Gynecologic Surgeons Research Articles

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.

Laparoscopic Myomectomy Simulation Model for Post-Graduate Learners: Mastering Enucleation

<h3>Study Objective</h3> The objectives of this video are to highlight the fundamentals of laparoscopic myomectomy for postgraduate learners, and to describe a low fidelity simulation model for fibroid enucleation during straight stick laparoscopic myomectomy. <h3>Design</h3> Surgical simulation pilot. <h3>Setting</h3> Surgical simulation lab with use of laparoscopic box trainer. <h3>Patients or Participants</h3> Feedback on the simulation model was obtained from 2 fellowship trained minimally invasive gynecologic attending surgeons (MIGS) and 17 OB/GYN residents evenly distributed across post-graduate year. <h3>Interventions</h3> Using the described model, we assessed user experience and face validity via pre- and post-tests. <h3>Measurements and Main Results</h3> On post-test, 94% of post-graduate learners felt the tactile feedback on the fibroid to be realistic or very realistic. 100% felt starting the plane of enucleation to be realistic or very realistic. 88% felt as though the density of fibroid and number of tenaculum tear-offs was realistic or very realistic. Lastly, 94% of participants felt peeling fibers from the fibroid to be realistic or very realistic. Difficulties with the injection of vasopressin and excess mobility of the uterus during enucleation were cited as points for improvement. After the simulation, 76% felt comfortable or very comfortable with creating the hysterotomy and identifying the correct plane for enucleation as compared to 29% prior. Similarly, 82% of learners felt comfortable or very comfortable with enucleation via traction-counter traction approach as compared to only 35% prior. <h3>Conclusion</h3> This proposed low-fidelity model for laparoscopic myomectomy realistically simulated the fundamental steps of fibroid enucleation and served as a promising method to teach the nuances of haptic feedback on pilot testing. As no historical data is available, in future studies we aim to measure construct validity with predictive validation techniques in a cohort of attending surgeons, MIGS fellows, and OB/GYN residents across several sites.

Laparoscopic Nerve Detrapment and Neurolysis of Somatic Pelvic Nerves in Deep Endometriosis: Prospective Study of 433 Patients

<h3>Study Objective</h3> To review efficacy and feasibility of laparoscopic decompression and neurolysis for cases of endometriosis involving sacral plexus and/or somatic nerves causing somatic compression and ano-genital pain on a large case series. <h3>Design</h3> Prospective case-series, single-centre, single-surgeon study on 433 patients. In a 7-year period. <h3>Setting</h3> Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, Verona - Italy; 7-years period <h3>Patients or Participants</h3> 433 patients with deep infiltrating endometriosis complaining of recurrent sciatica and ano-genital pain in addition to "usual" endometriosis symptoms <h3>Interventions</h3> (A) medial approach for deep pelvic endometriosis with rectal and/or parametrial involvement extending to pelvic wall and somatic nerve; (B) lateral approach for isolated endometriosis of pelvic wall and somatic nerves. All the procedures were performed by a gynecologic pelvic surgeon skilled in neuro-anatomy (M.C.) <h3>Measurements and Main Results</h3> All the treated patients showed laparoscopic and pathology report evidence of compression above the somatic nervous structures, requiring decompression, whereas in 145 (33,5%) patients, there was clear infiltration of those structures, deepening to the perineural and axonal planes. Complete relief from neurologic symptoms was achieved in all patients at 6 months after surgery, post-operative neuritis was reported in 62 patients (14.3%). <h3>Conclusion</h3> Pelvic wall spread of deep infiltrating endometriosis might be more usual than thought. Laparoscopic retroperitoneal nerve-sparing approach to endometriosis extending to the pelvic wall with somatic nerve compression proved to be a feasible and safe procedure, effective in pain relief, recovery of impaired neurological functions and neuromotoric impairment motoric symptoms of the pelvis and the leg related to endometriosis. It should be limited to referral laparoscopic centres lead by surgical neuro-anatomy skilled surgeons.

