Round Ligament Research Articles

Single-incision laparoscopic percutaneous extraperitoneal closure (SILPEC) for inguinal hernia with prolapsed ovary.

Most studies reporting the outcomes of laparoscopic ovarian prolapsed hernia operations with large sample sizes are based on intracorporeal closure, while studies on extraperitoneal closure have limited sample sizes. We proactively used the single-incision laparoscopic percutaneous extraperitoneal closure (SILPEC) technique and obtained favorable outcomes, which we report in this paper. We retrospectively reviewed patients who had undergone laparoscopic surgery for inguinal hernia at our institution. They were retrospectively classified into two groups based on the pre- or intraoperative diagnosis of hernia with a prolapsed ovary, namely the prolapse group and the non-prolapse group, respectively. The data were statistically analyzed and p < 0.05 was considered statistically significant. A total of 771 subjects underwent SILPEC during the study period, including 400 girls. Among them, 63 girls were diagnosed with an ovarian prolapsed hernia. SILPEC was successfully performed through a single port in all cases, with a single exception, in whom the forceps was inserted directly through the right lower quadrant to pull up the ovary. The duration of surgery in the prolapse group was not higher than that in the non-prolapse group. During the SILPEC surgery, the ovaries were successfully reverted into the abdominal cavity by external compression of the inguinal area alone in 38 of the 63 patients. In the remaining 25 cases, the ovaries were reverted into the abdominal cavity by external compression of the inguinal area and traction of the round ligament with forceps. None of these cases failed to return to the ovaries. Our study results indicate that SILPEC may be performed safely for the treatment of ovarian prolapsed inguinal hernia. Since the ovary and fallopian tube are close to the internal inguinal ring due to the short round ligament, the procedure requires careful suturing with traction of the round ligament.

Vulvar Endometriosis by Suspected Spread Via the Round Ligament

Study Objective To present a rare case of vulvar endometriosis by suspected spread through the round ligament and review the literature regarding vulvar endometriosis. Design Case report. Setting Tertiary care hospital. Patients or Participants One patient. Interventions Patient with a painful 4 × 3 cm well-circumscribed, subcutaneous mobile mass on the left labia majora deep in the subcutaneous tissue with no overlying skin changes was worked up with CT-guided IR core biopsy that revealed endometriosis. Pelvic MRI revealed a fibroid uterus and 3.8 × 2.6 × 3.1 cm infiltrative soft tissue mass within the left mons pubis extending into the superior aspect of the left labia majora. The mass was noted to be contacting the distal aspect of the round ligament with resultant cyst in the canal of Nuck. Patient underwent laparoscopic myomectomy and local excision of the left vulvar mass for management. Measurements and Main Results Operative findings were consistent with endometrioma in the left vulva and endometriotic implant on the left round ligament at the insertion site into the inguinal canal. Pathology of both the left vulvar mass and excised left round ligament lesion revealed endometriosis. We suggest direct spread via the round ligament as the source of patient's vulvar endometriosis given these findings. Conclusion Spontaneous perineal and vulvar endometriosis is extremely rare, but in cases of clinically suspected vulvar endometriosis, the round ligament should be considered as the potential route of disease spread. Endometriosis should be suspected in extrapelvic lesions with observed cyclic response to the menstrual cycle and considerations should be given for diagnostic laparoscopy to look for pelvic disease in these cases. To present a rare case of vulvar endometriosis by suspected spread through the round ligament and review the literature regarding vulvar endometriosis. Case report. Tertiary care hospital. One patient. Patient with a painful 4 × 3 cm well-circumscribed, subcutaneous mobile mass on the left labia majora deep in the subcutaneous tissue with no overlying skin changes was worked up with CT-guided IR core biopsy that revealed endometriosis. Pelvic MRI revealed a fibroid uterus and 3.8 × 2.6 × 3.1 cm infiltrative soft tissue mass within the left mons pubis extending into the superior aspect of the left labia majora. The mass was noted to be contacting the distal aspect of the round ligament with resultant cyst in the canal of Nuck. Patient underwent laparoscopic myomectomy and local excision of the left vulvar mass for management. Operative findings were consistent with endometrioma in the left vulva and endometriotic implant on the left round ligament at the insertion site into the inguinal canal. Pathology of both the left vulvar mass and excised left round ligament lesion revealed endometriosis. We suggest direct spread via the round ligament as the source of patient's vulvar endometriosis given these findings. Spontaneous perineal and vulvar endometriosis is extremely rare, but in cases of clinically suspected vulvar endometriosis, the round ligament should be considered as the potential route of disease spread. Endometriosis should be suspected in extrapelvic lesions with observed cyclic response to the menstrual cycle and considerations should be given for diagnostic laparoscopy to look for pelvic disease in these cases.

