Vaginal Cuff Closure Research Articles

Comparison of The Laparoscopic Approach Versus The Vaginal Route Closure of Vaginal Cuff during Total Laparoscopic Hysterectomy

Comparison of The Laparoscopic Approach Versus The Vaginal Route Closure of Vaginal Cuff during Total Laparoscopic Hysterectomy

Impact of the Recorded Audio and Video Feedback on Simulated Surgical Performance: A Randomized Controlled Trial.

Simulation and coaching have become increasingly important in laparoscopic skills acquisition.This study was designed to evaluate if access to the recorded audio and video feedback after a single proctored session improves the acquisition of laparoscopic suturing skills in obstetrics and gynecology (OB/GYN) residents. Twenty OB/GYN residents received a single face-to-face coaching session on a laparoscopic vaginal cuff closure model. The session was recorded and residents were randomized to access either the video-only or the audio and video recording of the proctored session. The primary outcome measure was comparison of Global Operative Assessment of Laparoscopic Skills plus Vaginal Cuff Metrics (GOALS+) scores of the vaginal cuff closure prior to and following the proctored session. Only 30% of residents accessed the recorded sessions with junior residents most likely to access the recording.Baseline GOALS+ scores were significantly higher in senior residents (mean 21.7, SD 3.9) as compared to junior residents (mean 14.7, SD 3.2) (p<.001). While all learners' GOALS+ scores significantly improved after proctoring the intervention (p<.001), the senior residents continued to have significantly higher GOALS+ scores at the final assessment (mean 28.3, SD 4.2, p=.01) when compared to their junior residents (mean 24.0, SD 3.1). Due to the low uptake of the review of recorded proctored sessions among OB/GYN residents across skill and year levels, we were unable to assess the effect of recorded audio and video feedback on resident performance. However, the intervention of a single proctored session of simulated laparoscopic vaginal cuff closure significantly improved resident performance as assessed with GOALS+ scores.

8387 Instructional Video on Tandem Vaginal Cuff Closure

<h3>Study Objective</h3> To demonstrate the steps of tandem vaginal cuff closure, outline specific movements of the surgeon and assistant, and provide suggestions for efficient closure. <h3>Design</h3> Instructional Video. <h3>Setting</h3> Operating room of large academic hospital. <h3>Patients or Participants</h3> Single patient undergoing a laparoscopic vaginal cuff closure at the time of hysterectomy. <h3>Interventions</h3> In this technique, two surgeons close the vaginal cuff at the time of hysterectomy through an umbilical port for the 5mm camera and two 5mm lateral ports for instrumentation. This eliminates the need for fascial closure and improves cosmesis. The surgeon stands at the patient's left and holds the needle driver in the right hand. The surgeon positions the needle correctly to facilitate an efficient and effective cuff closure starting from the patient's right and proceeding toward the left. The direction of closure is from posterior to anterior. At least 5mm of vaginal mucosa is incorporated into each bite, and uterosacral and cardinal ligaments are incorporated bilaterally to provide support. A key component is to push the needle through the tissue, with over supination of the surgeon's wrist while lifting the needle cephalad. This over-supination allows better visualization and provides the correct angle for needle reloading. The assistant, standing on the patient's right, provides visualization, places the loop of the barbed suture over the needle, and manipulates the anterior or posterior cuff over the needle. <h3>Measurements and Main Results</h3> Complete and efficient vaginal cuff closure with incorporation of uterosacral and cardinal ligaments for support. <h3>Conclusion</h3> With the use of two skilled surgeons, we demonstrate the efficient movements required to carry out a tandem vaginal cuff closure.

