Infundibulopelvic Ligament Research Articles

Excision of Deep Endometriosis Nodules of the Sciatic Nerve in 10 Steps

To present 10 standardized and reproducible surgical steps allowing for complete excision of deep endometriosis nodules involving the sciatic nerve. Surgical education video. The local institutional review board confirmed that the video met the ethical criteria required for publication. Patient consent was obtained. Tertiary referral center. The excision of deep endometriosis involving the sciatic nerve may be performed following 10 steps: (1) Longitudinal incision of the peritoneum covering the external iliac artery, from the hypogastric vessels to the round ligament and the identification of the genitofemoral nerve. (2) Dissection of the iliolumbar space identified laterally by the psoas muscle and medially by the external iliac artery and vein [1-5]. (3) Identification of the obturator nerve. The dissection is performed on contact with the psoas muscle; when the nerve is surrounded by the nodule, its releasing is progressively carried out. (4) Identification of the obturator vessels, which cross the obturator nerve beneath and follow a lateral direction. (5) Opening of the lumbosacral space, below the level of the obturator nerve, and the identification of the sciatic nerve, resulting from the confluence of L4 to S3 roots. During this step, the deep endometriosis nodule is identified on contact with the greater sciatic foramen. (6) Opening of the broad ligament, between the external iliac vessels and the umbilical artery, and identification of the obturator nerve, as it is usually performed in pelvic lymphadenectomy. The surgeon may either perform a separate incision of the posterior leaf of the broad ligament and medial to the infundibulo-pelvic ligament or prolong medially the incision made at step 1. (7) Identification of the sciatic nerve, which is seen below and medially from the obturator nerve and obturator vessels. During this step, the posterior limit of the nodule is identified. (8) Identification of sacral roots S1, S2, and S3 [6]. The pudendal nerve and the posterior femoral cutaneous nerve may be identified below the S3 and medially from the sciatic nerve and before their exit through the greater sciatic foramen. The posterior and medial limit of the nodule is progressively released [7]. (9) The dissection is continued laterally, on contact with the ischium, down to the ischial spine and the coccygeus muscle. The lateral limit of the nodule is identified and released. (10) The anterior limit of the nodule is identified and, when required, is separated from the bladder. The latter 3 steps are less standardized, and the surgeon may alternate lateral, medial, posterior, and anterior dissection of the nodule, depending on the intraoperative circumstances. In most cases, the nerves are compressed but not infiltrated inside the epineurium, and their complete releasing is followed by significant or complete relief of pain and motor problems [6]. When the nodule infiltrates the nerves inside the epineurium, the excision may be performed into the nerve. Laparoscopic excision of deep endometriosis nodules involving the sciatic nerve is a challenging procedure, requiring good anatomic knowledge, surgical skills, preliminary specific training, and multidisciplinary postoperative care. Teaching such a complex procedure is a mandatory but delicate task. By following 10 sequential steps, the surgeon may reduce the risk of hemorrhage originating from the external iliac, obturator, and pudendal vessels; preserve somatic nerves; and successfully excise deep endometriosis nodules. Although the 10 steps attempt to standardize the surgical approach in a challenging localization of deep endometriosis, they are not mandatory and should be adapted to the patient.

Laparoscopic Uterine Artery Occlusion Combined with Uterine-sparing Pelvic Plexus Block and Partial Adenomyomectomy for Adenomyosis: A Video Case Report

OBJECTIVE Adenomyosis usually causes dysmenorrhea and anemia. Clinically, it is difficult to be solved by medicine and traditional surgery, and hysterectomy is always performed for radical treatment. In this article, we introduce a new method which could control the dysmenorrhea and anemia through laparoscopic uterine artery occlusion (LUAO) combined with uterine-sparing pelvic plexus block, and partial adenomyomectomy for uterus perservation.

Laparoscopic Single-site “In-bag” Ovarian Dermoid Cystectomy in a 16-week- pregnant Patient

