Laparoscopic Hemihysterectomy Research Articles

Reconsidering the best minimally invasive approach for patients with herlyn-werner-wunderlich syndrome: Should we push the frontiers for a better outcome?

Obstructed hemivagina and ipsilateral renal agenesis (OHVIRA) syndrome is a rare congenital defect of the Mullerian ducts characterized by uterine didelphys, unilateral obstructed hemivagina, and ipsilateral renal agenesis. It frequently presents during puberty, with complications such as pelvic pain, pelvic inflammatory disease and infertility. Surgical management is the mainstay treatment. A vaginal access for septum resection is usually used. However, it can be in difficult in several situations such as a very proximal septum with a small bulge, or in the case of virgin patients with social considerations regarding the hymenal ring integrity. Thus, a laparoscopic approach may be a beneficial alternative. In particular, laparoscopic hemi hysterectomy has recently gained remarkable interest due to its added benefit of treating the cause rather than treating only the symptoms. It removes the source of the bleeding, thus stopping the flow. However, it transforms a bicornuate uterus into a unicornuate uterus, leading to some obstetrical concerns. Should we push the frontiers further and consider laparoscopic hemi hysterectomy for better outcomes as the mainstay management of patients with OHVIRA syndrome?

8849 Niamh Joyce MD, OBSTETRICS AND GYNECOLOGY, MRCOG, Fellow in Reproductive Medicine

<h3>Study Objective</h3> Video demonstration of fertility sparing laparoscopic treatment for a symptomatic Müllerian Tract abnormality <h3>Design</h3> Single Case Report. <h3>Setting</h3> Tertiary Academic Hospital. 3 port laparoscopy, with patient in Trendelenburg Lithotomy position <h3>Patients or Participants</h3> A 16-year-old nulliparous patient presented with intractable dysmenorrhea since menarche aged 15, associated with syncope. There was no response to analgesia or hormonal contraception and the impact on quality-of-life necessitated surgical review. Initial assessment by pelvic ultrasound identified normal ovaries and uterus but a solid appearing right adnexal lesion. Further imaging by MRI showed evidence of a double uterus with only the left sided uterus communicating with the vagina in keeping with an ASRM class II(b) abnormality. Differential diagnosis included Mullerian duct abnormality and accessory and cavitated mass. A uterine didelphys with only a left ostia was seen on hysteroscopy. Laparoscopy showed a uterine didelphys with a non-communicating, engorged right uterus and right fallopian tube. Her case was discussed at a multidisciplinary meeting where it was decided the most suitable treatment was to perform a laparoscopic hemi-hysterectomy with right salpingectomy to remove the right sided non communicating cavity and tube. This procedure was recorded with the patient's consent and will be shown as part of the video presentation. <h3>Interventions</h3> Laparoscopic hemi-hysterectomy for resection of non-communicating uterine horn. EBL minimal. Operative time 37 Mins, hospital stay 1 night. <h3>Measurements and Main Results</h3> A successful laparoscopic intervention was performed, and the patient was discharged day 1 post op. Review at clinic revealed completed resolution of symptoms, normal menses. Future fertility was a primary concern and was successfully conserved. Histology demonstrated a functioning endometrial cavity with focal adenomyosis. <h3>Conclusion</h3> Class II Müllerian abnormalities are uncommon, affecting around 0.06% of females. Symptoms can include pain or menstrual dysfunction as well as fertility/obstetric complications. When necessary, a minimally invasive approach can be utilized to treat these conditions.

Laparoscopic Hemi-Hysterectomy for Excision of a Functional Rudimentary Uterine Horn Keys to Success