Surgical Management of Inguinal Endometriosis

Study Objective To demonstrate surgical management of an inguinal endometrioma. Design Stepwise demonstration of surgical techniques with narrated video footage. Setting Yale New Haven Hospital, New Haven, CT. Patients or Participants A 31-year-old woman with a painful right inguinal endometrioma. Interventions The patient underwent diagnostic examination with pelvic MRI, which noted concern for an inguinal endometrioma. Biopsy confirmed endometriosis. She then underwent diagnostic laparoscopy, with resection of intra-pelvic and inguinal endometriosis. The technical steps of management and resection of an inguinal endometrioma have been detailed in the video with an emphasis on anatomic landmarks by utilizing visual illustrations. An incision was made at the inguinal ligament and taken down to the superficial fascia using Bovie cautery. The mass was progressively mobilized from the superficial inguinal ring superiorly, sartorius muscle laterally, and adductor longus muscle medially. Several perforating branches of the femoral vein as well as the round ligament of the uterus, at the level of the external inguinal ring, were ligated and tied off. The mass was removed in full, and the resected bed fulgurated. A drain was placed and the incision was closed in multiple layers. Measurements and Main Results Diagnostic laparoscopy revealed intrapelvic Stage I endometriosis. The right round ligament and internal inguinal ring were without evidence of endometriosis. The 3.1 × 3 × 2.8 cm inguinal mass was fully resected. Final pathology confirmed both intrapelvic and inguinal endometriosis. Conclusion Inguinal endometriosis is exceedingly rare, with an estimated incidence of 0.6%. Given the broad differential diagnosis, imaging should be performed. In addition, biopsy can be considered, provided a hernia has been ruled out. Surgical management should entail diagnostic laparoscopy and excisional surgery. To demonstrate surgical management of an inguinal endometrioma. Stepwise demonstration of surgical techniques with narrated video footage. Yale New Haven Hospital, New Haven, CT. A 31-year-old woman with a painful right inguinal endometrioma. The patient underwent diagnostic examination with pelvic MRI, which noted concern for an inguinal endometrioma. Biopsy confirmed endometriosis. She then underwent diagnostic laparoscopy, with resection of intra-pelvic and inguinal endometriosis. The technical steps of management and resection of an inguinal endometrioma have been detailed in the video with an emphasis on anatomic landmarks by utilizing visual illustrations. An incision was made at the inguinal ligament and taken down to the superficial fascia using Bovie cautery. The mass was progressively mobilized from the superficial inguinal ring superiorly, sartorius muscle laterally, and adductor longus muscle medially. Several perforating branches of the femoral vein as well as the round ligament of the uterus, at the level of the external inguinal ring, were ligated and tied off. The mass was removed in full, and the resected bed fulgurated. A drain was placed and the incision was closed in multiple layers. Diagnostic laparoscopy revealed intrapelvic Stage I endometriosis. The right round ligament and internal inguinal ring were without evidence of endometriosis. The 3.1 × 3 × 2.8 cm inguinal mass was fully resected. Final pathology confirmed both intrapelvic and inguinal endometriosis. Inguinal endometriosis is exceedingly rare, with an estimated incidence of 0.6%. Given the broad differential diagnosis, imaging should be performed. In addition, biopsy can be considered, provided a hernia has been ruled out. Surgical management should entail diagnostic laparoscopy and excisional surgery.

Laparoscopic Supra-Cervical Hysterectomy Using Instrument with Wristed Movement

Study Objective To demonstrate the use of a novel bipolar surgical grasping device in Laparoscopic Supra-Cervical Hysterectomy (LSH). Design A single surgical case is selected. Setting Private GYN Surgical practice operating in an ambulatory surgical center. Patients or Participants Single patient with menorrhagia requiring LSH. Interventions Laparoscopic Supra-Cervical Hysterectomy and Opportunistic Bilateral Salpingectomy are performed in the usual manner with a novel bipolar graspinging device with articulating head. Salpingectomy begins with division of the tube on the broad ligament to the cornua. Two contiguous bites are always taken from medial to lateral prior to transection with endoscopic scissors. The round ligament and utero-ovarian ligament pedicles are coagulated and divided. Dissection proceeds cauded to the area of the ascending branches of the uterine artery. Following retrograde fill of the bladder, the visceral peritoneum of the uterus is divided cephalad to the vesico-uterine plicae. Bladder is reduced on the pubo-cervical-vesical fascia. The cervix is then transected at the cervico-isthmic junction. Hemostasis is achieved at the base of the resection on the cervix. Specimen is delivered en-bloc through a posterior colpotomy. The parietal peritoneum is then sutured intercurrently between infiidibulopelvic ligaments. Copious irrigation and inspection to ensure hemostasis is conducted prior to closure. Measurements and Main Results Successful completion of surgery Conclusion Laparoscopic grasper / coagulator with articulating head adds to functionality and versatility without need to resort to use of robotics. To demonstrate the use of a novel bipolar surgical grasping device in Laparoscopic Supra-Cervical Hysterectomy (LSH). A single surgical case is selected. Private GYN Surgical practice operating in an ambulatory surgical center. Single patient with menorrhagia requiring LSH. Laparoscopic Supra-Cervical Hysterectomy and Opportunistic Bilateral Salpingectomy are performed in the usual manner with a novel bipolar graspinging device with articulating head. Salpingectomy begins with division of the tube on the broad ligament to the cornua. Two contiguous bites are always taken from medial to lateral prior to transection with endoscopic scissors. The round ligament and utero-ovarian ligament pedicles are coagulated and divided. Dissection proceeds cauded to the area of the ascending branches of the uterine artery. Following retrograde fill of the bladder, the visceral peritoneum of the uterus is divided cephalad to the vesico-uterine plicae. Bladder is reduced on the pubo-cervical-vesical fascia. The cervix is then transected at the cervico-isthmic junction. Hemostasis is achieved at the base of the resection on the cervix. Specimen is delivered en-bloc through a posterior colpotomy. The parietal peritoneum is then sutured intercurrently between infiidibulopelvic ligaments. Copious irrigation and inspection to ensure hemostasis is conducted prior to closure. Successful completion of surgery Laparoscopic grasper / coagulator with articulating head adds to functionality and versatility without need to resort to use of robotics.