Double Trouble: Tips for Colpotomy and Vaginal Cuff Closure with Uterine Bicollis and Longitudinal Vaginal Septum

<h3>Study Objective</h3> To describe the laparoscopic technique for colpotomy, approach for laparoscopic excision of longitudinal vaginal septum, laparoscopic cuff closure with and without intact vaginal septum and considerations for uterine manipulation in patients with uterine bicollis and longitudinal vaginal septum. <h3>Design</h3> Two case reports. <h3>Setting</h3> Two laparoscopic cases at a single tertiary care center in the United States. <h3>Patients or Participants</h3> Two patients undergoing total laparoscopic hysterectomy (TLH) with uterine bicollis and longitudinal vaginal septa, one with a bicornuate uterus and one with uterine didelphys. <h3>Interventions</h3> The first patient with bicornuate uterus underwent TLH using a manipulator with small colpotomizer cup to accommodate the small caliber of the hemivagina and cervices. Colpotomy was performed by placing the manipulator first in the right cervix, then the left. Her vaginal septum left in situ as it was not bothersome. The septum was successfully integrated into the vaginal cuff. The second patient with uterine didelphys underwent TLH using a manipulator without a cup. The colpotomy was completed in a similar manner. Her septum was excised laparoscopically as it caused dyspareunia. The vaginal defect was repaired laparoscopically and cuff closed in the usual fashion. <h3>Measurements and Main Results</h3> Options for manipulation include a small manipulator cup, a manipulator without cup, vaginal devices such as sponge stick, vaginal/rectal probe or Briesky-Navratil retractor. Vaginal septa can be successfully incorporated into the vaginal cuff from a laparoscopic closure or excised laparoscopically. <h3>Conclusion</h3> Alternative means for uterine manipulation are often necessary in patients with uterine bicollis and longitudinal vaginal septa. Longitudinal vaginal septa can be successfully incorporated into the vaginal cuff for laparoscopic closure or excised and repaired laparoscopically.

7578 Hysterectomy with or without Oophorectomy for Transgender Male Patients: Preoperative and Intraoperative Considerations

<h3>Study Objective</h3> To review the preoperative and intraoperative considerations for gynecologic surgeons when performing hysterectomy with or without oophorectomy for transgender male patients. <h3>Design</h3> Stepwise demonstration of techniques with narrated video footage. <h3>Setting</h3> Approximately 0.3% of hysterectomies performed annually in the U.S. are for transgender male patients, most commonly to alleviate gender dysphoria. A hysterectomy with or without oophorectomy can be offered to patients who have met criteria outlined by the World Professional Association for Transgender Health (WPATH) guidelines. <h3>Patients or Participants</h3> Transgender male patients seeking hysterectomy with or without oophorectomy. <h3>Interventions</h3> Important perioperative counseling points for transgender male patients include: •Establishing terminology to minimize gender dysphoria •Discussing options for fertility preservation •Discussing the importance of continuing testosterone therapy post-oophorectomy to reduce the loss of bone density •Reviewing intraoperative and postoperative expectations Important intraoperative considerations for the performance of safe and effective hysterectomy with or without oophorectomy for transgender male patients include: •Maintaining a margin of at least 2 cm between the surgical instrument and the ovary during coagulation and transection of the infundibulopelvic ligament to prevent ovarian remnant syndrome •Performance of a two-layer vaginal cuff closure to reduce the risk of vaginal cuff complications <h3>Measurements and Main Results</h3> The patients recovered well without any postoperative complications. <h3>Conclusion</h3> In conclusion, it is essential to minimize the patient's experience of gender dysphoria by providing gender-affirming care before, during and after surgery. In particular, the surgeon should take care to perform oophorectomy with an adequate margin to minimize the risk of ovarian remnant syndrome and use a two-layer laparoscopic vaginal cuff closure to decrease the risk of vaginal cuff complications.

Laparoscopic Suturing of the Vaginal Cuff: A Surgical Education Module for Obstetrics and Gynecology Residents

