall myoma burden differed across the 3 routes and was greatest in the AM group (mean weight: 696.2 ± 784.5 g for AM vs 586.6 ± 426.1 g for LM and 586.6 ± 426.1 g for RM; mean number: 16.8 ± 15.0 for AM vs 7.2 ± 7.0 for LM and 6.7 ± 4.7 for RM; p <.001 for both). The 3 routes differed in operative time and length of stay, with RM having the longest operative time (mean, 239.7 minutes; p <.001) and AM the longest length of stay (mean, 2.2 ± .9 days; p <.001). Other perioperative outcomes were similar across the surgical approaches. Increasing myoma burden was associated with an increased risk of perioperative complications for all surgical approaches, with a threshold of 13 myomas associated with an almost 2-fold higher risk of perioperative complications (odds ratio, 1.77; 95% confidence interval, 1.17-2.70; p = .009). Cumulative incidence of perioperative complications with increasing specimen weight was greater in the RM cases as compared with AM (p = .002) or LM (p = .020), whereas the cumulative incidence of perioperative complications with increasing myoma count was lowest with AM compared with LM (p <.001) or RM (p <.001)., Conclusion: Myomectomy for extreme myomas is feasible using an abdominal, laparoscopic, or robotic approach. Increased myoma burden is associated with an increased risk of perioperative complications. A threshold of 13 myomas was associated with an almost 2-fold higher risk of perioperative complications for all modes. Perioperative complication outcomes were more favorable in AM or LM over RM with increased myoma weight and AM over LM or RM with increased myoma number., (Copyright © 2018 AAGL. Published by Elsevier Inc. All rights reserved.)

Uterine fibromatosis is common in women, with an estimated prevalence of up to 15-50% after 35 years. About 80% of women affected by fibromatosis have symptoms and require medical or surgical treatment. Nowadays, the gold standard for the surgical treatment of uterine fibromatosis is the use of minimally invasive surgery. The surgical skills and improvements offered by robotic approach can be relevant in reproductive surgery, in particular in minimally invasive myomectomy. However, the lack of tactile feedback of robotic platform is an important technical drawback that can reduce the accuracy of surgical procedures. Here, we present the design and the preliminary test of the wearable fabric, yielding display wearable haptic interfaces able to generate a real-time tactile feedback in terms of stiffness for applications in gynecologic robotic surgery. We preliminarily tested the device in the simulation of a real scenario of conservative myomectomy with the final purpose of increasing the accuracy and precision during surgery. The future goal is the integration of a haptic device with the commercially available robotic surgical systems with the purpose of improving the precision and accuracy of the surgical operation, thus allowing a better understanding concerning the anatomical relationship of the target structures. This in turn could determine a change in the surgical strategy in some cases, letting some patients selected for a demolitive approach retaining their uterus. This could improve surgical outcomes in fertile women enrolled for minimally invasive surgery for uterine fibroids and may be a facilitation for young gynecological surgeons or during residency teaching plans and learning programs.

Fibroids are the most common benign tumors in women of childbearing age and can be found in almost 80-90% of all women by age 50 years. They can cause pain, excessive menstrual bleeding or infertility. The development of fibroids increases with age. Since the age of women in industrial countries who are trying to conceive is generally increasing, there has been a growing demand for minimally invasive and uterine-sparing surgical treatment of fibroids. Whereas the main focus of previous surgical techniques for the treatment of fibroids was enucleation of the tumour with subsequent closure of the uterine incision, modern devices developed over the past decade can destroy fibroids by using ultrasound or radio-frequency without incising the uterine wall. Thus, there is no uterine scar, which would impart a risk of rupture during labour or pregnancy. This article provides an overview of the latest techniques and devices used for uterine-sparing surgical treatment of fibroids. While laparoscopic myomectomy is still the gold standard, novel laparoscopic and transcervical radiofrequency ablation techniques use low-voltage and alternating current to induce heat in the uterine tissue, which triggers necrosis in fibroids. This enables the removal of multiple fibroids without the need for large incisions in the uterine wall. In addition, we address the benefits and potential risks, as well as the impact on fertility and pregnancy, of the different surgical approaches used for the treatment of uterine fibroids.

Purpose: To evaluate the feasibility of using contained endobags (Morsafe ® ) in the retrieval of the specimen during laparoscopic surgeries in presumably benign myomatous pathology., Material and Methods: We conducted a retrospective single center case - control study on 239 patients, between 01.05.2014 and 31.12.2017 for uterine myomata, presumed to be benign. The analyzed parameters were the method for contained specimen retrieval, the time of bag manipulation, practicability of action and the perioperative complications rate. The present work has been reported in accordance with the STROCSS criteria and guidelines [1]., Results: the main laparoscopic interventions were myomectomy (n = 148 cases) and LASH (laparoscopic supracervical hysterectomy) (n = 68 cases), LASH with bilateral salpingectomy (n = 7), LASH and bilateral adnexectomy (n = 3), LTH (laparoscopic total hysterectomy) (n = 3), LTH and bilateral adnexectomy (n = 1), radical LTH with lymphonodectomy (n = 2), LTH with bilateral salpingectomy (n = 1) and adenomyomectomy (n = 6). In 3 cases using contained closed bags, there was an evidence of malignancy in the pathological sections: leiomyosarcoma (n = 1) and endometrial carcinoma (n = 2). There were no adverse events and no intra - or postoperative bag - induced complications. Regarding the intraoperative duration, the time of bag introduction was about 7 min, and morcellation approximately 12 min., Conclusion: in - bag morcellation through endobag (Morsafe ® ) proved to be a safe laparoscopic method in retrieval of myomatous tissue, potentially reducing the risk of dissemination and thereby improving the patients' safety avoiding spreading of benign disease and malignancy, but preserving the benefits of minimally invasive surgery. The advantages concerned not only the operating time and costs, but also the safety aspects in case of malignancy. As the system can help to reduce risk of cell dissemination it could also reduce the risk in case of occult malignancy., (Copyright © 2019. Published by Elsevier Ltd.)

