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Laparoscopic Tips and Tricks:

Advancing Your Skills (Didactic)

PROGRAM CHAIR

Stephanie N. Morris, MD

Andrew I. Brill, MD James K. Robinson, MD

Professional Education Information Target Audience Educational activities are developed to meet the needs of surgical gynecologists in practice and in training, as well as, other allied healthcare professionals in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.

Table of Contents

Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 3 Essential Pelvic Anatomy for Advanced Laparoscopic Surgery A.I. Brill ......................................................................................................................................................... 5 Difficult Peritoneal Access: Overcoming Adhesions and Obesity J.K. Robinson .............................................................................................................................................. 13 Surgical Techniques for Superficial and Deep Endometriosis A.I. Brill ........................................................................................................................................................ 18 Ovarian Cystectomy: Preservation of Fertility S.N. Morris ................................................................................................................................................. 23 The Large Uterus: Tips for Successful Laparoscopic Hysterectomy S.N. Morris ................................................................................................................................................. 27 Simplifying Laparoscopic Myomectomy S.N. Morris ................................................................................................................................................. 32 Strategies for Safe and Efficient Tissue Removal A.I. Brill ....................................................................................................................................................... 37 Cuff Management: Issues of Support and Controversies of the Cervix J.K. Robinson .............................................................................................................................................. 45 Cultural and Linguistics Competency ......................................................................................................... 49

PG 109 Laparoscopic Tips and Tricks: Advancing Your Skills (Didactic)

Stephanie N. Morris, Chair

Faculty: Andrew I. Brill, James K. Robinson

Course Description This course will help gynecologic surgeons advance their skills by providing strategies to overcome

common clinical challenges and expand their surgical armamentarium. This will be accomplished through

an in-depth review of key laparoscopic pelvic anatomy and tips to help navigate challenging clinical situations, such as obesity and difficult peritoneal access. Techniques for mastering challenging surgical

procedures encountered in general practice, such as hysterectomy for the large uterus, support of the

vaginal/cervical cuff at the time of hysterectomy, myomectomy, large ovarian cystectomy, tissue extraction, and the surgical management of endometriosis will be explored in detail. Experienced

surgeons will utilize videos, evidence-based medicine and clinical expertise to provide participants with relevant knowledge, practical solutions, and step-by-step strategies which can be incorporated into

current practice in order to safely and successfully complete more advanced surgery. The course is

aimed at surgeons with some laparoscopic experience who are looking to advance their skills.

Course Objectives At the conclusion of this course, the participant will be able to: 1) Locate the essential anatomy of the

deep pelvic side wall; 2) apply strategies for difficult peritoneal access; 3) explain safe techniques for

tissue extraction; 4) demonstrate steps used to simplify laparoscopic myomectomy; 5) implement approach to hysterectomy with a large uterus; and 6) apply techniques to support the vaginal cuff after

hysterectomy in appropriate cases.

Course Outline 8:00 Welcome, Introductions and Course Overview S.N. Morris

8:05 Essential Pelvic Anatomy for Advanced Laparoscopic Surgery A.I. Brill

8:30 Difficult Peritoneal Access: Overcoming Adhesions and Obesity J.K. Robinson

8:55 Surgical Techniques for Superficial and Deep Endometriosis A.I. Brill

9:20 Ovarian Cystectomy: Preservation of Fertility S.N. Morris

9:45 Questions & Answers All Faculty

9:55 Break

10:10 The Large Uterus: Tips for Successful Laparoscopic Hysterectomy S.N. Morris

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10:35 Simplifying Laparoscopic Myomectomy S.N. Morris

11:00 Strategies for Safe and Efficient Tissue Removal A.I. Brill

11:25 Cuff Management: Issues of Support and Controversies of the Cervix J.K. Robinson

11:50 Questions & Answers All Faculty

12:00 Course Evaluation

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PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Viviane F. Connor Consultant: Conceptus Incorporated Frank D. Loffer, Executive Vice President/Medical Director, AAGL* Linda Michels, Executive Director, AAGL* Jonathan Solnik Other: Lecturer - Olympus, Lecturer - Karl Storz Endoscopy-America SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: CooperSurgical, Ethicon Women's Health & Urology, Intuitve Surgical Other: Royalties - CooperSurgical Linda Bradley Grants/Research Support: Elsevier Consultant: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharmaceuticals Speaker's Bureau: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharm Keith Isaacson Consultant: Karl Storz Endoscopy Rosanne M. Kho Other: Honorarium - Ethicon Endo-Surgery C.Y. Liu* Javier Magrina* Ceana H. Nezhat Consultant: Intuitve Surgical, Lumenis, Karl Storz Endoscopy-America Speaker's Bureau: Conceptus Incorporated, Ethicon Women's Health & Urology William H. Parker Grants/Research Support: Ethicon Women's Health & Urology Consultant: Ethicon Women's Health & Urology Craig J. Sobolewski Consultant: Covidien, CareFusion, TransEnterix Stock Shareholder: TransEnterix Speaker's Bureau: Covidien, Abbott Laboratories Other: Proctor - Intuitve Surgical FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Stephanie N. Morris* Andrew I. Brill Consultant: Karl Storz Endoscopy-America, Ethicon Endo-Surgery, Conceptus Incorporated, CooperSurgical Speaker's Bureau: Karl Storz Endoscopy-America, Ethicon Endo-Surgery, Conceptus Incorporated, CooperSurgical

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James K. Robinson Consultant: Gyrus ACMI (Olympus), Intuitve Surgical Jubilee Brown* Asterisk (*) denotes no financial relationships to disclose.

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Essential Retroperitoneal and Topographic Essential Retroperitoneal and Topographic

AnatomyAnatomy For The Laparoscopic SurgeonFor The Laparoscopic Surgeon

Andrew I. Brill, MDAndrew I. Brill, MDDirector, Minimally Invasive Gynecology & Reparative SurgeryDirector, Minimally Invasive Gynecology & Reparative Surgery

California Pacific Medical CenterCalifornia Pacific Medical CenterSan Francisco, CASan Francisco, CA

DisclosuresDisclosures

•• ::

•• Consultant: Karl Storz EndoscopyConsultant: Karl Storz Endoscopy--America, Ethicon EndoAmerica, Ethicon Endo--Surgery, Surgery, Conceptus Incorporated, CooperSurgicalConceptus Incorporated, CooperSurgicalConceptus Incorporated, CooperSurgicalConceptus Incorporated, CooperSurgical

•• Speaker's Bureau: Karl Storz EndoscopySpeaker's Bureau: Karl Storz Endoscopy--America, Ethicon EndoAmerica, Ethicon Endo--Surgery, Surgery, Conceptus Incorporated, CooperSurgicalConceptus Incorporated, CooperSurgical

Learning Objectives: Able to describe.Learning Objectives: Able to describe...::

Describe topographical Describe topographical pelvic anatomypelvic anatomy

Review the keyReview the key vascular anatomy of abdominal wallvascular anatomy of abdominal wallReview the key Review the key vascular anatomy of abdominal wall vascular anatomy of abdominal wall

Identify the link Identify the link between anatomy and techniquebetween anatomy and technique

Discuss the anatomical Discuss the anatomical components of pelvic sidewallcomponents of pelvic sidewall

Why Master Surgical Anatomy?Why Master Surgical Anatomy?

More Efficient More Efficient FasterFaster

Can Minimize Complications!Can Minimize Complications!

More Effective More Effective Better ResultsBetter Results

More Confident More Confident SaferSafer

a significant amount of medical a significant amount of medical ill b itt d!ill b itt d!errors will be committed!errors will be committed!

No procedure should ever be No procedure should ever be considered a total failure……considered a total failure……

It can always be It can always be It can always be It can always be used as a bad example!used as a bad example!

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Present surgical education systems are deficient Present surgical education systems are deficient

in evaluating performance and competencyin evaluating performance and competencyg p p yg p p yAnatomyAnatomy DissectionDissection

Indication: Indication: endometriosisendometriosis

Good Technique Good Technique WithoutWithoutAnatomyAnatomy Good Technique Good Technique WithoutWithout AnatomyAnatomy

Always think of what’s under the surfaceAlways think of what’s under the surface

urachusurachusOblit Oblit umb a.umb a.

Oblit Oblit umb a.umb a.

