Faculty Bibliography

STUDY OBJECTIVE:To illustrate a robotic-assisted laparoscopic resection for cervicovaginal myomectomy. DESIGN:Step-wise instruction using video and case report (Canadian Task Force classification III). SETTING:A tertiary referral center. PATIENT:A 39-year-old woman. INTERVENTION:Robotic-assisted laparoscopy resection of leiomyoma. MEASUREMENTS AND MAIN RESULTS:, with a known cervicovaginal myoma that in the past underwent uterine artery embolization, presented with recurrence of her severe abnormal vaginal bleeding. She was referred for surgical resection of the mass. Magnetic resonance imaging revealed a 5-cm posterior cervicovaginal leiomyoma. The patient wanted to preserve her reproductive organs. A total robotic procedure lasted 123 minutes, with an estimated blood loss of 100 mL. She was discharged uneventfully on the day 0 postoperatively. Pathology results showed a 37-g leiomyoma of the uterus. The patient presented at her 2-weeks postoperative visit with no more complaint of vaginal bleeding. CONCLUSION:Robot-assisted laparoscopic surgery is a feasible approach for cervicovaginal myoma with minimal complications.

Background/UNASSIGNED:Endometriosis is a widely known benign disease, but 0.5%-1% of cases are associated with malignancy. It has been linked with ovarian neoplasms, particularly endometrioid and clear cell adenocarcinoma histology. Rhabdomyosarcomas are rarely associated with endometriosis. Case/UNASSIGNED:A 35-year-old patient underwent surgical management of endometriomas to optimize infertility treatment. She later developed abdominal pain with rapid recurrence of ovarian masses. This prompted additional surgery with biopsies diagnosing ovarian rhabdomyosarcoma. Retroactive review of pathologic specimens from her prior surgery demonstrated the neoplasm originated from her prior endometrioma. Focal areas suggested possible underlying ovarian adenosarcoma with stromal overgrowth. Discussion/UNASSIGNED:The incidence of rhabdomyosarcoma arising from endometriosis is exceedingly rare. The accuracy of diagnosing endometriosis and ruling out neoplasm requires coordinated efforts of a multidisciplinary team, involving radiologists, pathologists, oncologists, and gynecologic surgeons.

Vaginal cuff dehiscence is an infrequent complication of hysterectomy, with the potential for evisceration and additional morbidity. This review aims to describe the incidence, risk factors, preventative measures, and management. Identification of specific risk factors is problematic because many studies either lack comparison groups or are underpowered as a result of the rarity of this complication. Good surgical technique to optimize vaginal cuff healing and minimize the risk of postoperative cuff infection are important as is avoidance of early intercourse, traumatic vaginal penetration, or excess strain on the vaginal cuff during the postoperative period. Judicious use of electrocautery or other thermal energy, use of delayed absorbable sutures, and adequate tissue bites can further decrease the risk of dehiscence. Prompt recognition and management are critical to achieve best outcomes.

The most common location of extragenital endometriosis is the bowel. Medical treatment may not provide long-term improvement in patients who are symptomatic, and consequently most of these patients may require surgical intervention. Over the past century, surgeons have continued to debate the optimal surgical approach to treating bowel endometriosis, weighing the risks against the benefits. In this expert review we will describe how the recommended surgical approach depends largely on the location of disease, in addition to size and depth of the lesion. For lesions approximately 5-8 cm from the anal verge, we encourage conservative surgical management over resection to decrease the risk of short- and long-term complications.

Iliopsoas abscess (IPA) is a rare condition seen in a variety of specialties that presents with nonspecific complaints. Presented herein is the development of an IPA after robotic staging with sentinel lymphadenectomy for endometrial carcinoma. The patient was a 61-year-old woman with history of prolonged immunosuppressive therapy due to psoriasis. She presented with an IPA 8 weeks after a robotic-assisted laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and sentinel lymph node dissection. The patient was treated and cured with empiric antibiotics and drainage by interventional radiology. Although infrequent, one must keep IPA as a possible diagnosis in immunosuppressed patients who have undergone dissection of the retroperitoneal space during gynecologic surgery.

This article focuses on the anatomy, literature, and our own experiences in an effort to assist in the decision-making process of choosing between an umbilical or vaginal port. Umbilical access is more familiar to general surgeons; it is thicker than the transvaginal entry, and has more nerve endings and sensory innervations. This combination increases tissue damage and pain in the umbilical port site. The vaginal route requires prophylactic antibiotics, a Foley catheter, and a period of postoperative sexual abstinence. Removal of large specimens is a challenge in traditional laparoscopy. Recently, there has been increased interest in going beyond traditional laparoscopy by using the navel in single-incision and port-reduction techniques. The benefits for removal of surgical specimens by colpotomy are not new. There is increasing interest in techniques that use vaginotomy in multifunctional ways, as described under the names of culdolaparoscopy, minilaparoscopy-assisted natural orifice surgery, and natural orifice transluminal endoscopic surgery. Both the navel and the transvaginal accesses are safe and convenient to use in the hands of experienced laparoscopic surgeons. The umbilical site has been successfully used in laparoscopy as an entry and extraction port. Vaginal entry and extraction is associated with a lower risk of incisional hernias, less postoperative pain, and excellent cosmetic results.

BACKGROUND AND OBJECTIVES/OBJECTIVE:The inadvertent dissemination of uterine cancer cells with the power morcellator has received much attention in the press and a warning from the U.S. Food and Drug Administration. Many hospitals prohibit the use of the morcellator in gynecologic surgery. We conducted a survey in an attempt to assess gynecologic surgeons' beliefs regarding the intracorporeal power morcellation of fibroids in light of the risk of dissemination of malignancy in patients in whom the presence of cancer is unknown before surgery. METHODS:We conducted an Internet-based survey of 3505 members of the Society of Laparoendoscopic Surgeons (SLS) to assess demographics, current use of the intracorporeal power morcellator, and whether the recent negative press has affected gynecologic surgeons' use of the morcellator. RESULTS:= .013). Three hundred sixty-one (76%) of the participants currently perform laparotomy in fewer than a quarter of their cases; most those cases are still performed using laparoscopic and robot-assisted techniques. CONCLUSION/CONCLUSIONS:The recent negative press suggesting that intracorporeal power morcellation can disseminate occult malignancy and affect survival has decreased the use of the morcellator. Despite the declining use of power morcellation, most practicing gynecologic surgeons have not converted their procedures to laparotomy.