Bilateral Salpingectomy Research Articles

Inversion of uterus due to prolapsed submucous fundal fibroid

Inversion of uterus is rarely encountered by gynecologist during practice; inversion in a non- pregnant uterus is further rarer; only case reports are published in literature on non-puerperal uterine inversion. We present a case of a 40-years multipara who had a history of irregular and excessive vaginal bleeding associated with severe lower abdominal pain during vaginal bleeding for two years. She was referred from general hospital with suspicion of cervical cancer. Being a rare clinical condition diagnosis and management of uterine inversion is challenging. High index of clinical suspicion is necessary which can be aided by radiographic imaging. Our case was diagnosed as a case of complete uterine inversion secondary to fundal fibroid clinically. She underwent abdominal hysterectomy with bilateral salpingectomy with bilateral sacrospinous vault suspension after resuscitation with fluids, blood transfusion and broad-spectrum antibiotics.

Management of a uterine serosal heterotopic pregnancy after in vitro fertilization in a woman with bilateral salpingectomy: A case report and literature review

Heterotopic pregnancy (HP) is defined as the simultaneous presence of intrauterine pregnancy and ectopic pregnancy (EP). HP after bilateral salpingectomy is extremely rare and may lead to serious complications if it is misdiagnosed and untreated timely. Here, we presented the first reported case of uterine serosal HP in a woman after assisted reproductive technology with bilateral salpingectomy because of bilateral tubal ectopic pregnancy. A 27-years-old pregnant woman after in vitro fertilization with bilateral salpingectomy complained of a sudden onset of unprovoked abdominal pain, which was persistent and dull. She denied vaginal bleeding. Serum beta-human chorionic gonadotropin levels are difficult to predict HP. Transvaginal ultrasonography demonstrated 1 gestational sac in the uterine cavity and 1 thick-walled cystic mass over the upper of the uterus, with a large amount of fluid in the Pouch of Douglas. Emergency laparotomy revealed a uterine serosal pregnancy combined with intrauterine pregnancy. This patient was successfully managed via emergency laparotomy to remove residual tissue and repair the rupture of the uterine serosal pregnancy. At postoperative 4 days, repeat transvaginal ultrosonography presented 1 intrauterine gestational sac with a visible fetal bud and cardiac tube pulsation. Now the patient recover well and is in an ongoing pregnancy. It is noteworthy that HP/ectopic pregnancy is still not prevented after bilateral salpingectomy. In cases of multiple embryo transfer, even if intrauterine pregnancy has been established, it is important to rule out HP/ectopic pregnancy in time. Early diagnosis and early management can significantly improve clinical outcomes.

Racial Disparities in Sterilization Procedure Performed at Time of Cesarean Section.

While bilateral tubal ligation has historically been performed for sterilization at cesarean delivery (CD), recent data supports the use and safety of opportunistic bilateral salpingectomy during CD to decrease lifetime ovarian cancer risk. Prior studies have described racial disparities in sterilization rates, but there is a paucity of data regarding racial disparities in type of sterilization procedure. Our objective was to determine differences in sterilization procedure type performed at CD by race (Black vs. non-Black) to evaluate for equity in bilateral salpingectomy utilization. We performed a retrospective cohort study of patients included in the American College of Surgeons National Surgical Quality Improvement Program database who underwent sterilization at time of CD from January 2019, to December 2020, identified using Current Procedural Terminology codes. Patients without documented race were excluded. Multivariable logistic regression was used to determine odds of undergoing bilateral salpingectomy compared with bilateral tubal ligation by race while controlling for confounders. Of 28,147 patients who underwent CD, 3,087 underwent concurrent sterilization procedure, and 2,161 met inclusion criteria (Black: n = 279; non-Black: n = 1,882). Black patients were significantly more likely to have hypertension (10.8 vs. 5.3%, p < 0.01), bleeding disorders (3.9 vs. 1.3%, p < 0.01), preoperative anemia (hemoglobin < 11 g/dL; 36.9 vs. 21.3%, p < 0.01), and be of American Society of Anesthesiologist class 3 or higher (29.4 vs. 22.5%, p = 0.01) than non-Black patients. After adjusting for differences, Black patients were almost 50% less likely than non-Black patients to undergo bilateral salpingectomy compared with bilateral tubal ligation for sterilization at CD (adjusted odds ratio = 0.52, 95% confidence interval: 0.36-0.75). Despite evidence that bilateral salpingectomy decreases ovarian cancer risk and is safe at CD, there is a racial disparity in bilateral salpingectomy utilization. While the cause of this disparity is unclear, further research is warranted to determine root causes and equitable solutions. · Opportunistic salpingectomy is recommended for primary prevention of ovarian cancer in patients undergoing pelvic surgery who have completed childbearing.. · Black patients were almost 50% less likely to undergo bilateral salpingectomy compared with bilateral tubal ligation than non-Black patients even after controlling for possible confounders.. · Further research is needed to determine root cause of the racial disparity in bilateral salpingectomy utilization rate..