Objective: The primary objective was to compare the overall survival of women with unsuspected uterine malignancy (UUM), including sarcomas and adenosarcomas, diagnosed after laparotomic versus laparoscopic myomectomy. The secondary objective was to determine the incidence of UUM diagnosed after myomectomy., Methods: We analyzed the national health insurance database, which covers almost the entire Korean population, between 2006 and 2010 to calculate the incidence and mortality of UUM diagnosed after myomectomy. Diagnosis and procedure codes were used to identify women with or without UUM., Results: During the study period, 78,826 patients who underwent myomectomy among women in the database (23 million per year) were enrolled. The women were divided into a laparotomic myomectomy group (n = 56,213) and a laparoscopic myomectomy group (n = 22,613). The incidence of UUM diagnosed after myomectomy was 0.08% in both groups (47/56,213 and 18/22,613 women, respectively). There was no difference in mean age, socioeconomic status, diagnostic code, UUM incidence at 5-year intervals, survival rate, or mean survival time. The 5-year survival rates of women with UUM were 95.7% and 88.9% in the laparotomic and laparoscopic groups, respectively. A Kaplan-Meier survival analysis showed no difference in the overall survival rates according to the surgical method (P = 0.447)., Conclusions: The incidence of UUM after myomectomy was 0.08% after laparotomic or laparoscopic myomectomy. Although morcellator use does not reduce the overall survival rate, clinicians should explain the risks of intraperitoneal tumor dissemination to patients and do their best to prevent tumor spillage when using this tool., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose of Review: Submucosal uterine leiomyomas are a common benign pelvic tumor that can cause abnormal uterine bleeding and may contribute to infertility and miscarriage. Hysteroscopic myomectomy is the treatment of choice to alleviate bleeding from these myomas and to normalize the uterine cavity. This review discusses the techniques and recent evidence for hysteroscopic myomectomy and examines the two primary surgical tools employed today: the bipolar resectoscope and hysteroscopic mechanical morcellator., Recent Findings: Hysteroscopic myomectomy has been a popular treatment for symptomatic submucosal fibroids for decades; it is a minimally invasive, low-cost, low-risk procedure, and is associated with high patient satisfaction. There have been rapid advances in the surgical technology available for this procedure. Both the bipolar resectoscope and the hysteroscopic mechanical morcellator are appropriate tools to remove submucosal myomas. Although the hysteroscopic morcellators have been associated with shortened operative time and a decreased learning curve, the data are limited for their use on type 2 fibroids. The strength of the bipolar resectoscope lies in its ability to resect deeper type 2 fibroids., Summary: The evidence suggests that no one technique should be used for all patients, but rather a choice of technique should be taken on a case-by-case basis, depending on the myoma number, size, type, and location. Gynecologists must become knowledgeable about each of these techniques and their associated risks to safely offer these surgeries to their patients.

The purpose of this study was to compare the safety and efficacy of an electrothermal bipolar vessel sealing device (LigaSure™) and traditional electrical cauterization in laparoscopic myomectomy (LM). A total of 756 patients with symptomatic uterine myomas who underwent LM were reviewed retrospectively. A total of 225 cases of LM using LigaSure™ (LML group) were compared with a control group treated with traditional electrical cauterization (LME group) under propensity-matched analysis. Outcome measures for both groups were compared, such as operative time, blood loss (BL), complications, need for blood transfusion, hospital expenses, and hospital stay. Six subgroups were divided according to main myoma size and energy source. No cases required switching to abdominal myomectomy. The number of myomas removed, BL, need for blood transfusion, and complications were not significantly different, whereas hospital stay was longer in the LME group than in the LML group and total hospital expenses were higher in the LML group (p < 0.001). The overall operation duration was significantly longer in the LML group but was not significantly different for main myoma >10 cm (LML vs LME, 121.58 ± 41.77 vs 121.69 ± 44.95, p = 0.99); this likely reflects the operative efficiency on using LigaSure™ to manage large tumors. Significant linear correlations between myoma weight and operative time and BL were seen in both groups. Conventional diathermy is more effective for small-to-medium myomas. Use of the LigaSure™ was efficient for myomas >10 cm.

Background: To compare conventional electrosurgery, LigaSure (Valleylab, Boulder, CO), and Harmonic scalpel (Ethicon Endosurgery, Cincinnati, OH) in terms of perioperative and postoperative outcomes during laparoscopic myomectomy (LM)., Methods: We retrospectively studied 817 women with symptomatic fibroids who underwent LM between January 1997 and September 2015. Three different instruments were used separately during surgery. The number and weight of removed fibroids, blood loss, operative time, postoperative decrease in the hemoglobin level, and length of hospital stay were measured for statistical analysis., Results: No significant increase in complications was found in the three groups. Patients in the LigaSure and Harmonic scalpel groups had more numbers of removed fibroids, heavier fibroids removed, and higher rate of pretreatment with GnRH agonist (p < 0.001). These patients also had higher amount of intraoperative bleeding (p = 0.003) and longer operative time (p < 0.001) than those in the conventional electrosurgery group. However, no worse postoperative clinical outcome but shorter length of hospital stay was found in the LigaSure and Harmonic scalpel groups (2.1 ± 0.6, 2.0 ± 0.4 vs 2.5 ± 0.8 days, p < 0.001)., Conclusion: The use of all three devices is feasible in LM. LigaSure and Harmonic scalpel can reduce the length of hospital stay without worse surgical outcomes., (Copyright © 2017. Published by Elsevier Taiwan LLC.)

Purpose of Review: As the Food and Drug Administration raised concern over the power morcellator in 2014, the field has seen significant change, with patients and physicians questioning which procedure is safest and most cost-effective. The economic impact of these decisions is poorly understood., Recent Findings: Multiple new technologies have been developed to allow surgeons to continue to afford patients the many benefits of minimally invasive surgery while minimizing the risks of power morcellation. At the same time, researchers have focused on the true benefits of the power morcellator from a safety and cost perspective, and consistently found that with careful patient selection, by preventing laparotomies, it can be a cost-effective tool., Summary: Changes since 2014 have resulted in new techniques and technologies to allow these minimally invasive procedures to continue to be offered in a safe manner. With this rapid change, physicians are altering their practice and patients are attempting to educate themselves to decide what is best for them. This evolution has allowed us to refocus on the cost implications of new developments, allowing stakeholders the opportunity to maximize patient safety and surgical outcomes while minimizing cost.