To demonstrate a novel "in-bag" ovarian cystectomy technique for a large adnexal mass in pregnancy. Stepwise demonstration with narrated video. An academic tertiary care hospital. The patient was a 26-year-old woman, gravida 1, para 0, at gestational age of 7 weeks and 3 days who presented to the emergency department with persistent left pelvic pain and was diagnosed with a 16 cm × 10 cm × 12 cm dermoid cyst. She re-presented at gestational age of 16 weeks and 3 days with worsening pelvic pain, and the decision was made to proceed with surgical intervention. Laparoscopic transumbilical single-site surgery for the surgical management of adnexal masses in pregnancy has been demonstrated to be feasible and safe [1-3]. However, single-site laparoscopic ovarian cystectomy can be very challenging in pregnancy, especially when the need for suturing arises. Exteriorizing the ovary and cyst after intraperitoneal drainage may allow for extracorporeal suturing that is faster and easier; however, it may increase the probability of spillage of cystic contents if it is not performed in a bag, which can then cause peritonitis in cases of dermoid cysts. A combination of in-bag and extracorporeal ovarian cystectomy is a novel alternative minimally invasive approach that is cosmetic, safe, and effective. Several helpful techniques in this novel combination technique include the following: • Creating an umbilical incision of at least 2 cm or one that is large enough for better manipulation of both the surgical bag and adnexal mass. • Tightening the bag appropriately around the infundibulopelvic ligament so that it is not too tight leading to compromised blood supply and tissue necrosis, yet not too loose resulting in leakage of cystic contents. • Ensuring that the infundibulopelvic ligament is stabilized within the surgical bag. • Inserting small-sized wound retractor into the bag for better exposure during cystectomy. • Having a double-suction irrigation setup for large adnexal masses, as demonstrated in this patient, to reduce the spillage of cystic contents. The procedure was successfully performed in approximately 110 minutes, and the fetal heart rate postprocedure was 128 bpm through bedside transabdominal ultrasound. Estimated blood loss was 5 mL, and the patient was discharged the same day with an uneventful 4-week postoperative follow-up. Laparoscopic single-site "in-bag" ovarian dermoid cystectomy is feasible, effective, and safe in pregnant patients with a large adnexal mass. This technique results in better stabilization of the ovarian cyst and reduction of cystic content spillage.

Anatomical basis of lymph node detection in gynecologic cancers: a review from a surgical perspective.

Pelvic and para-aortic lymphadenectomy are associated with increased risk of complications and are responsible for a significant proportion of morbidity and impaired quality of life following surgical management of pelvic malignancies. Sentinel lymph node (SLN) was developed as a trade-off between systematic and no lymphadenectomy to limit morbidity while conserving good oncological staging and outcomes. In this comprehensive review, we aimed to synthetize the anatomical basis of the SLN procedure in patients with pelvic malignancies from a surgical perspective. The reliability of the SLN procedure is based on the knowledge of the dissemination pathways for each type of tumors. The most recent understanding of the uterine lymphatic anatomy defined three consistent channels: an upper paracervical pathway (UPP) with draining medial external and/or obturator lymph nodes; a lower paracervical pathway (LPP) with draining internal iliac and/or presacral lymph nodes and the infundibulo-pelvic pathway (IPP) with a course along the fallopian tube and upper broad ligament via the infundibulo-pelvic ligament to its origin. In patients with endometrial cancer, most SLNs are located on the UPP pathway: obturator and external iliac whereas 80% of the SLNs in patients with cervical cancer are located in the external iliac, interiliac and obturator area. Surgical training is a key step toward improving detection rates and exhaustiveness of SLN research while reducing overall morbidity. This is all the more important that the indications for performing complete lymphadenectomy are becoming increasingly rare.

48. Chronic Adnexal Torsion Presenting as Intermittent Pelvic Pain

<h3>Background</h3> Adnexal torsion is typically treated as a surgical emergency to prevent ovarian necrosis. Many young women present with transient pelvic pain along with an adnexal cyst and are ruled out for torsion secondary to resolution of their pain. It is still possible, however, that when intermittent pain continues in the setting of an ovarian or para ovarian cyst, the adnexa is chronically torsed. This series includes four postmenarchal patients with likely chronic adnexal torsion who had viable ovaries at the time of surgery. <h3>Case</h3> Case 1: A 12-year-old presented with acute left lower quadrant pain and was diagnosed with a 6 cm left ovarian simple cyst. Her pain improved quickly with no intervention but continued to return intermittnetly over the next several months. She eventually underwent a scheduled laparoscopic cystectomy and was found to have a 6 cm paratubal cyst, torsed several times around the infundibulopelvic (IP) ligament with a viable ovary. See Figure 1. Case 2: A 16-year-old presented with 3 days of worsening abdominal pain that started while bowling. Imaging revealed a 9.6 cm simple ovarian cyst. Her pain resolved without intervention. One month later, after soccer practice, she -presented with another episode of acute pain and imaging revealed a 6.8 cm ovarian cyst. Pain resolved again, and she later underwent a scheduled laparoscopic cystectomy revealing torsion around the IP ligament. Pathology revealed a serous cystadenoma. Case 3: A 15-year-old presented with a 5-month history of mild right lower quadrant pain. During that period, she had 3 episodes of acute, severe pain lasting one day, before self-resolving. She presented on the third episode of severe pain, and computed tomography showed a 7.5cm cystic left ovarian mass with thickened walls. She was non-emergently referred for a persistent cyst and on laparoscopy she had an enlarged, torsed right ovary. Ovarian cystectomy was performed, and pathology revealed a mature teratoma. See Figure 2. Case 4: A 13-year-old presented with two years of inconsistent left lower quadrant pain. She was found to have an 8cm left adnexal cyst. She was seen in the ED twice and ruled out for ovarian torsion both times. After the pain woke her up in the middle of the night with accompanying nausea and emesis, she was seen in clinic and scheduled for an outpatient laparoscopic cystectomy. Torsion of the IP ligament was found due to a large paratubal cyst. <h3>Comments</h3> In a patient with an adnexal cyst and intermittent pelvic pain, chronic torsion should be considered and can be definitively diagnosed with laparoscopy. Although none of these patients lost an ovary, chronic torsion of the adnexa may impair fertility.

