Faculty Bibliography

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.

OBJECTIVE:Ovarian cancer laparoscopic staging of patient with intraperitoneal renal transplant. METHODS:43-year-old female with intra-peritoneal renal transplant was referred status post laparoscopic bilateral ovarian cystectomies. The pathology report revealed serous adenocarcinoma with clear cell and papillary features of ovaries and endometrium. She was asymptomatic with benign examination. PET/CT of chest/abdomen/pelvis showed area of metabolic activity in left ovary and right common iliac pelvic lymph nodes. RESULTS:During laparoscopic staging [1], the intraperitoneal kidney transplant was firmly adhered to the uterus, right pelvic sidewall and adnexa. Right pelvic lymph node debulking was performed but not paraaortic lymph node dissection because of increased morbidity of this case. The final pathology showed ovarian serous adenocarcinoma with clear cell features, without involvement of endometrium, negative lymph nodes and peritoneal washings. We believe that the intrauterine pathological finding during the first surgery was "drop lesion" from the ovary to the uterine cavity. Thus, the final stage assigned was IC1, secondary to ovarian cyst rupture at the initial surgery. She received six cycles of intravenous Carboplatin and Taxol. There is no evidence of recurrence in nine-month follow up. CONCLUSION/CONCLUSIONS:The incidence of malignancies is increasing in cases of renal transplant secondary to the age of patients and the immunosuppressive therapy [2,3]. Laparoscopic surgical treatment for gynecologic malignancies can be challenging due to location of transplanted kidney in the pelvis [4]. We present a rare case of laparoscopic ovarian cancer staging with intraperitoneal renal transplant, which can be safely performed in hands of a skilled laparoscopic surgeon.

BACKGROUND AND OBJECTIVES/OBJECTIVE:The relationship between leiomyoma and endometriosis is poorly understood. Both contribute to considerable pain and may cause subfertility or infertility in women. We conducted this retrospective study to assess the rate of coexistence of endometriosis in women with symptomatic leiomyoma. The primary outcome measured was the coexistence of histology-proven endometriosis in women with symptomatic leiomyoma. METHODS:This is a retrospective review of a data-based collection of medical records of 244 patients treated at a tertiary medical center, who were evaluated for symptomatic leiomyoma from March 2011 through December 2015. Of those, 208 patients underwent laparoscopic or laparoscopic-assisted myomectomy or hysterectomy. All patients provided consent for possible concomitant diagnosis and treatment of endometriosis. The remaining 36 patients underwent medical therapy and were excluded from the study. All patients who had myomectomy or supracervical hysterectomy underwent minilaparotomy for extracorporeal morcellation and specimen removal beginning in April 2012. RESULTS:Of the 208 patients with the presenting chief concern of symptomatic leiomyoma and who underwent surgical therapy, 181 had concomitant diagnoses of leiomyoma and endometriosis, whereas 27 had leiomyoma. Of the 27 patients, 9 also had adenomyosis. Patients with only fibroid tumors were, on average, 4.0 years older than those with endometriosis and fibroids (mean age, 44 vs 40 ± SD). Patients with both pathologies were also more likely to present with pelvic pain and nulliparity than those with fibroid tumors alone. CONCLUSIONS:In our patient population, 87.1% of patients with a chief concern of symptomatic fibroids also had a diagnosis of histology-proven endometriosis, which affirms the need for concomitant diagnosis and intraoperative treatment of both conditions. Overlooking the coexistence of endometriosis in women with symptomatic leiomyoma may lead to suboptimal treatment of fertility and persistent pelvic pain. It is important for physicians to be aware of the possibility of this association and to thoroughly evaluate the abdomen and pelvis for endometriosis at the time of myomectomy or hysterectomy in an effort to avoid the need for reoperation.

STUDY OBJECTIVE/OBJECTIVE:To describe our technique for the repair of a cesarean section uterine scar defect after removal of an ectopic pregnancy from the scar in a patient desiring future pregnancies. DESIGN/METHODS:Step-by-step explanation of the procedure using video (Canadian Task Force classification III). SETTING/METHODS:Uterine scar dehiscence/defect is a known complications of multiple cesarean deliveries that can result in abnormal bleeding, infertility, and cesarean scar ectopic pregnancy. With the increasing number of cesarean sections performed in the United States, the prevalence of this complication is rising. Nonetheless, there currently are no standardized surgical treatment guidelines available to manage this pathology through a minimally invasive approach. INTERVENTIONS/METHODS:In this video, we describe our technique for the surgical management of a symptomatic cesarean section scar defect. We performed a robotic-assisted laparoscopic repair of this defect in a 40-year-old G4P3013 with a recent cesarean section scar ectopic pregnancy managed by endometrial curettage, with subsequent persistent abnormal vaginal bleeding. A repeat ultrasound revealed a low uterine segment defect consistent with dehiscence. She was referred to us because she desired a conservative treatment given her desire for future pregnancies. The defect was localized by hysteroscopy and laparoscopy after developing the bladder flap. The scar tissue around the defect was resected, and the freshened edges of the defect were closed using delayed absorbable suture. Chromopertubation confirmed the watertightness of the repair. Postoperatively, the patient had regular normal periods, and her hysterosalpingogram didn't show any uterine defect. CONCLUSION/CONCLUSIONS:Robotic-assisted laparoscopic repair of cesarean section scar defect is a feasible and safe procedure when done with respect to anatomy and following sound surgical technique. With the increasing number of cesarean sections, gynecologists will be dealing with this pathology more frequently, and need to become more familiar with different techniques that can be helpful in performing such a repair.