7553 Laparoscopic Management of Rectal Prolapse

<h3>Study Objective</h3> to study surgical management aspect of rectal prolapse. <h3>Design</h3> It's a single case study. <h3>Setting</h3> Laparoscopic mesh rectopexy performed in a hospital located in rural place. <h3>Patients or Participants</h3> 1. <h3>Interventions</h3> Laparoscopic mesh rectopexy. <h3>Measurements and Main Results</h3> Follow up till 1 year post surgery. Complete relief from symptoms and no fresh complaints. <h3>Conclusion</h3> Rectal prolapse management by laparoscopic anterior mesh rectopexy may also be domain of gynaecologic laparoscopic surgeons if one is competent.

7578 Hysterectomy with or without Oophorectomy for Transgender Male Patients: Preoperative and Intraoperative Considerations

<h3>Study Objective</h3> To review the preoperative and intraoperative considerations for gynecologic surgeons when performing hysterectomy with or without oophorectomy for transgender male patients. <h3>Design</h3> Stepwise demonstration of techniques with narrated video footage. <h3>Setting</h3> Approximately 0.3% of hysterectomies performed annually in the U.S. are for transgender male patients, most commonly to alleviate gender dysphoria. A hysterectomy with or without oophorectomy can be offered to patients who have met criteria outlined by the World Professional Association for Transgender Health (WPATH) guidelines. <h3>Patients or Participants</h3> Transgender male patients seeking hysterectomy with or without oophorectomy. <h3>Interventions</h3> Important perioperative counseling points for transgender male patients include: •Establishing terminology to minimize gender dysphoria •Discussing options for fertility preservation •Discussing the importance of continuing testosterone therapy post-oophorectomy to reduce the loss of bone density •Reviewing intraoperative and postoperative expectations Important intraoperative considerations for the performance of safe and effective hysterectomy with or without oophorectomy for transgender male patients include: •Maintaining a margin of at least 2 cm between the surgical instrument and the ovary during coagulation and transection of the infundibulopelvic ligament to prevent ovarian remnant syndrome •Performance of a two-layer vaginal cuff closure to reduce the risk of vaginal cuff complications <h3>Measurements and Main Results</h3> The patients recovered well without any postoperative complications. <h3>Conclusion</h3> In conclusion, it is essential to minimize the patient's experience of gender dysphoria by providing gender-affirming care before, during and after surgery. In particular, the surgeon should take care to perform oophorectomy with an adequate margin to minimize the risk of ovarian remnant syndrome and use a two-layer laparoscopic vaginal cuff closure to decrease the risk of vaginal cuff complications.

8504 Postmenopausal Endometriosis at the Time of Laparoscopic Trachelectomy

<h3>Study Objective</h3> To review endometriosis management in the postmenopausal population. To review indications for a trachelectomy following a hysterectomy. To demonstrate a safe and feasible way to perform a laparoscopic trachelectomy. <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 64-year-old with a history of bladder pain syndrome and a past surgical history of a supracervical hysterectomy and bilateral salpingo-oophorectomy for risk reduction, in the setting of BRCA2 mutation and a history of breast cancer. Patient was experiencing postmenopausal bleeding and found to have cervical dysplasia. Pelvic MRI showed concern for a 1cm cervical mass. <h3>Interventions</h3> At time of laparoscopy white plaques were identified just lateral to cervix. Plaques were excised, sent for frozen pathology, and found to be benign. A laparoscopic trachelectomy was performed and incorporated the lateral borders of these lesions for complete excision. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Laparoscopic trachelectomies are safe and feasible surgeries to perform by a trained gynecologic surgeon. Amongst the concern for endometriosis, one must consider the diagnosis of malignancy, especially in the postmenopausal population.

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.