86. Unilateral Ovarian Agenesis: A Systematic Review of the Literature and Report of Two Cases

<h3>Background</h3> Ovarian agenesis (OA) is a rare and often incidental finding. Noncompeting embryological, vascular, and mechanical hypotheses comprise possible etiologies, though exact predisposing factors remain unknown. Here, we report two cases of unilateral OA (UOA) and results from the first systematic review. <h3>Case</h3> A 15-year-old girl with history of nephrolithiasis and pelvic pain presented for diagnostic laparoscopy due to suspected endometriosis. Three prior ultrasounds demonstrated normal-appearing ovaries with right corpus luteum cyst. Surgery revealed normal round ligaments, normal postpubertal uterus, right fallopian tube with paratubal cyst and enlarged right ovary. The left ovary, left distal fallopian tube, and left uteroovarian ligament were absent. Multiple peritoneal biopsies were positive for endometriosis. Right paratubal cyst was removed. Postoperative MRI did not identify a heterotopic left ovary. The second patient is a 30-year-old G3P1011 with a history of genital chlamydia, prior laparotomy to retrieve a foreign body, and right tubal ectopic pregnancy treated medically two years prior. She presented with severe abdominal pain and positive pregnancy test. An ultrasound demonstrated normal bilateral ovaries and a cystic right adnexal structure concerning for ectopic pregnancy. Patient elected for unilateral salpingectomy. Operative findings were significant for bleeding gestational sac extruding from the broad ligament. The left ovary and round ligaments were normal, but the right ovary, distal fallopian tube and infundibulopelvic ligament were absent. In both cases a second attending physician was consulted intraoperatively to confirm the absent ovary. <h3>Comments</h3> We conducted a systematic literature review on OA on 6/29/20 using Cochrane Library, Medline, Embase, Google Scholar, Scopus, and Web of Science databases, resulting in 66 relevant articles with 85 cases of OA. Descriptive statistics and univariate analysis were performed in SAS and Excel. The average age of diagnosis was 23.8 years. Ultrasound was the most common imaging technique (49%), and the majority of cases had laparoscopic surgery (65%). Of the cases that mentioned pre-operative imaging results, 13/51 did not mention ovarian anomalies. Abdominal/pelvic pain (27%), and infertility/subfertility (21%) were the most common presenting symptoms. UOA was the most common type of OA (96%) with both sides equally affected. Some ipsilateral fallopian tube absence was present in 81% cases. Approximately 26% of cases had concomitant uterine abnormalities, while 20% had renal abnormalities. These findings are important as they may guide workup and follow-up for females if ovarian agenesis or heterotopic ovarian location is diagnosed.

Performance Assessment for Total Laparoscopic Hysterectomy in the Operating Room: Validity Evidence of a Procedure-specific Rating Scale

The technical conduct of total laparoscopic hysterectomy (LH) is critical to surgical outcomes. This study explored the validity evidence of an objective scale specific to the assessment of technical skills (H-OSATS) for 7 tasks of an LH with salpingo-oophorectomy procedure performed in the operating room. Observational cohort study. Two academic hospitals in Marseille and Montpellier, France. Three groups of operators (novice, intermediate, and experienced surgeons) were video recorded during their live performances of LH on a simple case. For each group, a dozen unedited videos were obtained for the following tasks: division of the round ligament, division of the infundibulopelvic ligament, creation of the bladder flap, opening of the posterior peritoneum, division of the uterine vessels, colpotomy, and closure of the vault. Two qualified raters blindly assessed each video using the H-OSATS rating scale. Inter-rater reliability and test-retest reliability were calculated as measures of internal structure. In a separate round of evaluations, the raters provided a global competent/noncompetent decision for each performance. As a measure of consequential validity, a pass/fail score was set for each task using the contrasting group method. Three tasks (creation of the bladder flap, colpotomy, and closure of the vault) displayed sound validity evidence: a meaningful total score difference among the 3 groups of experience as well as between the intermediate and experienced surgeons, reliability outcomes of >0.7, and a pass/fail score with a theoretical false-positive rate of <10%. The validity evidence of the H-OSATS rating scale differed for separate evaluations of the 7 tasks. Three tasks (i.e., creation of the bladder flap, colpotomy, and closure of the vault) revealed sound validity evidence, including at the level of the attending surgeon, whereas other tasks were more consistent with low-stakes formative evaluation standards.