<h3>Study Objective</h3> To present a case of unicornuate uterus with a non-communicating rudimentary horn complicated with hematometra and describe important steps for successful laparoscopic surgical management. <h3>Design</h3> Description of the relevant anatomy and surgical technique with the use of video. <h3>Setting</h3> academic tertiary hospital. <h3>Patients or Participants</h3> A 19-yo female patient with history of dysmenorrhea. Exam revealed normal vagina and cervix deviated to the left, with an adnexal mass on the right. Ultrasound and MRI further delineated a right rudimentary horn with active endometrium, possible hematometra. A renal ultrasound ruled out renal anomaly. Hysteroscopy revealed a normal appearing unicornuate uterus with a tubal ostium. A Rummi manipulatorwas placed. Then, laparoscopic pelvic survey confirmed a left unicornuate uterus with an enlarged right rudimentary horn, no endometriosis was found. Next, ureterolysis was performed, followed by right salpingectomy with ovarian preservation. Vasopressin was injected to the base of the horn (20 units in 100 ml of normal saline). The right utero-ovarian and round ligament were taken down with ligasure device and bladder flap was developed. Next, monopolar L hook was used to resect the rudimentary horn. This was followed by uterine closure in two layers with 2-0 V lock barbed suture. Rudimentary horn was exteriorized in a 10 cm endobag. <h3>Interventions</h3> surgical procedure: diagnostic hysteroscopy, laparoscopic hemihysterectomy for excision of a functional non communicating rudimentary horn. <h3>Measurements and Main Results</h3> Patient was discharged on the same day of the procedure and had an uncomplicated postsurgical course. <h3>Conclusion</h3> Understanding the nature of the uterine anomaly before surgery is of paramount importance for the management of obstructive anomalies of the female genital tract. Laparoscopy is a safe and effective treatment modality to provide pain relief, avoid sequelae, and allow for the preservation of reproductive function.

Novel ureteral navigation with a fluorescent catheter during hemi-hysterectomy in cloacal exstrophy

We used a near-infrared ray catheter (NIRC) in a child with cloacal exstrophy presenting with hematometra and assessed whether the NIRC could help with complicated adhesiolysis during hemi-hysterectomy in children. A 6-French pig tail-type NIRC was inserted into the left ureter with guidance from a cystoscope. Laparoscopic hemi-hysterectomy with fluorescence observation was performed using the VISERA ELITE 2 system. NIRC insertion into the left ureter was not as difficult as expected despite the eccentric position of the left ureter orifice. When we found an enlarged left uterus and fallopian tube, adhesion was extremely severe around them due to chronic inflammation caused by hematometra. When near-infrared rays were applied, a fluorescent ureteral catheter that emitted bright green excitation light was observed on the dorsal side of the enlarged left uterus and fallopian tube. Under ureteral navigation with an NIRC, dissection of the adhesions was performed safely and smoothly. Hemi-hysterectomy and adnexectomy were performed successfully. The patient was doing well 2 years postoperatively without any complications. An NIRC can provide useful real-time visualization of the ureter course and reduce the risk of ureteral damage in children with advanced adhesions.

A case of didelphys uterus: tackling the double trouble adenomyosis and infertility

To present a case of didelphys uterus with severe pelvic pain and primary infertility with focal adenomyosis of outer myometrium (FOAM) of the left hemiuterus and tips and tricks for hemihysterectomy as a fertility preserving surgery. Descriptive step-by-step video demonstration of a case of didelphys uterus with adenomyosis of the hemiuterus. Local institutional review board approval for publication was obtained. Endometriosis Centre, Apollo Hospitals, Hyderabad, India. Women with uterus didelphys with FOAM of the left hemiuterus with severe pelvic pain and infertility. A 30-year-old woman presented with chronic pelvic pain and severe progressive dysmenorrhea with primary infertility for 3 years. She was diagnosed with uterus didelphys and longitudinal vaginal septum 3 years back and underwent hysteroscopy for septal resection and diagnostic laparoscopy for pain in an outside setting; however, no laparoscopic intervention was performed. The patient was diagnosed with FOAM of the left hemiuterus involving 75% of the hemiuterus. After detailed discussion and counseling regarding different options, laparoscopic hemihysterectomy was performed as pelvic pain relief was a major expected outcome along with fertility preservation. Pain relief with improved quality of life and fertility preservation. The postoperative period was uneventful. The patient was discharged on the second postoperative day with no complaints. Her chronic pelvic pain and dysmenorrhea resolved. She was not prescribed any medication after the surgery. During the routine follow-up, she had a regular menstrual cycle with a visual analogue score of 0/10. The safe removal of a hemiuterus in case of a didelphys uterus with pathology of hemiuterus through a minimally invasive technique is possible, which cures the pain caused by adenomyosis and enables quick recovery while preserving future fertility.

Inappropriate surgery in a patient with misdiagnosed Robert\u2019s uterus

BackgroundRobert’s uterus is a rare Mullerian anomaly, which can be described as an asymmetric, septate uterus with a non-communicating hemicavity. Herein, we present the case of a misdiagnosed Robert’s uterus, resulting in an invasive and disadvantageous surgery.Case presentation A 16-year-old woman was referred to our department because of dysmenorrhea and suspicion of uterine malformation. We misdiagnosed Robert’s uterus as a unicornuate uterus with a non-communicating rudimentary horn and hematometra, and performed laparoscopic hemi-hysterectomy. Although the patient’s symptoms were relieved, our surgical procedure left the lateral uterine wall weak, making the patient’s uterus susceptible to uterine rupture in any future pregnancy.ConclusionsAlthough the early diagnosis of Robert’s uterus is challenging, it is important in order to determine appropriate surgical interventions and management for maintaining the quality of life and ensuring safety in future pregnancies.