<h3>Study Objective</h3> We aim to review the assembly of a laparoscopic box trainer with a validated vaginal cuff model and to highlight principles for efficient two-handed laparoscopic vaginal cuff closure using three unique port configurations (ipsilateral, contralateral, and midline). This video was created as part of a surgical education module for Obstetrics and Gynecology residents. <h3>Design</h3> Surgical education video. <h3>Setting</h3> Laparoscopic box trainer with a validated vaginal cuff model. <h3>Patients or Participants</h3> Education module for Ob/Gyn resident physicians. <h3>Interventions</h3> The validated vaginal cuff model incorporates multiple layers to represent the vaginal epithelium and vaginal wall. We demonstrate laparoscopic suturing using a running technique from ipsilateral, contralateral, and suprapubic port configurations. A braided suture with a knot at the end simulates a unidirectional barbed suture that does not require knot tying. Critical steps needed for proper cuff closure are highlighted. <h3>Measurements and Main Results</h3> In this video, we highlight a reproducible setup of a validated vaginal cuff model within a laparoscopic box trainer. We demonstrate correct needle loading for enhanced accuracy in needle entry and exit. Efficient techniques to achieve adequate exposure, incorporation of vaginal epithelium, appropriate suture tension, and optimized ergonomics are also reviewed. <h3>Conclusion</h3> We present a surgical education video to teach safe and efficient laparoscopic suturing techniques to Ob/Gyn resident physicians using multiple two-handed port configurations. Key surgical principles include proper needle loading, needle entry, exposure, and optimized ergonomics.

8761 Batwing Endometriosis: Radiographic Findings and Surgical Approach

<h3>Study Objective</h3> To present radiographic findings suggestive of deep infiltrating endometriosis of the uterosacral ligaments and posterior torus uterinus (referred to as batwing endometriosis) and review surgical considerations and approach to excision of disease. <h3>Design</h3> Description of imaging findings and surgical technique. <h3>Setting</h3> Academic teaching hospital. <h3>Patients or Participants</h3> Patients with batwing endometriosis on preoperative pelvic magnetic resonance imaging (MRI) and concordant intraoperative findings. <h3>Interventions</h3> Preoperative pelvic MRI and laparoscopic or robotic excision of endometriosis with and without hysterectomy. <h3>Measurements and Main Results</h3> Batwing endometriosis can often be associated with an obliterated posterior cul-de-sac and present significant challenges during laparoscopy. Here we review a systematic approach to aid with restoration of this space and focus on relevant anatomy to consider. The following important steps are discussed: methods for navigating ureterolysis, ways to shave disease and preserve neurovascular and ligament support, and finally, techniques to consider with vaginal cuff closure for concurrent hysterectomy. In addition to highlighting batwing endometriosis on MRI, key pelvic structures are identified including the ureter, uterine vessels, and pararectal space which all aid in dissection. <h3>Conclusion</h3> Identification of batwing endometriosis on preoperative pelvic MRI may improve surgical planning. Knowledge of important anatomic considerations and surgical steps allows for safe and effective excision for patients with batwing endometriosis.

Left in the Dark: Laparoscopic Cuff Closure for Left-Handed Learners

<h3>Study Objective</h3> This video seeks to educate both learners and educators on techniques for left-handed laparoscopic vaginal cuff closure through three different port configurations. It also aims to highlight disparities between right and left-handed trainees in surgical training and mentorship. <h3>Design</h3> Narrated surgical video. <h3>Setting</h3> Two teaching hospitals (academic and community based). <h3>Patients or Participants</h3> Three patients undergoing total laparoscopic hysterectomy for various indications. <h3>Interventions</h3> Left-handed laparoscopic vaginal cuff closure through three different port configurations. <h3>Measurements and Main Results</h3> We illustrate several key points for educators and left-handed learners including: -Port placement options for the left-handed surgeon -Advantages and disadvantages of various port configurations -Recommended direction of suturing based on port placement -Techniques for assisting a left-handed surgeon -Direct comparison between right and left-handed suturing, demonstrating that they are mirror images of one another <h3>Conclusion</h3> Left-handed laparoscopic vaginal cuff closure can be effectively accomplished through any port configuration. Educators and left-handed learners should be familiar with port placement options, techniques for assisting a left-handed surgeon, and direction of suturing for left-handed cuff closure to optimize surgical education and minimize patient time under anesthesia.

Indocyanine green-guided sentinel lymph node mapping during laparoscopic surgery with vaginal cuff closure but no uterine manipulator for cervical cancer.