Cost-Effectiveness of Risk-Reducing Surgery for Breast and Ovarian Cancer Prevention: A Systematic Review.

Policymakers require robust cost-effectiveness evidence of risk-reducing-surgery (RRS) for decision making on resource allocation for breast cancer (BC)/ovarian cancer (OC)/endometrial cancer (EC) prevention. We aimed to summarise published data on the cost-effectiveness of risk-reducing mastectomy (RRM)/risk-reducing salpingo-oophorectomy (RRSO)/risk-reducing early salpingectomy and delayed oophorectomy (RRESDO) for BC/OC prevention in intermediate/high-risk populations; hysterectomy and bilateral salpingo-oophorectomy (BSO) in Lynch syndrome women; and opportunistic bilateral salpingectomy (OBS) for OC prevention in baseline-risk populations. Major databases were searched until December 2021 following a prospective protocol (PROSPERO-CRD42022338008). Data were qualitatively synthesised following a PICO framework. Twenty two studies were included, with a reporting quality varying from 53.6% to 82.1% of the items scored in the CHEERS checklist. The incremental cost-effectiveness ratio/incremental cost-utility ratio and cost thresholds were inflated and converted to US$2020, using the original currency consumer price index (CPI) and purchasing power parities (PPP), for comparison. Eight studies concluded that RRM and/or RRSO were cost-effective compared to surveillance/no surgery for BRCA1/2, while RRESDO was cost-effective compared to RRSO in one study. Three studies found that hysterectomy with BSO was cost-effective compared to surveillance in Lynch syndrome women. Two studies showed that RRSO was also cost-effective at ≥4%/≥5% lifetime OC risk for pre-/post-menopausal women, respectively. Seven studies demonstrated the cost-effectiveness of OBS at hysterectomy (n = 4), laparoscopic sterilisation (n = 4) or caesarean section (n = 2). This systematic review confirms that RRS is cost-effective, while the results are context-specific, given the diversity in the target populations, health systems and model assumptions, and sensitive to the disutility, age and uptake rates associated with RRS. Additionally, RRESDO/OBS were sensitive to the uncertainty concerning the effect sizes in terms of the OC-risk reduction and long-term health impact. Our findings are relevant for policymakers/service providers and the design of future research studies.

Excision of triple compartment deep infiltrating endometriosis with visceral involvement

Background: Excision of multi-compartment deep infiltrating endometriosis with visceral involvement is challenging. We illustrate an interdisciplinary approach to complete minimally invasive excision in a single surgery. Case: We present a case of deep infiltrating endometriosis with visceral involvement in the anterior, middle, and posterior compartments. A collaborative surgical approach was taken with gynecologic, colorectal, and urologic surgeons to perform a robot-assisted total laparoscopic hysterectomy, bilateral salpingectomy, ovarian cystectomy, and unilateral oophorectomy with concurrent segmental resection of rectosigmoid and excision of transmural bladder and vaginal nodules. Conclusion: Thorough preoperative evaluation and an interdisciplinary approach to surgical planning involving radiology, gynecology, colorectal surgery, and urology allowed for complete simultaneous resection of bladder, rectosigmoid, and pelvic deep infiltrating endometriosis without complications via a minimally invasive route.

8189 “Failed CS-BS” a Role for vNOTES in Patient with 4 Prior Cesarean Sections and Severe Adhesive Disease Desiring Sterilization