Endometriosis Affecting the Base of Appendix and the Middle Rectal Artery: A Case Report

Study Objective To demonstrate the rare case of deep endometriosis affecting the base of appendix and the middle rectal artery. Also, highlight the robotic approach assisting for a precise dissection and landmark identification. Design Case report for anatomical study and description of the procedure using video. Setting Tertiary Hospital. Patients or Participants A 38-year-old nulliparous woman presents with acyclic pelvic pain for one year, worse during sexual intercourse. She also had diarrhea during menstrual cycles and constipation the rest of the month. She underwent two failed in vitro fertilizations (IVF) and still had one frozen embryo. In the physical examination her uterus was partially fixed, and she felt pain in the posterior vaginal fornix touch. The MRI evidenced an 83.5 cc uterus, bilateral uterosacral thickening, bilateral round ligament nodules measuring 0.9 cm in the right and 1.7cm in the left. There were also an irregular fibrous tissue and adhesions on the anterior and lateral uterine aspects measuring 3.3 × 1.3 × 1.8 cm in proximity with the posterior vesical wall and right adnexa. Interventions We performed a robotic-assisted laparoscopic resection of superficial and deep lesions of endometriosis including peritoneum, uterosacral ligaments, retrocervix, round ligaments, uterus and bladder, rectum, a rare lesion in proximity with de middle rectal artery on the right and a large lesion in the base of appendix, affecting the cecum and the ileum, treated with ileocecal resection (typhlectomy) with primary ileocolic anastomosis. Measurements and Main Results Patient was discharged in the sixth postoperative day, with mild abdominal pain. The histological diagnosis confirmed endometriosis of all specimens. Conclusion We had a favorable outcome regarding the surgical approach in resecting an extensive disease with atypical lesions, including proximity to an arterial vessel and a large intestinal nodule that compromised the base of appendix. To demonstrate the rare case of deep endometriosis affecting the base of appendix and the middle rectal artery. Also, highlight the robotic approach assisting for a precise dissection and landmark identification. Case report for anatomical study and description of the procedure using video. Tertiary Hospital. A 38-year-old nulliparous woman presents with acyclic pelvic pain for one year, worse during sexual intercourse. She also had diarrhea during menstrual cycles and constipation the rest of the month. She underwent two failed in vitro fertilizations (IVF) and still had one frozen embryo. In the physical examination her uterus was partially fixed, and she felt pain in the posterior vaginal fornix touch. The MRI evidenced an 83.5 cc uterus, bilateral uterosacral thickening, bilateral round ligament nodules measuring 0.9 cm in the right and 1.7cm in the left. There were also an irregular fibrous tissue and adhesions on the anterior and lateral uterine aspects measuring 3.3 × 1.3 × 1.8 cm in proximity with the posterior vesical wall and right adnexa. We performed a robotic-assisted laparoscopic resection of superficial and deep lesions of endometriosis including peritoneum, uterosacral ligaments, retrocervix, round ligaments, uterus and bladder, rectum, a rare lesion in proximity with de middle rectal artery on the right and a large lesion in the base of appendix, affecting the cecum and the ileum, treated with ileocecal resection (typhlectomy) with primary ileocolic anastomosis. Patient was discharged in the sixth postoperative day, with mild abdominal pain. The histological diagnosis confirmed endometriosis of all specimens. We had a favorable outcome regarding the surgical approach in resecting an extensive disease with atypical lesions, including proximity to an arterial vessel and a large intestinal nodule that compromised the base of appendix.

Laparoscopic Excision of an Ectopic Pregnancy in a Non-Communicating Uterine Horn

Study Objective Describe an approach to a laparoscopic excision of a uterine horn ectopic pregnancy. Design N/A. Setting The patient was positioned in dorsal lithotomy in stirrups. Four ports were placed including an infra-umbilical port, a supra-pubic port, and two right or left lower quadrant ports 10mm from the midline above the level of the anterior superior iliac spine. Patients or Participants N/A. Interventions The right round ligament was coagulated and cut. The vesicouterine peritoneum was incised and the perivesical space was opened. The right fallopian tube was coagulated along the mesosalpinx. The right uterine artery and vein were isolated laterally and traced to the right horn pregnancy as well as to the left unicornuate uterus. A purse-string suture was performed using a running unidirectional barbed suture to isolate the vasculature pedicle feeding the horn pregnancy. The horn was separated from the uterus using the Harmonic Ace. The resulting pedicle was oversewed with barbed suture. Measurements and Main Results N/A. Conclusion Use of a purse string suture can be considered to minimize blood loss and spare the uterine vasculature at the time of uterine horn ectopic excision. Describe an approach to a laparoscopic excision of a uterine horn ectopic pregnancy. N/A. The patient was positioned in dorsal lithotomy in stirrups. Four ports were placed including an infra-umbilical port, a supra-pubic port, and two right or left lower quadrant ports 10mm from the midline above the level of the anterior superior iliac spine. N/A. The right round ligament was coagulated and cut. The vesicouterine peritoneum was incised and the perivesical space was opened. The right fallopian tube was coagulated along the mesosalpinx. The right uterine artery and vein were isolated laterally and traced to the right horn pregnancy as well as to the left unicornuate uterus. A purse-string suture was performed using a running unidirectional barbed suture to isolate the vasculature pedicle feeding the horn pregnancy. The horn was separated from the uterus using the Harmonic Ace. The resulting pedicle was oversewed with barbed suture. N/A. Use of a purse string suture can be considered to minimize blood loss and spare the uterine vasculature at the time of uterine horn ectopic excision.