6

umbilicusumbilicus

Major Vessels of Abdominal WallMajor Vessels of Abdominal Wall

Superficial Epigastric VesselsSuperficial Epigastric VesselsSuperficial Epigastric VesselsSuperficial Epigastric Vessels

Inferior Epigastric VesselsInferior Epigastric Vessels Inferior Epigastric VesselsInferior Epigastric Vessels

-- anatomic origins anatomic origins --

7

Identifying the Inferior Epigastric VesselsIdentifying the Inferior Epigastric Vessels

11 22 33

112233112233

LUQLUQ

Peritoneal Tenting

Left Upper QuadrantLeft Upper Quadrant

LUQ = 3

Pop

1

2

3

8

Superior epigastric vessels (se)

MCLMCL

se se

rectus sheathrectus sheathMCLMCL

4-5FB

Relinquishing the Big PictureRelinquishing the Big Picture

Where am I?Where am I?

3 U’s: ureter 3 U’s: ureter uterosacral uterosacral uterine auterine a

9

Out of sight never out of mindOut of sight never out of mind Dissecting the Lateral SidewallDissecting the Lateral Sidewall

AnatomyAnatomy DissectionDissection

10

Medial Umbilical LigamentMedial Umbilical Ligament

Pelvic Sidewall Pelvic Sidewall –– 3 Surgical Layers3 Surgical Layers

UreterUreter

I l ili lI l ili l

avascular

Internal iliac vessels Internal iliac vessels Cardinal ligament sheathCardinal ligament sheath

External iliac vessels External iliac vessels Obturator vessels and muscle Obturator vessels and muscle

avascular

Pelvic Sidewall Pelvic Sidewall –– 3 Surgical Layers3 Surgical LayersPelvic Sidewall DissectionPelvic Sidewall Dissection

11

ThinkThink

AnatomyAnatomy

Anatomical surgery demands Anatomical surgery demands awareness……awareness……..

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Difficult Peritoneal Access: Overcoming Adhesions and

ObesityJames K. Robinson, MD, MS

The George Washington University

• Consultant: Gyrus ACMI (Olympus), IntuitveSurgical

• At the conclusion of this session the participant will be able to:– Identify the risks inherent in primary peritoneal access.

– Identify different approaches to primary peritoneal access.

– Identify patients at the highest risk of peritoneal access li icomplications.

– Identify principals and techniques to minimize risks associated with high risk peritoneal access.

– Identify principals and techniques of intraoperative adhesiolysis.

– Identify principals and techniques of port site closure.

9 videos = 10 minutesDidactic = 10 minutes (20 slides)

• Primary Access

– Complications Data (2 slides)

• Video (Bowel Injury, Vascular Injury)

– Approaches and associated complications (3 slides)

• Veress, Open, Direct

– Umbilical Approach

• Video (access video, compression video)

– High risk patients

• Images

– Alternative access

– Palmers Point Approach

• Videos (Lap view of gastric dilation and decompression, needle placement and pressures)

– Microlaparoscopy

– Preliminary Ultrasound evaluation

• Secondary Access and Adhesions

– Complications Data

• Videos (Bladder Injury, adhesiolysis)

– Location

• Closure

– Video (Carter Thomason)

Complications Associated with Trocars

• Surgical Trocars associated with surgical complications more than any other laparoscopic device– Trocars 33%, Clips 9%, Veress 8%, Coagulation device 5%,

Scissors/scalpel 3%Scissors/scalpel 3%

• > 25% of all surgical malpractice claims site trocar insertion as the main cause if injury

• Fatal Trocar injuries– Vascular > Bowel

Maude Data Base. JMIG. 2005;12:302

Risk of Adhesions with Prior Laparotomy

Omental and/or Bowel

• Prior surgical scar

– Pfannensteil – 27%

– Low Vertical – 55%

Type of Prior Surgery and Adhesions

• Obstetrical – 22%

– No difference b/w pfannensteil vs midline

– High Vertical – 67%

• When adhesions exist– Omental only ‐ 84%

– Omental and Bowel – 16%

pfannensteil vs midline

• Gynecologic – 42%

– Pfannensteil – 31%

– Midline – 70%

Brill. Obstet Gynecol. 1995;85:299.

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Entry Injury Videos

• Vascular Injury

• Bowel Injuryj y

Modified 10 Step Veress Approach

1. Consider alternate approach in high risk patients (open or Palmer’s)

2. Safety check – patient flat, veress functional, no periumbilical masses foley placed

3. Incision – 5‐10 mm intraumbilical incision (evert the umbilicus)

4. Insertion of veress – 90 degrees, elevate umbilical sheath

5. Do not move the veress needle – to avoid enlarging an injury

6. Pressure check ‐ < 10 mmHg

7. Insufflate – to 25 mmHg

8. Trocar placement – 90 degrees

9. Injury check – 360 degree view and pressure reduction to 15 mmHg

10. Ancillary placement – Under direct visualization

Varma. Surg Endosc. 2008;22:2686.

Our Closed Approach

1. Evert the umbilicus (video)

2. Set the insufflator (video) Pressure ‐ 25 mmHg

Flow ‐ 1 liter/min (low)

3 Insert veress through the umbilical base with carbon dioxide3. Insert veress through the umbilical base with carbon dioxide flowing (video) Entry pressure will be < 3 mm Hg and often drop below 0.

4. Fill to 25 mmHg (pressure video)

5. Optical Trocar Placement (video)

Hasson Open Approach

• Harry Hasson first described the “open approach” in 1970.

• In 2000 he described his experience with 5284 consecutive patientsconsecutive patients.

• 0.5% complication rate associated with primary access.

• No major vascular or complicated GI injuries

Hasson HM .Obstet Gynecol.2000;96:763.

Direct Optical Entry

• Utilizes a bladeless optical trocar

• Direct trocar placement through the base of the umbilicus under direct visualization without pre insufflationwithout pre‐insufflation.

• Studies have demonstrated similar safety to closed and open approaches

• Largest multi‐centered trial with 17,350 consecutive patients

Tinelli A. Surg Innov. 2011;18:201.

Liu HF. Chin Med J (Engl). 2009;122:2733.

Which Approach is Better?

• Cochrane Database (2008)

– There is no significant difference in risk of primary entry associated complications between closedentry associated complications between closed, open or direct entry approaches.

– Entry associated complication diminish with experience.

Ahmad G. Cochrane Database. 2008;16(2).

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High Risk Patients

Risk Factors

• Prior Midline Laparotomy

• Morbid Obesity

• Very Thin

Images

y

• Pregnancy

• Large Pelvic or abdominal mass

Palmer’s Point• First described by Raoul Palmer in 1974.

• Ideal for:– Pelvic mass

– Predictable adhesions

– Pregnancy

– Failed umbilical attempt

• Relative contraindications:– Hepatosplenomegaly

– Prior gastric bypass or splenectomy

– LUQ mass

Palmer R. J Reprod Med. 1974;13:1-5.Granata M. Fertil Steril. 2010;94:2716.

Palmer’s Point Technique

• Closed Veress technique

• 2‐5 mm incision 3 cm below the left costal margin in the mid‐clavicular line

• Gastric suctioning

• Consider Trendelenburg

Tulikangas. Fertil Steril. 2003;79:411-2.

• Proximity of stomach and effect of gastric i

Palmer’s Point

suction

• Entry technique and laparoscopic view of periumbilical adhesions

Microlaparoscopy at Palmer’s Point

• Microlaparoscopic veress/trocar is inserted via Palmer’s point

• 1.2 mm laparoscope is i t d d th h thintroduced through the veress/trocar in order to inspect for periumbilical adhesions.

Microlaparoscopy and Adhesions

• 814 consecutive patients divided into 4 categories• Group 1 (469) – No prior

abdominal surgery

• Microlaparoscopy at Palmer’s point with umbilical adhesion analysis – 9.82% overall

abdominal surgery

• Group 2 (125) – Prior laparoscopic surgery

• Group 3 (131) – Prior suprapubic laparotomy

• Group 4 (89) – Prior midline laparotomy

adhesion rate– Omental ‐ Bowel

• Group 1 – 0.68% 0.42%

• Group 2 – 1.6% 0.80%

• Group 3 ‐ 19.8% 6.87%

• Group 4 – 51.7% 31.46%

Audebert A. Fert Steril. 2000;73:631.

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Visceral Slide and PUGSI

Visceral Slide

• The longitudinal distance the intestine or omentum travels as visualized by t bd i l US d i

PUGSI

• Periumbilical ultrasound guided saline infusion

– Tend abdoman with towel ltransabdominal US during

an exaggerated inspiration and expiration cycle

– Exaggerated = 1.5 x normal tidal volume

– Normal is = or > 1 cm movement

clamps

– Observe 19 ga needle enter peritoneum

– Inject 10 mls sterile saline

– Localized fluid pocket is abnormal finding

Visceral Slide and PUGSI

• Abnormal PUGSI had a sensitivity and specificity of 100% for obliterating periumbilical adhesions

Nezhat C. Fertil Steril. 2009;91:2714.