Study Objective To demonstrate the utility of vNOTES for opportunistic bilateral salpingectomy for permanent sterilization after failed attempt at bilateral tubal ligation at the time of previous Cesarean section. Design Stepwise demonstration with narrated video footage. Setting vNOTES opportunistic bilateral salpingectomy for permanent sterilization after failed bilateral tubal ligation during previous Cesarean section. Patients or Participants 31-yo G4P3013 with 4 prior Cesarean sections desiring permanent sterilization, BMI 38. Interventions During previous Cesarean section, bilateral adnexa unable to be accessed due to dense adhesions from previous surgeries. Patient to have vNOTES instead of conventional laparoscopy. Measurements and Main Results Patient underwent a successful vNOTES bilateral salpingectomy, with pathology confirming bilateral fallopian tubes. Conclusion vNOTES bilateral salpingectomy is a reasonable alternative to conventional laparoscopy in patients with severe adhesive disease. To demonstrate the utility of vNOTES for opportunistic bilateral salpingectomy for permanent sterilization after failed attempt at bilateral tubal ligation at the time of previous Cesarean section. Stepwise demonstration with narrated video footage. vNOTES opportunistic bilateral salpingectomy for permanent sterilization after failed bilateral tubal ligation during previous Cesarean section. 31-yo G4P3013 with 4 prior Cesarean sections desiring permanent sterilization, BMI 38. During previous Cesarean section, bilateral adnexa unable to be accessed due to dense adhesions from previous surgeries. Patient to have vNOTES instead of conventional laparoscopy. Patient underwent a successful vNOTES bilateral salpingectomy, with pathology confirming bilateral fallopian tubes. vNOTES bilateral salpingectomy is a reasonable alternative to conventional laparoscopy in patients with severe adhesive disease.

Robotic Tubal Reanastomosis Following Bilateral Partial Salpingectomy of Tubal Infundibula

<h3>Study Objective</h3> Demonstrate how to perform a robotic tubal reanastomosis in a patient who previously had a bilateral partial salpingectomy of the infundibula. <h3>Design</h3> Case report. <h3>Setting</h3> The patient was positioned in dorsal lithotomy and Trendelenburg. 4 arms and an assistant port were used. <h3>Patients or Participants</h3> One patient case is illustrated in this video. <h3>Interventions</h3> Robotic tubal reanastomosis. <h3>Measurements and Main Results</h3> The patient achieved a spontaneous intrauterine pregnancy after the surgery. <h3>Conclusion</h3> Tubal reanastomosis following bilateral partial salpingectomy of the infundibula is challenging, but pregnancy is still possible. Care should be taken to excise the mid-portion of the ampulla if a bilateral partial salpingectomy is performed in case the patient has regret and desires a reversal.

8983 Pararectal Schwannoma Causing Pelvic Pain

<h3>Study Objective</h3> To describe a surgical management of a very rare case of rectal schwannoma as cause of chronic pelvic pain and postoperative outcome. <h3>Design</h3> Video Presentation. <h3>Setting</h3> University tertiary care hospital. <h3>Patients or Participants</h3> 41-yo G0P0000 presents for evaluation of chronic pelvic pain for many months. Past medical history: Migraines, Anxiety disorder. Past Surgical History: Laparoscopic Hysterectomy and bilateral salpingectomy followed by right oophorectomy few months later. Physical exam: the cervix and uterus noted to be absent, no other abnormalities were found. <h3>Interventions</h3> Rectal Schwannoma is extremely rare and only 12 cases have been reported, our patient had already underwent total laparoscopic hysterectomy, bilateral salpingectomy and right oophorectomy for pelvic pain without relief, MRI was done and showed para rectal mass, laparoscopic resection of the mass was done. <h3>Measurements and Main Results</h3> At the 2-week postoperative follow up, the patient reported resolution of her painful symptoms. <h3>Conclusion</h3> Chronic pelvic pain is often a challenge to diagnose and to manage given the large number of etiologies, rectal schwannoma is extremely rare but can be the etiology behind pelvic pain, MRI helps with diagnosis and laparoscopic resection is possible with complete pain relief

Laparoscopic Hysterectomy Following Robotic Radical Trachelectomy

<h3>Study Objective</h3> To demonstrate safe laparoscopic technique in performing hysterectomy following a previous radical trachelectomy. <h3>Design</h3> Stepwise demonstration using narrated video footage. <h3>Setting</h3> An academic safety net county hospital. <h3>Patients or Participants</h3> A 38-yo G5P0050 with a history of Stage 1B1 squamous cell carcinoma of the cervix was treated with robotic radical trachelectomy in 2011. She represented ten years later with abnormal uterine bleeding from a large prolapsing fibroid requiring multiple blood transfusions. Patient desires to proceed with definitive surgical management and underwent laparoscopic hysterectomy, bilateral salpingectomy, and cystoscopy. <h3>Interventions</h3> In certain cases of cervical cancer, patients can be offered fertility sparing options such as trachelectomy. Following radical dissection of the parametria, pelvic anatomy becomes distorted due to the development of fibrotic tissue. Additionally, following a trachelectomy a colpotomizer cup cannot be used to help lateralize and protect the ureters from inadvertent injury. Therefore, a completion hysterectomy has an elevated risk of urologic injury. We demonstrate a surgical technique to perform a completion hysterectomy laparoscopically. 1. Ureteral stent placement aids in identification of the ureters in the previously dissected surgical field. 2. Identification of pelvic anatomy and restoring normal anatomy is vital in performing a completion hysterectomy laparoscopically. <h3>Measurements and Main Results</h3> The patient underwent a laparoscopic hysterectomy, bilateral salpingectomy, bilateral ureterolysis, and cystoscopy without intraoperative complications. Her postoperative course was uncomplicated and had no further complaints at her six-week postoperative visit. <h3>Conclusion</h3> This case demonstrates a surgical technique to perform a laparoscopic hysterectomy following a robotic radical trachelectomy.

