1279 Total Laparoscopic Hysterectomy in an 18 Week Sized Uterus with Persistent Gestational Trophoblastic Disease

Abstract

Video Objective To describe and illustrate an innovative minimally invasive surgical technique to allow a total laparoscopic hysterectomy with safe and feasible extraction of an 18 week sized uterus with gestational trophoblastic neoplasia (GTN). Setting The patient is a 44 year old G4P2012 with a diagnosis of GTN, status post dilation and evacuation with increasing b-hCG levels during follow-up. Workup for metastatic disease was negative. She completed childbearing and opted for a hysterectomy as definitive treatment. Interventions Intraoperatively, the uterus appeared to be 18 weeks in size. Laparoscopic dissection started by bilateral salpingectomy and transection of the utero-ovarian ligaments, preserving the ovaries. The broad ligament was then skeletonized, and the round ligaments were transected bilaterally. The bladder flap was created, and the uterine vessels were transected bilaterally using an advanced bipolar device. A sponge on a stick soaked in methylene blue was used to delineate the cervix and vagina. The cervix was then dilated to 14’’ and evacuation was performed using 12 suction. The suction continued until all products were removed and the uterus was significantly smaller in size. The colpotomy was performed and the uterus was extracted intact. Conclusion This is the first case in the literature to describe a minimally invasive technique that demonstrates a safe and feasible laparoscopic removal of an enlarged uterus and illustrates alternative extraction techniques to avoid laparotomy in GTN. In this case, a combination of laparoscopic transection of vascular pedicles followed by a dilation and evacuation was used prior to colpotomy. The addition of dilation and evacuation allowed us to reduce the overall size of the uterus and remove it intact through the vagina with minimal bleeding, avoiding unnecessary laparotomy. This allowed the patient to have a faster post-surgical recovery, minimal blood loss (EBL 20) and no hospitalization in comparison to standard laparotomy for persistent GTN.