Pelvic Sidewall Research Articles

Extralevator abdominoperineal excision

Extralevator abdominoperineal excision (ELAPE) has been introduced to alleviate the disappointing results of conventional abdominoperineal excision (APE) with respect to inadvertent bowel perforation, positive circumferential resection margins (CRM), and local recurrence rates. The main principle of this operation is to shift the resection plane away from the anorectal junction, which is the area at highest risk of perforation and CRM positivity. This is accomplished by resection of the levator ani muscle, which is followed at its outer surface close to its origin at the pelvic side wall. The anterior region is also addressed with comfortable access to the dissection area by placement of the patient in prone jackknife position. All measures aim to avoid a waist at the anorectal junction. This article describes the procedure in detail, including strategies to close the perineal defect. In a brief review of the literature, the favorable results of ELAPE are discussed. Conclusion. It can be concluded that the perineal phase of ELAPE is highly standardized and can be taught in a step-by-step fashion. There is evidence that ELAPE results in lower rates of inadvertent bowel perforations, lower rates of positive CRM, and lower rates of local recurrence.

Extended Lateral Pelvic Sidewall Excision [Elsie] for Locally Advanced & Recurrent Rectal Cancer Involving the Lateral Pelvic Sidewall – An Evaluation of a Novel Technique and Its Outcomes

Background: In the context of locally advanced or recurrent rectal cancer, disease extension to the lateral pelvic sidewall is associated with lower rates of complete resection and poorer survival overall. Adaptions to surgical approach may improve complete resection rates but whether improvement in survival will follow is unclear.

Delayed Haemorrhage Following Pelvic Side Wall Excision With Internal Iliac Vessel Resection in Locally Recurrent Rectal Cancer.

Delayed Haemorrhage Following Pelvic Side Wall Excision With Internal Iliac Vessel Resection in Locally Recurrent Rectal Cancer.

Imaging and Management of Rectal Cancer

High-resolution phased array external magnetic resonance imaging (MRI) is the first investigation of choice in rectal cancer for local staging, both in the primary and restaging situations. Use of MRI helps differentiate between those with good prognosis, which can be offered upfront surgery and the poor prognostic cases where treatment intensification is needed. MRI identified poor prognostic factors are threatened or involved mesorectal fascia, T3 tumors with >5 mm extramural spread, those with extramural vascular invasion, pelvic sidewall nodes and mucinous tumors. At restaging, use of MRI helps evaluate response and an MR tumor regression grading system is being evaluated. Complete response seen on clinical examination and endoscopy, needs confirmation on MRI using both T2-weighted and diffusion-weighted sequences to justify a "watch and wait" approach. In this subset of patients, MRI also plays a role in monitoring and detecting early regrowth. In those with partial response, MRI helps define surgical margins and can be used as a roadmap to decide between sphincter preserving surgeries and radical sphincter sacrificing surgeries; pelvic exenteration and pelvic sidewall lymph node dissection. Poor responders on MRI may benefit from adjuvant chemotherapy. Use of MRI thus helps in individualizing treatment in rectal cancer.

Role of one-step nucleic acid amplification (OSNA) to detect sentinel lymph node low-volume metastasis in early-stage cervical cancer

IntroductionGrowing evidence in the literature supports the accuracy of sentinel lymph node (SLN) biopsy in early-stage cervical cancer. One-step nucleic acid amplification (OSNA) is a rapid assay able to detect...

High-dose-rate interstitial brachytherapy with hypoxic radiosensitizer KORTUC II for unresectable pelvic sidewall recurrence of uterine cervical cancer: a case report