Dissection Techniques for Dense Adhesions between Uterus, Bladder, and Anterior Abdominal Wall

<h3>Study Objective</h3> The objective of the video is to serve as a teaching tool in order to demonstrate surgical techniques to aid in adhesiolysis of dense adhesions between the uterus, bladder, and anterior abdominal wall. <h3>Design</h3> This video first outlines the medical and surgical history relevant for the patient. The surgical techniques used in the video are then listed prior to the narrated video of the adhesiolysis. <h3>Setting</h3> The surgical video was recorded during a robotic assisted laparoscopic total hysterectomy, bilateral salpingectomy, and cystoscopy. <h3>Patients or Participants</h3> The video includes one patient. The primary surgeon is a minimally invasive gynecologic surgeon. A minimally invasive gynecologic surgery fellow assisted with this surgery as well as a urologist. <h3>Interventions</h3> A robotic assisted laparoscopic total hysterectomy, bilateral salpingectomy, and cystoscopy was performed during the surgery. <h3>Measurements and Main Results</h3> Adhesiolysis was safely performed. A cystoscopy at the end of the procedure demonstrated no injury to the bladder as well as bilateral jets. The patient recovered well postoperatively with no complications. <h3>Conclusion</h3> This video demonstrates surgical techniques for management of dense bladder adhesions which can be used in a wide variety of surgical scenarios.

8493 Six Clip Hysterectomy

<h3>Study Objective</h3> To demonstrate an efficient, alternative method of performing a total robotic hysterectomy with bilateral salpingo-oophorectomy/salpingectomy using six surgical clips. <h3>Design</h3> Video presentation with narration explaining surgical technique and steps to perform a hysterectomy with six surgical clips. <h3>Setting</h3> Hospital operating room. Patient positioned in dorsal lithotomy in steep Trendelenburg with robot docked in place. Surgeon at console. <h3>Patients or Participants</h3> A 54-year-old woman with pelvic pain and thickened endometrium with history of endometrial ablation years prior for menorrhagia. She presented for total robotic hysterectomy with bilateral salpingo-oophorectomy. <h3>Interventions</h3> The patient was taken to the operating room for a robotic hysterectomy with bilateral salpingo-oophorectomy. The abdomen was entered and the da Vinci Xi robot (da Vinci Intuitive Surgical, Sunnyvale, CA) was docked. The left round ligament was transected, and the retroperitoneal space was entered. Using a large robotic clip applier, a surgical clip was placed on the left uterine artery at its origin. A second clip was placed on the left infundibulopelvic ligament which was then transected. A third clip was placed on the left uterine vessels at the level of the cardinal ligament. The steps were repeated on the opposite side. After the sixth and final clip was placed on the right uterine vessels, the cardinal ligaments were transected bilaterally and the colpotomy was completed. The specimen was removed, while the six surgical clips remained in the body. Minimal bleeding was encountered. Patient recovered well post-operatively with no issues. When performing a hysterectomy with bilateral salpingectomy, the clips are placed on the utero-ovarian ligaments as opposed to the infundibulopelvic ligaments. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> We demonstrate an efficient, cost-effective, and alternative method of performing a robotic hysterectomy using six surgical clips. There is less energy use, less thermal damage, and decreased blood loss. This technique is applicable with both bilateral salpingo-oophorectomy and bilateral salpingectomy at the time of hysterectomy.