Lipoma or Liposarcoma? Robotic Resection of a Retroperitoneal Mass

Study Objective Demonstrate robotic-assisted resection of a large retroperitoneal lipomatous mass. Design Surgical video Setting Tertiary-care operating room using DaVinci Xi system with four 8 mm trocars, and a 12 mm assistant port. Patients or Participants A 48-year-old female with a multi-fibroid uterus and seven centimeter lipomatous mass in her right hemipelvis Interventions The patient underwent robotic-assisted excision of the right retroperitoneal mass, total hysterectomy, right salpingo-oophorectomy, left salpingectomy, and cystoscopy. Measurements and Main Results Although superficial lipomas are common and most likely benign, retroperitoneal lipomatous tumors are rare. Tumors greater than ten centimeters have a higher malignant potential and are typically found in the deep retroperitoneal space. Robotic-assisted laparoscopy revealed a large lipomatous mass in the right retroperitoneal space consistent with radiographic imaging. The surgeon divided the round ligament and extended the incision parallel to the infundibulopelvic ligament to enter the right retroperitoneum. He then carefully dissected and resected the lipomatous tumor from the pararectal space and performed the remainder of the procedures without complication. Benign lipomas and low grade liposarcoma are difficult to differentiate. The latter has a high rate of local recurrence if incompletely resected, therefore complete resection should be the surgical goal. Pathology revealed partially encapsulated mature adipose tissue consistent with lipoma with negative fluorescent in situ hybridization (FISH) analysis using a dual color MDM2/CEN12 probe set confirming the likely benign behavior of the mass. Conclusion Retroperitoneal lipomatous tumors are rare. Distinguishing between lipomas and liposarcomas is a diagnostic challenge both radiographically and intraoperatively. Confirmatory histopathology, and often molecular pathology, is necessary for the final diagnosis. Knowledge of the pathology of retroperitoneal lipomatous masses and the related surgical anatomy and goals are imperative to optimal management.

Surgical Management of Cesarean Scar Ectopic with Fertility Preservation

Study Objective To highlight retroperitoneal anatomy and show surgical techniques to minimize blood loss during cesarean scar ectopic resection. Design A step-by-step explanation of the surgery using video (instructive video). Setting University Hospital. Patient was in dorsal lithotomy position. Patients or Participants A 33 year-old woman G4P1 with a cesarean scar ectopic pregnancy at 10weeks gestation that failed methotrexate injection. Interventions This video highlights entry into the retroperitoneal space and dissection technique for identifying the uterine arteries at their origins. Bulldog clamps are placed on all vascular pedicles that supply the uterus (bilateral uterine arteries and bilateral infundibulopelvic ligaments) to aid with hemostasis. Additionally, Vasopressin is used to further reduce blood loss. Applying these techniques allowed for successful resection of the ectopic pregnancy with only 50 cc of estimated blood loss. Control of bleeding resulted in thorough resection of the ectopic pregnancy while conserving as much surrounding myometrium as possible. The uterine defect is repaired in three layers. Measurements and Main Results Operative time was 199 minutes, with an estimated blood loss of 50ml. Surgical resection of the ectopic pregnancy allowed the patient to preserve her fertility. Subsequently, the patient had an uncomplicated pregnancy which resulted in a live birth. Conclusion Knowledge of the avascular spaces and dissection techniques that allow for access to the origin of the uterine artery can be very useful in complex cases. Bulldog clamps can be used for transient occlusion of blood supply to the uterus resulting in resection of a cesarean scar ectopic with minimal blood loss. This is an option for patients who desire future fertility.

A Stepwise Strategy to Minimally Invasive Salpingo-Oophorectomy in the Post-Hysterectomy Patient