Ancillary Trocar Placement

• DIRECT VISUALIZATION to avoid:

Vascular – Inferior Epigastrics (Video)

Bowel

Bladder (Video)Bladder – (Video)

• Always drain the bladder prior to suprapubic port placement

• Consider backfilling the bladder to delineate the border

Adhesiolysis• Create planes

• Create windows

• Apply traction

• Do not tear

• Use cold scissors close to viscera

• Stay intraperitoneal

• Take your time !!!

• Run the bowel

Port Site Closure

• Port Site Hernia Incidence – 0.65‐2.8% in General Surgery Literature

• All ports > or = 10 mm require fascial closure

• 5 and 8 mm ports sites should be closed if5 and 8 mm ports sites should be closed if extensive manipulation could have expanded the fascial defect

Tonouchi H. Arch Surg. 2004;139:1248.

Carter Thomason Video

16

• Tonouchi H. Arch Surg. 2004;139:1248.

• Maude Database. JMIG. 2005;12:302.

• Brill. Obstet Gynecol. 1995;85:299.

• Hasson HM .Obstet Gynecol.2000;96:763.

• Tinelli A. Surg Innov. 2011;18:201.

• Liu HF. Chin Med J (Engl). 2009;122:2733.

• Ahmad G. Cochrane Database. 2008;16(2).

• Palmer R. J Reprod Med. 1974;13:1‐5.

• Granata M. Fertil Steril. 2010;94:2716.

• Tulikangas. Fertil Steril. 2003;79:411‐2.

• Audebert A. Fert Steril. 2000;73:631.

• Varma. Surg Endosc. 2008;22:2686.

• Nezhat C. Fertil Steril. 2009;91:2714.

• Tonouchi H. Arch Surg. 2004;139:1248.

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EndometriosisEndometriosisTechniques for Superficial & Deep Endometriosis Techniques for Superficial & Deep Endometriosis

????Andrew I. Brill, M.D.

Director, Minimally Invasive GynecologyCalifornia Pacific Medical Center


•• Consultant: Karl Storz EndoscopyConsultant: Karl Storz Endoscopy--America, America, Ethicon EndoEthicon Endo--Surgery, Conceptus Incorporated, Surgery, Conceptus Incorporated, CooperSurgicalCooperSurgicalCooperSurgicalCooperSurgical

•• Speaker's Bureau: Karl Storz EndoscopySpeaker's Bureau: Karl Storz Endoscopy--America, Ethicon EndoAmerica, Ethicon Endo--Surgery, Conceptus Surgery, Conceptus Incorporated, Incorporated, CooperSurgicalCooperSurgical

Learning ObjectivesLearning Objectives

•• Describe the laparoscopic appearance of Describe the laparoscopic appearance of endometriosisendometriosis

•• Explain the relationship between Explain the relationship between endometriosis and pelvic painendometriosis and pelvic pain

•• List the potential limits of medical and List the potential limits of medical and surgical therapy for endometriosissurgical therapy for endometriosis

•• Incorporate strategy for anatomical Incorporate strategy for anatomical removal of pelvic endometriosisremoval of pelvic endometriosis

EndometriosisEndometriosis

General ConsiderationsGeneral Considerations

EndometriosisEndometriosisOverviewOverview

–– Progressive diseaseProgressive disease

–– May exist in subclinical, microscopic forms that are not May exist in subclinical, microscopic forms that are not

visible at time of laparoscopic evaluationvisible at time of laparoscopic evaluation

–– Patients with higher stages more likely to experience Patients with higher stages more likely to experience

recurrences and to have them earlier than women with recurrences and to have them earlier than women with

lower stageslower stages

–– Women with deeply infiltrative disease more likely to Women with deeply infiltrative disease more likely to

experience painexperience pain

EndometriosisEndometriosisA myriad of appearancesA myriad of appearances

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EndometriosisEndometriosisProgenitors of PainProgenitors of Pain

•• Location of lesion related to visceraLocation of lesion related to viscera

•• Type of lesionType of lesion

T t l b f l iT t l b f l i•• Total number of lesionsTotal number of lesions

•• Depth of penetration of lesionDepth of penetration of lesion

•• InflammationInflammation

•• Stretching/scarring of tissueStretching/scarring of tissue

•• ? Chemical expressions? Chemical expressions

Deep culDeep cul--dede--sac and paravaginal endometriosissac and paravaginal endometriosiscorrrelate corrrelate

with with

focal points of tendernessfocal points of tendernessfocal points of tendernessfocal points of tenderness

Ripps & Martin J Reprod Med 1992Ripps & Martin J Reprod Med 1992

digital rectal examdigital rectal examisis

sine qua non! sine qua non!

Relevance of rRelevance of r--AFS ClassificationAFS ClassificationVercellini et al F&S 1996Vercellini et al F&S 1996

•• Not correlated with frequency of pain symptomsNot correlated with frequency of pain symptoms

•• Not correlated with severity of pain symptomsNot correlated with severity of pain symptoms

•• Why? Why? -- does not take into accountdoes not take into account

–– Cellular activityCellular activity

–– Depth of infiltrationDepth of infiltration

–– Individual lesionsIndividual lesions

EndometriosisEndometriosisSupport of Surgical TreatmentSupport of Surgical Treatment

•• Primal arguments favoring seePrimal arguments favoring see--andand--treattreat

–– Decreased treatment timeDecreased treatment time

D d tD d t–– Decreased costDecreased cost

–– Decreased number of side effectsDecreased number of side effects

–– No need for second ‘operative’ laparoscopyNo need for second ‘operative’ laparoscopy

–– Appeals to will of surgical egoAppeals to will of surgical ego

EndometriosisEndometriosisSurgical Treatments Pro v ConSurgical Treatments Pro v Con

•• Sharp excisionSharp excision–– Dissection of implants from normal tissueDissection of implants from normal tissue–– ProPro-- tissue specimentissue specimen–– ConCon-- injury to adjacent structures and bleedinginjury to adjacent structures and bleeding–– Requires certain level of expertiseRequires certain level of expertise

•• ElectrocoagulationElectrocoagulationElectrocoagulationElectrocoagulation–– Destruction of implants by thermal energyDestruction of implants by thermal energy–– ProPro-- familiar technology and hemostasisfamiliar technology and hemostasis–– ConCon-- injury to structures , lack of specimen, and injury to structures , lack of specimen, and

possibility of incomplete destruction of implantpossibility of incomplete destruction of implant•• Laser vaporizationLaser vaporization

–– Sharp dissection or vaporization with high density energySharp dissection or vaporization with high density energy–– ProPro-- ease of use and hemostasisease of use and hemostasis–– ConCon-- lack of specimen, risk of incomplete destruction, lack of specimen, risk of incomplete destruction,

injury to adjacent structure, expense of upkeep of laserinjury to adjacent structure, expense of upkeep of laser

EndometriosisEndometriosisCan Surgery be Curative?Can Surgery be Curative?

•• Make a diagnosisMake a diagnosis

/ d/ d llll didi•• Remove / destroy Remove / destroy allall disease?disease?

•• Prevent recurrence?Prevent recurrence?

•• Identify a lesion?Identify a lesion?

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Endometriosis: Microscopic DiseaseEndometriosis: Microscopic Disease

AuthorAuthor ResultsResults MethodologyMethodology

Murphy, 1986Murphy, 1986 25%25% SEMSEM

Vasquez 1984Vasquez 1984 75%75% LM & SEMLM & SEMVasquez, 1984Vasquez, 1984 75%75% LM & SEMLM & SEM

Nicole, 1990Nicole, 1990 13% 13% (WITH ENDO)(WITH ENDO) LMLM6%6% (WITH INFERT)(WITH INFERT) LMLM

Redwine, 1989Redwine, 1989 2%2% LMLM

66% 66% (PERIT POCKETS)(PERIT POCKETS) LMLM

Portuondo, 1982Portuondo, 1982 65% 65% (PELVIC WASHINGS)(PELVIC WASHINGS) CYTOLOGYCYTOLOGY

EndometriosisEndometriosisRecurrent NightmaresRecurrent Nightmares

Patient MD

Endometriosis: Excision of Deep LesionsEndometriosis: Excision of Deep LesionsKoninckx, F&S 1996Koninckx, F&S 1996

•• N = 225N = 225

•• “complete” excision 90%“complete” excision 90%

•• Mean depth of penetration = 10mm Mean depth of penetration = 10mm (6(6--20mm)20mm)Mean depth of penetration 10mm Mean depth of penetration 10mm (6(6 20mm)20mm)

•• ComplicationsComplications

–– Perforation into posterior vaginal fornix 14%Perforation into posterior vaginal fornix 14%