8525 Efficacy and Safety of Single Port Robotic Hysterectomy with Concomitant Urogynecologic and Gynecologic Oncology Procedures

<h3>Study Objective</h3> To assess the feasibility of the DaVinciâ Single Port (SP) robotic platform for urogynecologic and gynecologic oncology surgical procedures. <h3>Design</h3> Retrospective cohort analysis. <h3>Setting</h3> The first SP robotic procedures performed as same day surgeries at an academic tertiary medical center by board certified Female Pelvic Medicine and Reconstructive Surgery and/or Gynecologic Oncology surgeons from December 2021-April 2022. <h3>Patients or Participants</h3> 15 patients underwent SP robotic hysterectomy (RH) and either bilateral salpingectomy (BS) or salpingo-oophorectomy (BSO) with or without concomitant procedures. <h3>Interventions</h3> SP RH and concomitant procedures were performed using a 1.5 cm umbilical incision, the Access Port ä (Intuitive Surgical) and the SP platform robotic camera and instruments. <h3>Measurements and Main Results</h3> Our primary outcome was conversion to a multiport procedure and intraoperative complications. Perioperative details were abstracted from the chart including operative time, estimated blood loss (EBL), and intraoperative complications, PACU length of stay (LOS) and pain scores POD#1 Surgical Pain Scale (SPS) scores. Indications for the 15 SP RH with BS or BSO included prolapse (N=10), risk reduction (N=2,) endometrial cancer (N=1), cervical (N=1), and endometrial (N=1) intraepithelial neoplasia. Concomitant procedures included: 10 (67%) SP sacrocolpopexies, 9 (60%) midurethral slings, 2 (13%) SP sentinel lymph node mapping, and 1 breast reconstruction. There was no conversion to a multiport procedure, intraoperative or immediate postoperative complications with a mean EBL of 66.7 ± 26.1 cc. Mean operative time and PACU LOS were 182 ± 53 and 216 ± 57 min. Median PACU pain scores were low (2, IQR 4) and only one patient required a single dose of postoperative tramadol. Similarly, median POD#1 SPS scores were low for pain at rest and with activity (3 (IQR 4) and 3 (IQR 4.75)) and for the worst pain 5.5 (IQR 4,25). <h3>Conclusion</h3> SP robotic approach for urogynecologic and gynecologic oncology hysterectomy with concomitant procedures performed by sub-specialty surgeons is safe and feasible.

8400 Distal Ureteral Resection with Ureteroneocystotomy; A Case of Robotic Assisted Laparoscopic Management of Ureteral Endometriosis

<h3>Study Objective</h3> Video presentation showing distal ureterectomy and reimplantation. <h3>Design</h3> Case presentation with showing procedural techniques in detail. <h3>Setting</h3> Tertiary academic teaching hospital. <h3>Patients or Participants</h3> 39-y.o. G6P3033 with past medical history of upper extremity deep venous thrombosis and surgical history of tubal ligation as well as endometrial ablation for menorrhagia, presented to the emergency room with right lower quadrant pain and was found to have right hydronephrosis and a 1.6 cm right ureterovesical junction mass on CT scan. She underwent a cystoscopy and right ureteric balloon dilation with stent placement with no evidence of bladder endometriosis. MRI showed a 1.6cm nodule at a low-intensity signal in T2-weighted sequences, suspicious for ureteral endometriosis. <h3>Interventions</h3> She underwent diagnostic laparoscopy with total hysterectomy and bilateral salpingectomy, robotic assisted distal ureterectomy with ureteroneocytotomy and stent placement. Her anticoagulation was held 48h prior to the surgery and re-initiated the day after her surgery. <h3>Measurements and Main Results</h3> The stent was discounted at 8 weeks post-operative. At 12 weeks post-operative she had an ultrasound done with normal fin dings and resolved hydronephrosis. <h3>Conclusion</h3> Preoperative planning and multidisciplinary team approach to management of severe endometriosis affecting the ureter is of paramount importance. While medical management is often the first-line therapy for endometriosis, urinary tract involvement often represents advanced stage of the disease, thereby timely diagnosis and appropriate surgical intervention is required to avoid permanent kidney injury.