Purpose of Review: Minimally invasive gynecologic procedures, in particular laparoscopic hysterectomy and myomectomy, often require tissue morcellation., Recent Findings: Whether morcellated or not, myometrial cells can be found in the abdomen and pelvis after either laparoscopic or open myomectomy. Following morcellation, careful inspection for and removal of tissue fragments and copious irrigation and suctioning of fluid can remove residual tissue and cells without the use of containment bags. The dogma of not 'cutting-through' cancer is not correct for many surgical specialties and irrelevant with regards to leiomyosarcoma (LMS) and minimally invasive gynecologic surgery. Eliminating residual disease in the pelvis and abdomen should be the goal of myomectomy or hysterectomy., Summary: Morcellation of excised tissue is necessary for many women with symptomatic fibroids who choose to undergo laparoscopic myomectomy or hysterectomy. LMS is an uncommon disease, with a poor prognosis due to early hematogenous metastasis to lung, bone and liver. Preoperatively, it is often difficult to differentiate from benign fibroids. LMS has a high propensity for local recurrence despite performance of total hysterectomy. Efforts to remove all tissue and cells from the pelvis and abdomen should be the goal of minimally invasive surgery with morcellation.

Study Objective: To compare operative outcomes of single-port laparoscopic myomectomy (SP-LM) vs conventional laparoscopic myomectomy (CLM), including subjective and objective cosmetic aspects., Design: Prospective randomized controlled trial (Canadian Task Force classification I)., Setting: University hospital., Patients: Women with uterine myoma scheduled for laparoscopic myomectomy., Interventions: Sixty-six women were assigned at random to either the SP-LM or CLM group. Surgical outcomes, including patient and observer scar assessments, were evaluated between the groups according to the intention-to-treat principle., Measurements and Main Results: There were no significant differences in demographic characteristics and properties of myomectomy between the groups. There also were no differences in surgical outcomes, such as operation time, estimated blood loss, and complications, between the 2 groups. The mean total score of the Observer Scar Assessment Scale was lower in the SP-LM group at 1 week (13.0 ± 3.2 vs 18.3 ± 4.8; p < .001) and 8 weeks (9.9 ± 3.2 vs 14.3 ± 3.8; p < .001) after discharge. Similar results were obtained for the Patient Scar Assessment Scale at 1 week (11.6 ± 7.2 vs 18.5 ± 12.8; p = .024) and 8 weeks (9.5 ± 6.0 vs 18.8 ± 9.1; p < .001) after discharge. Postoperative pain and analgesic consumption did not differ between the groups, except in patient-controlled analgesia consumption at 6 hours after operation, which was lower in the SP-LM group (12.7 ± 6.3 mL vs 16.4 ± 6.2 mL; p = .039). Operative outcomes were similar in the 2 groups., Conclusion: SP-LM is associated with more favorable cosmetic outcomes and better patient satisfaction compared with CLM. There were no differences in operative outcomes and complications between the 2 modalities., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Study Objective: To determine the incidence of postoperative ascending infection without antibiotics with the use of a pediatric Foley catheter (PFC) after operative hysteroscopy for intrauterine pathology., Design: Retrospective case series (Canadian Task Force classification III)., Setting: University-affiliated outpatient medical center., Patients: Patients who underwent operative hysteroscopy for uterine septum, arcuate uterine anomaly, or multiple submucosal myomas between 1992 and 2015., Interventions: In all patients, a PFC was placed in the endometrial cavity at the conclusion of operative hysteroscopy and left in place for 7 days to reduce intrauterine adhesion formation., Measurements and Main Results: A total of 1010 patients who underwent operative hysteroscopy for uterine septum (n = 479), arcuate uterine anomaly (n = 483), or multiple submucosal myomas (n = 48) were studied. All patients presented with infertility, recurrent pregnancy loss, or excessive uterine bleeding (in patients with submucous myomas). In all patients, a PFC was placed at the conclusion of the procedure and left in place for 7 days. An 8Fr PFC was used after hysteroscopic division of uterine septum or arcuate uterine anomaly, and a 10Fr PFC was used after hysteroscopic myomectomy. Patients with a history of pelvic inflammatory disease were excluded. Following PFC placement, patients were prescribed estrogen for 6 weeks and progestogen for the last 10 days of the estrogen course. No prophylactic antibiotic therapy was provided. All patients were discharged to home on the same day. Postoperative pain was well controlled with oral pain medication in 98.5% of the patients. There were no reported postoperative infections, and all patients had an uneventful recovery., Conclusion: In 1010 consecutive operative hysteroscopies followed by temporary (7-day) PFC placement, no clinically significant uterine infection was observed., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