Lymph node metastasis is a critical prognostic factor in cervical cancer. Considering the potential complications of lymphadenectomy and desirability of avoiding systemic lymphadenectomy, accurate intraoperative prediction of the existence of lymph node metastasis is important in patients undergoing surgery for cervical cancer. We evaluated the feasibility and value of indocyanine green (ICG) use for sentinel lymph node (SLN) mapping during laparoscopic surgery performed for cervical cancer. This single-center cohort study included 77 patients undergoing a new laparoscopic radical surgery method with pelvic lymphadenectomy for early-stage cervical cancer. The surgery, performed without using a uterine manipulator, included creation of a vaginal cuff. Bilateral ICG-guided SLN mapping and rapid histopathological examination were performed, and results were analyzed in relation to final histopathologic diagnoses. The SLN pelvic side-specific detection rate was 93.5%, sensitivity (SLN-positive cases/SLN-detected pelvic lymph node-positive cases) was 100%, intraoperative negative predictive value (NPV) was 97.8%, and final pathological NPV was 100%. The detection rate was significantly lower for tumors ≥ 2cm in diameter than for tumors < 2cm in diameter. Micrometastases were missed by intraoperative examination in 3 cases. The high NPV suggests the feasibility and usefulness of ICG-based SLN mapping plus rapid intraoperative examination for identification of metastatic SLNs. Use of ICG-based mapping for intraoperative identification of SLNs in patients undergoing this new laparoscopic surgery method for early-stage cervical cancer was particularly effective for tumors < 2cm in diameter. However, incorporating a search for micrometastases into rapid intraoperative histopathologic examination may be necessary.

V04-11 COMBINATION OF ROBOTIC-ASSISTED LAPAROSCOPIC PEDICLED PERITONEAL FLAP VAGINOPLASTY WITH PENILE SKIN INVERSION TECHNIQUE IN MALE-TO-FEMALE TRANSGENDER SURGERY. INSTRUCTIVE VIDEO-ARTICLE

You have accessJournal of UrologyCME1 May 2022V04-11 COMBINATION OF ROBOTIC-ASSISTED LAPAROSCOPIC PEDICLED PERITONEAL FLAP VAGINOPLASTY WITH PENILE SKIN INVERSION TECHNIQUE IN MALE-TO-FEMALE TRANSGENDER SURGERY. INSTRUCTIVE VIDEO-ARTICLE Eusebio Luna, Sidhbh Gallagher, Edward Gheiler, Ariel Kaufman, Luanda Perez, Dailianys Barrios, Melanie Milanes, and Fernando Bianco Eusebio LunaEusebio Luna More articles by this author , Sidhbh GallagherSidhbh Gallagher More articles by this author , Edward GheilerEdward Gheiler More articles by this author , Ariel KaufmanAriel Kaufman More articles by this author , Luanda PerezLuanda Perez More articles by this author , Dailianys BarriosDailianys Barrios More articles by this author , Melanie MilanesMelanie Milanes More articles by this author , and Fernando BiancoFernando Bianco More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002560.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Gender-Affirming vaginoplasty comprises vulvar and vaginal canal creation.1 Those procedures can be considered separately, and we focus our video-article on vaginal canal construction. In male-to-female transgender surgery, penile skin inversion to line the neovagina is considered the gold standard procedure.2 In our experience, the combination of this technique with The Davydov procedure, commonly used for vaginoplasty in female patients with Mayer-Rokitansky-Kuster-Hauser-Syndrome (MRKH) 3 grants an excellent depth of the vaginal canal, and great comfort to the patient during vaginal intercourse. METHODS: This video abstract features the vaginal canal creation in a 33-year-old male with a long-standing history of gender dysphoria. The intervention starts with the peritoneal walls harvesting at the level of Douglas Pouch, to create a vascular pedicled peritoneal flap. Next, a careful robotic perineal body dissection allowed us establishing external communication of the neovaginal canal. Afterward, the robotic-assisted anastomosis between the previously dissected inverted penile skin and the peritoneal flap is carried. The vaginal cuff closure and colpopexy finish the intervention. RESULTS: Operative time was 140 minutes, blood loss 80 cc, a perineal pack, and a Foley catheter were placed after the intervention and removed on the 7th postoperative day. The patient remained hospitalized for two days. There were no reported complications other than some right labia minora epidermolysis on the 6th postoperative day which has since resolved. The vaginal dimension at the 4th postoperative month is 6 inches in depth. Periodic dilations with a 1.5 inches dilator are needed. CONCLUSIONS: The combination of robotic-assisted laparoscopic pedicled peritoneal flap vaginoplasty with penile skin inversion technique represents a feasible and reliable option for patients interested in male-to-female transgender surgery. Source of Funding: none © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e370 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Eusebio Luna More articles by this author Sidhbh Gallagher More articles by this author Edward Gheiler More articles by this author Ariel Kaufman More articles by this author Luanda Perez More articles by this author Dailianys Barrios More articles by this author Melanie Milanes More articles by this author Fernando Bianco More articles by this author Expand All Advertisement PDF DownloadLoading ...