–– Enterotomy & bowel resection 6%Enterotomy & bowel resection 6%

–– Late bowel perforation/peritonitis 3%Late bowel perforation/peritonitis 3%

Surgery for EndometriosisSurgery for EndometriosisNet ResultsNet Results

•• Majority experience pain reliefMajority experience pain relief

•• Recurrence rates are significantRecurrence rates are significant

•• Stage I more apt to relapseStage I more apt to relapse

•• Pregnancy rates are variablePregnancy rates are variable

Treating Endometriosis with SurgeryTreating Endometriosis with SurgeryObservationsObservations

•• Conservative surgery results in varied success ratesConservative surgery results in varied success rates

•• All ablative techniques (laser, thermal, monopolar, All ablative techniques (laser, thermal, monopolar, and bipolar) are equivalentand bipolar) are equivalent

•• Resection has been regarded as superior; however Resection has been regarded as superior; however •• Resection has been regarded as superior; however, Resection has been regarded as superior; however, complete resection may not be possible secondary complete resection may not be possible secondary to microscopic disease and increased risk of to microscopic disease and increased risk of complicationscomplications

•• Surgical complications are prevalent and underSurgical complications are prevalent and under--reportedreported

•• Results are, and will always be surgeon dependentResults are, and will always be surgeon dependent

Putative Reasons for Surgical FailuresPutative Reasons for Surgical Failures

•• Microscopic lesions not destroyedMicroscopic lesions not destroyed

•• Atypical appearing lesions missed by surgeonAtypical appearing lesions missed by surgeon

•• Inaccessible lesions (deep & behind structures)Inaccessible lesions (deep & behind structures)

•• Incomplete ablation or resectionIncomplete ablation or resection

•• Other causes of pain besides endometriosisOther causes of pain besides endometriosis

•• Any combination of the aboveAny combination of the above

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Endometriosis: Surgical PrinciplesEndometriosis: Surgical Principles

Identify bladder, bowel, vessels, and ureterIdentify bladder, bowel, vessels, and ureter

Restore anatomical relationshipsRestore anatomical relationships

Treat endometrioma as last surgical stepTreat endometrioma as last surgical stepg pg p

Mobilize / identify the ureter (ureterolysis)Mobilize / identify the ureter (ureterolysis)

Mobilize / identify the rectum (probe/ ring)Mobilize / identify the rectum (probe/ ring)

Preferentially use mechanical dissectionPreferentially use mechanical dissection

Judiciously employ energyJudiciously employ energy--based devicesbased devices

Retroperitoneal DissectionRetroperitoneal Dissection

Peritoneal ResectionPeritoneal Resection PeriPeri--ureteral Dissectionureteral Dissection

know your instrumentationknow your instrumentation Uterosacral ResectionUterosacral Resection

21

PeriPeri--rectal Excisionrectal ExcisionRectovaginal DissectionRectovaginal Dissection

Observations Observations Surgical treatmentsSurgical treatments

–– Efficacious for reduction or elimination Efficacious for reduction or elimination in symptomsin symptoms

–– Rates of recurrence are quite similar to Rates of recurrence are quite similar to medical therapymedical therapy

–– Insufficient data to recommend best Insufficient data to recommend best approach (e.g., coagulation approach (e.g., coagulation vsvsresection)resection)

22

Ovarian Cystectomy:Preservation of fertilityy

Stephanie Morris, MDNewton‐Wellesley Hospital, MA

Harvard Medical School

Disclosure

• I have no financial relationships to disclose.

Objectives:

• Explain the risks associated with ovarian cystectomy and the clinical implications

• Demonstrate technique for laparoscopic ovarian cystectomy with the goal of fertilityovarian cystectomy with the goal of fertility preservation

• Who to take to the OR• L/s vs exlap

– Compl

• Cyst rupture– Dermoid– MalignancyMalignancy

• Surgical technique– Follicles in the cortex

• Endometrioma and fertility– Affect fertility?– Surgery affect fertility– Removal vs coagulation

• Fertility after cystectomy vs oophrectomy• Size limits ‐ drainage

Pre‐operative evaluation• Imaging : Ultrasound

• Serum markers

• Referral to gyn oncology (ACOG)– Premenopausal (younger than 50 years)

– CA125 levels greater than 200 units/mL

– Ascites

– Evidence of abdominal or distant metastasis

– Family history of breast or ovarian cancer (in a first‐degree relative)

ACOG PB 83

Laparoscopy vs. Laparotomy

• Laparoscopic surgery for benign ovarian tumors was associated with – Fewer adverse outcomes

• (intraop complications, post op fever/infections)

– Less post op pain

– Fewer days in the hospital

‐Laparoscopy vs. Laparotomy for benign ovarian tumors. Cochrane Database of Systematic Reviews. 11, 2010

‐ACOG PB #83

23

Surgical technique

• Incision

• Removal of cyst wall

• Preservation of ovarian tissue

• +/‐ Closure of ovarian cortex

• Adhesion prevention

Cyst rupture/spill : What does it really mean?

• Laparoscopy vs. laparotomy

• Clinical Significance

– Peritonitis with dermoid cysts

– Malignancy

Dermoid cyst: Risk of peritonitis

• +/‐ Increased risk of spill with laparoscopy

– Rates vary from 15‐100%

– Review of 14 studies w/ 470 l/s dermoid cytectomies

• 310 cases with spill (66%)

• Risk of peritonitis 0.2%

• Cyst size not related to risk of spill

– Trend towards increased spill with increased size

• Laparoscopy does not increase risk of peritonitisZanetta G. J Reprod Med, 1999Shawki O. Gynecol Surg, 2007Kondo W. BJOG, 2010Benezra V. Gynecol Surg, 2005

Minimizing Risk of Peritonitis

• Contain spillage

– Within bag

– Within cul de sac

C i i i ti• Copious irrigation

What does rupture/spillage of an malignancy mean clinically?

• Early ovarian cancer prognosis– Stage 1A– Stage 1C spontaneous– Stage 1C iatrogenic

• Some studies suggest prognosis of 1C same with• Some studies suggest prognosis of 1C same with iatrogenic or spontaneous rupture

• Others suggest other factors – tumor grade, ascites, dense adhesions – were assoc with poor outcomes

ACOG PB # 83Mizuno M. Oncology, 2003Sainz de la Cuesta R. Obstet Gynecol, 1994Dembo A. Obstet Gynecol, 1990

Suture vs. Bipolar for Hemostasis

• Intra‐ovarian suture for hemostasis causes less post op adhesions than bipolar– Pellicano M. Fertil Steril, 2008

• Bipolar electrocoagulation adversely affectsBipolar electrocoagulation adversely affects ovarian function, compared with suture– Fedele L. J AAGL, 2004

24

To Close or Not to Close

• Closure of ovarian cortex

Cystectomy and fertility

• Endometrioma

• Non‐endometriotic cysts

• Effect of surgical technique

Endometrioma and fertility

• Effect of endometrioma on fertility

– IVF patients with poorer response

• Treatment of cysts does not necessarily improve responseimprove response

– No consensus

– ESHRE recommends removal of endometrioma > 4 cm to confirm diagnosis, improve access to follicles and to possibly improve ovarian response

– Concerns re: effect of cystectomy on fertilitySomigliana E. Fert Steril 2006Tsoumpu I. Fertil Steril 2009. Kennedy S. Hum Reprod 2005

Endometriomas and fertility

• More follicles are removed with cystectomy for endometrioma than other benign ovarian cysts

– Shi J. Int J Gyn Ob. 2011 – YES– Dogan E. Int J Gyn Ob. 2001 ‐ NO

• Decreased serum AMH after resection of endometrioma– Lee D. Gynaecol Endo, 2011.

• AMH decreased more with endometrioma vs. non‐endometrioma cysts and more with bilateral cysts than unilateralwith bilateral cysts than unilateral

– Chang H. Fertil Steril, 2010

• Endometrioma and prior ovarian cystectomy for endometrioma both decreased serum AMH Hwu Y. Reprod Bio Endo, 2011

• Bilateral endometrioma has more profound negative impact than unilateral endometrioma (regardless of either conservative or surgical intervention)

– Hwu Y. Reprod Bio Endo, 2011

• ?More quantitative rather than qualitative damage– Ragni G. Am J Ob Gyn 2005

Surgical treatment

• Drainage – not recommended

– Recurrence rate of up to 88% at 6 mo

– No Pathology

F t ti d bl ti• Fenestration and ablation

• Excision

Ablation vs. excision

• Excision was associated with

– Reduced rate of recurrence

– Reduced need for further surgery

Reduced rate of symptoms– Reduced rate of symptoms

• dysmenorrhea, dyspareunia and non‐menstrual pain

– Increased rate of spontaneous pregnancy

Excisional surgery vs ablative surgery for ovarian endometrioma. Cochrane Database Syst Rev 2005

25

Ablation vs. excision

• Markers of ovarian function decreased after both cystectomy and coagulation of endometrioma, but more after cystectomy

– Antral follicle count decreased after both cystectomy y yand coagulation, but more after cystectomy

– Ovarian response to ovulation induction was reduced in cystectomy compared to coagulation group

– RCT of women with bilateral endometriomas – one side cystectomy an one side coagulation

Var T. Fertil Steril, 2011

How big is too big?