Efficiencies in Robotic Radical Trachelectomy

<h3>Study Objective</h3> To demonstrate an efficient and stepwise approach to performing a robotic radical trachelectomy. <h3>Design</h3> Video description of dissection of the retroperitoneal space and identification of key structures, the nerve sparing technique, creation of a deep and lateral bladder flap, cerclage placement and specimen removal, and reapproximation of the vagina to the uterus. Patient provided consent for the video and publication. This video with no identifying patient data was exempt from Institutional Review Boards Approval. <h3>Setting</h3> Robotic-assisted laparoscopy was performed. <h3>Patients or Participants</h3> We present a patient with early-stage cervical adenocarcinoma who was an appropriate candidate for fertility-sparing surgery. <h3>Interventions</h3> After the right retroperitoneum space is entered, key landmarks are noted. After finding the ureter, the paravesical and obturator spaces were created. The superior vesical artery, obturator nerve, and uterine artery are identified and dissected. The ureter is dissected off the flap to the level of the right uterine artery and uterosacral ligament. The rectovaginal septum is then dissected as the next natural field. The same steps are repeated on the left side. The bladder flap is created, making sure that it is both deep and lateral for easier dissection of the vesicovainal ligament and visualization during robotic surgery. The uterocervical junction is incised circumferentially. The round ligaments and uterine manipulator are left in place to aid in the placement of the cerclage, removal of the specimen, and suturing of the vagina to the uterus. <h3>Measurements and Main Results</h3> Utilizing these efficiencies resulted in a shorter operative time of 2 hours and 38 minutes (versus 5 hours and 8 minutes) in this robotic radical trachelectomy. <h3>Conclusion</h3> The efficiencies were the following: an orderly fashion in going from field to field which resulted in less movements, dissecting the bladder flap deep and lateral which aided in taking down the vesicovaginal ligament and visualization, and utilizing the uterine manipulator throughout the case.

Robotic-Assisted Laparoscopic Treatment of Bladder Endometriosis

<h3>Study Objective</h3> To show the combined surgical approach of cystoscopy and robotic-assisted laparoscopy for a complete and safe resection of bladder endometriosis. <h3>Design</h3> A clinical case and surgical cystoscopic and robotic approach of bladder endometriosis resection demonstrated by video. <h3>Setting</h3> Bladder endometriosis is defined as the presence of endometrial glands and stroma in the detrusor muscle and is the most common site affected in urinary tract endometriosis. Surgical treatment should guarantee complete removal of the bladder nodule to minimize recurrence, so transurethral surgery alone should be avoided in favor of segmental bladder resection. Robotic-assisted laparoscopy provides advantages as 3D visualization and facilitation of suturing techniques compared to conventional laparoscopy. <h3>Patients or Participants</h3> A 32-year-old nulliparous patient, complaining of sensation of incomplete emptying of the bladder and dysuria, with worsening in the menstrual period. Patient had been using combined oral contraception but reported worsening of symptoms since she stopped the use in 2019. During letrozole treatment for infertility she discovered a bladder nodule of probable endometriotic origin. MRI showed signs of deep endometriosis in the vesicouterine recess, with infiltration of the anterior uterine serosa and left round ligament, measuring around 3.0 × 2.0 × 0.9 cm, in addition to the nodular lesion that infiltrates and retracts the upper wall of the bladder, projecting to the bladder lumen of 3.8 × 2.5 × 2.1 cm. <h3>Interventions</h3> It was performed cystoscopy and bilateral double-J catheter passage, followed by robotic-assisted laparoscopic resection of bladder endometriosis with partial cystectomy. Surgical field was prepared and the paravesical accessed to the bladder nodule. Bladder was sutured with barbed thread and surgical specimen removed by colpotomy. <h3>Measurements and Main Results</h3> Anatomopathological exam confirms endometriosis. <h3>Conclusion</h3> Endometriosis of urinary tract can have an appropriate surgical resection by laparoscopic management with or without robotic assistance. Having knowledge of the surgical technique and the platform allows a safe and complete resection, minimizing complications.

Go Wide before Closing in: A Safe Approach to Minimally Invasive Hysterectomy for a Large Broad Ligament Leiomyoma