A case of obstructed hemivagina and ipsilateral renal anomaly syndrome complicated with pyometra: tips and tricks for laparoscopic hemihysterectomy

A case of obstructed hemivagina and ipsilateral renal anomaly syndrome complicated with pyometra: tips and tricks for laparoscopic hemihysterectomy

Laparoscopic Hemi-Hysterectomy-Retrospective Study of Case Series of over 9 Years

Background: Word hemi-hysterectomy and removal of rudimentary functional horn may be used interchangeably in published data. The same term may be used when a non-obstructive hemi-uterus is removed when there is an associated pathology. The article tries to standardise classification of Mullerian dysgenesis where this procedure is required according to ESHRE ESGE classification, preoperative diagnosis and discuss the operative details. Objective: The objective was to study the demographic profile, symptoms, association of endometriosis, variation in the anatomy, accuracy of preoperative diagnosis, to classify according to ESHRE ESGE classification and to standardize the laparoscopic surgical steps of hemi-hysterectomy. Study Design: This is a retrospective case series of cases of Mullerian dysgenesis with obstructive hemi-uterus or non-obstructive hemi-uterus with pathology treated by laparoscopic hemi-hysterectomy. (Canadian task force classification III). Methods: Data from hospital electronic records of all cases tagged with word laparoscopic hemi-hysterectomy were collected for 9 years from Jan 2009 to Dec 2018. Results: Total 19 patients of hemi-hysterectomy were analysed. Pre-operative diagnosis was made in 100% of patients. 100% patients with obstructive horn had dysmenorrhoea. ESHRE ESGE class U4aC3V0 was more frequently seen followed by U5aC4V4 and U3bC3V2 as obstructive and U4bC3V0, as non-obstructive. Associated endometriosis along with other pathology was seen in 74% of the patients. 3 patients with HWWS had ipsilateral renal agenesis. Laparoscopic hemi-hysterectomy was offered to all such patients. The operative steps & variants were studied. Post-operative outcome was uneventful in all. Conclusion: An experienced surgeon should deal with these problems of Mullerian dysgenesis discussed in this study. The other variants diagnosed also must be treated by an experienced surgeon only. Laparoscopic hemi-hysterectomy is almost the most standard surgical method to treat pelvic pain in cases with rudimentary non-communicating horns or in cases of non-obstructive horns with other associated pathologies. Post-operative recovery is uneventful, and all patients reported pain free periods as well as they are free of chronic pain which they had before surgery.

Robotic Assisted Laparoscopic Hemi-Hysterectomy Bilateral Sentinel Node Biopsy in a Women with Lynch Syndrome, Endometrial Cancer, Double Uterus, Cervix and Vagina

Robotic Assisted Laparoscopic Hemi-Hysterectomy Bilateral Sentinel Node Biopsy in a Women with Lynch Syndrome, Endometrial Cancer, Double Uterus, Cervix and Vagina

First Case of Mole in the Horn

A 31-year-old (G3P1L0A1 [gravida 3, para1, living 0, abortion1]) woman presented with a molar pregnancy in the rudimentary horn of a unicornuate uterus. Magnetic resonance imaging was consistent with a molar pregnancy in the rudimentary left horn. Her beta–human chorionic gonadotropin (hCG) to 38,000 mIU/ml the next day and 1,100mIU/ml after 1 week. Hysteroscopy revealed a single cervix with a tubular cavity. The right ostium was clearly visualized (Fig. 1A). The left ostium was not seen. Just beyond the internal os on the left side, an opening was seen, which could have been the communication with the left horn (Fig. 1B). Laparoscopy revealed a unicornuate uterus with a 5 × 5 cm left rudimentary horn (Fig. 2A). The bilateral tubes and ovaries were normal. Rudimentary horn excision was performed (Figs. 2B-D). The specimen was retrieved within an indigenous glove endobag by mechanical morcellation through extension of the left lateral port. There was no spillage. The specimen showed multiple vesicles (Fig. 3A). The patient's beta-hCG dropped to 38,000 the next day and 1,100 after 1 week. It was not detectable after 4 weeks. Histopathological examination of the specimen showed a complete mole (Fig. 3B). She was followed up for 6 months with beta-hCG, which was not detectable. The present case is the first case of a molar pregnancy in the rudimentary horn managed by laparoscopic hemihysterectomy. Endobag retrieval is important without any spillage in the peritoneal cavity or the port site. Follow-up is essential to detect rising or plateauing of beta-hCG, which could indicate gestational trophoblastic neoplasia. Fig. 2Laparoscopy. (A) The unicornuate uterus with a left rudimentary horn. (B) The left round ligament, mesosalpinx, and ovarian ligament cauterized and cut. (D) The uterus with the bilateral ovaries at the end of the procedure. (C) The fibromuscular stalk cauterized and cut. View Large Image Figure Viewer Download Hi-res image Fig. 3(A) Vesicles within the horn. (B) Villus distended with stromal fluid and cistern formation (trophoblastic proliferation). View Large Image Figure Viewer Download Hi-res image

