Uterine Manipulator Research Articles

An Extraordinary Location of Sentinel Lymph Nodes in a Patient with Endometrial Cancer

To show dissection of sentinel lymph nodes. A step-by-step demonstration of the technique with narration. Endometrial cancer (EC) is the most common gynecologic malignancy worldwide. Sentinel lymph node biopsy with indocyanine green (ICG) has become more widely used and has been featured in recently published guidelines for EC [1]. Minimally invasive approaches with the sentinel lymph node concept (conventional laparoscopy, laparoscopic-assisted vaginal surgeries or robotic) to EC staging have resulted in lower rates of peri- and postoperative complications than conventional staging procedures [2]. No video article has been published in the literature about high pelvic, para-aortic sentinel lymph node dissection. An informed consent form was obtained from the patient. An institutional review board approval was not required. A 45-year-old female with gravidity 0, parity 0, and body mass index of 23.4 kg/m2 presented with complaints of abnormal uterine bleeding (spotting). Increased endometrial thickness was detected on transvaginal ultrasound (10 mm) in the postmenstrual period. Endometrioid-type endometrial adenocancer with focal squamous differentiation International Federation of Gynecology and Obstetrics grade I was detected on endometrial biopsy. The patient had hepatitis B virus positivity and no other chronic disease. A laparotomic myomectomy had been performed in 2016. Laparoscopic high pelvic, low para-aortic sentinel lymph node dissection with ICG and hysterectomy (without uterine manipulator)+bilateral salpingo-oophorectomy were performed (Supplemental Video 1). The operation time for the procedure was 110 minutes and the estimated blood loss was <20 mL. No major complications occurred during or after the surgery. The patient stayed in the hospital for 1 day. The final pathology result showed an International Federation of Gynecology and Obstetrics grade I, endometrioid-type endometrial adenocancer with focal squamous differentiation, as a 1.5×1 cm tumorous mass invading less than one-half of the myometrium. Neither lymphovascular invasion nor sentinel lymph node metastasis was detected. A multicenter, prospective study showed that sentinel lymph node dissection with ICG in clinical stage 1 EC is feasible and has a high degree of diagnostic accuracy in detecting EC metastases. In that study, isolated para-aortic sentinel lymph node was detected in 3 of 340 patients (<1%) [2]. Another study reported the detection rate of isolated para-aortic sentinel lymph node to be 1.1% in patients with intermediate- and high-risk EC [3]. There are in some cases 2 distinct channels emanating from one side, and it is important to follow each and to acknowledge there may be more than one sentinel, one of which is lower in a typical location and one higher as in this case. This video article is the first video demonstration of bilateral isolated high pelvic, para-aortic sentinel lymph node dissection in EC.

Clinical Relevance of Uterine Manipulation on Oncologic Outcome in Robot-Assisted versus Open Surgery in the Management of Endometrial Cancer

In this study, we investigated the impact of uterine manipulation on endometrial cancer survival outcomes. We analyzed patients with endometrial cancer who underwent robot-assisted staging and open staging surgery between 2010 and 2020. Either uterine manipulators or vaginal tubes were utilized in robot-assisted staging. Propensity score matching was performed to correct baseline characteristics. Progression-free survival (PFS) and overall survival (OS) were analyzed using Kaplan-Meier curve analysis. In total, 574 patients, including those undergoing robot-assisted staging with a uterine manipulator (n = 213) or vaginal tube (n = 147) and staging laparotomy (n = 214), were analyzed. Propensity score matching was performed for age, histology, and stage as covariates. Before matching, Kaplan-Meier curve analysis showed that PFS and OS were significantly different among the three groups (p < 0.001 and p = 0.009, respectively). In the propensity-matched cohorts of 147 women, the previously suggested differences in PFS and OS were not observed in patients undergoing robot-assisted staging with a uterine manipulator or vaginal tube or open surgery. In conclusion, robotic surgery using a uterine manipulator or vaginal tube did not compromise survival outcomes in endometrial cancer management.