8809 Laparoscopic Cornual Resection after Ectopic Pregnancy in Fallopian tube Remnant

<h3>Study Objective</h3> To review ectopic pregnancies after salpingectomies. To demonstrate a safe and feasible approach to a laparoscopic cornual resection after an ectopic in a fallopian tube remnant. <h3>Design</h3> A single person case report with a stepwise demonstration of surgical techniques with narrated video footage. <h3>Setting</h3> Tertiary-care academic center. <h3>Patients or Participants</h3> A 31-year-old has a history a history of a right salpingo-oophorectomy in childhood and a left salpingectomy after a history of two ectopic pregnancies. She presented with a right fallopian tube remnant ectopic pregnancy, which was treated with methotrexate. Prior to embryo transfer, it was recommended for her to have this right tubal remnant removed. <h3>Interventions</h3> Vasopressin was administered into the uterus for bleeding prevention into the right cornua. A uterine manipulator was placed, and methylene blue was injected to delineate the tubal ostia and thus the area of resection. A small wedge resection of the cornua was performed and the uterus closed in 2 layers with a 2-0 V-loc suture. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Ectopic pregnancies after bilateral salpingectomies are rare. In patients who desired invitro fertilization after a history of an ectopic pregnancy in a fallopian tube remnant, may safely undergo a resection of the uterine cornua, by a trained gynecologic surgeon.

Strategies to Minimize Blood Loss during Laparoscopic Hysterectomy for Management of Cesarean Scar Ectopic Pregnancy

<h3>Study Objective</h3> Demonstrate techniques to minimize blood loss during laparoscopic hysterectomy for management of cesarean scar ectopic pregnancy. <h3>Design</h3> Stepwise demonstration using narrated video footage. <h3>Setting</h3> An academic tertiary care hospital. <h3>Patients or Participants</h3> 33-year-old G5P4004 with one prior cesarean delivery presented to the ER with abdominal pain and vaginal spotting in early pregnancy. Her vital signs were normal with a Hemoglobin of 8.9. Ultrasound revealed a ∼6-week cesarean scar ectopic pregnancy. She was counseled on management options including laparoscopic resection of the ectopic with repair of uterine defect or laparoscopic hysterectomy. The patient was satisfied with her parity and opted for hysterectomy. <h3>Interventions</h3> The patient underwent total laparoscopic hysterectomy, bilateral pelvic wall dissection, bilateral salpingectomy, and cystoscopy. Various considerations and techniques were used intraoperatively to minimize blood loss. 1. Major vasculature (uterine and utero-ovarian arteries) was interrupted before placement of uterine manipulator 2. Uterine manipulator was placed under laparoscopic guidance in a retroverted fashion to avoid disruption of pregnancy 3. The correct plane was identified during dissection between the bladder and pregnancy to avoid injury or bleeding 4. Additional bleeding was anticipated and encountered even after major blood supply was interrupted, likely related to collateral vasculature to the pregnancy <h3>Measurements and Main Results</h3> Successful management of cesarean scar ectopic pregnancy was performed via laparoscopic hysterectomy. Estimated blood loss was 100cc and the surgery was uncomplicated. <h3>Conclusion</h3> Cesarean scar ectopic pregnancy is more common with the rising rate of cesarean deliveries. Risk of hemorrhage in this scenario is higher due to possible trophoblastic involvement up to level of uterine arteries. However, various techniques may be used to decrease blood loss during definitive surgical treatment.

8168 Umbilical Endometriosis and Vaginal Stump Endometriosis Developing after Total Laparoscopic Hysterectomy

<h3>Study Objective</h3> Even when endometriotic lesions in the pelvis are mild, they can survive in the vaginal stump and the trocar port-site after total laparoscopic hysterectomy. It is difficult to preoperatively assume the presence of fine lesions in the Douglas pouch when endometriosis is not detected elsewhere from imaging findings. Endometriotic lesions may survive in the vaginal stump, even in the absence of endometriosis in the uterus or adnexa. <h3>Design</h3> Case Presentation. <h3>Setting</h3> Yokohama City University. <h3>Patients or Participants</h3> A patient with less common/rare site endometriosis. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> A 40-year-old G0P0 presented with multiple uterine leiomyomas. Because of exacerbated hypermenorrhea, the patient underwent total laparoscopic hysterectomy and bilateral salpingectomy. Intraperitoneal findings included an approximately 1-cm endometriotic lesion in the peritoneum of the Douglas pouch, and partial adhesion of the rectum to the broad ligament. The vaginal canal was incised, and the uterus was transected, transvaginally morcellated and removed from the body cavity. Pathological examination revealed uterine leiomyoma, with no salpingeal abnormalities or endometriotic lesions. At 2 and 5 months postoperatively, the patient reported monthly genital bleeding; however, no apparent abnormalities were clinically observed. At 9 months postoperatively, the patient still experienced similar genital bleeding and noticed pain that occurred around the umbilicus simultaneously. Colposcopy revealed several red endometriosis-like lesions in the vaginal stump. The patient was eventually diagnosed with vaginal stump endometriosis. In addition, periodic pain appeared in the umbilical region as well, and the presence of endometriosis on umbilical port-site was suspected. Magnetic resonance imaging showed the umbilical trocar port-site endometriosis. Oral dienogest was started 11 months after surgery and maintained, and the patient's symptoms almost resolved after 5 months. <h3>Conclusion</h3> When patients complain of periodic genital bleeding or abdominal pain after total laparoscopic hysterectomy, vaginal stump and port-site endometriosis should be suspected. Vaginal stump endometriosis can be histologically diagnosed using colposcopy-guided biopsy, and dienogest may relieve symptoms.