A "cooler" simulation model for robotic cuff closure and sacrocolpopexy.

The objective of this video was to demonstrate the build and use of a single robotic simulation model for a double-layer vaginal cuff closure and sacrocolpopexy vaginal mesh attachment. Simulation models are frequently used to improve surgical skills and augment operating room experience for surgical trainees. To create our robotic simulation model, we utilized the Advincula arch manipulator handle with a sacrocolpopexy tip attached to the ALLY Uterine Positioning System. To simulate the vagina, we used a pink, slim can cooler/coozie attached to the sacrocolpopexy tip. The edges of the coozie represented the vaginal cuff following a hysterectomy. Mesh attachment was demonstrated using a precut Y-shaped polypropylene mesh. Simulation has become a critical part of education in surgical training programs as it enhances learner knowledge and improves surgical confidence and preparedness in the operative setting.

Over/under: examining the cost difference in vaginal vs. laparoscopic cuff closure following a laparoscopic hysterectomy

Vaginal cuff closure following a total laparoscopic hysterectomy (TLH) can be approached laparoscopically or transvaginally. Route of closure is primarily determined by surgeon preference and may also be influenced by clinical/patient characteristics. The objective of this study is to compare the proportion of laparoscopic (LSC) closure to the proportion of transvaginal (TV) closure of the vaginal cuff following a TLH. We also aim to compare the cost utility of both cuff closure approaches. This is a retrospective cross-sectional study of all TLH cases performed at our institution between June 2018 – May 2019. We collected patient demographics, surgery parameters (vaginal cuff closure method, necessity for X-ray), and time measurements between case milestones (case start-to-end, X-ray completed, patient out of room). Of note, our institution carries a unique protocol that may not be the standard across other institutions, which mandates an abdominal X-ray (AXR) to evaluate for retained foreign bodies in patients with a BMI ≥35 when a laparoscopic case includes a TV cuff closure. This protocol does not apply in LSC cuff closure following TLH. Exclusion criteria included conversion to open procedure and involvement of concomitant procedures. Based on review of existing literature, operating room (OR) costs have been estimated to range between $30 - $81 per minute and post-operative radiologic images cost about $168 per procedure. Data were analyzed with Chi-square test and two-tailed t-test (α = 0.05). During the study period, 120 qualifying TLH cases were performed. Eighty-seven patients (73%) underwent LSC closure and thirty-three patients (27%) underwent TV closure. Mean age and BMI did not significantly differ between LSC and TV closure groups. Fifteen patients in the LSC closure group and nineteen patients in the TV closure group had BMI > 35. Service type differs between the two groups (p<.001). For the LSC closure group, the mean case time was shorter by a mean difference of 66 minutes (133 minutes for LSC versus 199 minutes for TV; 95% CI = -84.1, -47.8). If all TV closures were done laparoscopically, this translates to a potential cost saving of $1,980 - $5,346 per case. The mean time difference between case end time and out of OR time was shorter by 15.75 minutes in cases that did not require AXR. Nineteen patients who had a TV closure after TLH also required AXR for BMI>35. Thus, 19 AXR would be potentially avoided if TV closures were replaced by LSC closures. With added OR time and cost of AXR, there is a potential saving of $12,169 - $27,431 per year if LSC closures were chosen. Compared to TV cuff closure, LSC vaginal cuff closure following a TLH may afford a cost benefit due to decreased operating room time. Given our institutional policy, further cost savings can be seen by avoiding additional AXR.