Operating without a uterine manipulator in robotic-assisted hysterectomy

Operating without a uterine manipulator in robotic-assisted hysterectomy

Uterine manipulators: how and when to use them

Uterine manipulators: how and when to use them

A RETROSPECTIVE STUDY OF OUR NINE YEARS OF EXPERIENCE WITH ABNORMAL PLACENTATION — RISK FACTORS AND PREGNANCY OUTCOMES

Purpose: Placenta previa and morbidly adherent placenta are life-threatening conditions that necessitate close monitoring during pregnancy and can result in increased ante- and intrapartum complications. This study aims to evaluate the frequency of placental disorders in our population, reveal the impact of the known risk factors on maternal morbidity, and study new predisposing conditions and their effects on pregnancy outcomes. Materials and Methods: We performed a single-centered retrospective study in which we analyzed 330 women diagnosed with abnormal placentation—placenta previa and placenta accreta spectrum (PAS). We included all the women that gave birth at Nadezhda Hospital, from March 2013 to August 2021. We processed the data using the chi-square test, Cramer's V test, and cross-section analysis. Results: The frequency of placenta previa in our population is higher than the worldwide reported data. We were unable to demonstrate the connection between previous uterine manipulations (c-section, D&amp;C, operative hysteroscopy, etc.) and the occurrence of higher-grade placenta previa in our population. However, the more surgeries performed, the more complications during pregnancy and delivery occur (antepartum bleeding, increased blood loss, surgical management of postpartum hemorrhage, peripartum hysterectomy). Pregnancies following assisted reproductive techniques (ART) are at a three-times higher risk of placenta previa. Endometriosis determines a greater risk of developing an abnormally adherent placenta. Conclusion: More prospective studies need to be performed to define the exact risk factors for abnormal placentation that affect the Bulgarian population. A better understanding of the condition will lead to better management of higher-risk pregnancies, thus reducing maternal and fetal morbidity.

Short-term and Long-term Outcomes in Patients with Early-stage Cervical Cancer, Comparing Clinical and Adjuvant Therapy between Laparoscopic and Open Radical Hysterectomy: A Systematic Review and Meta-analysis