This study aims to determine whether clinical evaluation of improved MyoSure hysteroscopic tissue removal system can remove type II submucosal myomas with safety and high success rate of the first operation.Fifty-three patients with type II submucosal myomas hospitalized in the Huzhou Maternity and Child Care Hospital were enrolled in this study. The submucosal myomas were with the diameter of >2 cm and ≤5 cm. All patients have surgical indications.Fifty-one of 53 hysteromyomas were successfully resected through 1-time operation. The average time was 37.92 ± 18.57 minutes, average amount of bleeding: 24.80 ± 12.12 mL, average length of stay: 2.02 ± 0.14 days. One patient had a transient postoperative fever and one patient had slight fluid overload with hyponatremia.The success rate of the first operation for resecting type II submucosal myomas showed an increase using improved MyoSure hysteroscopic tissue removal system, which can be a new, safer, and more efficient operation for treating type II submucosal myomas., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To evaluate the association between the U.S. Food and Drug Administration (FDA) communication discouraging use of power morcellators on changes in surgical practice for women with uterine leiomyomas., Methods: This is a cross-sectional study using data from 2013 to 2014 in the Healthcare Cost and Utilization Project State Inpatient and State Ambulatory Surgical Databases from Arizona, Florida, Kentucky, and New Jersey. Women with a diagnosis of leiomyomas who underwent hysterectomy or myomectomy were included in the analysis. Multivariable models were used to assess changes in the proportion of hysterectomies performed laparoscopically, vaginally, or by laparotomy in the 15 months before the FDA safety communication in April 2013 (January 2013 to March 2014) to the 9 months after the FDA communication (April to December 2014). Changes in the proportion of women who underwent myomectomy compared with hysterectomy were also evaluated during this time period., Results: There were 77,637 hysterectomy and myomectomy cases analyzed from states with both inpatient and ambulatory surgery data; 59% of patients were outpatients. Overall, there was a 4% (95% CI 3.2-4.8%) decrease in the use of laparoscopic hysterectomy for treatment of uterine leiomyomas from 62% of all hysterectomies before the FDA communication on morcellation to 58% afterward. Changes in surgical practice were more pronounced in the inpatient compared with outpatient setting; inpatient laparoscopic hysterectomy decreased by 7% (95% CI 6.1-7.9%) from 24% to 17% of all hysterectomies with an accompanying increase in abdominal hysterectomy of 8% (95% CI 6.7-8.6%) from 71% to 79%. There were no significant changes in the proportion of women with leiomyomas who underwent myomectomy compared with hysterectomy., Conclusion: The FDA communication discouraging the use of power morcellators was associated with a decline in laparoscopy to perform hysterectomy, particularly in the inpatient setting. There was no change in the selection of myomectomy compared with hysterectomy for leiomyoma treatment after the FDA communication.

Objective: To demonstrate the multiple advantages of the suprapubic port in robotic assisted laparoscopic myomectomy., Design: Video demonstration of a robotic assisted laparoscopic myomectomy technique using a suprapubic incisional retractor (GelPOINT)., Setting: Hospital., Patient(s): A 32-year-old primigravid women with heavy menstrual bleeding and pelvic pain with a 12-cm leiomyoma (International Federation of Gynecology and Obstetrics type 5)., Intervention(s): Illustrate a surgical approach during robotic assisted laparoscopic myomectomy with the use of a 5-cm suprapubic incision, an incisional retractor (GelPOINT) for the enucleation, and extraction of a large leiomyoma., Main Outcome Measure(s): The effective enucleation and extraction of a leiomyoma specimen using an incisional retractor and GelPOINT. The steps of the technique and the role of GelPOINT are demonstrated., Result(s): The procedure was performed without incident, and the patient experienced pain relief and lighter menses postoperatively. This technique has been performed successfully since June 2014 on 22 women., Conclusion(s): During a robotic assisted laparoscopic myomectomy the suprapubic incision is both advantageous and practical. The small incision allows the surgery to remain minimally invasive; the primary umbilical trocar is inserted under direct visualization in an already insufflated abdomen; the location of the incision allows the surgical assistant easy access to the port; the passing of the needles occurs under direct visualization with minimal camera manipulation; and last, the extraction of large tissue can be performed within a specimen pouch through this same suprapubic incision in a short period., (Copyright © 2017 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Study Objective: To demonstrate a laparoscopic myomectomy technique for the removal of multiple submucous myomas., Design: A step-by-step demonstration of the surgical procedure (Canadian Task Force classification III-C)., Setting: In cases of multiple submucous myomas, hysteroscopic resection of myomas might not be a viable option, especially in cases requiring fertility preservation. It may cause significant damage to the endometrial surface, leading to the formation of endometrial synechiae [1]. The procedure is technically challenging and requires prolonged operating time owing to impaired visibility and the need for repeated specimen removal. This can lead to complications, such as fluid overload and, rarely, air embolism [2]. Thus, laparoscopic myomectomy may be a better option in such cases [1]., Interventions: A 30-year-old nulligravida presented with a 3-year history of heavy menstrual bleeding and dysmenorrhea. She had received no symptom relief with hormonal medications and magnetic resonance-guided focused ultrasound. On examination, she was anemic, and her uterus was enlarged to 16-weeks gravid size. Ultrasonography revealed an intramural fundal myoma of 6 × 4.2 cm and numerous submucous myomas of 1 to 3.2 cm. During hysteroscopy, multiple submucous myomas of varying sizes ranging from type 0 to type 1 were seen. On laparoscopy, an incision was made on the uterine fundus with an ultrasonic device after injecting vasopressin (20 U in 200 mL dilution), and the fundal myoma was enucleated. The incision was then extended to open the endometrial cavity for the removal of the submucous myomas. Most of the myomas were removed with mechanical force, along with the minimal use of ultrasonic energy. A total of 46 myomas were removed, and the myometrium was closed in 2 layers. The duration of the surgery was 210 minutes, and estimated blood loss was 850 mL. The patient did not require blood transfusion, but was advised to take hematinics. At a 6-month follow-up, the patient reported significant improvement in her symptoms. A repeat hysteroscopy revealed moderate synechiae in the midline and 2 small submucous myomas near the internal os. The synechiae were incised with hysteroscopic scissors, and the submucous myomas were resected with a bipolar resectoscope. The patient was advised to attempt conception after 2 months., Conclusion: Laparoscopic myomectomy is an alternative to hysteroscopic resection for multiple submucous myomas. A repeat hysteroscopy is useful for identifying any residual myomas and synechiae., (Copyright © 2017 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To present our initial experience with reduced-port robotic surgery (RPRS) for myomectomy using the Octo-Port system (DalimSurgNet, Seoul, Korea)., Design: Prospective and noncomparative study (Canadian Task Force classification II-3)., Setting: University hospital., Patients: Nineteen consecutive patients with symptomatic uterine myomas desiring conservative minimally invasive robotic surgery from October 2015 to December 2016., Interventions: An 8.5-mm or 12-mm robotic camera cannula was inserted through 1 of the Octo-Port channels and an 8-mm conventional robotic port was inserted into a 10-mm channel of the Octo-Port through a 3-cm transumbilical incision. An additional 8-mm conventional robotic port was inserted into a typical robotic port site in the patient's right abdomen., Measurements and Main Results: Feasibility and operative outcomes of RPRS myomectomy. The median docking time and console time were 10 minutes (range, 4-22) and 90 minutes (range, 29-198). The largest myoma was located on the anterior uterine wall in 11 patients (57.9%). The median myoma size and weight were 7.2 cm (range, 4.1-10.5) and 141 g (range, 42-590), respectively. Median operative blood loss and change in hemoglobin were 100 mL (range, 30-700) and 2.6 mg/dL (range, .1-3.8), respectively. The procedure was successfully performed via RPRS in 89.5% of patients; 2 patients required placement of 1 to 2 additional robotic ports, resulting in a return to traditional multiport robotic surgery. There were no major postoperative complications or postoperative hernias., Conclusion: Our experience demonstrated the feasibility of RPRS for myomectomy using the Octo-Port system in selected patients., (Copyright © 2017 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To report a single surgeon's experience with 109 laparoendoscopic single-site myomectomy (LESS-M) using conventional laparoscopic instruments and a homemade glove port system., Materials and Methods: A total of 109 consecutive women who underwent LESS-M between March 2011 and April 2015 were reviewed., Results: The mean age and body mass index were 38.3 ± 6.5 years and 22.1 ± 3.0 kg/m 2 . The mean diameter of the largest myoma and the mean number of myomas were 8.1 ± 2.4 cm and 1.6 ± 0.7. The mean weight of the myomas was 223.2 ± 159.7 g. The most common type of myoma was intramural (61%), followed by subserosal (23%), submucosal (9%), and intraligamental (7%). The most common site of the myomas was anterior (39%), followed by posterior (38%), lateral (15%), and fundal (9%). The mean operative time and estimated blood loss were 138.5 ± 43.8 min and 104.9 ± 270.1 mL. Two patients (1.8%) required intraoperative transfusion. The mean hospital stay was 2.5 ± 0.6days. There were no conversions to laparotomy, but three patients(2.8%) were converted to two-port laparoscopic myomectomy. No patient experienced any major complication, including bowel, ureter, bladder injuries, or incisional hernia. Six women became pregnant after the operation, and five of these patients delivered their babies at full term by cesarean section. One patient delivered her baby at a gestational age at 32 weeks due to idiopathic polyhydramnios by cesarean section. One patient had the second pregnancy and delivery after LESS-M. Fourteen patients (12.8%) had small recurrent myomas that did not require treatment., Conclusion: LESS-M is a feasible alternative for patients with symptomatic myomas, and this technique can provide cosmetic advantages compared to conventional laparoscopic surgery., (Copyright © 2017. Published by Elsevier B.V.)