A multimodal concept for vaginal cuff closure by modification of the Bakay technique in total laparoscopic hysterectomy: a randomized clinical study

BackgroundThe aim of this study was to compare the outcomes of modified Bakay technique (MT) to standard colpotomy (ST) and cuff closure in total laparoscopic hysterectomy (TLH).MethodsThis two-centre, randomized-controlled study included a total of 160 patients who were scheduled for TLH for benign diseases (ClinicalTrials.gov Identifier is NCT05080114 and the first posted date was 15/10/2021). The patients were allocated into two groups by a computer-based randomization programme as ST group and MT group. Total operative time, cuff closure time, length of hospital stay, intra- and postoperative complications according to the Clavien-Dindo classification, pre- and postoperative vaginal length, and patient satisfaction according to the Patient Global Impression of Improvement (PGI-I) questionnaire were assessed.ResultsSeventy-seven patients in the ST group and 80 patients in the MT group underwent TLH. The total operative time was significantly shorter in the MT compared to the ST (55.5 vs. 59 min, respectively; p = 0.001). The median total operative time for colpotomy, extraction of uterus, and vaginal cuff closure steps was 9 (range 6–12 in MT vs. 6 to 11 in ST) min in both groups. The median hospital stay was 2 (range 1–4) days in both groups. Intraoperative blood loss was not significantly different between the groups (90 mL in ST vs. 80 mL in MT; p = 0.456). The mean uterine weight for the ST group and MT group was comparable (258.6 ± 88.6 g vs. 232.9 ± 102.5 g, respectively; p = 0.107). The preoperative vaginal length was not significantly different between the groups (p = 0.502). The median postoperative vaginal length was significantly higher in the MT group compared to the ST group on Day 90 (8 cm vs. 7,5 cm, respectively; p = 0.001). The PGI-I questionnaire score on Day 90 postoperatively was 2 (range 1–5) in both groups (p = 0.636). The complication rates were similar between the groups (p = 0.230).ConclusionThe MT can be safely performed in most of the cases requiring TLH with the advantages of vaginal cuff closure before the alteration of pelvic anatomy, support to primary healing of the vaginal cuff, and routine concomitant apical support.

Vaginal Cuff Closure by Endosuturing in Total Laparoscopic Hysterectomy as Compared to Transvaginal Route of Suturing

Introduction: In present times, Total Laparoscopic Hysterectomy (TLH) is one of the commonly performed gynaecological procedure. Vaginal vault or cuff closure is crucial and critical in performance of TLH. During TLH, vaginal vault or cuff closure is done using a variety of available sutures. The techniques of suturing and approaches, either endoscopic or transvaginal, can vary. The skill, experience and preference of the surgeon counts in the final outcome of the surgery. Aim: To compare and study the frequency of minor and major complication rates of intracorporeal (endosuturing) cuff closure technique and routinely used transvaginal route of suturing vaginal vault in TLH. Materials and Methods: This prospective cohort research was conducted in the tertiary care hospital from May 2018 to December 2019. A total of 102 TLH were studied. In 51 cases (50%), vault was sutured endoscopically and in other 51 cases (50%), vault was sutured transvaginal, using single continuous interlocking suturing of vaginal vault with Vicryl 1-0 in all cases. Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) software version 24.0. Results: In the follow-up of three months period, there were no cases of Vaginal Cuff Dehiscence (VCD). In present study, 21 cases (20.6%) out of 102 presented with vaginal cuff complications. A 15.7% cases with minor vaginal cuff complications were noted in laparoscopic endosuturing group and 25.5% cases of vaginal suturing group presented with minor vaginal cuff complications. Conclusion: Both the techniques of suturing the vaginal vault following laparoscopic hysterectomy delivered the desired results. The laparoscopic route of suturing vaginal cuff following TLH had lesser complication rate though not statistically significant over vaginal route and none of the two groups had any major complication (VCD).