Study Objective Demonstrate a five-step strategy for effective, safe completion of a minimally invasive salpingo-oophorectomy in patients with prior hysterectomy. Design Step-by-step demonstration and explanation of technique using a surgical video Setting Tertiary-care operating room using standard equipment for laparoscopic surgery and three 5 mm trocars, a 30 degree laparoscope, and bipolar sealing device. Patients or Participants A 56 year-old female patient presents with pelvic pain and persistent adenxal mass and requesting definitive surgical management. Interventions Five steps were utilized to perform a laparoscopic bilateral sapling-oophorectomy in a patient with prior open total abdominal hysterectomy. The stepwise procedure was highlighted on one side without significant adhesions and then repeated on the opposite side with a more challenging adnexal mass Measurements and Main Results Post-hysterectomy sapling-oophorectomy can pose significant surgical complexity. With increasing data on the benefits of ovarian conservation during hysterectomy especially in pre-menopausal women such as cardiovascular health, bone and sexual health, more patients elect to preserve their ovaries. Up to 9% of these women who preserved their ovaries at the time of hysterectomy require future adnexal surgery. Some of the common indications for post hysterectomy sapling-oophorectomy are persistent adnexal masses, chronic pelvic pain, suspicious adnexal masses concerning for malignancy, and risk-reducing surgery. This video presents a five step strategy to facilitate this procedure to include pelvic and abdominal exploration, restoring normal anatomy, identification of the ureter, isolation, coagulation, and transection of the infundibulopelvic ligament and hemostasis and re-evaluation of ureter. Conclusion In this video we described a five step strategy to ensure safe, efficient and reproducible salpingo-oophorectomy in the post hysterectomy patient using a minimally invasive approach. Although this surgery can be challenging to perform in post hysterectomy given anatomical variance and adhesive disease, by following these five simple principles we aim to simplify this potentially difficult procedure.

Robotic Radical Hysterectomy for Cervical Adenocarcinoma after Preoperative Brachytherapy in 10 Steps

Minimally invasive surgery decreases postoperative morbidity after radical hysterectomy (RH) for early-stage cervical cancer. However, a randomized trial and large retrospective data question its safety after observing lower rates of survival than open surgery [1,2]. The causes of this higher recurrence rate are not definitely established but may result from cancer exposure to the peritoneum during vaginal section and cancerous cells' spillage enhanced by pneumoperitoneum or a uterine manipulator. The aim of this surgical video was to present a standardized step-by-step approach for robotic RH according to the recent recommendations from the ARCAGY -Group of National Investigators for the Study of Ovarian and Breast Cancers surgeon's group [3]. Step-by-step video demonstration of the technique. Tertiary center specialized in gynecologic oncology and minimally invasive surgery. A 48-year-old woman was diagnosed with a stage IB2 endocervical adenocarcinoma (International Federation of Gynecology and Obstetrics 2018) with a tumor size of 27 mm. Surgery was planned after preoperative pulsed dose rate uterovaginal brachytherapy. Surgery was performed following 10 reproducible steps: • Pelvic sentinel node identification according to the SENTICOL-III trial • Right infundibulopelvic and round ligaments transection • Right uterine vessels transection • Parametrectomy • Right uterosacral ligament transection • Bladder mobilization • Identical left dissection • Rectovaginal space development • Colpectomy by vaginal route after complete pneumoperitoneum exsufflation • Robotic vaginal cuff closure and pelvic inspection Thorough robotically assisted vaginal cuff closure was carried out as a comparative study suggesting that abdominal closure may decrease vaginal complications and dehiscence [3]. No international recommendations for the RH approach have yet been endorsed. Patients must be clearly informed about the benefit-risk ratio of the surgical route. If a minimally invasive RH is still decided, the patient should be referred to experienced centers, and precautionary measures must be implemented [4]. Colpotomy by vaginal route without pneumoperitoneum is recommended. Uterine manipulators have to be strictly avoided. Preoperative brachytherapy has been reported in experienced centers in France with favorable histologic response with high rates of pathologic complete response (near 70%) and seems particularly worthwhile for tumor sizes ranging from 2 to 4 cm or presenting with lymphovascular invasion [5].

Tissue Tropisms and Transstadial Transmission of a Rickettsia Endosymbiont in the Highland Midge, Culicoides impunctatus (Diptera: Ceratopogonidae).