• Size not necessarily a contraindication to laparosocpy

Sagiv R. Obstet Gynecol 2005

References• ACOG Practice Bulletin 83. Management of adenexal masses, 2007

• Sagiv R. Laprpscopic management of extremely large ovarian cysts, Obstet Gynecol 2005

• Benezr V. Comparison of laparoscopy vs laparotomy for the surgical treatment of ovarian dermoid cysts. Gynecol Surg, 2005.

• Chang H. Impact of laparoscopic cystectomy on ovarian reserve: serial changes of serum AMH levels. Fertil Steril, 2010

• Dembo A. Prognostic factors in patients with stage I epithelial ovarian cancer. Obstet Gynecol 1990

• Dogan E. retrospective analysis of follicle loss adrer laproscopic excision of endometrioma compared with benign nonendometriotic ovarian cysts. Int J Gyn Ob. 2001

• Exacoustos C. Laparoscopic removal of endometriomas: sonographic evaultion of residual functioning ovarian tissue. Am J Ob Gyn 2004

• Fedele L. Bipolar elextrocoagulation vs suture of solitary ovary after laparoscopic excision of ovarian endometrioma. J AAGL, 2004.

• Hart R. Excisional surgery vs ablative surgery for ovarian endometrioma. Cochrane Database Syst Rev 2005

• Hwu Y. The impact of endometrioma and laparoscopic cystectomy on serum AMH levels. Reprod Bio Endo, 2011.

• Kennedy S. ESHRE guideline for the diagnosis and treatment of endometriosis. Hum Reprod 2005

• Kondo W. Does prevention of intraperitneal spillage when removing a dermoid cyst orvent granulomatous peritonitis? BJOG, 2010.

• Laparoscopy vs. Laparotomy for benign ovarian tumors. Cochrane Database of Systematic Reviews. 11, 2010

• Lee D. Effects of laparoscopic surgery on serum AMH levels in reproductive‐aged women with endometrioma. Gynaecol Endo, 2011.

• Mizuno M. Long‐term prognosis of stage I ovarian carcinoma. Prognostic importance of intraoperative rupture. Oncology 2003

• PellicanoM. Ovarian endometrioma: postoperative adhesions following bipolar coagulation and suture. FertilSteril, 2008

• Ragni G. Damage to ovarian reserve associated with laparoscopic excision: a quantitative rather than a qualitative injury. Am J Ob Gyn 2005

• Sainz de la Cuesta R. Prognostic importance of intraop‐ erative rupture of malignant ovarian epithelial neoplasms Obstet Gynecol 1994neoplasms. Obstet Gynecol 1994.

• Shawki O. LaparosocpicManagement of ovarian dermoid cyst: potential fear of dermoid spill, myth and facts. Gynecol Surg, 2007

• Shi J. Follicle loss after laparoscopic treatment of ovarian endometriotic cysts. Int J Gyn Ob, 2011

• Somigliana E. The presence of ovarian endometriomas is associated with a reduced responsiveness to gonadotropins. Fert Steril 2006

• Tsoumpu I. The effect of surgical treatment for endometrioma on IVF outcomes: a systemic review and meta‐analyisis. Fertil Steril 2009.

• Var T. The effect of laparoscopic ovarian cystectomy vs. coagulation in bilateral endometriomas on ovarian reserve as determined by antral follcle count and ovarian volume: a prospective randomized study. Fertil Steril, 2011

• Zanetta G. Laparoscopic excision of ovarian dermoid cysts with controlled intraoperative spillage. J ReprodMed, 1999.

26

The Large Uterus: Tips for Laparoscopic Hysterectomy

Stephanie Morris, MD

Newton‐Wellesley Hospital, MAHarvard Medical School


• Demonstrate step-wise approach to hysterectomy of the large fibroid uterus– 5 Key Pre- & Peri-operative considerations

5 Key Steps to performing laparoscopic– 5 Key Steps to performing laparoscopic hysterectomy

1. Pre operative considerations

• Patient selection– Set yourself up for success

– Prior surgery

– BMI

• Pre-operative lupron– Improves pre and post operative Hgb/Hct

– Decreases uterine volume

– Decreases procedure related blood loss

2. Patient positioning

• Arms tucked at sides

• Gel pad/foam

• Dorsal lithotomy

Barnett et al., JMIG 2007;14(5):664-672

3. Uterine manipulator• Total vs supracervical

• Can be of limited use with very large uterus initially

• Take the time to place properly– Use as a landmark – part of the

anatomy

Uterus

Bladder Bladder

UterusUterosacral Ligaments

Uterus

27

Using the Rumi-Koh 4. Port placement

• Camera port position

• Lateral port position– Location of adenxa

Trocar Placement

5. 30 degree laparoscope

• Improves visualization

• Bladder flap

• Lateral view

• During transection of uterus• During transection of uterus from vagina or cervix

Use of a 30 degree scope

Use of the 30 degree scope Hysterectomy Key Steps

• 6. Round ligament and bladder flap

• 7. Adenxa - release lateral attachments

• 8. Post leaf and uterine vessels

• 9 Vaginal cuff: transection and closure• 9. Vaginal cuff: transection and closure

• 10. Specimen removal

28

6. Round ligament and bladder flap

• Round ligament:– Open up round ligament

– Stay lateral

– Go through whole round ligament

• Anterior Leaf/Bladder Flap

• VIDEO OPENING UP ROUND

• VIDEO ANTERIOR LEAF

• Anterior Leaf/Bladder Flap– 30 degree scope

– Use cervical cup to help identify midline

– Identify cervix to help restore normal anatomy

– Push manipulator cephalad – put bladder on stretch

• VIDEO USE OF 30 DEGREE

• VIDEO USE OF MANIPULATOR TO PUSH BLADDER UP

6. Round ligament and bladder flap

6. Round ligament and bladder flap 7. The adnexa

• Stay close to ovary– BSO or no BSO

• Avoid ascending branch of the uterine vessels

• VIDEO ADNEXA RELEASE

• Back bleeding can be hard to control

7. The adnexa 8. Posterior leaf and Uterine Vessels

• Release ureter laterally

• Allow skelotonization of uterine vessels

• VIDEO POST LEAF RELEASE URETER LATERALLY

• VIDEO POST LEAF

• Peel fibroid out of broad ligament

SKELONTIZATION OF UTERINE VESSLES

• VIDEO PEEL FIBROID OUT OF BROAD LIGAMENT

29

8. Posterior leaf and Uterine Vessels Distancing Your Ureters

“Pushing” the uterus cephalad increases the distance between the colpotomy site, uterine vessels and ureters.

Uterine Manipulators:Uterine Manipulators:Importance of colpotomy cupImportance of colpotomy cup

Uterine vessels

• Skelotonize uterine vessels• Dessicate only the vessles• Avoid ureters• Koh cup – above level of

cup and dissect down

VIDEO SKELOTONIZATION OF UTERINE VESSLES

PICTURE LOCATION OF • Push manipuler cephalad to

displace bladder and uterters

• Secure both sides before transection of the vessels

UTERINE VESSELS

Uterine vessels for TLH Now with a lateral fibroid

30

9a. The Vaginal Cuff: transection 9b. The vaginal cuff: closure

9c: LSH: cervical stump 10. Specimen removal

• LSH– Morcellation

• TLH– Vaginal removalg

– Vaginal morcellation• In bag

• Not in bag

– Laparoscopic morcellation

Obstacles: bladder adhesions

• Back fill bladder • VIDEO BLADDER ADHESIONS

• VIDEO BACK FILLING BLADDER

• OVER SEW BLADDER

References• Gutmann J et al. GnRH agonist therapy before myomectomy or

hysterectomy. JMIG 2005; 12: 529-537.