Introduction: The use of vasopressin and other vasoconstrictive agents to reduce blood loss during laparoscopic myomectomy significantly reduces blood loss and operative time. However, serious cardiovascular complications following the use of intramyometrial injection of vasopressin solution have also been reported. Most of these side effects are believed to be due to inadvertent intravascular injection of vasopressin solution., Aims and Objectives: To describe a new design of an injection needle. Pisat's visual vasopressor injection needle (VVIN) can be used during laparoscopic myomectomy to minimise the incidence of an inadvertent intravascular injection of a vasoconstrictor solution., Results: A total of 53 patients who underwent laparoscopic myomectomy at various hospitals in Mumbai, India were studied over a period of two years. Out of these, 23 patients were operated upon using a standard 5 mm laparoscopic injection needle, and 30 patients were operated on by using a VVIN. Out of the 23 patients in whom a regular needle was used, four patients (17.39%) demonstrated a significant (over 20% of pre-injection value), but transient, elevation in pulse and blood pressure readings at one minute post injection. This gradually returned to baseline at 10 minutes after the injection. None of the 30 patients in whom VVIN was used after confirming a negative aspiration demonstrated any significant change in post-injection pulse or blood pressure recordings., Conclusions: Using a VVIN during a laparoscopic myomectomy enables the surgeon to detect an inadvertent vascular puncture very early, even in a small calibre blood vessel, and with much more sensitivity than a regular needle. This increases patient safety during the intramyometrial injection of a vasoconstrictive agent during myomectomy and reduces the incidence of catastrophic complications.