Rickettsia is a genus of intracellular bacteria which can manipulate host reproduction and alter sensitivity to natural enemy attack in a diverse range of arthropods. The maintenance of Rickettsia endosymbionts in insect populations can be achieved through both vertical and horizontal transmission routes. For example, the presence of the symbiont in the follicle cells and salivary glands of Bemisia whiteflies allows Belli group Rickettsia transmission via the germ line and plants, respectively. However, the transmission routes of other Rickettsia bacteria, such as those in the Torix group of the genus, remain underexplored. Through fluorescence in situ hybridization (FISH) and transmission electron microscopy (TEM) screening, this study describes the pattern of Torix Rickettsia tissue tropisms in the highland midge, Culicoides impunctatus (Diptera: Ceratopogonidae). Of note is the high intensity of infection of the ovarian suspensory ligament, suggestive of a novel germ line targeting strategy. Additionally, localization of the symbiont in tissues of several developmental stages suggests transstadial transmission is a major route for ensuring maintenance of Rickettsia within C. impunctatus populations. Aside from providing insights into transmission strategies, the presence of Rickettsia bacteria in the fat body of larvae indicates potential host fitness and vector capacity impacts to be investigated in the future.IMPORTANCE Microbial symbionts of disease vectors have garnered recent attention due to their ability to alter vectorial capacity. Their consideration as a means of arbovirus control depends on symbiont vertical transmission, which leads to spread of the bacteria through a population. Previous work has identified a Rickettsia symbiont present in several species of biting midges (Culicoides spp.), which transmit bluetongue and Schmallenberg arboviruses. However, symbiont transmission strategies and host effects remain underexplored. In this study, we describe the presence of Rickettsia in the ovarian suspensory ligament of Culicoides impunctatus Infection of this organ suggests the connective tissue surrounding developing eggs is important for ensuring vertical transmission of the symbiont in midges and possibly other insects. Additionally, our results indicate Rickettsia localization in the fat body of Culicoides impunctatus As the arboviruses spread by midges often replicate in the fat body, this location implies possible symbiont-virus interactions to be further investigated.

Back to the Future: Schauta-Amreich Radical Vaginal Hysterectomy Assisted by Laparoscopy with Sentinel Lymph Node Biopsy for Early-stage Cervical Cancer

The popularity of laparoscopy to perform radical hysterectomy has massively increased over the last 2 decades. However, oncologic outcomes (overall and disease-free survival) have been found to be better in patients managed by laparotomy compared with laparoscopy, challenging this surgical route. Compared with laparotomy, vaginal access reduces postoperative morbidity, while avoiding potential cancer spread associated with laparoscopy. We describe the procedure of Schauta-Amreich radical vaginal hysterectomy with bilateral salpingo-oophorectomy, assisted laparoscopically, and associated with pelvic sentinel lymph node procedure in a 56-year-old woman with an International Federation of Gynecology and Obstetrics stage IB2 cervical epidermoid carcinoma. A sentinel lymph node procedure was first performed by laparoscopy. Radical hysterectomy was prepared through laparoscopy by dividing the infundibulopelvic, round, and broad ligaments. The procedure was continued by the vaginal route using the Schuchardt incision. We describe each step of the procedure and provide a video. Histology showed a margin-free resection in both the vagina and parametrium with negative sentinel lymph nodes. This description of the Schauta-Amreich radical vaginal hysterectomy technique with a video file could support the teaching of a procedure that may gain in popularity.

Sentinel lymph node technique in early-stage ovarian cancer (SENTOV): a phase II clinical trial

ObjectiveEarly-stage ovarian cancer might represent an ideal disease scenario for sentinel lymph node application. Nevertheless, the published experience seems to be limited. Our objective was to assess the feasibility and...

47: Pelvic congestion syndrome: A laparoscopic approach

The goal of this video is to demonstrate a laparoscopic approach for the management of chronic pelvic pain secondary to pelvic congestion syndrome presented by large tortuous ovarian vessels. Pelvic congestion syndrome is found in 30% of patients complaining of chronic pelvic pain and in who work up reveals no pathologies. Although the etiology of pelvic congestion syndrome is still not clear, multiple treatment modalities are available for the symptomatic patient. Our patient is a 69-year-old patient with one-year history of left lower quadrant pelvic pain. CT abdomen/ pelvis showed congested pelvic vessels on the left side and a small persistent ovarian cyst. Decision was made to perform laparoscopic ligation of the left ovarian veins with concurrent bilateral salpingo-oophorectomy. Laparoscopic high ligation of the ovarian vessels is described. After adequate exposure of the infundibulopelvic ligament and identification of the surrounding structures, the ovarian vein was isolated, sealed, and transected above the pelvic brim. Careful systematic dissection of the pelvic sidewall ensures uncomplicated resection of the congested ovarian venous plexus. Our video demonstrates a minimally invasive approach to pelvic congestion syndrome. The laparoscopic high ligation technique is often chosen when a concurrent gynecologic surgery is required.