BACKGROUND: Cervical cancer represents one of the most common gynecological malignancies worldwide and the standard treatment has been radical abdominal hysterectomy (RAH). Recent surgical developments can be done through minimally invasive surgery (MIS) using laparoscopic radical hysterectomy (LRH), but the data regarding LRH are still conflicting. AIM: Therefore, we undertook a systematic review and meta-analysis comparing the short-term and long-term outcomes of laparoscopic versus RAH in women with early-stage cervical cancer. METHODS: A systematic search was performed within PubMed, Cochrane, Science Direct, and Google Scholar databases to research the outcome of LRH versus RAH in early-stage cervical cancer. Two reviewers independently reviewed titles, abstracts, and full article text to identify studies meeting inclusion and exclusion criteria. If there any discrepancies, it will be resolved by discussion. The Newcastle–Ottawa scale (NOS) was used to assess the risk of bias of non-randomized studies in this analysis. We used Review Manager 5.4 to calculate the result of 95% CI for the outcomes, odds ratio (OR), and mean differences (MD). The endpoints of interest are short-term, during operation, early post-operation, and long-term outcomes. RESULT: The initial search identified 3.030 citations after a comprehensive review of the final 35 observational studies included, involving 6.919 early-stage cervical cancer patients. Pooled analysis showed that LRH had better intraoperative outcomes, estimated blood loss (EBL) significantly lower LRH (MD = 145.88 [95% CI: 132.84–158.92; p &lt; 0.0001; I2 = 94%]), lesser intraoperative urinary tract injury (OR = 0.91), and vascular injury (OR = 0.76) but was not significant, number of pelvic lymph nodes resected tended to be higher in RAH with MD = 3.63 (95% CI: 3.10–4.15; p &lt; 0.0001; I2 = 95%), shorter bowel recovery time post-operative (MD = 0.05 [95% CI: 0.34–0.66; p &lt; 0.001]). Uniquely, the duration of surgery was not significantly different but still shorter in LRH with MD = 0.73. Long-term outcome was not significantly different for LRH from survival (OR = 1.17) and recurrence (OR = 0.83). LRH had shorter length of stay post-operative (MD = 13.23 [95% CI: 12.98–13.47; p &lt; 0.001; I2 = 100%]) and tend to use significantly fewer adjunctive chemotherapy treatments (OR = 1.84 [95% CI: 1.38–2.45; p &lt; 0.001; I2 = 73%]), the same was seen in radiotherapy treatment (OR = 1.27 [95% CI: 1.03–1.58; p = 0.03; I2 = 68%]). DISCUSSION: The result demonstrated that for the long-term outcome, there was no significant difference between the two techniques. In general, LRH is considered to be associated with better recovery, smaller scar, and faster back to normal life than ARH. Some comparative studies have reported that survival outcome and perioperative complications after LRH are comparable to those after ARH. However, some study found that MIS was associated with a higher risk of death than open surgery for patients with tumor size ≥2 cm (HR 1.66, 95% CI: 1.19–2.30) and had significantly worse progression-free survival than those in the open surgery group with tumor size &gt;2 cm and ≤4 cm (p = 0.044). This may be because of the use of uterine manipulator or because the difference approaches in handling the vaginal margin. Thus, avoiding tumor spillage and diminishing tumor handling during MIS may be beneficial. A Korean study demonstrated that LRH was associated with a lower total cost of care within 6-month postoperatively than RAH. It appeared that using laparoscopic approach was the least expensive approach from a societal perspective followed by robotic and then abdominal hysterectomy. CONCLUSION: This systematic review and meta-analysis of observational studies found that among patients who underwent radical hysterectomy for early-stage cervical cancer, LRH had a better outcome in intraoperative, faster post-operative recovery time, and less need for adjunctive therapy.

An optimized robotic surgical technique for cervical cancer: investigating whether the use of the pulling robotic arm has better surgical outcomes.

The evidence for adopting the 3rd robotic arm (RA) called the pulling RA rather than a uterine manipulator to manipulate the uterus in the robotic radical hysterectomy (RRH) for cervical cancer is still limited. We present a single-center retrospective experience comparing using the pulling RA to replace a uterine manipulator vs. using a uterine manipulator to manipulate the uterus in RRH. 106 patients diagnosed with IA, IB1-IB2 and IIA1 cervical cancer were retrospectively included for intraoperative and postoperative parameters analysis. 50 patients received RRH by adopting the pulling RA instead of a uterine manipulator to pull the uterus (3-RA RRH group), and another 56 patients were performed RRH with a uterine manipulator (2-RA RRH group). RRH with the pulling RA consisted of a camera arm, 3 RAs including a pulling RA, and 2 conventional assistant arms (3-RA RRH group). In comparison, RRH with a uterine manipulator included 2 RAs and 2 conventional assistant arms (2-RA RRH group). Besides, 3-RA' RRH group was selected from the 25th-50th cases in the 3-RA RRH group based on the learning curve and was compared with the 2-RA RRH group in terms of intraoperative and postoperative parameters. The patients' early post-operative complication (≤7 days) (p=0.022) and post-operative anemia (p < 0.001) of the 3-RA RRH were significantly lower than that in the 2-RA RRH group. The results of comparing the 2-RA RRH group with the 3-RA' RRH group were consistent with the aforementioned results, except for the operative time (220.4 vs. 197.4 minutes, p=0.022) and hospital stay (7.8 vs. 8.7 days, p=0.034). The median follow-up in the 3-RA RRH and 2-RA RRH groups was 29 and 50 months till March 2023. The 3-RA RRH and 2-RA RRH groups' recurrence rates were 2% (1/50) and 5.4% (3/56), respectively. The mortality in the 3-RA RRH and 2-RA RRH groups was 2% (1/50) and 3.5% (2/56), respectively. Our study suggested that replacing the uterine manipulator via the 3rd RA is viable; the results showed comparable surgical outcomes between the two methods. Thus, 3-RA RRH could be considered a well-executed surgical option in well-selected patients.