<h3>Study Objective</h3> Demonstrate total laparoscopic hysterectomy technique for a large broad ligament leiomyoma. <h3>Design</h3> Surgical video <h3>Setting</h3> Tertiary-care operating room using standard equipment for laparoscopic surgery and four 5 mm trocars, a 30-degree laparoscope, and bipolar sealing device. <h3>Patients or Participants</h3> A 47-year-old female with pelvic pressure, bulkiness and occasional right sided pelvic pain found to have a twenty-centimeter broad ligament leiomyoma. <h3>Interventions</h3> She desired to have a definitive surgical treatment. She underwent total laparoscopic hysterectomy, bilateral salpingectomy, and cystoscopy. <h3>Measurements and Main Results</h3> Although leiomyomas are the most common benign tumors of the female pelvis, broad ligament leiomyomas are rare. Broad ligament is the most common extrauterine site for the occurrence of leiomyoma with the incidence of <1%. Laparoscopy revealed a large pelvic mass extending through the right board ligament and retroperitoneal space consistent with radiographic imaging. The surgery began on the left side by ligating the blood supply to the uterus in the retroperitoneal space, disconnecting the suspensory ligaments of the uterus. On the right side, the round ligament transected and the incision extended parallel to the infundibulopelvic ligament to enter the right retroperitoneum. The uterine artery was ligated at its origin and the mass was carefully enucleated out of lateral pararectal space while preserving the branches of hypogastric nerve. We utilized the colpotomy cup to demarcate our anatomical landmark and complete the hysterectomy. Pathology revealed benign leiomyoma and reported no malignancy in uterus, cervix and bilateral fallopian tubes. <h3>Conclusion</h3> Board ligament leiomyomas may pose significant anatomical distortion and adhesive disease making minimally invasive surgical approach very challenging. Anatomic knowledge is imperative to safely gain access to the retroperitoneal space, ligate the blood supplies at its origin, preserve crucial pelvic nerves and excise these masses without increasing morbidity to the patient.

Vascular Control during Robotic Myomectomy for 13cm Broad Ligament Fibroid

Study Objective Demonstrate surgical approach for a large 13 cm broad ligament fibroid, highlighting retroperitoneal anatomy and a novel method to decrease blood loss. Design A step-by-step explanation of the surgery using video (instructive video). Setting University hospital. Patients or Participants A 34-year-old woman with a 13 cm broad ligament fibroid who desires future fertility. Interventions We review entry into the retroperitoneum, more specifically, the pararectal space in a case with normal anatomy. Then, we present a case with a large broad ligament fibroid and systematically review the patient's MRI prior to showing surgical footage. The retroperitoneal dissection is initiated by transecting the round ligament and dissection continues parallel to the infundibulopelvic (IP) ligament until the psoas muscle and external iliac are identified. Blunt dissection is used to find the ureter on the medial leaflet of the broad ligament. Ureterolysis is performed given the extent of invasion by the fibroid. The pararectal space is then entered using a push and spread technique. Continued dissection laterally in the areolar tissue is used to localize the uterine artery at its origin. Once the uterine artery is skeletonized, a bulldog clamp is carefully placed to decrease blood flow. The fibroid is dissected in a clockwise fashion, starting from our dissection in the retroperitoneal space. The distal uterine artery, which is wedged between the uterus and the fibroid, is carefully dissected. Once the fibroid is completely separated from the uterine artery and surrounding tissue, the bulldog clamp is removed and vascular supply is restored. Measurements and Main Results EBL during resection of the highlighted fibroid was minimal, with overall EBL 100mL after dissection of several additional fibroids. The patient's symptoms improved and fertility was preserved. Conclusion Using retroperitoneal dissection and bulldog clamps, safe dissection of large broad ligament fibroids can be accomplished with minimal blood loss. Demonstrate surgical approach for a large 13 cm broad ligament fibroid, highlighting retroperitoneal anatomy and a novel method to decrease blood loss. A step-by-step explanation of the surgery using video (instructive video). University hospital. A 34-year-old woman with a 13 cm broad ligament fibroid who desires future fertility. We review entry into the retroperitoneum, more specifically, the pararectal space in a case with normal anatomy. Then, we present a case with a large broad ligament fibroid and systematically review the patient's MRI prior to showing surgical footage. The retroperitoneal dissection is initiated by transecting the round ligament and dissection continues parallel to the infundibulopelvic (IP) ligament until the psoas muscle and external iliac are identified. Blunt dissection is used to find the ureter on the medial leaflet of the broad ligament. Ureterolysis is performed given the extent of invasion by the fibroid. The pararectal space is then entered using a push and spread technique. Continued dissection laterally in the areolar tissue is used to localize the uterine artery at its origin. Once the uterine artery is skeletonized, a bulldog clamp is carefully placed to decrease blood flow. The fibroid is dissected in a clockwise fashion, starting from our dissection in the retroperitoneal space. The distal uterine artery, which is wedged between the uterus and the fibroid, is carefully dissected. Once the fibroid is completely separated from the uterine artery and surrounding tissue, the bulldog clamp is removed and vascular supply is restored. EBL during resection of the highlighted fibroid was minimal, with overall EBL 100mL after dissection of several additional fibroids. The patient's symptoms improved and fertility was preserved. Using retroperitoneal dissection and bulldog clamps, safe dissection of large broad ligament fibroids can be accomplished with minimal blood loss.

Decidualized Juvenile Cystic Adenomyoma Mimicking a Cornual Heterotopic Pregnancy