8344 The Impact of Surgeon Volume on Laparoscopic Hysterectomy Outcomes

<h3>Study Objective</h3> To evaluate the impact of surgeon volume on outcomes after laparoscopic hysterectomy for benign indications. <h3>Design</h3> Retrospective chart review. <h3>Setting</h3> Single tertiary care academic institution. <h3>Patients or Participants</h3> A total of 494 patients who underwent laparoscopic hysterectomy performed by 22 benign gynecologic surgeons. <h3>Interventions</h3> Laparoscopic or robotic-assisted hysterectomy performed between March 2019 and April 2020. <h3>Measurements and Main Results</h3> Of the total 494 benign laparoscopic hysterectomies performed, 448 hysterectomies were performed by high volume surgeons (9 surgeons) and 46 hysterectomies were performed by low volume surgeons (13 surgeons). High volume was defined as 12 or more hysterectomies completed during the study year. Low volume surgeons ranged from 1 to 8 hysterectomies performed during the study period. Demographic and preoperative characteristics were similar between groups except age (45 years vs 41 years, p=.033). The two groups had similar intraoperative characteristics including route of hysterectomy, operative time, estimated blood loss and uterine weight. Intraoperative complications were similar between groups including transfusion rates, viscus injury, and intraoperative consults. However, there was a significantly higher rate of intraoperative conversion to laparotomy in the lowvolume group (1% vs 9%, p=.004). Pathology results were similar between groups. No pathologic findings were seen in 16% of cases in the high-volume group and 26% of cases in the low volume group (p=.11). Endometriosis was confirmed on pathology similarly between groups (11% vs 9%, p=.78). Pathology outcomes of leiomyomas, adenomyosis, and endometrial hyperplasia were similar between groups. There were no differences in postoperative complications, emergency department visits, or readmissions. <h3>Conclusion</h3> Low volume surgeons had significantly higher rates of intraoperative conversion to laparotomy at time of laparoscopic hysterectomy. In this study, surgeon volume did not significantly impact other outcomes including pathology. However, a limitation of the study was the small sample size in the low volume group which was <10% of the cohort.

Minimizing Repeat Surgeries for Endometrioma: Impact of Surgical Intervention by Minimally Invasive Gynecologic Surgeons

<h3>Study Objective</h3> The objective of this study is to determine whether patients who are diagnosed with ovarian endometrioma(s) on imaging undergo fewer total surgeries for treatment of their endometrioma and endometriosis if the initial surgery is performed a minimally invasive gynecologic surgery (MIGS) specialists compared to a general obstetrician-gynecologist. <h3>Design</h3> Single center, IRB-approved retrospective chart review. <h3>Setting</h3> Academic, tertiary care institution in the United States. <h3>Patients or Participants</h3> Records of 383 females age 18 with endometrioma(s) diagnosed on pelvic imaging who underwent surgical treatment were included in this study. Patients without endometrioma on final pathology or with diagnosis of malignancy were excluded. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> Patients who underwent primary surgery by MIGS specialists were significantly less likely to undergo a second and third surgery than if initially performed by a general Ob/Gyn (second surgery n=19, 10.4% vs. n=24, 18.2%, third surgery n=2, 1.1% vs. n=9, 6.8%; p<0.01). A higher proportion of patients whose first surgery was performed by MIGS had only 1 surgery than patients whose first surgery was performed by a general Ob/Gyn (n=162, 88.5% vs. n=99, 75.0%). MIGS specialists were more likely to use a laparoscopic approach compared to general Ob/Gyn for all cases (first surgery n=183, 54.8% vs. n=106, 31.7%, second surgery n=41, 73.2% vs. n=9, 16.1%, third surgery n=11, 84.6% vs. n=1, 7.7%; p<0.01). <h3>Conclusion</h3> Patients diagnosed with endometriomas on imaging who undergo surgical management are less likely to undergo subsequent surgery if their initial surgery was performed by a MIGS specialist as compared to a general obstetrician-gynecologist. These findings have important implications for surgical referral patterns of patients with endometriomas on preoperative imaging.