Hysterectomy through Minimally Invasive Surgery for Cervical High-grade Intraepithelial Neoplasia: Reassessment of the Specimens' Eligibility for Histological Examination.

The objective was to investigate the microscopic artifacts made in the uterus of cervical high-grade squamous intraepithelial lesion (HSIL) resected by hysterectomy through minimally invasive (H-MI) procedures and to verify whether these specimens are suitable for histopathological assessment. This single-center retrospective study analyzed 28 patients with cervical HSIL, consisting of 21 premenopausal and seven postmenopausal women, who underwent H-MI. The proportion of the cervical mucosa covered by intact surface epithelium (residual ratio [RR]) was measured on microscopically. Surgical margin's status was also verified. All cases developed detachment of the cervical surface epithelium to a varying extent. The RR was significantly higher in the premenopausal patients (median: 75.5%) than in the postmenopausal patients (median: 37.6%). Among the premenopausal patients, the RR was lower in the cases on whom uterine manipulator (UM) was used (median: 70.5%) than in the cases without UM use (median 92.7%). Among the 21 cases whose resected uterus contained HSIL, the vaginal resection margin was not assessable in three (14.2%) of the seven postmenopausal cases due to the artifact. Although transvaginal manipulation of the uterus causes detachment of the cervical surface epithelium, H-MI for cervical HSIL provides an acceptable specimen for histological assessment in premenopausal patients, even if UM is used. In postmenopausal women, H-MI easily develops artifactual loss of cervical surface epithelium, sometimes providing an unfavorable specimen for microscopic assessment.

Assessment of Pre-operative Vaginal Preparation for Laparoscopic Hysterectomy.

Determine the difference in microbial growth from the vagina and uterine manipulator among patients undergoing laparoscopic hysterectomy after randomization to one of three vaginal preparation solutions (10% Povidone-iodine, 2% Chlorhexidine, or 4% Chlorhexidine). This was a prospective randomized controlled trial in an academic community hospital. Patients were ≥ 18 years old and scheduled for laparoscopic hysterectomy for benign and malignant indications. Fifty patients were identified and randomized into each arm. Prior to surgery, the surgical team prepared the vaginal field using 10% Povidone-iodine, 2% Chlorhexidine, or 4% Chlorhexidine, according to group assignment. Cultures were collected from the vagina after initial preparation, prior to the colpotomy, and on surfaces of the uterine manipulator. Bacterial count from the baseline vaginal fornix/cervical canal cultures did not differ significantly among the three groups. There was a difference in bacterial count among the second cervical canal/vaginal fornix cultures (p < 0.01), with the Povidone-iodine arm demonstrating the highest level of growth of cultures (93.8%), followed by 2% Chlorhexidine (47.4%), and 4% Chlorhexidine (20%). There was no difference in growth on the uterine manipulator handle and no difference in vaginal itching or burning was found across the three arms postoperatively. Bacterial growth prior to colpotomy was the lowest with 4% Chlorhexidine followed by 2% Chlorhexidine, the Povidone-iodine group exhibited the highest bacterial growth. There was no difference in moderate to severe vaginal itching or burning. This showed that 4% Chlorhexidine is superior in reducing bacterial growth when used in laparoscopic hysterectomy.

The sealing effect of magnetic-sealing uterine manipulator in isolated uterus from patients with early-stage cervical cancer: a pre-clinical study.