Study Objective: To demonstrate the feasibility of laparoscopic management of a huge cervical myoma., Design: Step-by-step video demonstration of the surgical procedure (Canadian Task Force classification III-C)., Setting: Uterine myoma is the most common benign neoplasm of the female reproductive tract, with an estimated incidence of 25% to 30% at reproductive age [1,2]. Patients generally have no symptoms; however, those with such symptoms as severe pelvic pain, heavy uterine bleeding, or infertility may be candidates for surgery. The traditional management is surgery; however, uterine artery embolization or hormonal therapy using a gonadotropin-releasing hormone agonist or a selective estrogen receptor modulator should be preferred as the medical approach. Surgical management should be performed via laparoscopy or laparotomy; however, the use of laparoscopic myomectomy is being debated for patients with huge myomas. Difficulties in the excision, removal, and repair of myometrial defects, increased operative time, and blood loss are factors keeping physicians away from laparoscopic myomectomy [1,2]., Interventions: A 40-year-old gravida 0, para 0 woman was admitted to our clinic with complaints of chronic pelvic pain, dyspareunia, and infertility. Her health history was unremarkable. Ultrasonographic examination revealed a 14 × 10-cm myoma in the cervical region. On bimanual examination, an immobile solid mass originating from the uterine cervix and filling the pouch of Douglas was palpated. The patient was informed of the findings, and laparoscopic myomectomy was recommended because of her desire to preserve her fertility. Abdominopelvic examination revealed a huge myoma filling and enlarging the cervix. Myomectomy was performed using standard technique as described elsewhere. A transverse incision was made using a harmonic scalpel. The myoma was fixed with a corkscrew manipulator and enucleated. Once bleeding was controlled, the myoma bed was filled with Spongostan to prevent possible bleeding from leakage. Owing to the anatomic structure of the cervical region, the incision was closed in a monolayer with 0 Vicryl. Total intraoperative blood loss was 300 mL, the total weight of the myoma was 670 g, and the operation lasted approximately 140 minutes. The patient experienced no intraoperative complications. She was discharged on postoperative day 1 and did not exhibit any problems at follow-up. The final histopathological examination confirmed the diagnosis of uterine leiomyoma., Conclusion: Laparoscopic management of huge myomas in difficult locations such as the cervical region seems to be a feasible and safe surgical option, especially in experienced hands., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To demonstrate the feasibility of laparoscopic management of a huge myoma nascendi., Design: Step-by-step video demonstration of the surgical procedure (Canadian Task Force classification III-C)., Setting: Uterine myoma is the most common benign neoplasm of the female reproductive tract, with an estimated incidence of 25% to 30% at reproductive age [1,2]. Patients generally have no symptoms; however, those with such symptoms as severe pelvic pain, heavy uterine bleeding, or infertility may be candidates for surgery. The traditional management is surgery; however, uterine artery embolization or hormonal therapy using a gonadotropin-releasing hormone agonist or a selective estrogen receptor modulator should be preferred as the medical approach. Surgical management should be performed via laparoscopy or laparotomy; however, the use of laparoscopic myomectomy is being debated for patients with huge myomas. Difficulties in the excision, removal, and repair of myometrial defects, increased operative time, and blood loss are factors keeping physicians away from laparoscopic myomectomy [1,2]., Interventions: A 35-year-old woman was admitted to our clinic with complaints of chronic pelvic pain and heavy menstrual bleeding. Her medical history included multiple hospitalizations for blood transfusions, along with a recently measured hemoglobin level of 9.5 g/dL and a hematocrit value of 29%. She had never been married and had no children. Pelvic ultrasonography revealed a 12 × 10-cm uterine myoma located on the posterior side of the corpus uteri and protruding through to the cervical channel. This was a huge intramural submucous myoma in close proximity to the endometrial cavity and spreading through the myometrium. On vaginal examination, the myoma was found to extend into the vagina through the cervical channel. Laparoscopic myomectomy was planned because of the patient's desire for fertility preservation. Abdominopelvic exploration revealed a huge myoma filling the posterior side of the corpus uteri and extending to the isthmus uteri and cervical channel. A myomectomy was performed using standard technique as described elsewhere. A vertical incision was made using a harmonic scalpel. The myoma was fixed with a corkscrew manipulator and enucleated. During the procedure, the endometrial cavity was torn and was closed with 2-0 Vicryl separately. Total intraoperative blood loss was 250 mL, the total weight of the myoma was 245 g, and the operation lasted about 120 minutes. The patient experienced no intraoperative complications. She was discharged on postoperative day 1 and did not exhibit any problems at follow-up. The final histopathological examination confirmed the diagnosis of uterine leiomyoma., Conclusion: Laparoscopic management of huge myomas in difficult locations appears to be a feasible and safe surgical option, especially in experienced hands., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To report the use of augmented reality (AR) in gynecology., Design: AR is a surgical guidance technology that enables important hidden surface structures to be visualized in endoscopic images. AR has been used for other organs, but never in gynecology and never with a very mobile organ like the uterus. We have developed a new AR approach specifically for uterine surgery and demonstrated its use for myomectomy., Setting: Tertiary university hospital., Patient(s): Three patients with one, two, and multiple myomas, respectively., Intervention(s): AR was used during laparoscopy to localize the myomas., Main Outcome Measure(s): Three-dimensional (3D) models of the patient's uterus and myomas were constructed before surgery from T2-weighted magnetic resonance imaging. The intraoperative 3D shape of the uterus was determined. These models were automatically aligned and "fused" with the laparoscopic video in real time., Result(s): The live fused video made the uterus appear semitransparent, and the surgeon can see the location of the myoma in real time while moving the laparoscope and the uterus. With this information, the surgeon can easily and quickly decide on how best to access the myoma., Conclusion(s): We developed an AR system for gynecologic surgery and have used it to improve laparoscopic myomectomy. Technically, the software we developed is very different to approaches tried for other organs, and it can handle significant challenges, including image blur, fast motion, and partial views of the organ., (Copyright © 2016 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Electromechanical power morcellation is an important tool of modern laparoscopy. Recent reports on the spread of previously undetected malignancy by power morcellation indicate the need for additional protective devices to reduce this risk. We conducted a study to obtain the first data concerning the safety of an endobag with three closable ports during morcellation and subsequent bag extraction under in vitro conditions, mimicking the settings in our operating theater. The second purpose of the study was to establish a minimal width of the skin incision necessary to safely extract the sealed bag after morcellation., Methods: The morcellation test was carried out on 11 stained porcine muscle tissue samples with one additional sample as a control. The insufflation pressure was set at 12 mmHg. After filling the endobag with blue dye solution, an additional extraction test was conducted by pulling the closed bag through a template with apertures of various diameters. For each opening, a series of ten bag extractions was carried out., Results: No loss of solid material or fluid was recorded during the morcellation test. The extraction test showed a loss of fluid for template openings smaller than 18 mm. The force necessary to extract the bag was inversely related to the width of the aperture., Conclusions: The data suggest that under the evaluated conditions, the use of a closable morcellation bag can considerably improve the patient's safety during morcellation. Further studies are necessary to evaluate the influence of the bag on operating time, intervention costs and complications.