Transition to Universal Same Day Discharge (SDD) in Times of Corona Virus Disease-19 (COVID): A Success Story

<h3>Study Objective</h3> To evaluate success of universal SDD after minimally invasive hysterectomy. The COVID pandemic presented a unique scenario in which universal SDD was implemented abruptly across study institutions. This allowed for evaluation of patients with characteristics under-represented in SDD literature: large uteri due to leiomyoma, obesity defined as body mass index (BMI) ≥30, and later surgical end time. <h3>Design</h3> Retrospective chart review with before/after study design comparing pre-COVID to COVID cohorts. <h3>Setting</h3> High-volume, academic and academic-affiliated medical centers. Due to COVID, in the after-cohort, surgery could only be scheduled if SDD was planned. <h3>Patients or Participants</h3> Patients undergoing benign, laparoscopic or robotic-assisted hysterectomy during two 11-month periods: September 2018-July 2019 and May 2020-March 2021. <h3>Interventions</h3> Minimally invasive hysterectomy performed by three Minimally Invasive Gynecologic Surgeons. <h3>Measurements and Main Results</h3> 320 patients met inclusion criteria, 107 pre-COVID and 213 COVID. Mean age for both groups was 44.9. Patients were predominately non-Hispanic Black (40.2% pre- vs. 34.7% COVID) and non-Hispanic White (55.1% pre- vs. 63.4% COVID). Mean BMI was 33 for both groups. Pre-COVID, 2% of patients were discharged same day, whereas COVID 92% were discharged same day. Mean specimen weight was 478.2gm vs. 436.3gm for the two periods. In the COVID cohort, there was no difference in SDD success based on BMI (p 0.678), BMI <30 (49.5%), 30-39.9 (29.1%), 40-49.9 (15.3%), and ≥50 (6.1%). There was no difference in SDD success by specimen weight (p 0.077) stratified as <250gm (48.5%), 250-499gm (15.3%), or ≥500gm (36.2%). SDD success was not dependent on surgical end time (p 0.678) with end time stratified into ≤12:00 (45.4%), 12:01-14:59 (35.7%), and ≥15:00 (18.9%). There were no re-admissions in either cohort. <h3>Conclusion</h3> Abrupt transition to SDD is safe and feasible, including for patients with obese BMI and enlarged uterus. SDD success was not affected by later surgical end time.

8465 Same-Day Discharge (SDD) after Total Laparoscopic Hysterectomy (TLH) in a High-Risk Patient Population

<h3>Study Objective</h3> To examine whether SDD (discharge prior to midnight on day of surgery) is safe and feasible in a high-risk patient population. Secondary outcome was post-operative complications within twelve weeks of surgery. <h3>Design</h3> Retrospective chart review. <h3>Setting</h3> High-volume, safety-net hospital caring for predominantly Hispanic-White, African American, non-English speaking, and/or uninsured or under insured patients with 5^th grade average reading level. <h3>Patients or Participants</h3> Patients receiving TLH June 2014 - January 2019. This captures the transition in practice to universal SDD in 2017. <h3>Interventions</h3> TLH performed by two high volume Minimally Invasive Gynecologic Surgeons. <h3>Measurements and Main Results</h3> 309 patients, 95 (31%) had SDD while 214 (69%) were admitted. After the transition in 2017, the SDD rate increased from 0% (2014) to 73% (2018). No statistically significant differences were noted in baseline characteristics between groups including: Age, race, ethnicity, hemoglobin, or surgery indication. The majority of patients self-reported a language other than English as their primary language (58% SDD vs. 53% admission). There were no differences between group's pre-operative comorbidities including BMI (33kg/m²), presence of hypertension, diabetes, or opioid use. There was no statistically significant difference between groups based on ASA classification, with most being class 2 (58% vs. 60%) or 3 (40% vs. 38%). There were no differences between SDD and admission groups in mean estimated blood loss (134mLs vs. 166mls) or uterine weights (314gms vs. 327gms). Six patients (2%) were readmitted post-operatively, and there was no difference in readmission rate between groups. <h3>Conclusion</h3> SDD is safe in a high-risk patient population and does not increase post-operative readmission rate. Patients who are uninsured or underinsured, do not speak English as a primary language, have low health literacy, and/or who are ASA class 2-3 can safely be offered SDD. We demonstrate that high-risk patients should be included in SDD research and highlight the importance of equity and inclusivity in surgical outcomes research.