Traditional uterine manipulator is considered as the main reason for short survival of patients with early-stage cervical cancer during minimally invasive surgery. This study aims to assess the sealing effect of magnetic-sealing uterine manipulators (MUMs) in isolated uteruses. The study was performed on isolated uterus from patients with early-stage cervical cancer who underwent open abdominal radical hysterectomy between November 2019 to April 2021. Right-angle forceps closure tests (groups 1 and 3) were defined as control tests. One experimental MUM closure test (group 2) and 2 control tests were respectively carried out in each of the isolated uterus. DNA ploidy analysis system was used to observe exfoliated cells. Statistical analysis was performed using Wilcoxon signed-rank test to assess the sealing effect of MUM. We identified 36 patients. No regional node metastasis was discovered and only one tumor was larger than 4.0 cm in diameter. The mean of exfoliated tumor cells in groups 1, 2, and 3 were 1, 1, and 2, respectively. There was no significant difference in the quantity of exfoliated cells between groups 1 and 3 (p=0.476), so the results of the 2 groups were merged. Subsequently, a significant difference was observed between combined right-angle forceps closure tests and MUM closure tests (p=0.022). The sealing effect of MUM was better than that of right-angle forceps. MUM can effectively seal cervical cancer cells in the cup cover, avoiding the dissemination of tumor cells. Chinese Clinical Trial Register Identifier: ChiCTR1900026012.

Minimally invasive radical hysterectomy and the importance of avoiding cancer cell spillage for early-stage cervical cancer: a narrative review.

Radical hysterectomy is a standard surgery to treat early-stage uterine cervical cancer. The Laparoscopic Approach to Cervical Cancer (LACC) trial has shown that patients receiving minimally invasive radical hysterectomy have a poorer prognosis than those receiving open radical hysterectomy; however, the reason for this remains unclear. The LACC trial had 2 concerns: the learning curve and the procedural effects. Appropriate management of the learning curve effect, including surgeons' skills, is required to correctly interpret the result of surgical randomized controlled trials. Whether the LACC trial managed the learning curve effect remains controversial, based on the surgeons' inclusion criteria and the distribution of institutions with recurrent cases. An appropriate surgical procedure is also needed, and avoiding intraoperative cancer cell spillage plays an important role during cancer surgery. Cancer cell spillage during minimally invasive surgery to treat cervical cancer is caused by several factors, including 1) exposure of tumor, 2) the use of a uterine manipulator, and 3) direct handling of the uterine cervix. Unfortunately, these issues were not addressed by the LACC trial. We evaluated the results of minimally invasive radical hysterectomy while avoiding cancer cell spillage for early-stage cervical cancer. Our findings show that avoiding cancer cell spillage during minimally invasive radical hysterectomy may ensure an equivalent oncologic outcome, comparable to that of open radical hysterectomy. Therefore, evaluating the importance of avoiding cancer cell spillage during minimally invasive surgery with a better control of the learning curve and procedural effects is needed.

Influence of uterine manipulator use on the incidence of lymphovascular propagation in the treatment of endometrial cancer

Background Endometrial cancers are among the epithelial malignancies of the lining of the uterine cavity. The invasion of carcinoma into the lymphovascular space (LVSI) is considered a risk factor for the course of the disease. Material and methods We evaluated 170 female patients. Our primary objective was to find any difference in the incidence of LVSI in female patients treated with and without an intrauterine manipulator. In addition, we analyzed the effect of the type of intrauterine manipulator used on the incidence of LVSI, tumor grading, myometrial invasion, and the method of obtaining primary histology with regard to the incidence of LVSI. Results Using a manipulator during surgery was not associated with LVSI (with a manipulator vs. without, 11.5 vs. 21.7%; OR 1.8; 95% CI 0.73–4.39; p = 0.199). However, the method used to obtain the primary histology had a statistically significant effect on the incidence of LVSI in our set (p-value = 0.011). Conclusions In our study, we did not confirm the effect of a uterine manipulator on the possible increase of LVSI positive cases. The secondary analysis indicated a higher incidence of LVSI in the female patients diagnosed with curettage than in those who underwent hysteroscopy. Trail registration: Trail is registered in ClicincalTrails.gov with identifier: NCT05261165.