<h3>Study Objective</h3> To describe a rare case of a juvenile cystic adenomyoma presenting as a heterotopic pregnancy. <h3>Design</h3> Case report. <h3>Setting</h3> Private teaching hospital. <h3>Patients or Participants</h3> A 26-yo G3P1 at 7wga presented to the emergency department with complaint of vaginal spotting and mild cramping. Ultrasound identified a heterotopic pregnancy. An intrauterine pregnancy was noted with a 1.9cm gestational sac, a 1.1cm CRL, and FHR 161bpm. A second gestational sac was noted in the posterior left uterus measuring 1.58cm with CRL 0.94cm and <5mm of myometrium surrounding the sac. No cardiac activity detected. <h3>Interventions</h3> The patient was counseled regarding options for management including abortive vs non-abortive, medical vs surgical. She ultimately decided to undergo surgical treatment with preservation of the intrauterine pregnancy. Intraoperative laparoscopic ultrasound was performed with similar findings. Robotic assisted cornual wedge resection and removal of the ectopic mass was performed with preservation of the ipsilateral fallopian tube and intrauterine pregnancy. <h3>Measurements and Main Results</h3> Final pathology failed to demonstrate any fetal tissue, but rather demonstrated cystic adenomyoma. <h3>Conclusion</h3> Juvenile cystic adenomyosis (JCA) is a rare form of focal adenomyosis which is usually located near the uterine insertion of the round ligament, contains a cystic inner area >1cm and is encountered before the age of 30 years. Some authors report JCA to be an accessory cavitated uterine mass (ACUM) anomaly developing because of gubernaculum dysfunction. The only difference between the two conditions is the presence of a denser area of adenomyosis surrounding the cystic area lined with endometrium in JCA. This case demonstrates decidual changes observed in ectopic endometrial tissue within an area may be misdiagnosed as a focus of ectopic pregnancy. In non-emergency situations, waiting for the decidualization effect of ectopic endometrium to subside can help in the definitive diagnosis of such cases.

Case Report: Young Nulligravid with Chronic Non-Puerperal Uterine Inversion Secondary to a Prolapsed Myoma with Malignant Histopathology

<h3>Study Objective</h3> To present an interesting case report of a 23-year-oldnulligravid with a 5-month history of heavy and prolonged vaginal bleeding with intermittent hypogastric pain. Examination showed a necrotic mass measuring 7 × 8 × 5 cm occupying the vaginal vault with no palpable cervix and uterus. Ultrasound confirmed a prolapsed submucous myoma with uterine inversion. Admitting diagnosis was chronic and complete non-puerperaluterine inversion secondary to prolapsed infected submucous myoma with secondary anemia. The patient was anemic with leukocytosis and she was given intravenous antibiotic and transfused with packed RBC, properly typed and crossmatched. Biopsy of the prolapsed mass revealed an infarcted polyp. Surgical plan was to preserve fertility and perform a hysteroscopic- and laparoscopic- guided vaginal myomectomy followed by uterine repositioning. On diagnostic hysteroscopy, there was no identifiable cervix, the prolapsed mass was too large and surgical landmarks were not identified. Concurrent laparoscopy revealed the uterus was inverted into a constricted "flower-pot" cervical ring towards the vaginal canal at the level of the round ligaments and bilateral ovaries and fallopian tubes were grossly normal. Proceeded with amputation of the prolapsed mass in a piecemeal fashion followed by attempts at uterine repositioning by Huntington's and Hultain's maneuvers but were not successful. The remaining vaginal mass was too large to pass through the cervix hence decision was to proceed with laparoscopic total hysterectomy with bilateral salpingectomy. Histopathology revealed Malignant Spindle Cell Neoplasm. <h3>Design</h3> N/A. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> N/A. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Uterine inversion is rare in the non-puerperal period and is often difficult to diagnose and manage. There should be high index of suspicion in the setting of a mass protruding from the vagina, non-palpable uterus, and pelvic organs not visualized on ultrasound. When inversion is chronic, reverting maneuvers may prove difficult rendering fertility-sparing techniques implausible. In the setting of fertility preservation, malignancy must be ruled out.

Oophoropexy for Prevention of Recurrent Torsion of Normal Adnexa

<h3>Study Objective</h3> The conservative management of otherwise normal adnexal torsion by de-torsion may lead to recurrent torsion events. With the aim of reducing recurrent torsion events, various oophoropexy techniques have been suggested. We aimed to investigate the efficacy of oophoropexy in preventing recurrent torsion. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> University affiliated department of Obstetrics and Gynecology. <h3>Patients or Participants</h3> Cases of oophoropexy operated between January 2010 and March 2021. <h3>Interventions</h3> Laparoscopic oophoropexy techniques (plication of the utero-ovarian ligament and/or fixation to the round ligament), using non-absorbable sutures. <h3>Measurements and Main Results</h3> 15 patients with recurrent torsion of otherwise normal adnexa who underwent oophoropexy were identified. At time of the first torsion event, the mean patients' age was 18.3 ± 7.4 years, and 4 (26.7%) were pre-menarchal. The recurrent torsion involved the right adnexa in 9 (60.0%) cases, the left adnexa in 4 (26.7%) cases, and both adnexa in 2 (13.3%) cases. The mean interval between the first and second torsion events was 17.8 ± 20.2 months. In 3 (20.0%) cases, no recurrence occurred following oophoropexy, while in the remaining 12 (80.0%) cases, up to 4 recurrences were diagnosed. <h3>Conclusion</h3> Laparoscopic oophoropexy procedures, although feasible and safe, may not prevent recurrent torsion of otherwise normal adnexa.