8711 Robotic Assisted Treatment of Deep Endometriosis, with Bowel and Ureteral Involvement

<h3>Study Objective</h3> To demonstrate a minimal invasive approach to treat a patient with deep endometriosis causing renal exclusion. <h3>Design</h3> A surgical video highlighting anatomy and describing the steps of a multidisciplinary surgery. <h3>Setting</h3> Tertiary care hospital. The patient was in dorsal lithotomy position. <h3>Patients or Participants</h3> Female, 41-year-old, G1 with a previous cesarean 8 years ago. Suffering from chronic pelvic pain. After imaging tests, the patient was diagnosed with deep endometriosis, the main lesions being: a retrocervical lesion with involvement of the vagina and intestine, a lesion causing ureteral constriction and 2 intestinal lesions. <h3>Interventions</h3> At first, the patient was submitted to laparoscopic nephrectomy, with subsequent removal of the piece vaginally. Afterwards, she underwent robotic-assisted surgery, being performed hysterectomy with left parametrectomy and bilateral salpingectomy, adhesiolysis, resection of peritoneal lesions, intestinal shaving, appendectomy, left ureterectomy, ureterolysis and neurolysis. <h3>Measurements and Main Results</h3> The robotic assisted treatment of deep endometriosis was completed without complication. At post-operative follow-up, the patient was doing well without concerns. <h3>Conclusion</h3> In this video, we demonstrate a treatment for patients with stage 4 endometriosis, through minimally invasive surgery, with preservation of nerves and noble structures. Robotic surgery has proved to be an attractive strategy for treating these types of injuries, with good results, as shown in the video.

Deep Infiltrating Endometriosis Affecting Ileoanal Anastomosis (J-Pouch): Surgical Approach

<h3>Study Objective</h3> To review a patient case of deep infiltrating endometriosis of an ileoanal anastomosis. <h3>Design</h3> Case report. <h3>Setting</h3> Academic institution, Minimally Invasive Gynecologic Surgery and Colorectal combined procedure. <h3>Patients or Participants</h3> 38-year-old with history of ulcerative colitis status post ileoanal anastomosis (J-pouch) with deep infiltrating endometriosis. <h3>Interventions</h3> Robotic-assisted total laparoscopic hysterectomy with bilateral salpingectomy, left oophorectomy, excision of deep infiltrating endometriosis of J-pouch, ureteral ICG injection, and pouchoscopy. <h3>Measurements and Main Results</h3> Patients with endometriosis are at increased risk of co-morbid inflammatory bowel disease. Ileoanal anastomosis is indicated in patients with disease affecting the entire colon and rectum such as ulcerative colitis. The J-pouch is created with an anastomosis of folded terminal ileum following total resection of the colon and rectum. An enterotomy of the pouch and anal anastomosis are then completed, forgoing the need for ileostomy. The primary vascular supply consists of terminal branches of the superior mesenteric artery and is therefore limited. The patient presented with pain and on MRI was found to have deep infiltrating endometriosis of the ileoanal anastomosis approximating 3.2 by 1.0 cm, as well as a left endometrioma. Intra-operatively, the deep infiltrating lesion was identified on the efferent limb on the antimesenteric border of the J-pouch ileum and removed using a shave technique. Care is taken to avoid the vascular supply to the J-pouch on the mesenteric aspect, as no collateral supply is available. An omental pedicle flap was created and secured overlying the pouch to reduce the risk of fistula formation. The patient underwent the procedure without complications. <h3>Conclusion</h3> Patients with endometriosis are at increased risk of comorbid inflammatory bowel disease. Knowledge of J-pouch anatomy is crucial to dissection in cases of endometriosis involvement, including delicate blood supply. The use of an omental flap can be helpful to prevent formation of future adhesions. A multidisciplinary approach is key to patient care.