Does the Use of a Uterine Manipulator or Intracorporeal Colpotomy Confer an Inferior Prognosis in Minimally Invasive Surgery–Treated Early-stage Cervical Cancer?

To identify whether the use of a uterine manipulator (UM) or intracorporeal colpotomy conferred inferior short-term survival among patients treated for early-stage cervical cancer. Retrospective cohort study. Tertiary university-based hospital. 1169 patients with stage IB1 to IB2 cervical cancer. All patients underwent minimally invasive radical hysterectomy and pelvic lymphadenectomy. A total of 1169 patients diagnosed with preoperative stage IB1 to IB2 cervical cancer were primarily treated with surgery from 2018 to 2019. The eligible patients had a median age of 48 years (range, 23-76 years), and the median follow-up time was 34 months (range, 3.57-50.87 months). The 2-year overall survival rate of the patients with pathologic stage IB1 and IB2 was 99.8% and 98.8%, respectively, according to the 2018 International Federation of Gynecology and Obstetrics staging system. Univariable analysis revealed that the UM group had a 7.6-times higher risk of death than that of the manipulator-free group (p=.006), but multivariable analysis clarified that only tumor size (p=.016; hazard ratio, 2.285; 95% confidence interval, 1.166-4.479) and parametrial involvement (p=.003; hazard ratio, 3.556; 95% confidence interval, 1.549-8.166) were independent risk factors for overall survival. There was no statistically significant difference in survival between patients who underwent intracorporeal and protective colpotomy. Short-term survival outcomes in women undergoing minimally invasive radical hysterectomy for treatment of early-stage cervical cancer did not differ when a UM was avoided or when a protective colpotomy was performed.

Exophytic interstitial ectopic pregnancy removal: novel use of Endoloop for uterine cavity preservation

Exophytic interstitial ectopic pregnancy removal: novel use of Endoloop for uterine cavity preservation

Survival after minimally invasive radical hysterectomy without using uterine manipulator for early-stage cervical cancer: A systematic review and meta-analysis.

Minimally invasive radical hysterectomy has been reported to increase the risk of cancer relapse and death compared with open surgery in women with early-stage cervical cancer. The use of a uterine manipulator is considered one of the risk factors. To investigate whether women with early-stage cervical cancer treated with minimally invasive radical hysterectomy without using uterine manipulator have oncological outcomes similar to those of open surgery. Searches were performed in MEDLINE, Embase and CENTRAL from their inception until 31 March 2022. Inclusion criteria were: (1) randomised controlled trials or observational cohort studies published in English, (2) studies comparing minimally invasive radical hysterectomy without using a uterine manipulator with open radical hysterectomy in women with early-stage cervical cancer, and (3) studies comparing survival outcomes. Two authors independently conducted data extraction and assessed study quality. We calculated the hazard ratios (HR) and the 95% confidence intervals (CI) using the inverse variance approach for survival outcome. Six observational studies with 2150 women were included. The minimally invasive surgery group had a significantly higher risk of cancer relapse compared with open surgery group (HR 1.55, 95% CI 1.15-2.10). Minimally invasive radical hysterectomy without using a uterine manipulator resulted in an inferior recurrence-free survival compared with open radical hysterectomy in the treatment of women with early-stage cervical cancer.