In order to improve oncologic outcomes in radiotherapy treatments of patients with unresectable pelvic sidewall recurrences of uterine cervical cancer, we combined high-dose-rate interstitial brachytherapy (HDR-ISBT) with newly tested hypoxic radiosensitizer Kochi oxydol-radiation therapy for unresectable carcinomas (KORTUC II), an enzyme-targeting radiosensitization treatment involving intra-tumoral injection of sodium hyaluronate mixed with hydrogen peroxide. We report on a 63-year-old patient referred to our department with an extensive pelvic sidewall recurrence of uterine cervical cancer after initial hysterectomy. The tumor size was 55 × 25 × 80 mm, with a calculated volume of 89.7 cc. Whole pelvic irradiation of 50 Gy in 25 fractions was administered, combined with weekly cisplatin injections. KORTUC II injections were given two times: at day 21 (42 Gy) and at day 24 (48 Gy). After finishing whole pelvic irradiation, HDR-ISBT of 25 Gy in 5 fractions b.i.d. over 3 days was administered. KORTUC II was also injected at the time of implantation. Dose-volume histogram (DVH) values for clinical target volume were D90, D98, and D100 of 6.0, 5.0, and 3.5 Gy per fraction, respectively. D2cc values were 2.1, 4.1, 3.2, and 2.0 Gy per fraction for the bladder, rectum, sigmoid colon, and small bowel, respectively. No acute adverse events ≥ grade 3 were observed. Repeated grade 3 pyelonephritis occurred as a late complication at 11, 24, and 26 months after the treatment, and was successfully resolved with antibiotics. Moreover, grade 2 late toxicity was documented, including sciatic neuralgia, lower limb lymphedema, and urinary incontinence. At present, 32 months after HDR-ISBT, the patient remains free of disease, with no toxicity-related deterioration in physical condition.

A Rare Case of Idiopathic Pyometra in a Premenopausal Patient.

Pyometra is a very uncommon disease principally occurring in postmenopausal women. It is characterized by the accumulation of purulent material within the uterine cavity. This paper presents the clinical history of a 35-year-old premenopausal woman with otherwise normal menstruation who developed heavy menstruation and was diagnosed with a benign pyometra of indeterminate etiology in March 2017. The patient underwent repeated ultrasound-guided drainage, dilation and curettage, and antibiotic therapy. Biopsies of the pelvic sidewall revealed endometriosis in June 2017. The heavy menstruation and suppurative fluid in the uterus of the patient persisted in which intramuscular leuprolide acetate was prescribed to address the endometriosis and heavy menstrual bleeding. Ultimately, the leuprolide acetate effectively resolved the patient's bleeding and pyometra. The medication was concluded after 12 months of supervision and the patient is currently symptom free. Pyometra is an unusual condition rarely identified in premenopausal women. Drainage and antibiotic therapy are routinely employed; however, one may consider gonadotropin-releasing hormone agonist medication to potentially confer a beneficial patient outcome in rare cases where endometriosis and bleeding are intractable.

Smooth Muscle Tumors of the Visceral Adnexal and Uterine Ligaments and Adnexal Connective Tissue: A Clinicopathologic Study of 67 Cases.

The endopelvic fascia is a biomechanical network of supportive tissue that suspends and secures the female reproductive organs to the pelvic sidewall. Several visceral adnexal and uterine ligaments are part of this framework, and we have observed that smooth muscle tumors (SMTs) arising from these structures morphologically resemble gynecologic smooth muscle neoplasms. To determine whether gynecologic smooth muscle tumor criteria for malignancy are valid in these tumors, we evaluated the morphologic features of 67 tumors from 67 patients and correlated our findings with patient outcome. Using current uterine SMT WHO definitions, 57 tumors (85%) were classified as leiomyoma, 2 (3%) as smooth muscle tumor of uncertain malignant potential (STUMP), and 8 (12%) as leiomyosarcoma. Clinical follow-up was available for 88% of patients (range: 1-296 mo, mean: 174 mo, median: 79 mo). Only 1 case of leiomyosarcoma had metastasis at time of presentation, but 6 of 8 (75%) patients eventually died of disease. The other 2 cases of leiomyosarcoma that have not recurred are 11 and 16 mo from initial diagnosis. No cases of STUMP or leiomyoma recurred. On the basis of morphologic features and patient outcome, we believe these tumors distribute into similar categories of leiomyoma, STUMP and leiomyosarcoma, paralleling the biologic potential of uterine SMTs as well as SMTs of other gynecologic sites. We propose use of uterine WHO SMT criteria to classify spindled SMTs that arise in the visceral adnexal and uterine ligaments and adnexal connective tissue.