Is There a Role for Minimally Invasive Surgery in Cervical Cancer Treatment: Carry on, Discard, or Modify? A Literature Review and Case Series Presentation.

Oncological surgery is constantly evolving. Recommendations and guidelines are updated periodically in light of new research. Since surgery is a key step in the treatment of cervical cancer in Romania and considering the new findings, this study aims to assess the new guideline recommendations and the surgical treatment options available. The paradigm shift that took place in 2018 left the question: does minimally invasive surgery still play a role in the treatment of cervical cancer? K ouml;hler surgical technique seems to address some of the issues raised by the minimally invasive surgery with good results. H ouml;ckel proposes total mesometrial excision to decrease the risk of recurrence. This study presents 3 cases of cervical cancer patients with stages ranging from IB1 to IIIB that had undergone total mesometrial excision and vaginal cuff closure using the laparoscopic approach to minimize the risk of local recurrence. The case series presented showed that it is feasible and safe to merge these techniques. Further prospective studies are needed in order to assess the risk and benefits of these techniques.

Two Cases of Vaginal Cuff Closure by Simultaneous Vaginal and Laparoscopic Approach for Prolapse of the Small Intestine Due to Vaginal Cuff Dehiscence After Total Hysterectomy

Two Cases of Vaginal Cuff Closure by Simultaneous Vaginal and Laparoscopic Approach for Prolapse of the Small Intestine Due to Vaginal Cuff Dehiscence After Total Hysterectomy

Virtual Reality Simulation Has Weak Correlation with Overall Trainee Robot-Assisted Laparoscopic Hysterectomy Performance

Both simulator practice and intraoperative performance serve to inform surgical trainee training, but the skill transfer from simulation to the intraoperative setting remains unclear. This study evaluates the correlation between trainee performance on virtual reality simulation and (1) overall intraoperative performance during robotic-assisted laparoscopic hysterectomy (RALH) procedures and (2) suturing performance during vaginal cuff closure portion of the case. Retrospective subgroup analysis of randomized controlled trial. Academic hospital. Patients with RALH (N=29). Gynecological trainees (N=21) performed simulation tasks using the da Vinci skills simulator on the day of surgery before performing RALH. Attending surgeons assessed participants' intraoperative performance using Global Evaluative Assessment of Robotic Skills (GEARS). Performance of the vaginal cuff closure step was subsequently assessed using GEARS scoring of anonymized videos. Spearman's correlation was used to quantify the relationship between simulation and intraoperative performances. Trainees achieved a median intraoperative GEARS score of 18.5/30 (interquartile range: 17-22) and a median total simulator score of 84.4/100 (interquartile range: 78.1-87.5). More advanced residents exhibited worse overall simulator performance (median score 86.6/100 compared with 78.8/100, p=.03) and similar intraoperative GEARS scores during overall RALH and vaginal cuff closure compared with less experienced trainees. Total simulation performance score was negatively correlated with GEARS Bimanual Dexterity (ρ=-0.46, p=.02) and Force Sensitivity subscores (ρ=-0.39, p=.05). There was no correlation between total GEARS intraoperative vaginal cuff closure scores and overall simulation performances; however, total Tubes simulation score was correlated with higher GEARS Force Sensitivity subscore (ρ=0.73, p=.05). In this study, there was limited correlation between simulation score metrics and trainees' overall intraoperative performance. Furthermore, we identified that GEARS scores could not distinguish between similar trainee skill levels. These findings underscore the need to develop intraoperative assessment tools that can better discriminate different but similar skill levels.

“Does a Two-Layer Vaginal Cuff Closure at the Time of Laparoscopic Hysterectomy Reduce Complications Vs. a One-Layer Closure?”