Vasopressin Injection Purse-String Ectopic Resection (VIPER) Technique for Laparoscopic Management of Cornual Ectopic

<h3>Study Objective</h3> To describe the VIPER technique for the laparoscopic management of cornual ectopic pregnancy; a technique that minimizes blood loss and mitigates risk of conversion to laparotomy. <h3>Design</h3> Case series. <h3>Setting</h3> High-volume, academic and academic-affiliated medical centers. <h3>Patients or Participants</h3> All patients presenting with cornual ectopic pregnancy managed surgically. <h3>Interventions</h3> Laparoscopic cornual resection by five Minimally Invasive Gynecologic Surgeons. The VIPER technique utilizes four ports (umbilical, left lower quadrant, and ipsilateral right sided) and a 30-degree laparoscope. After obtaining visualization, dilute vasopressin is injected into the myometrium adjacent to the pregnancy. The affected fallopian tube is disconnected distally. A purse-string stitch with uni-directional barbed suture is placed circumferentially around the pregnancy and cinched. This stitch achieves hemostasis regardless of rupture status. The needle is left attached, and a wedge resection of the cornua is performed with an ultrasonic device. The myometrial defect is repaired with the remaining suture. <h3>Measurements and Main Results</h3> 17 patients underwent laparoscopic cornuectomy between 2012 to 2022, with 7 found to be ruptured. The mean patient age was 30 years (range 20-41), mean body mass index was 31.4kg/m² (range 22-52), and mean gestational age was 8 weeks 6 days (range 5 weeks 6 days to 11 weeks 1 day). Patient risk factors included history of prior sexually transmitted infection (3 patients), in vitro fertilization (1 patient), and prior ectopic pregnancy (1 patient). The other twelve patients had no risk factors. The mean operative time was 107 minutes (range 50-229), with mean estimated blood loss of 41mL for non-ruptured and 412mL for ruptured ectopic pregnancies. The mean hemoperitoneum identified was 1117mL, (range 50mL to 3325mL). There were no conversions to laparotomy. 70.6% of patients were discharged on the day of surgery. <h3>Conclusion</h3> The VIPER technique is feasible and effective for the management of both non-ruptured and ruptured cornual ectopic pregnancy.

Surgical Management of Endometriosis of the Bladder and Ureter

<h3>Study Objective</h3> To demonstrate a step-by-step approach for the surgical management of urinary tract endometriosis using conventional laparoscopy for partial cystectomy and robotic-assisted laparoscopy for ureteroneocystostomy. <h3>Design</h3> Surgical video. <h3>Setting</h3> Academic tertiary referral center for endometriosis. <h3>Patients or Participants</h3> The first patient was a 38-year-old G3P3 with a history of hysterectomy presenting with dysuria had an MRI which revealed a T2 hypointense bladder nodule consistent with endometriosis. The second patient was a 25-year-old nulliparous woman with history of stage IV endometriosis with DIE into the bowel and both ureters causing subsequent hydronephrosis requiring bilateral ureteral stents and subsequently bilateral percutaneous nephrostomy tubes. <h3>Interventions</h3> In the first case, a cystoscopy was performed to confirm MRI findings of bladder lesion and to delineate borders and depth of invasion. Conventional laparoscopy was utilized to perform bilateral ureterolysis, bladder mobilization, partial cystectomy for complete excision of the lesion, and two-layered bladder closure. Use of indigo carmine assisted with ureteral orifice identification. In the second case, cystoscopy was performed with injection of ICG to assist with ureteral identification. After ureterolysis, distal ureteric obstruction due to extensive disease was confirmed on laparoscopy and ureteroscopy. Bilateral ureteroneocystostomy with placement of Double-J ureteral stents was performed using a robotic-assisted approach. Each patient had indwelling foley catheter for bladder decompression during recovery. <h3>Measurements and Main Results</h3> Both patients had an uneventful postoperative course. A postoperative retrograde cystogram confirmed adequate repair prior to removal of each foley catheter. Patient two had office stent removal 6 weeks postoperative. <h3>Conclusion</h3> Endometriosis is an increasingly common condition. It is important for gynecological surgeons to have the proper understanding of anatomy, surgical technique, and multidisciplinary care needed with urology for safe and complete excision of bladder and ureter endometriosis.