Sentinel Lymph Node Technique in Apparent Early Ovarian Cancer: Laparoscopic Technique

To demonstrate the feasibility of laparoscopic sentinel lymph node technique in presumed early-stage ovarian cancer. Video illustrating the laparoscopic performance of the sentinel lymph node technique in ovarian cancer. The Oncologic Gynecology Department at the University Hospital La Fe. Candidates for the technique presented an apparent early stage ovarian cancer. The technique was performed in the context of a clinical trial called SENTOV (NCT03452982). To date, lymphadenectomy is recommended after the diagnosis of apparent early-stage ovarian cancer as part of the surgical staging. Minimally invasive surgery can be considered for the purpose of restaging [1]. Up to 14% of the patients are upstaged because of positive lymph nodes after pelvic and para-aortic lymphadenectomy [2]. Regarding low-grade tumors, a lower rate of lymph node involvement has been reported [3]. Sentinel lymph node technique has been reported to be feasible in a recent pilot study [4]. Two clinical trials (Sentinel Lymph Node in Early Ovarian Cancer and Sentine Lymph Node in Early Ovarian Cancer) are currently ongoing to clarify the use of sentinel lymph node technique in early ovarian cancer. The injection points were at the infundibulopelvic and ovarian ligament stumps. Two hundred microliters of saline solution containing 37 MBq of technetium-99m nanocolloid followed by 0.5 mL of indocyanine green (ICG) was injected subperitoneally. We used a 27 G needle at each injection point. Immediately after injection and also at 15 and 30 minutes after injection, the operative field was checked guided by the acoustic signal of the gamma probe and the near-infrared camera. We performed a minimum dissection looking for the sentinel lymph node or nodes in the pelvic and para-aortic region. Any lymph node with a remarkable radioactivity count as high as 10 times the background and/or dyed with ICG was considered a sentinel lymph node and was harvested separately. A systematic surgical staging was performed after the sentinel lymph node procedure was completed. Because of its small size, the ICG molecule is not caught in the lymph node valve system and keeps migrating when performing lymphography. An exhaustive direct view of the dye path is required to avoid misleading detection of the real sentinel lymph node. This theoretical problem is resolved by the use of the 99mTC-nanocolloid. This tracer gets trapped into the lymph node valve system because of its molecular size and does not keep migrating as does ICG. As such, a combination of both methods is proposed. Laparoscopic performance of sentinel lymph node technique in ovarian cancer seems to achievable. Between 2017 and 2019, this procedure was performed in 30 patients (13 laparoscopic), in the context of our pilot experience [4] and the Sentinel Lymph Node in Early Ovarian Cancer clinical trial (NCT03452982).

Laparoscopic Vessel Clipping at Myomectomy - Uterine, Ovarian and Sampsons Artery

Video Objective To demonstrate the occlusion of three areas: the uterine artery, the round ligament and the infundibulopelvic ligament during myomectomy as a blood-sparing technique. Setting Two young patients presented with severe dysmenorrhea, AUB and subfertility. They underwent laparoscopic myomectomy, for whom the uterine artery, infundibulo-pelvic ligament and round ligament were occluded prior to the first uterine incision. Interventions After a survey, it was decided to use the lateral approach to uterine artery occlusion. The landmark was identified with traction on the medial umbilical ligament. The peritoneum was incised, and the ureter and uterine artery were exposed with careful blunt dissection. Temporary surgical clips were placed on bilateral uterine arteries. Subsequently, bilateral IP and round ligaments were similarly occluded. With devascularisation achieved, a linear incision was made over the myoma using a unipolar hook and carried through the serosa right to the myoma. Myometrium was sutured using the baseball technique. Myopia was removed by morcellation. Surgical clips were successfully removed from the uterine arteries and both IP and round ligaments. Peritoneal lavage was carried out, and Intercede barrier (Ethicon, Johnson & Johnson, Neuchatel, Switzerland) was placed. Blood loss was estimated by subtracting the instilled rinsing volume from the volume of fluid collected in the suction drain at the end of procedure. There were no post-operative complications. Conclusion Occlusion both the infundibulo-pelvic and round ligaments prior to laparoscopic myomectomy is a simple, reversible procedure, and does not significantly increase operative times. When used in conjunction with transient uterine artery occlusion, it may serve to further limit blood loss during surgery and hasten recovery. Larger studies are needed to define surgical outcomes, and recognize short and long term complications, if any.