Technical Aspects of Endosurgical Extraperitoneal Aortic Lymph Node Dissection in Gynaecologic Oncology

Introduction Laparoscopic aortic node dissection can be performed using extraperitoneal techniques. The surgical technique has been made much easier by the development of multifunction instruments, combining sophisticated bipolar thermal fusion and sharp incision, or using harmonic hemostasis. These instruments improve ergonomy, and may reduce the lymphocyst formation rate, the more frequent complication of extraperitoneal lymph node dissection. Robotic assistance is feasible and safe, but that does not provide significant improvement in perioperative outcomes. Laparoscopic or robot-assisted single port has been used by several investigators, which led to the same conclusions. Interestingly, the left lateral extraperitoneal approach can be extended to the left pelvic sidewall, allowing to resect suspicious nodes, sentinel nodes or to complete left pelvic lymph node dissection.

Pelvic sidewall excision with en bloc complete sciatic nerve resection in locally re-recurrent rectal cancer.

ANZ Journal of SurgeryVolume 90, Issue 6 p. 1202-1204 IMAGES FOR SURGEONS Pelvic sidewall excision with en bloc complete sciatic nerve resection in locally re-recurrent rectal cancer Dewei J. Lee MBBS, Dewei J. Lee MBBS Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, AustraliaSearch for more papers by this authorPeadar S. Waters MB BCh, BAO, MD, MCh, MedED, FRCS, Peadar S. Waters MB BCh, BAO, MD, MCh, MedED, FRCS orcid.org/0000-0003-2947-9206 Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, AustraliaSearch for more papers by this authorJosé T. Larach MD, José T. Larach MD Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, AustraliaSearch for more papers by this authorJacob J. McCormick FRACS, Jacob J. McCormick FRACS Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, AustraliaSearch for more papers by this authorAlexander G. Heriot MA, MB, Bchir, MD, FRCS (Gen.), FRCSEd, FRACS, Alexander G. Heriot MA, MB, Bchir, MD, FRCS (Gen.), FRCSEd, FRACS Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, AustraliaSearch for more papers by this authorSatish K. Warrier MBBS, MS, FRACS, Satish K. Warrier MBBS, MS, FRACS Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, AustraliaSearch for more papers by this author Dewei J. Lee MBBS, Dewei J. Lee MBBS Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, AustraliaSearch for more papers by this authorPeadar S. Waters MB BCh, BAO, MD, MCh, MedED, FRCS, Peadar S. Waters MB BCh, BAO, MD, MCh, MedED, FRCS orcid.org/0000-0003-2947-9206 Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, AustraliaSearch for more papers by this authorJosé T. Larach MD, José T. Larach MD Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, AustraliaSearch for more papers by this authorJacob J. McCormick FRACS, Jacob J. McCormick FRACS Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, AustraliaSearch for more papers by this authorAlexander G. Heriot MA, MB, Bchir, MD, FRCS (Gen.), FRCSEd, FRACS, Alexander G. Heriot MA, MB, Bchir, MD, FRCS (Gen.), FRCSEd, FRACS Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, AustraliaSearch for more papers by this authorSatish K. Warrier MBBS, MS, FRACS, Satish K. Warrier MBBS, MS, FRACS Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, AustraliaSearch for more papers by this author First published: 21 October 2019 https://doi.org/10.1111/ans.15512Citations: 3Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume90, Issue6June 2020Pages 1202-1204 RelatedInformation

Nodal drainage pathways in primary rectal cancer: anatomy of regional and distant nodal spread.

Nodal involvement is a significant prognostic factor in rectal cancer and difficult to assess preoperatively. An understanding of the patterns of nodal spread from different regions of the rectum can assist in this process and is essential for the purposes of surgical planning. In this article we define patterns of spread to mesenteric and pelvic sidewall nodal subgroups and discuss the importance of accurate anatomic localization of nodes for the purposes of staging and surgical planning.

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.