7897 Bladder Injury Caused by Uterine Manipulator

<h3>Study Objective</h3> This video demonstrates identification and management of a bladder injury caused by a uterine manipulator <h3>Design</h3> Surgical video <h3>Setting</h3> Academic medical center <h3>Patients or Participants</h3> A 34-year-old G0 with endometriosis, bilateral endometriomas, and subserosal fibroids desiring fertility underwent a robotic-assisted abdominal exploration with excision of endometriosis and myomectomy. Uterine manipulator was placed at the start of the case. Exposure to the surgical field was limited by inadequate uterine manipulation, which was thought to be attributed to the significant adhesive disease. At the start of the anterior compartment dissection, it was suspected that the uterine manipulator tip may have perforated into the bladder. A 3mm perforation was confirmed on cystoscopy. <h3>Interventions</h3> A bladder flap was further developed but the defect was too caudal to be accessed in this plane. The space of Retzius was entered and intentional cystotomy was made. The bladder injury was repaired transvesically with 2 sutures of 2-0 PDS. An additional suture was placed in the vagina to close the vaginal aspect of defect. The cystotomy was closed in a traditional 2-layer fashion. <h3>Measurements and Main Results</h3> Repeat cystoscopy confirmed a watertight closure of the bladder injury and the intentional cystotomy repair. The retropubic space was reperitonealized. The patient did well post-operatively with bladder decompression with foley catheter for 10 days. Subsequent CT cystogram showed no leakage of urine. The catheter was removed after the post-op imaging and a voiding trial. <h3>Conclusion</h3> This case highlights a rare complication of uterine manipulator use. There are benefits of using uterine manipulators especially in cases of advanced endometriosis and laparoscopic hysterectomy are well known and hence used readily in minimally invasive gynecologic surgery. It is therefore important to be aware of potential complications and have knowledge of how to address them.

7909 The Martin Technique: Alternative Approach to Hysterectomy in Patients with Prolapsing Myomas

<h3>Study Objective</h3> Prolapsing myomas are typically treated using vaginal myomectomy. Patients who desire definitive surgery may be treated using a staged procedure. When hysterectomy is performed concurrently, it is often done using a vaginal or open approach. Cervical dilation due to the prolapsing myoma can preclude the use of a uterine manipulator commonly used during laparoscopic hysterectomy. To our knowledge, there is no technique described in the literature that utilizes a uterine manipulator to facilitate laparoscopic hysterectomy following vaginal myomectomy. The Martin Technique provides a minimally invasive alternative approach to hysterectomy following vaginal myomectomy. <h3>Design</h3> This video demonstrates a surgical case using the Martin Technique to show that effective uterine manipulation can be accomplished to perform laparoscopic hysterectomy following vaginal myomectomy. <h3>Setting</h3> The surgery is performed in dorsal lithotomy position to allow for vaginal and laparoscopic portions of the procedure. <h3>Patients or Participants</h3> The patient was diagnosed with a symptomatic prolapsing myoma and desired definitive treatment with total hysterectomy. She consented to video recording of her surgery and no identifying information was recorded. <h3>Interventions</h3> The patient underwent vaginal myomectomy using two looped sutures followed by transection of the stalk of the myoma. A cerclage was then placed and tied down over a 6mm dilator to allow for manipulator placement. A uterine manipulator then placed in the usual fashion and a total laparoscopic hysterectomy was performed. <h3>Measurements and Main Results</h3> Effective uterine manipulation was assessed throughout the surgery. Uterine manipulation was found to be safe and effective throughout the dissection, allowing for ample elevation of the uterus, appropriate visualization, and safe and efficient dissection. <h3>Conclusion</h3> The Martin Technique provides a laparoscopic approach to hysterectomy following vaginal myomectomy. Cervical cerclage corrects for cervical dilation caused by the prolapsing myoma. This allows for appropriate placement of a uterine manipulator, effective uterine manipulation throughout the surgery, and safe and efficient dissection to accomplish laparoscopic hysterectomy.