•

• Lethaby A. Pre-operative GnRH analogue therapy before hysterectomy or myomectomy for uterine fibroids. Cochran Database System Rev, 2001. Updated 2011

••

31

Simplifying Laparoscopic Myomectomy

Stephanie Morris, MD

Newton‐Wellesley Hospital, MAHarvard Medical School


• Demonstrate steps to simplify laparoscopic myomectomy

– Pre‐operative planning

Ways to reduce intra operative blood loss– Ways to reduce intra‐operative blood loss

– Surgical techniques

– Tips for removing different types of fibroids

Patient selection

• Number of fibroids

• Size of fibroids

– How big is too big?

Patient selection

• Number of fibroids

• Size of fibroids

– How big is too big?

• Location

Pre‐Operative Imaging• Ultrasound

– Limited when numerous fibroids

9cm

32

Pre‐Operative Imaging• MRI

– Great for mapping fibroid location and number

Pre‐operative use of GnRH Agonists

• Improves pre‐ and post‐op hgb/hct

• Decreases uterine volume and fibroid size– 35‐65%

• Decreases procedure related blood loss

– Does not change need for blood transfusion

• +/‐ Decrease in OR time– Studies vary

– Several individual RCT studies show less OR time

– Meta‐analysis, no difference in OR time (Cochrane)

• ? Affect surgical planes

Cochrane Review 2011; Lethaby A. 2002; Zullo F 1998; Gutmann, 2005;

In the OR

• Port placement

– Higher lateral ports

– Higher midline ports

LUQ

Trocar Placement

– LUQ port

– 5mm and 10mm

Port placement

Right LateralLeft Lateral

Midline Suprapubic5 mm

g5/12 mm5/12 mm

Umbilical5 mm

Head

In the OR

• Energy Source

–Bipolar

–Monopolar

–Ultrasonic Energy

– Laser

In the OR• Myoma manipulators

• Morcellator

– Efficiency

33

Intra‐operative Hemostasis:

• Vasopressin

– blood loss

need for transfusion

• Cochrane review: 300 cc less EBL300 cc less EBL

– Dilute vasopressin (0.05‐0.3 units/ml)

– Most studies for openmyomectomies

Kongnyuy E. Cochrane Review, 2007 (2011); Zhao F 2011; Fletcher H. 1996;

Intra‐operative Hemostasis

• Vasopressin

• Laparoscopic tourniquet

• Direction of incision

• “Pedicle” of the fibroid

U f h l• Use of thermal energy vs. suture

Walocha JA Hum Reprod 2003

Hemostasis

• Pre‐op Lupron

• Vasopressin

• Laparoscopic tourniquet

• Direction of incision• Direction of incision

• “Pedicle” of the fibroid

• Use of thermal energy

Intra‐Operative Vasopressin

• Dilute vasopressin (0.05‐0.3 units/ml)

– 20 units in 100 cc (0.2 units/ml)

• Decrease blood loss and need for transfusion

B tt th i t i t– Better or the same as using a tourniquet

– Cochrane review: 300 cc less EBL with vasopressin

• Most studies for openmyomectomies

• VIDEO OF VASOPRESSIN INJECTION

– Subserosal and base

Kongnyuy E. Cochrane Review, 2007 (2011); Zhao F 2011; Fletcher H. 1996;

Direction of Incision

• Vertical or transverse

• Considerations:

– Vasculature

– Ease of repairp

• VIDEO

Pedunculated fibroids

Fibroid

34

Pedunculated fibroids: Using a loop ligasure

Intramural and subserosal fibroids

Suturing techniques and aides

• Same technique as open

• Multiple layer closure

• Suturing aides

– Unidirectional barbed suture – Quill, VLock

– Suture clips – Lapra‐Ty

Multi‐layered closure

Suture clips Submucosal fibroids

35

Specimen removal

• Morcellation

• Mini‐lap

References• Fletcher H et al. A randomized comparison of vasopressin and tourniquet at hemostatic agents

during myomectomy. Obstet Gyencol 1996; 87: 1014‐8 •• Gutmann J et al. GnRH agonist therapy before myomectomy or hysterectomy. JMIG 2005; 12: 529‐

537.•• Kongnyuy E, Wiysonge S. Interventions to reduce hemorrhage during myomectomy for fibroids.

Cochran Database System Rev, 2007. Updated 2011 •• Lethaby A. Pre‐operative GnRH analogue therapy before hysterectomy or myomectomy for uterine

fibroids. Cochran Database System Rev, 2001. Updated 2011•• Walocha JA et al. Vascular system of intramural leimyomata reviewed by corrosion casting and

scanning electron microscopy. Hum Reprod 2003; 18: 1088.•• Zhao F et al. Evaluation of loop ligation of larger myoma pseedocapsule combined with vasopressin

on laparoscopic myomectomy. Fertility and Sterility 2011; 95: 762‐766•• Zullo F et al. A prospective randomized study to evaluate lueprolide acetate treatment before

laparoscopic myoectomy: Efficacy and ultrasonographic predictors. Am J Obstet Gyencol 1998; 178 (1): 108‐12.

36

Strategies for Safe and Efficient Strategies for Safe and Efficient Tissue Removal Tissue Removal

Andrew I. Brill, MDAndrew I. Brill, MDDirector, Minimally Invasive GynecologyDirector, Minimally Invasive Gynecology

California Pacific Medical CenterCalifornia Pacific Medical CenterSan Francisco, CASan Francisco, CA


•• Consultant: Karl Storz EndoscopyConsultant: Karl Storz Endoscopy--America, America, Ethicon EndoEthicon Endo--Surgery, Conceptus Incorporated, Surgery, Conceptus Incorporated, CooperSurgicalCooperSurgicalp gp g

•• Speaker's Bureau: Karl Storz EndoscopySpeaker's Bureau: Karl Storz Endoscopy--America, America, Ethicon EndoEthicon Endo--Surgery, Conceptus Incorporated, Surgery, Conceptus Incorporated, CooperSurgicalCooperSurgical

Learning ObjectivesLearning Objectives

•• Describe methods for removal of Describe methods for removal of different types of tissuedifferent types of tissue

•• List steps to minimize risk during tissue List steps to minimize risk during tissue morcellationmorcellationmorcellationmorcellation

•• Employ methods to facilitate tissue Employ methods to facilitate tissue removal during laparoscopyremoval during laparoscopy

•• Enumerate the types of instruments Enumerate the types of instruments available for laparoscopic tissue available for laparoscopic tissue extractionextraction

learn tips and tricks for escape!learn tips and tricks for escape!

Mass Tissue Removal Mass Tissue Removal Know Alternatives & ApproachesKnow Alternatives & Approaches

•• Different AnatomyDifferent Anatomy•• Consistency of TissueConsistency of TissueConsistency of TissueConsistency of Tissue•• Volume of TissueVolume of Tissue

•• OR…………….OR……………...

Equipment Won’t Work!Equipment Won’t Work!

37

By Type of TissueBy Type of Tissue

•• BenignBenign––SterileSterile–– InfectiousInfectious•• Contamination (bag)Contamination (bag)•• Contamination (bag)Contamination (bag)

•• Suspicious for MalignancySuspicious for Malignancy––Seeding (bag)Seeding (bag)

•• MalignantMalignant––Seeding (bag)Seeding (bag)

Relative Tissue ConsistencyRelative Tissue Consistency

•• Soft Soft –– Fallopian Tube / MyomaFallopian Tube / Myoma

•• FluidFluid--filled filled –– Ovarian CystOvarian Cyst

•• Particulate Particulate –– Dermoid CystDermoid Cyst

•• Firm Firm –– Fundus / MyomaFundus / Myoma

•• Hard Hard –– Calcified Myoma or DermoidCalcified Myoma or Dermoid

Tissue CaptureTissue Capture

•• GraspersGraspers–– Atraumatic Atraumatic –– 5 & 10 mm5 & 10 mm

••Less damage, less riskLess damage, less risk••Hold poorlyHold poorly

––FatigueFatigue

Spoon ForcepsSpoon Forceps

-- ultimate atraumatic grasper ultimate atraumatic grasper --

Tissue CaptureTissue Capture

––TraumaticTraumatic –– 5 & 10 mm5 & 10 mm

••More damage, more riskMore damage, more risk••Hold wellHold well

Recommended PracticesRecommended PracticesInsert Instruments PARALLEL Insert Instruments PARALLEL

toto

Abdominal Wall!Abdominal Wall!