Surgical Practice Patterns in the Management of Ovarian Torsion

<h3>Study Objective</h3> Ovarian torsion (OT) is a common gynecologic emergency with the potential for significant lifelong health and fertility sequelae. We aimed to evaluate surgical practice patterns in the management of patients with concern for OT, in particular factors associated with oophorectomy versus ovarian preserving surgery (OPS) and rates of minimally invasive surgery (MIS). <h3>Design</h3> Retrospective cohort analysis <h3>Setting</h3> Tertiary medical center <h3>Patients or Participants</h3> All patients presenting acutely with symptoms concerning for OT who underwent surgical management between 2016-2021. Patients with incidental torsion at the time of scheduled surgery were excluded from this analysis. <h3>Interventions</h3> Evaluation of patient demographics, background clinical context, imaging findings, and surgical variables including primary specialty, surgical approach, procedures performed, and perioperative outcomes. <h3>Measurements and Main Results</h3> One hundred twenty-six-patient underwent 129 surgeries for suspected ovarian torsion. Of this, 75 cases (59.52%) were confirmed to be torsed. In total, 73 (57.9%) patients underwent OPS while 52 (41.3%) underwent oophorectomy. Patients who underwent OPS compared to oophorectomy were noted to be significantly younger (mean age 23.3 vs 29.3, p = 0.012) and have a lower BMI (mean 25.0 vs 29.7, p = 0.011). The proportion of OPS cases varied significantly by subspecialty with OPS performed in 56.9% of cases performed by Obstetrics and Gynecology generalists, 67.7% of cases by minimally invasive gynecologic surgeons (MIGS), 6% of cases by gynecologic oncologists (GO), and 79% of cases by pediatric surgeons. This data is confounded by patient age, fertility goals, and concern for malignancy. 90.28% of OPS cases were performed via a MIS approach while 69.2% of oophorectomies were MIS. MIS rates varied significantly by surgical subspecialty: 88% among generalists, 96.7% among MIGS, 60% among gynecologic oncologists, and 60% among pediatric surgeons. <h3>Conclusion</h3> The surgical management of OT varies widely. Our data supports that age, BMI, and surgical subspecialty influence surgical approach and management.

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.

Uterine Artery Occlusion Techniques: Tips and Tricks... and Some Pitfalls

<h3>Study Objective</h3> To demonstrate the benefits and challenges of various uterine artery occlusion techniques available to minimally invasive gynecologic surgeons. <h3>Design</h3> Educational Video Presentation. <h3>Setting</h3> Teaching hospital, Minimally Invasive Gynecology OR Team, patients in lithotomy position with various port configurations. <h3>Patients or Participants</h3> Patients at a Medical Teaching Facility. <h3>Interventions</h3> Uterine Artery Occlusion during Myomectomy and Hysterectomy. <h3>Measurements and Main Results</h3> Various research has shown that uterine artery occlusion is associated with decreased blood loss during laparoscopic and robotic hysterectomy and myomectomy. This video compares the benefits and challenges to each of the follow occlusions techniques: bipolar coagulation, bulldog clamps, polymer clips, laparoscopic clip appliers, and suture ligation. Comparisons are made between these options related to cost, technical difficulty, the extent of dissection needed, risk of thermal spread, port size requirements, and other notable differences. Intraoperative video demonstrates tips and tricks for successful application of each of these occlusion options. In addition, we also include intraoperative video of various pitfalls that surgeons can encounter with suboptimal applications of these various methods, so as to help surgeons prevent running into these foreseeable pitfalls. <h3>Conclusion</h3> Various uterine artery occlusion techniques are available to help reduce blood loss during minimally invasive gynecologic surgery. Knowing the benefits and challenges to each method can assist surgeons in choosing the best technique for each clinical circumstance.