Laparoscopic Management of Type 2 Cesarean Scar Pregnancies - Planning and Procedural Execution

<h3>Study Objective</h3> With increasing caesarean deliveries, Caesarean scar pregnancies CSP are also on the rise. We report our experience from successful laparoscopic management of type 2 exogenic CSPs which invades deep, projects into the vesicouterine fold and has the dangerous potential for rupture and massive hemorrhage. <h3>Design</h3> NA. <h3>Setting</h3> tertiary referral center. <h3>Patients or Participants</h3> four women confirmed to have type 2 cesarean scar pregnancy. <h3>Interventions</h3> MRI was done for preoperative planning to clearly define the sac, note dehiscence of scar and adherence of uterine corpus to anterior abdominal wall. This spatial resolution gave a good mental picture. At Laparoscopy, first adhesions are released and round ligaments divided temporarily, giving better access to lower uterine segment for surgery and suturing. Prior to making an incision on the uterus, the complete scar with sac inside is exposed till the anterior cervix. Careful controlled dissection avoids excessive bleeding and staining, which could result in loss of anatomic orientation and even panic. Bilateral uterine artery occlusion and Local injection of vasopressin are interventions used for decreasing bleeding from otherwise highly vascular gravid uterus. After complete resection and removal of the products, Full thickness, equidistant repair of LUS defect is aided by barbed suture. A Hegar's dilator placed in situ during the suturing phase prevents accidental approximation of uterine walls. Here we humbly acknowledge that we have managed laparoscopically one of the most advanced CSP reported so far at 16 weeks gestational age. <h3>Measurements and Main Results</h3> all four women had procedures accomplished laparoscopically, with complete resection of the type 2 CSPs and satisfactory reconstruction of defect, also received the benefits of the minimally invasive surgery such as less pain, less scar and rapid return to work. <h3>Conclusion</h3> Laparoscopy here is proven safe and effective, in view of excellent visualization, complete removal of pathology, good reconstruction of the defect, and should be the choice where facilities exist.

Laparoscopic Peritoneal Pull through Vaginoplasty with Ovarian Hitching to Facilitate Transvaginal Oocyte Retrieval for Mrkh Syndrome

<h3>Study Objective</h3> Video demonstration of laparoscopic peritoneal pull through vaginoplasty using the midline bands and mobilization of ovaries in the pelvis to facilitate transvaginal oocyte retrieval in a case of MRKH. <h3>Design</h3> Interesting case video. <h3>Setting</h3> Lithotomy. <h3>Patients or Participants</h3> Case of MRKH Syndrome. <h3>Interventions</h3> Laparoscopy. Bladder and rectum was dissected away from midline band between the Uterine buds. NeoVagina created vaginally making a U-shaped incision at the perineum. Peritoneal flaps made using the midline band. This band was cut. The vaginal vault opened using a sponge on holder inserted through the neovagina. The right and left peritoneal flaps were pulled down to the introitus to line the anterolateral part of neovagina and stitched at the end, smooth surface facing out. Releasing incisions made around the ureter, to prevent kinking.The rectovaginal peritoneal was brought down and stitched at the introitus to line the posterior surface of vagina. The neoapex made by passing a circumferential suture of the peritoneum. A mould made was inserted in the neovagina. Ovaries were mobilized into the pelvis and hitched in the POD, after making releasing incisions over the infundibulopelvic and the round ligament to facilitate transvaginal oocyte retrieval. <h3>Measurements and Main Results</h3> Post surgery mould kept for 4 days. A vaginal dilator for 3 to 6 months. Tranvaginal oocyte retrieval planned after 12 weeks. Now 6 weeks post-surgery and can use the vaginal dilator 10 hrs/day. <h3>Conclusion</h3> A peritoneal pull through vaginoplasty can be performed for a case of MRKH using the peritoneum covering the midline band for lining the anterolateral surface of neovagina and rectovaginal peritoneal lining the posterior surface of neovagina. Since this patient needs IVF and surrogacy, the oocyte retrieval in a case of MRKH is a challenge since the ovaries are high at the pelvic brim. The ovaries can be mobilized into the pelvis and a tranvaginal oocyte retrieval can be performed.

A Twist of Fate: Laparoscopic Management of Recurrent Ovarian Torsion

<h3>Study Objective</h3> To describe and demonstrate laparoscopic oophoropexy techniques in a patient with recurrent ovarian torsion <h3>Design</h3> Surgical video presentation. <h3>Setting</h3> Academic tertiary care center. <h3>Patients or Participants</h3> This is a 22-yo nulliparous patient who had 3 episodes of recurrent ovarian torsion. Pelvic ultrasound between each ovarian torsion presentation showed normal doppler flow, however the ovary remained enlarged. <h3>Interventions</h3> For her first episode of ovarian torsion, the patient underwent a diagnostic laparoscopy with detorsion of the right adnexa and a right oophorpexy, where the utero-ovarian ligament was attached to the ovarian parenchyma using a single mattress suture. 10 months later she presented with another episode of ovarian torsion and was consented for laparoscopic right ovarian detorsion and oophoropexy. Due to the patient's now second episode of right ovarian torsion, her oophorpexy was performed using permanent suture and attaching the utero-ovarian ligament to the round ligament and ovarian stroma. 4 months after her second oophoropexy the patient presented with another episode of right ovarian torsion. She declined a third oophoropexy and opted for a right oophorectomy. <h3>Measurements and Main Results</h3> The patient recovered well after each surgical intervention for her ovarian torsion and was discharged on the same day of her operations. Pathology report from the right ovary showed a benign ovary with vascular congestion and marked edema, consistent with the clinical history of ovarian torsion. <h3>Conclusion</h3> This case of recurrent ovarian torsion is unusual in that there were two failed oophoropexy attempts and no ovarian cyst present. Even though our patient opted for an oophorectomy after her third ovarian torsion; laparoscopic detorsion and oophoropexy remains the best management option for recurrent ovarian torsion.