Wise Techniques for Excision of Severe Ureteric and Rectal Endometriosis

Video Objective To provide logical steps and demonstrate wise techniques to minimise complications during laparoscopic surgery for severe ureteric and rectal endometriosis. Setting A 40 year old para 2 (normal vaginal deliveries) with no significant past medical history, presented with 2 year history of dysmenorrhea, abdominal bloating with constipation. Her pelvic ultrasound showed a 13 cm left endometrioma. Recently, she also developed urinary frequency, urgency and nocturia, consistent with the pressure effect of her large cyst. Abdominal palpation revealed an 18 week size mass and pelvic examination demonstrated a tender fixed uterus. Her CA 125 was within normal range (21 U/ml). The diagnosis is severe endometriosis. Interventions The patient underwent laparoscopic excision of endometriosis including ovarian cystectomy. Conclusion Stage 4 endometriosis was confirmed by laparoscopy. Surgical steps and techniques to manage severe endometriosis are discussed as follow: The first step of surgery is to decompress the large ovarian cyst in order to obtain adequate space for the surgical working field. During decompression, we used an endo-loop to prevent spillage of the large endometrioma. The next step is to normalize pelvic anatomy with good dissection technique. In this case, an active bleeding point was very close to the left ureter on the pelvic side wall. Due to the risk of thermal damage to the ureter, direct surgical diathermy on the pelvic side wall without identifying the ureter should be avoided. Therefore, to achieve temporary haemostasis and gain an optimal surgical view, the assistant used a grasper to clamp the bleeding point during ureterolysis. To avoid rectal injury, the use of a rectal probe during rectovaginal adhesiolysis to delineate the rectum is a wise technique. In addition, appropriate uterine manipulation is important to delineate the uterosacral ligaments, so we have anatomical landmarks to safely excise endometriotic nodules.

Ureterolysis, Vasolysis and Neurolysis: The Trifecta in Deep Infiltrating Endometriosis

Video Objective To describe the surgical approaches and techniques employed in an extreme case of deep infiltrating endometriosis (DIE) affecting the lateral pelvic side wall. Setting A 32-year-old gravida 2, para 1 presented for definitive surgical management of pelvic pain due to endometriosis at an academic tertiary care center. Intraoperatively, severe retroperitoneal fibrosis tethered the external iliac vein, internal iliac artery, obturator nerve, medial umbilical ligament and ureter together. Interventions We demonstrate the surgical method and tools required to overcome a unique endometriotic nodule that would not allow for traditional lysis of adhesions from the pelvic side wall. Instead, we tunneled under the external iliac vasculature to approach the dissection from a lateral to medial direction in order to free the obturator nerve and internal iliac artery from the ureter and endometriotic nodule. Conclusion Extreme cases of DIE involving the pelvic side wall require surgical finesse when normal planes of dissection are obliterated. Knowledge of retroperitoneal anatomy is critical in order to overcome unexpected lateral pelvic side wall endometriosis as the disease is rarely confined to the surface. Innovative surgical thinking complemented by an array of surgical tools will ultimately allow the surgeon to master even the most difficult endometriotic resections.

Retroperitoneal Anatomy: A Guide to Laparoscopic Pelvic Sidewall Dissection

Video Objective This educational video reviews the important retroperitoneal anatomy of the pelvic sidewall, including the ureter, the uterine artery as it emanates from the internal iliac artery, and the pararectal and paravesical spaces. Setting Knowledge of retroperitoneal anatomy and the ability to safely explore the pelvic sidewall are essential skills for any gynecologic surgeon. Interventions A simple schematic is shown to demonstrate the anatomic relationship between important retroperitoneal structures. Then, a surgical video is presented to demonstrate the same anatomy in an actual case. Conclusion This video presents the essential retroperitoneal anatomy of the pelvic sidewall in a clear manner, and demonstrates a simple technique for laparoscopically identifying these structures. This educational video reviews the important retroperitoneal anatomy of the pelvic sidewall, including the ureter, the uterine artery as it emanates from the internal iliac artery, and the pararectal and paravesical spaces. Knowledge of retroperitoneal anatomy and the ability to safely explore the pelvic sidewall are essential skills for any gynecologic surgeon. A simple schematic is shown to demonstrate the anatomic relationship between important retroperitoneal structures. Then, a surgical video is presented to demonstrate the same anatomy in an actual case. This video presents the essential retroperitoneal anatomy of the pelvic sidewall in a clear manner, and demonstrates a simple technique for laparoscopically identifying these structures.