8442 Isthmocele Repair in Unusual Presentations

<h3>Study Objective</h3> To demonstrate unusual clinical presentations and surgical management of isthmocele. <h3>Design</h3> Surgical video. Two cases are presented of women with unusual presentations undergoing isthmocele repair. One video demonstrates a robot-assisted and hysteroscopic repair, while the other is a laparoscopic and hysteroscopic repair. <h3>Setting</h3> Academic tertiary care hospital. <h3>Patients or Participants</h3> A 30-year-old G1P1and a 33-year-old G1P1 were referred to a minimally invasive gynecologic surgeon for pelvic pain and abnormal uterine bleeding. <h3>Interventions</h3> The first patient was referred for evaluation of dysmenorrhea and dyspareunia. She had a known history of an emergent cesarean delivery. MRI demonstrated findings concerns for isthmocele. She underwent a hysteroscopy, robotic-assisted excision of endometriosis and isthmocele repair. The second patient was referred 3 months after her delivery for abnormal uterine bleeding. She presented with persistent abnormal uterine bleeding. Her cesarean was complicated by a left extension and postoperative hemorrhage leading to IR coiling of her left uterine artery and a take-back exploratory laparotomy for hemoperitoneum. MRI report described myometrial blood products continuous with the endometrial lining. She underwent a concomitant hysteroscopy and laparoscopic isthmocele repair. Given the left lateral location of her defect near the uterine insertion of the uterine artery, the left uterine artery was clipped at its origin during the surgery as a precautionary measure. The clip was later removed upon completion of the repair. During her surgery, an endometrioma was noted to overly the c-section scar defect. Both patients had full recoveries and were cleared for pregnancy 6 months after the repair. <h3>Measurements and Main Results</h3> Office hysteroscopy after both the procedures demonstrated no further appreciable defects. <h3>Conclusion</h3> Isthmocele presentations vary. Isthmoceles should remain high on a differential when working up a patient with post-partum pelvic pain and abnormal bleeding. Concomitant use of hysteroscopy during laparoscopic or robotic repair of isthmocele is recommended.

7404 Tips and Tricks for Diagnostic Laparoscopy for Endometriosis

<h3>Study Objective</h3> The objective of this video is to provide Obstetricians and Gynecologists (Ob/Gyns) with tips and tricks for effective preoperative planning, minimally invasive surgical evaluation and treatment, and postoperative management for endometriosis. <h3>Design</h3> Narrated video. <h3>Setting</h3> Endometriosis is a prevalent disease that can be effectively treated with surgical excision. It is important for all Ob/Gyns to be able to effectively evaluate for and treat endometriosis via laparoscopy. <h3>Patients or Participants</h3> Patients with endometriosis. <h3>Interventions</h3> This video describes 1) preoperative evaluation for endometriosis through history, physical exam, and imaging 2) when further preoperative evaluation is required 3) when consultation with a minimally invasive gynecologic surgeon and/or other specialists such as colorectal or urology is recommended 4) tips and tricks for effective minimally invasive surgical excision of endometriosis 5) postoperative management of endometriosis. <h3>Measurements and Main Results</h3> This video can serve as a resource for Ob/Gyns to effectively evaluate for and treat endometriosis. <h3>Conclusion</h3> Endometriosis is a prevalent and debilitating disease that all Ob/Gyn's will encounter in practice. It is imperative that Ob/Gyns are able to effectively surgically evaluate for and treat endometriosis.