248 Rectus flap for repair of Strangulated Obturator Hernia

Abstract Introduction Obturator hernia (OH) is a rare abdominal wall hernia which commonly presents as small bowel obstruction. Surgical options include suture repair or use of autologous tissue or a mesh repair when primary suture repair is not feasible. We describe a case involving the use of the rectus abdominus muscle to repair a large OH. Case report An 81-year-old female presented with three days of abdominal distension and vomiting. A computerised tomography scan confirmed small bowel obstruction due to an obstructed left OH. At laparotomy, a short segment of non-viable distal ileum was reduced from the sac and resected with a primary anastomosis. The obturator defect was not amenable for suture approximation and due to concerns of possible mesh infection, the ipsilateral rectus muscle belly was mobilised from the anterior sheath, routed extra-peritoneally to plug the defect without tension. The muscle was anchored with prolene sutures to the cooper’s ligament, pectineus muscle and the fascia overlying the inner surface of inferior pubic ramus. Four months post-operatively, she has made an excellent recovery with no concerns currently. Conclusions In OH with a large defect precluding primary suture repair, a range of options have been described (use of autogenous peritoneal fold, pectineus muscle, round ligament, ovary, uterine fundus, omental and mesh plugs, and biological mesh). We believe, to plug and cover the defect, rectus muscle flap is a viable option giving a tension free robust repair, especially in patients with gangrenous bowel and local contamination.

Objective follow-up after transection of uterine round ligament during laparoscopic repair of inguinal hernias in women: assessment of safety and long-term outcomes.

Whether to preserve the uterine round ligament during laparoscopic inguinal hernia repair in women is controversial. In this study, we aimed to compare outcomes of uterine round ligament preservation versus transection during such surgery and to explore the impact and long-term outcomes of transecting the round ligament. The study cohort comprised 419 women who had undergone laparoscopic inguinal hernia repair in Beijing Chaoyang Hospital and Qilu Hospital from January 2013 to January 2020; 393 (93.8%) of whom were successfully followed up. Patient characteristics and technical details of the operative procedure were collected and analyzed retrospectively. Early and late postoperative follow-up data, complications, especially symptoms related to retroflexed uterus, and fertility outcomes, were collected by a single follow-up nurse who was blinded to the operative procedure. There were 218 women (239 sides) in the uterine round ligament preservation group and 175 (182 sides) in the transection group. The patients in the preservation group were younger (45.9 vs. 53.6years, p = 0.000), and had lower American Society of Anesthesiologists scores (p = 0.000). The median follow-up times in the preservation and transection groups were 41.8 ± 24.2 and 42.7 ± 24.6months, respectively (p = 0.692). Compared with the transection group, the preservation group had longer operative times for repair of both primary and recurrent hernias. Intraoperative bleeding, length of hospital stay, development of seromas, recurrence rate, incidence of postoperative pain at the first and third postoperative months, and time of last outpatient visit were similar in the two groups. There were more premenopausal patients in the preservation group; however, we found no evidence that transection of the round ligament affected subsequent pregnancy or childbirth. Moreover, we identified no differences in dyspareunia, dysmenorrhea, chronic pelvic pain, or uterine prolapse. Transection of the round ligament during laparoscopic inguinal hernia repair in women does not increase the incidence of dyspareunia, dysmenorrhea, chronic pelvic pain, or uterine prolapse, whereas it has the advantage of reducing the operation time.

Extremely Rare Transitional Cell Carcinoma of The Round Uterine Ligament - Histopathogenesis, Immunohistochemical Analysis, Prognosis and Optimal Complex Treatment

For the first time in the English medical literature is presented an extremely rare transitional cell carcinoma of the round uterine ligament. Transitional cell carcinoma (TCC) of the ovary was first defined by Austin and Norris in 1987. Malignant primary tumors arising in the uterine broad ligament are extremely rare. To date, its pathogenesis is unclear. In the discussion we focus on the pathomorphological and immunohistochemical analysis of transitional cell carcinomas in the genital tract and their differential diagnosis from transitional cell carcinomas of the urinary tract / ureter and bladder. Due to the high malignant potential, the prognosis is unfavorable and requires optimal complex treatment, including radical surgery followed by systemic chemotherapy.

Rare Portal Venous Anomaly in a Living Liver Donor: A Case Report

Knowledge of the anatomy of the portal system is essential for safe liver resection. We report a very rare anatomic anomaly of the portal system in a living liver donor. A 24-year-old female living liver donor was found to have anomalies of the portal system on preoperative contrast-enhanced computed tomography. The ventral branch of the right anterior segment arose from the transverse portion of the left portal vein. The gallbladder and round ligament were positioned normally. Intraoperative cholangiography for evaluation of biliary anatomy revealed very low confluence of the right and left hepatic ducts. All the bile ducts from the right lobe merged into the right hepatic duct. A right lobe graft was performed, including the ventral area of the right anterior segment. The portal branch of the ventral area of the right anterior segment could be transected extrahepatically. In the recipient operation, each of the right main portal branches, including the right posterior segment branch and the dorsal branch of the right anterior segment, and the ventral branch of the right anterior segment, were anastomosed to the right and left branches of the portal vein, respectively, of the recipient. The transected right hepatic duct of the graft was anastomosed with the recipient's common hepatic duct. Sixteen years after the liver transplant, the recipient continues to do well and has good portal flow.