Robotic Interval Cytoreductive Surgery for Stage IV Epithelial Ovarian Cancer

Video Objective To demonstrate a surgical video where-in interval cytoreduction to no gross residual disease was performed robotically in a patient with Stage IV epithelial ovarian cancer. Setting Tertiary referral center. Interventions 43-year-old Caucasian female was diagnosed with stage IV-A high-grade serous ovarian adenocarcinoma after presenting with shortness of breath. Computed tomography showed bilateral pleural effusions, adnexal masses, retroperitoneal lymphadenopathy, omental caking. Thoracentesis confirmed adenocarcinoma of Mullerian primary. She received three cycles of neoadjuvant carboplatinum and paclitaxel with excellent clinical response and was taken to the operating room for robotic-assisted interval cytoreductive surgery. Trocars were placed on a straight horizontal line along the umbilical fold. The rectosigmoid colon was mobilized medially. Pararectal and paravesical spaces were developed. Ureterolysis was completed bilaterally. The uterine vessels were sealed at the hypogastric bifurcation. Infundibulopelvic (IP) ligament was sealed and cut. Bilateral pelvic sidewall peritoneum was resected. Bladder flap was developed. Colpotomy was performed and the hysterectomy specimen was removed. Procedure was then continued with debulking of enlarged lymph nodes, from bilateral pelvic sidewalls and peri-aortic area. The robotic arms were targeted to the upper abdomen for total omentectomy. Access to the lesser sac was gained by resecting short gastic vessels, along the greater curvature of the stomach. The incision was then extended to the splenic flexure and hepatic flexure. Total omentectomy was completed. Remaining subcentimeter tumoral nodules along the peritoneal surfaces were ablated with argon beam coagulator. The patient had an uneventful postoperative course and was discharged home on postoperative day 1. Pathology confirmed high grade serous ovarian carcinoma. She was resumed on chemotherapy two weeks after her cytoreductive surgery. Conclusion Laparoscopic/robotic interval cytoreductive surgery should be considered in advanced ovarian cancer patients, who have an excellent clinical response to NACT. Studies to accurately identify the appropriate patient population for laparoscopic/robotic debulking procedures are urgently encouraged and needed.

The Approach to Uterine Artery Ligation

Video Objective To demonstrate approaches to uterine artery ligation Setting Gynaecology department at a University Hospital. Interventions We demonstrate various methods of uterine artery ligation during complex gynaecological surgery. Conclusion Bleeding is a significant risk during procedures such as hysterectomies and myomectomies. During hysterectomy, the uterine artery is commonly ligated at the level of internal cervical os, though access may be limited in complex pathology such as fibroids, large uteri and adnexal masses. Furthermore, complications such as haemorrhage, ureteric and bladder injury may occur during attempts to secure difficult vascular pedicles. Such challenges can be overcome, by ligating the uterine artery at its vascular origin. During myomectomy, temporary occlusion using clips may help to reduce blood loss in selected cases. [1] We demonstrate simple and reproducible techniques of ligating the uterine artery at its origin. This valuable skill can be learnt by both novice as well as expert surgeons for utilisation during complex hysterectomy and myomectomy. We begin by performing ureterolysis by one of two approaches. [2] The posterior approach begins by opening the peritoneum overlying the ureter following visualisation at the pelvic side wall. Alternatively, a lateral approach is useful when views of the pelvic side wall are limited and includes division of the round ligament and peritoneum towards the base of infundibulopelvic ligament. Once ureterolysis is complete the obliterated umbilical artery is identified and followed into the pelvic side wall. Gentle traction can be used to confirm the ligament. Using open and spread, and traction and counter-traction techniques, the space lateral to the ureter and in front of the obliterated umbilical artery is gently dissected revealing the uterine artery. Using a Thunderbeat, we coagulated the vessels whilst maintaining distance from the ureter to avoid damage. One can use any preferred method for ligation including vessel sealing devices, sutures and temporary or permanent clips.

2953 Temporary Uterine Artery Ligation During Laparoscopic Myomectomy - Different Surgical Approaches

Video Objective Laparoscopic Uterine Artery Ligation may be performed during myomectomy in order to reduce the amount of blood loss during surgery. Setting Step-by-step video demonstration of three different techniques. Interventions Main steps of uterine artery ligation are described in detail as well as different laparoscopic variants to this procedure. Anterior Approach The impression of the uterine vessels can usually be seen anterior and laterally to the uterine cervix. After the identification of the path of the uterine arteries, the peritoneum of the anterior cul-de-sac is opened over the vessels and the uterine artery is carefully dissected next to the lateral border of the uterine cervix. This dissection must be extremely cautious because the uterine veins are very close to the artery. After the circumferential dissection of the artery, the temporary occlusion is conducted using 2-0 polyester suture. Posterior approach, lateral to the infundibulopelvic ligament For the ligation of the uterine artery posteriorly to the uterus and laterally to the pelvic infundibulum, the opening of the peritoneum of the broad ligament should start immediately below the round ligament, parallel to the external iliac vessels towards the base of the pelvic infundibulum. The avascular space is dissected by blunt dissection identifying the following landmarks: • Lateral: external iliac vessels; • Medial: pelvic infundibulum and the ureter attached to the peritoneum. The external iliac artery is dissected cranially in order to find the bifurcation of the common iliac artery and the internal iliac artery. The first medial branch of the anterior division of the internal iliac is normally the uterine artery. After dissection of the uterine artery it may be ligated according to the same technique described above. Conclusion Laparoscopic Uterine Artery legation may be performed during laparoscopic myomectomy to reduce intraoperative blood loss. According to surgical scenario, the surgeon may choose among one of the above-mentioned techniques to perform it.