Surgical Skills Curriculum Satisfaction Among Current Obstetrics and Gynecology Residents

<h3>Study Objective</h3> To determine differences in surgical skills curriculum (SSC) and exposure to surgical subspecialties for current OB/GYN residents. Identify areas for improvement and standardization among residency programs. <h3>Design</h3> Online survey using novel 54-item questionnaire. <h3>Setting</h3> Surveys distributed via email to program directors and coordinators of OB/GYN residency programs with request to forward survey to current residents. <h3>Patients or Participants</h3> Current OB/GYN residents were eligible. 114 participants answered the survey over a 4-week period from March to April 2022. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> The majority of the respondents were female (87.9%), ages 28 to 32 (76.7%), and from university-based residency programs (58.6%). 60.3% of respondents reported having a structured SSC. Most SSCs were led by a mixture of generalists and subspecialists (37.9%), with the subspecialist most commonly a minimally invasive gynecologic surgeon (40.7%). Most residents reported there was not enough structure in their SSC (62.1%) and not enough time dedicated to surgical skills (61.2%). Only 7.8% of respondents were very satisfied with their program's SSC and the majority reported that surgical skills education could be improved (81.0%). Residents with structured SSCs were more likely to be satisfied with their training (5-point Likert scale mean 2.42 vs 3.64, p<.001). On average, most residents reported rotating with surgical subspecialists 16 weeks per year (31.0%) with 3-4 days in the operating room per week (59.5%). Residents reported that operating with surgical subspecialists improved their surgical skills (97.1%) and prepared them for independent surgery (94.0%). The majority of residents agreed that all programs should have a standardized SSC (84.5%) and have access to equivalent resources (89.7%). <h3>Conclusion</h3> The majority of OB/GYN residents are unsatisfied with their current SSC and agree that a standardized curriculum is needed. Exposure to surgical subspecialists improves resident surgical skills and prepares trainees for independent surgery.

7989 Cannonball Fibroid Robotic Myomectomy with Specimen Extraction Using Excite Technique

<h3>Study Objective</h3> Demonstrate a safe surgical technique used for robotic myomectomy of a large "cannonball" fibroid with specimen removal through umbilical incision, with incision retractor and protected by a contained extraction system, using Extracorporeal C-Incision Tissue Extraction (ExCITE) technique. <h3>Design</h3> Case report illustrated with a video. <h3>Setting</h3> Patient is placed in semi-gynecological position. <h3>Patients or Participants</h3> 40-year-old woman reports pelvic pain, increased abdominal volume and polyuria. Nulligest patient with reproductive desire, no previous illnesses. Physical examination revealed a palpable globose mass 2 cm under the umbilical scar. MRI showed a voluminous and globose uterus of 920 cc, due to a "cannonball" FIGO 5 fundic myoma measuring 14.3 cm. <h3>Interventions</h3> 8 mm incision was performed in the umbilical scar for endoscope robotic trocar. Other two 8mm incisions was performed in each flank to other robotic trocars. And one 5mm incision was performed in right hypochondrium for laparoscopic assistance. Inspection shows a voluminous uterus with a large fundic fibroid measuring about 14 cm. Wedge hysterotomy was performed for fibroid enucleation, with subsequent hysterorrhaphy. Then, specimen was removed through the umbilical incision, protected by a contained extraction system and using a wound retractor, under ExCITE technique. <h3>Measurements and Main Results</h3> We obtained efficient specimen extraction with safe and agile tissue fragmentation, maintaining aesthetic benefit for the patient. Patient was discharged in the second postoperative day, showing great evolution. <h3>Conclusion</h3> Extraction of big fibroids is often challenging for the minimally invasive gynecological surgeon. Using ExCITE technique inside a specimen containment bag with sharp instrumentation protector, it is possible to perform safe, agile and reproducible extraction technique, with efficient removal of tissue, avoiding the use of eletromechanic morcellator and the opening of vaginal dome.