Gastrointestinal Symptoms as a Predictor of Deep Infiltrating Endometriosis of the Posterior Compartment of the Pelvis on MRI Imaging

Study Objective To determine if gastrointestinal symptoms can predict deep infiltrating endometriosis (DIE) of the posterior compartment of the pelvis on magnetic resonance imaging (MRI). Design Retrospective cohort study. Presenting gastrointestinal symptoms were collected from the modified International Pelvic Pain Society Pelvic Pain Assessment Form (mIPPS-PPAF). MRI reports and interdisciplinary conference notes were reviewed to identify DIE of the posterior compartment (rectosigmoid, uterosacral ligaments, posterior cul de sac, and pelvic side walls). Associations between symptoms and DIE were evaluated using logistic regression. Setting Academic tertiary care center. Patients or Participants Patients with suspected endometriosis undergoing an endometriosis protocol MRI with interdisciplinary conference review between 9/1/2015 and 7/31/2018 were identified from a clinical database. Patients with a pre-treatment mIPPS-PPAF were included. Interventions N/A Measurements and Main Results 104 patients met inclusion criteria; 89 (85.6%) presented with at least one gastrointestinal symptom. DIE of the posterior compartment was identified on MRI in 47 patients (45.2%). A bowel movement resulting in pain relief was the gastrointestinal symptom that most strongly predicted DIE (OR 3.36, 95%CI 1.31-8.61, p=0.012). For this symptom, sensitivity, specificity, positive and negative predictive values were 0.42, 0.82, 0.67, and 0.63, respectively. Other gastrointestinal symptoms such as nausea, emesis, rectal bleeding, and increased pain with change in frequency of bowel movements did not have a statistically significant association with DIE; a trend towards significance was seen for bowel movements making pain worse (OR 2.33, 95%CI 0.97-5.58, p=0.059). Of the 15 patients with no gastrointestinal symptoms, 5 were found to have DIE of the posterior compartment. Conclusion In patients with suspected endometriosis, those who noted that bowel movements relieved their pain had more than 3 times the odds of having DIE of the posterior compartment on an endometriosis protocol MRI. Preoperative evaluation with MRI may be of value in these patients; however, lack of gastrointestinal symptoms does not exclude the possibility of posterior compartment DIE.

1533 Robotic-Assisted Laparoscopic Excision of Deep Infiltrating Endometriosis Involving the Ureter

Video Objective This video demonstrates a safe and effective minimally invasive technique for enterolysis, oophorectomy and subsequent ureterolysis in the face of deep infiltrating (DIE) and deep fibrotic endometriosis. Setting The index patient is a 38 y/o G3P2012 patient with a history of endometriosis and a recurrent right endometrioma causing pelvic pain, dyschezia and dyspareunia. She was referred to our center for further management after previous surgical interventions failed to adequately address her symptoms. Interventions A preoperative pelvic MRI revealed a 7.6 cm right ovarian mass, replacing the majority of the right ovary and consistent with an endometrioma. Intraoperatively, the right ovary was encased in adhesions involving the small bowel, sigmoid colon, rectum and the right pelvic side wall. A deep fibrotic endometriotic nodule was also noted to be encasing the right ureter for most of its course towards the bladder. Careful and extensive dissection was performed, freeing the diseased ovary from all its attached structures. Resection of the fibrotic tissue surrounding the ureter was then carried out with good surgical rigor, thus successfully achieving the ureterolysis. A double J right ureteral stent was subsequently placed by the urology team. The patient had complete resolution of her pain symptoms at her post-operative visit. Conclusion Extensive fibrotic endometriosis involving the ureter can make ureterolysis quite difficult. Careful planning, knowledge of anatomical variance and proper surgical techniques are beneficial in overcoming such challenges. Despite its recalcitrant nature, endometriosis affecting the ureters can be effectively resected to afford a favorable outcome for patients.