Laparoscopic Hemi-Hysterectomy For an Obstructed Uterine Horn – Experience From a Statewide Quaternary Paediatric and Adolescent Gynaecology & Congenital Anomalies Service, Queensland, Australia.

Laparoscopic Hemi-Hysterectomy For an Obstructed Uterine Horn – Experience From a Statewide Quaternary Paediatric and Adolescent Gynaecology & Congenital Anomalies Service, Queensland, Australia.

Laparoscopic Hemihysterectomy for Obstructed Uterine Didelhys with Atretic Cervix Following Exploratory Laparotomy

A uterine didelphys with unilateral cervical atresia is a rare Mullerian anomaly. Laparoscopic management can be challenging when the patient has dense adhesions from a previous midline laparotomy. We present a case of a 17-year-old nulligravid adolescent who presented with cyclic pelvic pain. Ultrasound and hysterosalpingogram were consistent with a diagnosis of uterine didelphys with an atretic cervix and resulting hematometra from an obstructed hemiuterus. Six months prior, she had had an exploratory midline laparotomy to evaluate recent findings of an 18 cm pelvic mass.

Laparoscopic Hemi-Hysterectomy in a Patient with an 11-Week Pregnancy in a Communicating Rudimentary Horn

Laparoscopic Hemi-Hysterectomy in a Patient with an 11-Week Pregnancy in a Communicating Rudimentary Horn

An Unusual Extremely Distant Noncommunicating Uterine Horn with Myoma and Adenomyosis Treated with Laparoscopic Hemihysterectomy

A 41-year-old woman referred to us with dysmenorrhea and severe pelvic pain although she was previously submitted to right laparotomic adnexectomy for ovarian endometrioma and to a subsequent operative laparoscopy for pelvic adhesions. After ultrasound examination, the patient underwent diagnostic hysteroscopy and operative laparoscopy which confirmed the clinic suspect of an unicornuate uterus. However, it was very unusual to see an extremely distanced right horn, without communication with uterus, without adnexa, and with a small myoma belonging to it. Moreover, omentum and bowel were attached to fundus of right horn and thick adhesions fixed it to rectum and right pelvic wall. Therefore, identification of anatomical structures was difficult, as it was extremely arduous to isolate the ureter, which was involved inside the adhesions surrounding the right uterine horn. Nevertheless, laparoscopic right hemihysterectomy was successfully performed and right horn was sent to our pathologist who recognized hypotrophic endometrium and adenomyosis.

An Unusual Presentation of Uterine Didelphys and Obstructed Hemivagina

BackgroundCongenital disorders of the genitourinary system can be unpredictable. There are both medical and surgical interventions that can help manage symptoms. CaseA 10-year-old girl was evaluated 6 months post-menarche with dysuria and pelvic pain. Her symptoms were not relieved with menstrual suppression. Evaluation revealed a probable ectopic ureter versus ureterocele and uterine didelphys with suspicion for obstructed hemivagina and hematocolpos. Surgical exploration revealed an obstructed hemivagina with a high vaginal septum. When resection failed, she ultimately underwent a robot-assisted hemihysterectomy, with resolution of her symptoms. Summary and ConclusionsIn this case presentation, a surgical approach was necessary to adequately make a diagnosis. When vaginal septum resection failed, robot-assisted laparoscopic hemi-hysterectomy and resection of a vaginal pouch led to symptom resolution in this pediatric patient with a complex anomaly.