Background and Objectives: The well-known advantages of minimally invasive surgery make the approach well suited for hysterectomy and other gynecological procedures. The removal of specimens excised during surgery has been a challenge that has been answered by the use of power morcellation. With this study we sought to assess the feasibility of power morcellation within a specimen bag., Methods: This was a retrospective cohort study including patients from a private practice in suburban Chicago, Illinois, who underwent contained electromechanical power morcellation during a laparoscopic or robot-assisted hysterectomy or myomectomy from May 2014 through December 2015. Contained power morcellation was performed with the Espiner EcoSac 230 (Espiner Medical Ltd., North Somerset, United Kingdom) specimen bag. Descriptive statistics were performed for both categorical and continuous data., Results: Of the 187 procedures performed, 73.8% were myomectomies, and 26.2% were hysterectomies. The patients' mean age was 40 (range, 25-54) years and mean body mass index was 28.7 (range, 17.3-57.6). The average specimen weight was 300 g, with the largest weighing 2134 g. Estimated blood loss averaged 98.4 mL. The postoperative admission rate was 12.3%, most of which were due to nausea and urinary retention. Seventeen patients (9.1%) had postoperative complications, most of which were minor, and 4 (2.1%) were readmitted. There were no bag failures or complications that were due to the use of the specimen bag or to power morcellation., Conclusions: Performing electromechanical power morcellation within the Espiner EcoSac 230 specimen bag was successfully performed in 187 patients with no bag-related complications. This method of contained power morcellation is feasible, reliable, and reproducible, even for a large specimen.

Introduction: Endoscopic techniques have successfully reduced the invasiveness of hysterectomy, when compared to open procedures. Power morcellation, as a part of the minimal invasive concept, carries the risk of disseminating cells from the tissue specimen. The present observational study reports on first experiences using a new system (More-Cell-Safe, A.M.I., Austria) for contained in-bag morcellation during laparoscopic hysterectomy., Materials and Methods: The dual opening system allows two-port access without bag puncture. The optic is protected against spread cell contamination with a disposable sleeve. Application data were prospectively recorded on the first n = 7 consecutive patients and compared to n = 7 preceding patients undergoing uncontained morcellation., Results: Bag system use was surgically successful in 6 of 7 cases (85.7 %). Morcellated specimen weight ranged from 205 to 638 g (mean 413.33 ± 176.85; median 413). In one patient, the uterine specimen (1050 g) proved too large to be placed into the bag. Average time associated to the bag use was 16.2 ± 7.65 min, ranging from 8.5 to 26.5 min (median 14 min). Removed bags contained bloody fluid with residual tissue fragments weighing overall between 21 and 85 g. Spread spindle cells were detected in two cases after uncontained morcellation, but not after in-bag morcellation., Conclusion: The experiences from our small pilot series prove technical feasibility in the clinical setting.

Objective: To evaluate a modified single-access method of contained power morcellation performed with a single-access laparoscopic device and a new cordless electric morcellator. The study was a preliminary assessment of the feasibility and safety of the new technique., Study Design: A single university hospital observational study involving patients who underwent either laparoscopic myomectomy or laparoscopic hysterectomy. We evaluated the operative results, time required for the contained morcellation, any occurrence of bag leakage, and any complications., Results: The new contained power morcellation technique was applied in 12 patients (9 undergoing laparoscopic myomectomy and 3 undergoing laparoscopic hysterectomy). The mean bag introduction time was 21.8min (range, 14-37min); mean in-bag morcellation time was 11.5min (range, 1-26min); and mean total morcellation time was 36.8min (range, 19-66min). Visual inspection revealed no bag damage. There were no postoperative complications., Conclusion: Single-site in-bag morcellation performed with our new technique requires neither bag penetration nor piercing with a trocar and thus may prove beneficial for preventing spillage and dissemination of unwanted cells and tissue., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objective: To evaluate whether manualin-bag morcellation could be efficiently proposed as alternative to the uncontained power technique., Design: Randomized controlled trial., Setting: Academic hospital., Patient(s): One hundred fifty-two premenopausal women eligible for myomectomy were screened, and 104 were randomized., Intervention(s): Patients were randomized into two groups. In the experimental group, "in-bag" protected morcellation was performed. In the control group, patients were treated by uncontained power myoma removal., Main Outcome Measure(s): The primary endpoint was the comparison of morcellation operative time (MOT). The secondary endpoints were the comparisons of total operative time (TOT), simplicity of morcellation (as defined by the surgeon using a visual analogue scale scale), intraoperative blood loss, rate of complications, and postoperative outcomes., Result(s): A sample size of 51 per group (n = 102) was planned. Between March 2014 and January 2015, patients were randomized as follows: 53 to the experimental group and 51 to the control group. Most demographic characteristics were similar across groups. MOT was observed to be similar in both study groups (16.18 ± 8.1 vs. 14.35 ± 7.8 minutes, in the experimental and control groups, respectively). Fibroid size was identified as the principal factor influencing morcellation time (Pearson coefficient 0.484 vs. 0.581, in the experimental and control groups, respectively). No significant difference in TOT, simplicity of morcellation, delta Hb, postoperative pain, and postoperative outcomes were observed between groups., Conclusion(s): The protected manual in-bag morcellation technique represents a time-efficient and feasible alternative, which does not interfere with surgical outcomes in women undergoing laparoscopic myomectomy., Clinical Trial Registration: NCT02086435., (Copyright © 2016 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose. Myomectomy has been performed through laparoscopy. Suturing is known as rate-limiting step in laparoscopic myomectomy. The present study was aimed at comparing the clinical outcomes of absorbable knotless wound closure device with the results of conventional suturing. Methods. This prospective study included 62 women who underwent laparoscopic myomectomy at Taipei City Hospital, Zhongxiao Branch, from January 2010 through to August 2012. The patients were randomized into two groups according to suturing materials, the knotless group and the 2-0 Vicryl suture group. Patient demographics, overall operative time, and intraoperative blood loss were compared between two groups. Results. Demographic characteristics and laboratory variables before surgery were comparable. Operative time was significantly shorter in knotless group compared with that in 2-0 Vicryl suture group (112 ± 47 versus 147 ± 63 minutes; p < 0.05). The results revealed a significant difference in intraoperative blood loss between two groups (knotless versus 2-0 Vicryl: 112.8 ± 54.2 versus 143.6 ± 64.9). Use of absorbable knotless wound closure device was associated with greater hemostasis compared with that of 2-0 Vicryl. During a 2-year follow-up period, 12 patients (46.2%) from the group with absorbable knotless wound closure device and 14 patients (38.9%) from 2-0 Vicryl suture group became pregnant. Conclusion. Closure of myometrium using absorbable knotless wound closure device after laparoscopic myomectomy resulted in a shorter operative time and less blood loss.