✕

38

Recommended PracticesRecommended Practices

•• Visualize instrument tipsVisualize instrument tips•• If not observed:If not observed:––Keep tips closedKeep tips closed

D t i t tD t i t t––Do not move instrumentDo not move instrument

•• AwarenessAwareness––Sidewalls: vessels, nervesSidewalls: vessels, nerves––BowelBowel––BladderBladder

•• Via CannulaVia Cannula

––Pull tissue into cannulaPull tissue into cannula

••Open valve / disassemble & extractOpen valve / disassemble & extract

•• Remove tissue with cannulaRemove tissue with cannula

P ll ti th h t itP ll ti th h t it•• Pull tissue through port sitePull tissue through port site

•• Widens peritoneal / fascial defectsWidens peritoneal / fascial defects

•• Assess for entrapped fragmentsAssess for entrapped fragments

Laparoscopic Retrieval BagsLaparoscopic Retrieval Bags

•• Mechanical devicesMechanical devices––Easy to useEasy to use––Weak bag materials!Weak bag materials!––Risk Risk rupture and spreadrupture and spread

Cook Lap SacCook Lap Sac

•• Strong Strong –– parachute / nylon materialparachute / nylon material•• Harder to use Harder to use

Cook Lap Sac Cook Lap Sac -- TechniqueTechnique

•• Insertion Insertion –– roll up and push through roll up and push through cannula or abdominal defectcannula or abdominal defect

•• Open neck with graspersOpen neck with graspersOpen neck with graspersOpen neck with graspers

•• Fill with irrigating fluid to distendFill with irrigating fluid to distend

•• Insert tissueInsert tissue

•• Close neck with stringClose neck with string

39

Cook Lap Sac Technique (cont)Cook Lap Sac Technique (cont)

•• Grasp string and neck of bag Grasp string and neck of bag

•• Bring out abdominal wallBring out abdominal wall

•• Suction fluid to decompressSuction fluid to decompress

•• Morcellate/extract tissueMorcellate/extract tissue–– Under direct vision to avoid Under direct vision to avoid

perforation of bagperforation of bag

morcellation inmorcellation in--sacsac

25cm solid25cm solid--cystic adnexal masscystic adnexal mass

CuldotomyCuldotomy

Open laparoscopyOpen laparoscopy

Laparoscopic Mass Tissue RemovalLaparoscopic Mass Tissue Removal-- evolution evolution --

Electromechanical morcellationElectromechanical morcellation

Manual morcellationManual morcellation

CuldotomyCuldotomy

Extraction SitesExtraction Sites

•• Umbilicus Umbilicus –– 10, 12 mm 10, 12 mm -- cuttingcutting––Operating scope and grasperOperating scope and grasper

––Direct removalDirect removal

•• Easy to extend and repair incisionEasy to extend and repair incision•• Easy to extend and repair incisionEasy to extend and repair incision

•• 5 mm scope in lower or LUQ port5 mm scope in lower or LUQ port

––Direct MorcellationDirect Morcellation

•• ScalpelScalpel

UQ Visual PortUQ Visual Port––Umbilical MorcellationUmbilical Morcellation

40

Tissue Extraction SitesTissue Extraction Sites

•• Lower ports Lower ports (lateral > median)(lateral > median)

–– 5 mm 5 mm

••ectopic, simple cyst, hydrosalpxectopic, simple cyst, hydrosalpx

–– 1010––15 mm15 mm

••dermoid, myomadermoid, myoma


•• CuldotomyCuldotomy

––AdvantagesAdvantages

••Direct vision from aboveDirect vision from above

••Hold bowel awayHold bowel away

••Feed tissue from aboveFeed tissue from above


•• CuldotomyCuldotomy

–– Risks and disadvantagesRisks and disadvantages

•• InfectionInfection

Bl di / h tBl di / h t••Bleeding / hematomaBleeding / hematoma

••DyspareuniaDyspareunia

••Adhesions?Adhesions?

••Need to reposition patientNeed to reposition patient

•• Transcervical for LSHTranscervical for LSH

Loop ExcisionLoop Excision

•• Storz SuperLoop Storz SuperLoop andand Lina LoopLina Loop

StrategyStrategy––StrategyStrategy

•• Clarity of vital anatomyClarity of vital anatomy

•• Symmetric applicationSymmetric application

•• Level of vascular pediclesLevel of vascular pedicles

•• Velocity and gap for electrosectionVelocity and gap for electrosection

Lina LoopLina Loop Storz SupraloopStorz Supraloop

41

Electromechanical MorcellationElectromechanical Morcellation

Electromechanical Morcellation Electromechanical Morcellation Primary GoalsPrimary Goals

Safety and EfficacySafety and Efficacy→→ RisksRisks

––Tissue remnantsTissue remnants

Electromechanical Morcellation Electromechanical Morcellation

––Vascular injuryVascular injury

––Visceral injuryVisceral injury

––Richter’s or fascial herniaRichter’s or fascial hernia


•• TechniqueTechnique

––Grasp tissue near edgeGrasp tissue near edge

––PULL tissue into devicePULL tissue into device

––Minimize movement of deviceMinimize movement of device

––Observe cutting edge at all timesObserve cutting edge at all times


fixedfixed

42

Morcellation Port Locale?Morcellation Port Locale?

Uterine / fibroid dimensions?Uterine / fibroid dimensions?

Capacity of pelvis?Capacity of pelvis?

Viscera and vessels?Viscera and vessels?

Comfort with assistant?Comfort with assistant?


Port SelectionPort Selection——Midline SuprapubicMidline SuprapubicPort SelectionPort Selection——Midline SuprapubicMidline Suprapubic


Port SelectionPort Selection——UmbilicalUmbilicalPort SelectionPort Selection——UmbilicalUmbilical


Port SelectionPort Selection——Lateral LowerLateral LowerPort SelectionPort Selection——Lateral LowerLateral Lower

In Situ In Situ Electromechanical MorcellationElectromechanical MorcellationEfficiency ParametersEfficiency Parameters

•• Core guard opposite tissue contourCore guard opposite tissue contour

•• Hammock created by assistantHammock created by assistant

3030 degree lens to observe entry and exit pointsdegree lens to observe entry and exit points•• 3030-- degree lens to observe entry and exit pointsdegree lens to observe entry and exit points

•• Pull steadily away from uterus with clawPull steadily away from uterus with claw

•• Target interface between myoma and uterusTarget interface between myoma and uterus

•• Finish the base of the myoma conventionallyFinish the base of the myoma conventionally

•• Avoid for low lateral or submucous elementsAvoid for low lateral or submucous elements

Create Tissue HammockCreate Tissue Hammock

43

Efficiency: Surfacing and UnpeelingEfficiency: Surfacing and UnpeelingElectromechanical Morcellation: Electromechanical Morcellation: EfficiencyEfficiency

Tissue DensityTissue Densityperper

Visual and Auditory CuesVisual and Auditory Cues

SoftSoft==

AdenomyosisAdenomyosis

FirmFirm==

HardHard==

AdenomyosisAdenomyosisDegenerated MyomaDegenerated Myoma

Uterus and MyomaUterus and Myoma MyomaMyoma

CoreCoreandand

SteerSteerUnpeelUnpeel

UnpeelUnpeel

Preventing Hernia PostPreventing Hernia Post MorcellationMorcellationPreventing Hernia PostPreventing Hernia Post--MorcellationMorcellation

Close fascial Close fascial andand peritoneal peritoneal defects!defects!

44

Cuff Management: Issues of Support and Controversies of

the CervixJames K. Robinson, MD, MS

The George Washington University

• Consultant: Gyrus ACMI (Olympus), IntuitveSurgical

• At the conclusion of this session the participant will be able to:– Identify risks and benefits of laparoscopic total (TLH) vs subtotal (LSH)

hysterectomy

d f l d h l l f– Identify principals and techniques to minimize apical prolapse after laparoscopic hysterectomy (LH)

– Identify principals and techniques to minimize vaginal cuff cellulitis and dehiscence after TLH

– Identify principals and techniques to minimize genito‐urinary injury and fistula formation after LH

Outline – 24 slides + video• Historical perspective

• TLH vs LSH– Marfori Data

• Cervical Management– Amputation and endocervix (Videos – amputation, dessication, closure)

• Apical ProlapseApical Prolapse– US Lig suspension (Video)

• Cuff Infection and dehiscence– Closure (Video)

• Genito‐urinary injury and fistula formation– Simple Cystoscopy (Video)

Timeline

• First reported elective hysterectomy

– 1813, vaginal hysterectomy by Conrad Langenbeck

– 1863, first abdominal hysterectomy (subtotal) by Charles Clay

1929 fi l bd i l h EH Ri h d– 1929, first total abdominal hysterectomy EH Richardson

– 1989, first laparoscopic hysterectomy by Reich

– 1990, first laparoscopic supracervical hyst by Lyons

– 45% women over 70 in US is s/p hyst

LSH vs TLH “Do I stay or do I go?”Summary (Eat dessert first)

LSH Advantages

Evisceration

Cuff infection

GU injury

G l ti

TLH Advantages

Post‐operative bleeding

Dysplasia and cervical cancer

No risk of future Granulation

? Impact in future vault prolapse

↑Early sa sfac on scores

No risk of future trachelectomy

LSH should be used cautiously in women with CPP/known endometriosis

Spread of malignancy (when intact)

45

Cervical Management• Cyclic Bleeding

– 7‐11% Okaro et al. BJOG 2001. Oct;108(10):1017‐20.