Laparoscopic Hemihysterectomy in a 14-Year-Old Woman with a Blind Ended Rudimentary Horn

We present a case of a 14-year-old woman with dysmenorrhea since menarch, who was diagnosed by MRI of pseudo-unicornuate uterus, with a blind ended rudimentary contralateral cornis. no other genito-urinary anomalies were associated. We performed a laparoscopic hemihysterectomy, removing the right rudimentary horn, according to the recomendations of published data, and preventing damages to the functional uterus. Finally, we reconstructed the left unicornuate uterus together with the right Fallopian tube, and the other right pedicles. Patient is on her first week after surgery now, so we do not know how her medium or long term outcomes will be, but because right uterine artery and round ligament were not damaged, we asume there is no elevated risk of uterine prolapse or vascularization issues.

Robot-Assisted Total Laparoscopic Hemi-hysterectomy of a Didelphyic Uterus in a Patient with an Obstructed Hemivagina and Ipsilateral Renal Agenesis (OHVIRA)

Robot-Assisted Total Laparoscopic Hemi-hysterectomy of a Didelphyic Uterus in a Patient with an Obstructed Hemivagina and Ipsilateral Renal Agenesis (OHVIRA)

Laparoscopic Morcellation of Didelphic Uterus With Cervical and Renal Aplasia

This is a case report (and review of the literature) of a 12-year and 10-month-old girl with a rare congenital anomaly of uterus didelphys, unilateral cervix aplasia, and ipsilateral renal aplasia. She had severe dysmenorrhea from the first menses. In an effort to preserve fertility, a cervical fistula was made that closed over. A laparoscopic hemi-hysterectomy was done successfully and rapidly with laparoscopic morcellation. Because no ureter was present, it was not necessary to trace it. For this congenital anomaly, laparoscopic morcellation of the obstructed hemiuterus is the preferred treatment either as a primary procedure or as a secondary procedure following failure of a surgical cervical fistula for the young patient.

Laparoscopic Hemihysterectomy in a Case of Uterus Didelphys with Nonfused Rudimentary Uterine Horns with Functioning Endometria and Complete Cervical-Vaginal Agenesis

Abnormalities of the Mullerian system exist in a variety of forms. Conventional anomalies are easy to manage, but a rare combination of anomalies requires good clinical judgment to diagnose and manage. In this paper, we report on a 17-year-old girl with two rudimentary horns, with functional endometrium in one horn, and cervicovaginal agenesis. She was diagnosed to have vaginal agenesis 2 years prior and underwent vaginoplasty. The presence of an obstructive uterine anomaly was overlooked. She presented to us with cyclic abdominal pain 2 years later. On evaluation, a functional rudimentary horn was diagnosed and removed laparoscopically. Abnormalities in vertical fusion may rarely coexist with defects in lateral fusion and must be looked for in any adolescent with cyclical abdominal pain.

Classification for Endoscopic Treatment of Mullerian Anomalies with an Obstructive Cervix

Study Objective To describe our classification according to severity of developmental mullerian anomalies with obstructed cervix Design Retrospective review (Canadian Task Force classification II-2). Setting University-based, tertiary-level center for endoscopic surgery. Patients Ten women with developmental mullerian anomalies with obstructed cervix. Intervention Patients with didelphic uterus with a rudimentry nonfunctional horn and hypoplastic cervix (type 1) underwent hemihysterectomy or diagnostic endoscopy. Those with agenesis of cervix with normal uterus (type 2) had uterovaginal canalization or neocervix with full-thickness skin graft. Women with identical didelphic uteri and hypoplastic cervix (type 3) underwent uterovaginal canalization with or without endometrial ablation or hemihysterectomy. Patients with didelphic uterus with a rudimentary horn and hypoplastic cervix (type 4) had laparoscopic hemihysterectomy. Those with agenesis of the vagina and cervix but with functional endometrium (type 5) had laparoscopic-assisted full-thickness skin graft. Measurements and Main Results Average duration of surgery was 60 to 210 minutes. There were no intraoperative complications. Patients with type 1 anomaly are continuing infertility treatment. All three patients in type 2 continue to have regular menses without dysmenorrhea. In those with type 3 conditions, hemihysterectomy was performed in one woman and uterovaginal canalization was performed on the hypoplastic cervix in another. After the neocervix was created, endometrial ablation was performed. No evidence of cervical obstruction or hematometra was found in either patient. The patient with type 4 anomaly continues to have regular menstrual periods without dysmenorrhea. Women with type 5 disorder had good healing of vaginal skin grafts. Conclusion This classification helps identify mullerian anomalies in relation to obstructive cervix. It is useful in categorizing the disorders and determines management strategies and prognosis.