Optimizing Surgeon Longevity: Ergonomics in Robotic Surgery

<h3>Study Objective</h3> To describe the risk of physical injury to robotic surgeons and review optimal set up of the robotic console, bedside assistant, and uterine manipulator that decrease risk of a work-related injury. <h3>Design</h3> Video demonstration with narrated description. <h3>Setting</h3> Tertiary care academic teaching hospital. <h3>Patients or Participants</h3> Surgeons trained in robotic surgery. <h3>Interventions</h3> Ergonomically favorable operating room set up for the robotic console, bedside assistant, and uterine manipulator. <h3>Measurements and Main Results</h3> Per the US Labor Department, the highest incidence of work-related injuries is in healthcare. Prior research suggests robotic surgery is more ergonomically favorable in the upper back, shoulders, arms and wrists and mentally less stressful than conventional laparoscopy. However, over 50% of robotic surgeons have work related pain with less than 20% of all robotic surgeons having received formalized ergonomic training. This video reviews appropriate operating room set up for the robotic console, bedside assistant, and uterine manipulator along with common positioning and postural errors that may lead to physical strain. <h3>Conclusion</h3> In order to maximize career longevity and minimize work-related injuries, surgeons must understand the ergonomically correct set up that is recommended for the robotic console, bedside assistant, and uterine manipulator. Early adoption of these recommendations can help prevent physical injuries and should be an essential foundation of trainees' operative skills.

The Roeder Knot: An Innovative Tool for Laparoscopic Myomectomy

<h3>Study Objective</h3> Demonstrate and describe an innovative Roeder knot technique during a laparoscopic myomectomy. <h3>Design</h3> Stepwise demonstration of the technique with narrated video footage. <h3>Setting</h3> Traditionally myomectomy has been performed via a laparotomy; however, recent advances in minimally invasive surgery have allowed for increased utilization of a laparoscopic approach for myomectomy. Key to a successful myomectomy is control of bleeding and manipulation of a large irregular uterus, both of which are challenging laparoscopically. An absorbable suture can be used to create a Roeder knot, or slip knot, around the base of a fibroid and tensioned during a myomectomy to improve hemostasis, tissue traction, and uterine manipulation. <h3>Patients or Participants</h3> The case depicts a patient with a symptomatic multi-fibroid uterus with a 7cm pedunculated fibroid and a smaller 3cm pedunculated fibroid desiring surgical intervention. Dilute vasopressin was injected under the serosa prophylactically for hemostasis. A suture was secured around the base of both fibroids using a Roeder knot, and the suture secured to the laparoscopic port using a hemostat. The laparoscopic myomectomy was performed with a combination of monopolar and bipolar electrosurgery. <h3>Interventions</h3> This video demonstrates the Roeder knot technique utilizing a 120cm 0-absorbable suture. The technique for tensioning and securing the Roeder knot and application for tissue traction and uterine manipulation are demonstrated. <h3>Measurements and Main Results</h3> The patient underwent an uncomplicated laparoscopic myomectomy with minimal blood loss. <h3>Conclusion</h3> Utilizing the Roeder knot technique to ligate the base of the fibroid during laparoscopic myomectomy facilitates superior hemostasis with improvements in tissue tension and uterine manipulation. Creation and use of this knot is an easily reproducible technique performed at a lower cost than commercial ligating loops. Additionally, the flexible loop size allows for customization to be utilized with larger fibroids.

Navigating the Obliterated Anterior Cul-De-Sac with a Novel Zavanelli of the Cervix

<h3>Study Objective</h3> The objectives of this video include to review risk factors for the obliterated anterior cul-de-sac (OAC), discuss patient evaluation for an OAC including ultrasound imaging, and display surgical techniques for approaching an OAC. Surgical techniques include restoring normal anatomy, controlling the uterine vascular supply, beginning dissection posterolaterally, backfilling the bladder, starting the colpotomy posteriorly, and optimizing the surgeon's perspective with a novel Zavanelli maneuver of the cervix. <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> The obliterated anterior cul-de-sac (OAC) is an obstacle that is becoming much more common in gynecologic surgery with the increasing rate of cesarean section (CS). When patients have risk factors like a history of CS, surgical planning requires a high level of suspicion for preparedness. This video reviews the thorough pre-operative patient evaluation, including ultrasound findings that could indicate an OAC. The video exhibits surgical techniques for navigating an obliterated anterior cul-de-sac, including the restoration of normal anatomy, uterine vascular control, posterolateral dissection, backfilling the bladder, posterior colpotomy and a novel Zavanelli maneuver of the cervix, in which the uterine manipulator is removed, and cervix lifted cranially to provide the surgeon with a new perspective for safe dissection.