– 19% Ghomi A et al. JMIG. 2005;12:201–5.

– 24% Lieng M et al. BJOG 115(13):1605‐10, 2008 Dec.

– 2% Erian J et al. BJOG 115(6):

• Tips

– Reverse conization (video link)

– Endocervical Dessication ( id li k)

( )742‐8, 2008 May

– <1% Lyons T. JMIG (2007) 14, 275–277

• Reoperation for cyclic bleeding is 1‐ 2%.– Lieng M et al. BJOG

115(13):1605‐10, 2008 Dec.

(video link)

– Cervical Closure (video link)

Loop Amputation

• Radiofrequency cervical amputation

• Limited somewhat by uterine size

• Video Link

• Does not allow for conization or cervical closure

Apical ProlapseOnly short follow‐up studies exist for LH

Show no difference in rate of prolapse

Level 1 SupportLevel 1 Support Uterosacral/Cardinal ligament complex

Attached to cervix and upper vagina

•Learman LA et al. Obstet Gynecol 2003. Sept 102(3): 453-62.•Thakar R et al. NEJM 2002. 347;1318.•DeLancey JO. Am J Obstet Gynecol 1992. 166, 6pt1: 1717-24.

Avoiding Apical ProlapseTips

• Assess apical descent

• Incorporate US ligament complex at apical i i i ll TLH

Video

• US Ligament Incorporation (video link)

insertion in all TLHs

• Utilize high US ligament suspension when significant apical descent already exists

• High US Ligament suspension (video link)

Cuff Infection Infection

Febrile morbidity of TLH 5.3% regardless of cuff closure (1‐layer, 2‐layer or no closure)

• Shen et al. J Am Assoc Gynecol Laparosc. 2002;9:474–80.

8/1706 (0.5%) had infectious complications s/p LSH

• Bojahr B et al. JMIG 2006;13:183–9.

Fallopian Tubes – Do They Matter?

RCT of TLH +/‐ salpingectomy

• 3/137 infections with bil salpingectomy

• 14/145 infections w/o

• p=0.01

• Ghezzi F et al. BJOG. 2009 116 589 93

<1% in series of >1500 LSH• Lyons T. JMIG 2007;14,:275–7.

No difference in febrile morbidity b/t TLH and LSH in review of >1000 LH. (both approx 1%)

• Harmanli OH et al. AJOG 2009; 201:536.e1‐7.

2009;116:589‐93.

Cuff Infection

• Tips

– Test and treat preoperative vaginitis

– Thorough pre‐operative vaginal preparation

Pre incision antibiotics– Pre‐incision antibiotics

– Rapid drainage of post‐operative abscess

– Aggressive 2 week antibiotic treatment for all vaginal cuff infections

46

Cuff Dehiscence ‐ Incidence

TAH/VH ‐ 0.14 – 0.28%• Iaco PE et al. Eur J Obstet Gynecol

Reprod Biol 2006;125:134‐8.

• Hur H et al. JMIG 2007; 14:311.

TLH ‐ 0.79‐4.93%

LSH – Case Report• Harmanli OH et al. AJOG

2009;201:536.e1‐7.

0 9 93%• Hur H et al. JMIG 2007.14:311.

• Iaco PE et al. Eur J Obstet Gynecol Reprod Biol 2006;125:134‐8.

• Agdi M et al. JMIG 2009;16:313‐7.

Robotic TLH – 4.1%• Koh R et al. Obstet Gynecol 2009;

114:231‐5.

Cuff DehiscenceRisk Factors *

Menopause

Cuff cellulitis/abscess

Hematoma

Tissue Ischemia

Prevention *

Preoperative vaginal estrogen

Prevent Infection

Maintain hemostasis

Minimize thermal injury

1 ti bit

* Level 3 Evidence

Chronic valsalva

Early Coitus

Immunosuppresion

Cigarette smoking

1 cm tissue bites

Barbed suture ?

Avoid lifting and chronic cough

8 weeks vaginal rest

Preoperative health maintenance

Use of delayed absorbable suture

Genito‐urinary injury Retrospective review

• 1110 pts over 10yrs by 48 surgeons

• Harmanli OH et al. AJOG 2009;201:536.e1‐7.

Outcome LSHN=566

TLHN=450

OR

Urinary TractInjury

3 (0.5%) 10 (2.2%) 4.75 (1.2-18.5)

UrinaryRetention

4 (0.7%) 7 (1.6%) 1.7 (0.5-6.3)

2.7% risk injury with TLH in Finland database (>1100)

• Harkki . Am J Obstet Gynecol 1997;176:118‐22.

0.29% in large series of LSH (>1700)• Bojahr B et al JMIG 2006;13:183–9.

Retention

Genito‐urinary injury

Prospective cystourethroscopy of all hysterectomies in 3 centers (n=471)

• LH = 2% bladder, 0% ureter (n=49)• AH = 2.5% bladder, 2.2% ureter (n=278)• VH = 6.3% bladder, 1.4% ureter (n=144)

Vakili B et al. AJOG 2005;192:1599-1604.

24 of 25 injuries recognized intraoperatively

70% of injuries not recognized until the cystourethroscopy

Simple Cystoscopy

Fistula

National Swedish registry 1973‐2003 rates

(100,000 person years)

• TAH – 28 (371/117,000)

• SCH – 14 (69/45,000) – almost all bowel

Forsgren C. Obstet Gynecol 2009,114:594-9.

( , )

• TVH – 20 (22/19,000)

• TLH/LAVH – 96 (7/1800) – almost all urogenital

Morcellation Considerations

• “Endometriosis after laparoscopic supracervical hysterectomy with uterine morcellation: a case control study”

• “Disseminated peritoneal leiomyosarcomas after laparoscopic “myomectomy” and morcellation”

Schuster M. JMIG. 2012;19:183.

Anapama R. JMIG. 2011;18:386.

• “Progression of pelvic implants to complex atypical endometrial hyperplasia after uterine morcellation”

• “Disseminated peritoneal leiomyomatosis after laparoscopic supracervical hysterectomy with characteristic molecular cytogenetic findings of uterine leiomyoma”

Kill L. Ostet Gynecol. 2011;117:447.

Ordulu Z. Genes, Chromosomes & Cancer. 2010;49:1152.

47

• Okaro et al. BJOG 2001;108:1017‐20.

• Ghomi A et al. JMIG. 2005;12:201–5.

• Lieng M et al. BJOG. 2008;115:1605‐10.

• Erian J et al. BJOG. 2008;115:742‐8.

• Lyons T. JMIG. 2007;14:275–7.

• Learman LA et al. Obstet Gynecol. 2003;102(3): 453‐62.

• Hur H et al. JMIG 2007; 14:311.

• Agdi M et al. JMIG 2009;16:313‐7.

• Koh R et al. Obstet Gynecol 2009; 114:231‐5.

• Harkki . Am J Obstet Gynecol 1997;176:118‐22.

• Vakili B et al. AJOG 2005;192:1599‐1604.

• Forsgren C. Obstet Gynecol 2009,114:594‐9.

• Schuster M. JMIG. 2012;19:183.• Thakar R et al. NEJM. 2002;347:1318.

• DeLancey JO. Am J Obstet Gynecol 1992;166,6pt1:1717‐24.

• Shen et al. J Am Assoc Gynecol Laparosc. 2002;9:474–80.

• Bojahr B et al. JMIG 2006;13:183–9.

• Harmanli OH et al. AJOG 2009; 201:536.e1‐7.

• Ghezzi F et al. BJOG. 2009;116:589‐93.

• Iaco PE et al. Eur J Obstet Gynecol Reprod Biol 2006;125:134‐8.

• Anapama R. JMIG. 2011;18:386.

• Kill L. Ostet Gynecol. 2011;117:447.

• Ordulu Z. Genes, Chromosomes & Cancer. 2010;49:1152.

48

CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians

(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws

identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

program, the importance of the services, and the resources available to the recipient, including the mix of oral

and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English

Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

including those which provide federal financial assistance, to examine the services they provide, identify any

need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every

California state agency which either provides information to, or has contact with, the public to provide bilingual

interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

~

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsianIndo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

49

http://www.imq.org/

http://www.usdoj.gov/crt/cor/pubs.htm

http://www.usdoj.gov/crt/cor/13166.htm

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538

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