1812 Excision of Ovarian Remnant

Video Objective Dissection techniques for removal of ovarian remnant. Setting Patients with persistent ovarian tissue and persistent pelvic pain after Oophorectomy. Interventions Excision of persistent ovarian tissue. Conclusion Ovarian remnant is a challenging problem as it is seen in patient whose primary surgery was complicated due to excessive adhesions or severe endometriosis. If the initial dissection was incomplete, a portion of ovarian tissue may remain adhered and continue to cause pelvic pain. This surgery requires dissection of pelvic side wall where remnant is most commonly isolated. Complete ureterolysis, separation of sigmoid colon from pelvic side wall and vagina, isolation of round ligament, IP ligament and uterine artery are the key steps while excising the ovarian residual tissue. This video demonstrates these key steps of dissection. Such patients will often be referred to a minimally invasive gynecologic surgeon who are trained in dissection of pelvic side wall with knowledge of retroperitoneal anatomy and can safely perform this complex dissection.

Creation of a Neovagina: A Modified Davydov Approach

Video Objective This video presents a stepwise approach to the creation of a neovagina through a modified laparoscopic Davydov approach. Setting This procedure is most commonly performed for vaginal agenesis. First line treatment is self-dilation with multidisciplinary support. When first line treatment fails, a surgical approach to neovaginal creation is the Davydov procedure. This video illustrates the steps of a modified laparoscopic Davydov procedure for the creation of a neovagina in a patient with Mayer-Rokitansky-Kuster-Hauser Syndrome. Interventions The modified laparoscopic Davydov procedure is comprised of five steps: 1) define the anatomy (± salpingectomy), 2) create the neovaginal space, 3) line the neovagina with peritoneum, 4) dissect the pelvic sidewall, and 5) suture the neovagina over the stent. The modified laparoscopic approach involves round ligament preservation (instead of transection) for added vaginal support. It also involves transection of the utero-ovarian ligaments (instead of preservation) to keep ovaries in their anatomical location. More extensive pelvic sidewall dissection helps avoid tension on sidewall structures. Conclusion The Davydov procedure has high rates of sexual satisfaction and should be considered for the surgical creation of a neovagina.

2805 Complete Vision Loss after Laparoscopic Hysterectomy: A Case Report

Study Objective NA Design Case-report. Setting University-affiliated hospital. Patients or Participants 1 Interventions NA Measurements and Main Results Postoperative vision loss (POVL) is a rare but devastating complication that has only recently been reported following laparoscopic surgery. We present the case of a 34 year old female who experienced POVL following an uncomplicated laparoscopic hysterectomy. Her medical history was remarkable for anxiety, depression and endometriosis. She underwent a total laparoscopic hysterectomy, bilateral salpingectomy, and excision of deeply infiltrating endometriosis from the right pelvic sidewall. She was in the dorsal lithotomy position with both arms tucked. Operating time was 174 minutes and EBL was 75mL. Upon arrival to the surgical floor, approximately 4 hours postoperative, she became increasingly distressed, reporting complete absence of vision. A stroke code was called. No focal neurologic deficits were found. Pupils were equally reactive to light, but vision was reported as no light perception. No cerebral hemorrhage or ischemia were detected on CT/MRI. Funduscopic exam revealed no structural abnormalities. Tonometry demonstrated a normal intraocular pressure of 18mmHg in the left eye and 13mmHg in the right. The lens was clear, macula flat, and periphery was within normal limits bilaterally. Over the following days, her vision remained unchanged. She continued to describe a white wall, and unable to notice motion or light. Otherwise, she met all appropriate post-operative milestones from a gynecologic perspective. On postoperative day 7 the decision was made to start an IV methylprednisolone taper. The following morning she noticed mild light perception. Later that night, she reported a spontaneous partial return of visual acuity. She was discharged home the next day after completing the steroid taper. At her 2 week postoperative visit, uncorrected Snellen eye exam was 20/63 for her left eye and 20/50 for her right, which was consistent with her baseline. Conclusion POVL should be treated as an emergency, and managed in a multidisciplinary fashion.