8250 Two Approaches to Laparoscopic Removal of Essure® Coils: Salpingectomy and Cornuectomy

<h3>Study Objective</h3> To describe two uterine-sparing methods for laparoscopic Essure® coil removal. <h3>Design</h3> Demonstration of surgical steps involved in laparoscopic removal of Essure® coils. <h3>Setting</h3> University academic hospital. <h3>Patients or Participants</h3> The patient is a 39-year-old G1P1 with history of Essure® system sterilization presenting with chronic pelvic pain. <h3>Interventions</h3> Laparoscopic bilateral Essure® coil removal via bilateral salpingectomy and en bloc cornuectomy. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Laparoscopic Essure® coil removal is a practical uterine-sparing option with no difference in perioperative outcomes between cornuectomy and salpingectomy alone.

8979 Laparoscopic Lysis of Adhesions: Adhesiolysis, Enterolysis, and Salpingo-Ovariolysis in a Patient with Infertility

Study Objective To show the surgical steps used to perform adhesiolysis, enterolysis, and salpingo-ovariolys in a patient with a complex surgical history and a desire for pregnancy, planning to undergo in vitro fertilization treatment. Design Step-by-step video demonstration of the technique. Setting A university tertiary care hospital. Patients or Participants A 36-year-old gravida 2 para 0 with an extensive surgical history – including a cholecystectomy with subsequent exploratory laparotomy on post operative day 2 secondary to hematoma formation, and infertility. Interventions Studies have shown that salpingectomy for hydrosalpinx prior to undergoing in vitro fertilization treatment can improve pregnancy rates. In patients with a prior history of abdominal surgery or other inflammatory event, adhesion formation can obstruct access to the pelvis and distort pelvic anatomy, adding increased complexity to the intended procedure. A diagnostic laparoscopy with adhesiolysis, enterolysis, and salpingo-ovariolysis is performed prior assessing the integrity of the fallopian tubes and ultimately performing bilateral salpingectomy with the aim to improve in vitro fertilization success rates. Measurements and Main Results We discuss three important issues related to lysis of adhesion. First, preoperative and intraoperative considerations regarding abdominal entry and trocar placement. Second, guidelines for lysing specific types of adhesions are discussed, including technique and use of ultrasonic energy. Finally, management of sequela of adhesion lysis such as bowel injury, fallopian tube damage, and obtaining hemostasis are discussed. At postoperative follow up, the patient had healed well and was referred back to reproductive endocrinology to start in vitro fertilization treatments. Conclusion It can be difficult to know preoperatively the extent of adhesive disease in a patient with prior abdominal surgery. Preoperative review of imaging, history, and prior operative reports can help in planning entry. Visualization and skilled intra-operative surgical technique are necessary to perform safe adhesiolysis, enterolysis, and salpingo-ovariolysis. To show the surgical steps used to perform adhesiolysis, enterolysis, and salpingo-ovariolys in a patient with a complex surgical history and a desire for pregnancy, planning to undergo in vitro fertilization treatment. Step-by-step video demonstration of the technique. A university tertiary care hospital. A 36-year-old gravida 2 para 0 with an extensive surgical history – including a cholecystectomy with subsequent exploratory laparotomy on post operative day 2 secondary to hematoma formation, and infertility. Studies have shown that salpingectomy for hydrosalpinx prior to undergoing in vitro fertilization treatment can improve pregnancy rates. In patients with a prior history of abdominal surgery or other inflammatory event, adhesion formation can obstruct access to the pelvis and distort pelvic anatomy, adding increased complexity to the intended procedure. A diagnostic laparoscopy with adhesiolysis, enterolysis, and salpingo-ovariolysis is performed prior assessing the integrity of the fallopian tubes and ultimately performing bilateral salpingectomy with the aim to improve in vitro fertilization success rates. We discuss three important issues related to lysis of adhesion. First, preoperative and intraoperative considerations regarding abdominal entry and trocar placement. Second, guidelines for lysing specific types of adhesions are discussed, including technique and use of ultrasonic energy. Finally, management of sequela of adhesion lysis such as bowel injury, fallopian tube damage, and obtaining hemostasis are discussed. At postoperative follow up, the patient had healed well and was referred back to reproductive endocrinology to start in vitro fertilization treatments. It can be difficult to know preoperatively the extent of adhesive disease in a patient with prior abdominal surgery. Preoperative review of imaging, history, and prior operative reports can help in planning entry. Visualization and skilled intra-operative surgical technique are necessary to perform safe adhesiolysis, enterolysis, and salpingo-ovariolysis.