Background: Power morcellation during gynecological procedures may cause seeding of undiagnosed cancers. We used a national database to determine the prevalence of malignant and premalignant conditions that were present but undetected at the time of laparoscopic supracervical hysterectomy and laparoscopic myomectomy, surgeries in which morcellation is commonly used., Methods: Data from 2007 to 2012 were obtained from MarketScan, an administrative database of diagnostic and treatment data for 55.7 million commercially insured women in the United States. Because power morcellation is not captured with billing codes, we limited our analysis to women undergoing procedures that typically use morcellation and that are contraindicated in the case of suspected malignancy to describe the rates at which undetected cancers occur, thus potentially putting patients at risk for seeding of malignant tissue. We defined the rate of preoperative endometrial biopsy and postoperative cancers and hyperplasia by manually reviewing inpatient and outpatient International Classification of Disease, 9th edition, and Current Procedural Terminology codes for all suspected cases., Results: In all, 17,903 women underwent laparoscopic supracervical hysterectomy and 1,603 underwent laparoscopic myomectomy. The rate of uterine cancer among women undergoing hysterectomy was 2.96 per 1000 and increased with age from 0 per 1,000 at age younger than 35 to 9.07 per 1,000 at ages 55 to 64 (p < .05 for age ≥45 compared with <45). Preoperative endometrial biopsy was documented in 47% of women subsequently diagnosed with uterine cancer. The overall rate of malignant and premalignant gynecological conditions was 5.14 per 1,000 for laparoscopic supracervical hysterectomy and 1.87 per 1,000 for laparoscopic myomectomy., Conclusion: Approximately 1 in 350 women undergoing laparoscopic supracervical hysterectomy had an undiagnosed uterine cancer, with higher risks among older women. Approximately one-half of women had endometrial biopsies documented before hysterectomy. Safer alternatives, such as contained morcellation, should be evaluated to reduce the risk of complications after morcellation procedures., (Copyright © 2016 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Objectives: To compare surgical outcomes of different types of intracorporeal sutures for laparoscopic posterior myomectomy, by a prospective randomized study., Study Design: Prospective randomized study on 47 patients with single posterior intramural myoma (4-7cm in diameter) undergoing laparoscopic myomectomy. The patients enrolled were divided into two groups, one operated using conventional suture in double strand, and the other with bidirectional barbed suture Stratafix. The main outcome measures were suturing time, peri-operative variables, and post-operative adhesions in both groups., Results: The mean operative time was shorter with the Stratafix™ than with the conventional suture (66.3±8.2 vs. 73±8min; p=0.005). Suturing time was significantly shorter in the Stratafix™ than in the control group (8.8±2.4 vs. 15.5±2.8min; p=0.001). Intraoperative bleeding was significantly less in the Stratafix group (p=0.0012). Conversely, there was no statistically significant difference for postoperative adhesions between the two groups (26.7% vs. 21.4% p=0.5)., Conclusions: The use of barbed suture may reduce operative time, suturing time, and blood loss. No difference in post operative adhesions was found., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Introduction: Minimal invasive approaches have proven beneficial for patients undergoing myomectomy and hysterectomy, but necessary tissue morcellation carries the risk of cell dissemination in rare cases of inadvertent malignancy. Performing the morcellation process within a contained bag system may prevent spilling and therefore enhance safety of the laparoscopic procedures., Material and Methods: The present study describes the development and experimental evaluation of a new bag system in vitro and in vivo in a pig model of laparoscopic supracervical hysterectomies., Results: The main results on n = 8 procedures with in-bag morcellation compared to n = 8 controls without bag indicate reproducible feasibility and protective effect of the new bag, which is the first published to our knowledge that does not require puncturing in a standard multiport laparoscopy setting. Overall surgery time was significantly prolonged in the bag group by 12.86 min (P = 0.0052; 95 % confidence interval 4.64-21.07), but peritoneal washings were negative for muscle cells in all cases with bag use, compared to positive cytology in 5/8 cases without bag (P = 0.0256)., Conclusion: Clinical trials will now be necessary to investigate the reproducibility of these encouraging data in human application.

Study Objective: To compare the effectiveness and safety of a flexible carbon dioxide (CO2) laser fiber to the ultrasonic scalpel when employed through a robotic surgical system., Design: Retrospective cohort study., Design Classification: Level II-2 evidence., Setting: Reproductive surgery practice at an academic hospital., Patients: Two hundred thirty-six women who had undergone robot-assisted laparoscopic myomectomy with either CO2 laser (n = 85) or the ultrasonic scalpel (n = 151)., Interventions: Robot-assisted laparoscopic myomectomy employing either a flexible CO2 laser fiber or a robotic ultrasonic scalpel as the primary energy tool., Measurements and Main Results: Perioperative outcomes (estimated blood loss, operative time, length of hospital stay) of patients undergoing robot-assisted myomectomy with a flexible laser fiber or ultrasonic scalpel. Estimated blood loss and operative time were comparable (p = .95 and p = .55, respectively) between the 2 groups after adjusting for all confounders, whereas length of hospital stay remained significantly different (p = .004). Odds ratio for complications was 0.35 (95% confidence interval 0.08-1.56; p = .17), which denotes no difference in the risk for complications between the 2 groups., Conclusion: Robot-assisted laparoscopic myomectomy with a flexible CO2 laser fiber is safe and has comparable operative outcomes to the ultrasonic scalpel. The small size and flexibility of this device allows robotic surgeons to employ safe focal energy without sacrificing operative ergonomics., (Copyright © 2015 AAGL. Published by Elsevier Inc. All rights reserved.)