Study Objective This video reviews findings from our retrospective cohort study demonstrating that a two-layer vaginal cuff closure (2-LVC) decreases postoperative complications compared to a standard one-layer vaginal cuff closure (1-LVC) at time of time total laparoscopic hysterectomy (TLH). The 2-LVC technique is demonstrated in a stepwise approach. Design Results from our retrospective cohort study analyzing all postoperative complications within 30 days and vaginal cuff complications within 180 days of TLH are reviewed. The two-layer closure technique is demonstrated with narrated footage. Setting A single tertiary care center. Patients or Participants All women undergoing TLH for benign indications by Minimally Invasive Gynecology surgeons from 2011-2017. Interventions 1-LVC and 2-LVC at time of TLH are compared. Surgeon skill, colpotomy technique and suture material remained standardized. The 2-LVC technique is demonstrated with reapproximation of the vaginal mucosa followed by imbrication of the endopelvic fascia. Measurements and Main Results Of 2973 women who underwent TLH for benign indications, 40.8% (n= 1213) of vaginal cuffs were closed with 2-LVC and 59.2% (n=1760) with 1-LVC. There was no difference in intraoperative complications between groups. There were significantly less postoperative complications in the 2-LVC, due to the difference in cuff complications. No mucosal separations or cuff dehiscence in the 2-LVC occurred as compared to 16 cases in the 1-LVC. Conclusion 2-LVC significantly reduces total postoperative complications by lowering vaginal cuff complications and reducing the rate of vaginal cuff dehiscence. Although a rare event, the prevention of vaginal cuff dehiscence by adapting a two-layer vaginal cuff closure, as demonstrated in this video, into routine TLH practice patterns could notably diminish patient morbidity and health care cost. This video reviews findings from our retrospective cohort study demonstrating that a two-layer vaginal cuff closure (2-LVC) decreases postoperative complications compared to a standard one-layer vaginal cuff closure (1-LVC) at time of time total laparoscopic hysterectomy (TLH). The 2-LVC technique is demonstrated in a stepwise approach. Results from our retrospective cohort study analyzing all postoperative complications within 30 days and vaginal cuff complications within 180 days of TLH are reviewed. The two-layer closure technique is demonstrated with narrated footage. A single tertiary care center. All women undergoing TLH for benign indications by Minimally Invasive Gynecology surgeons from 2011-2017. 1-LVC and 2-LVC at time of TLH are compared. Surgeon skill, colpotomy technique and suture material remained standardized. The 2-LVC technique is demonstrated with reapproximation of the vaginal mucosa followed by imbrication of the endopelvic fascia. Of 2973 women who underwent TLH for benign indications, 40.8% (n= 1213) of vaginal cuffs were closed with 2-LVC and 59.2% (n=1760) with 1-LVC. There was no difference in intraoperative complications between groups. There were significantly less postoperative complications in the 2-LVC, due to the difference in cuff complications. No mucosal separations or cuff dehiscence in the 2-LVC occurred as compared to 16 cases in the 1-LVC. 2-LVC significantly reduces total postoperative complications by lowering vaginal cuff complications and reducing the rate of vaginal cuff dehiscence. Although a rare event, the prevention of vaginal cuff dehiscence by adapting a two-layer vaginal cuff closure, as demonstrated in this video, into routine TLH practice patterns could notably diminish patient morbidity and health care cost.

Two-Port Robotic Laparoscopic Hysterectomy

<h3>Study Objective</h3> To demonstrate a surgical video wherein a technique for port-reducing robot-assisted laparoscopic hysterectomy was performed with the use of a gel-capped multi-trocar port that accommodates necessary instruments to safely complete the procedure. <h3>Design</h3> Case report, step-by-step video describing a port-reducing robot-assisted laparoscopic hysterectomy with the gel-capped multi-trocar port. Institutional Review Board (IRB) approval was not required. <h3>Setting</h3> Tertiary referral medical center in New Haven, Connecticut. A 40-year-old female with symptomatic uterine leiomyoma who underwent failed medical management. She has completed her childbearing. Her body mass index was 41 kg/m². A pelvic sonogram showed a 10-centimeter uterus with a 10-centimeter fibroid. On examination, her uterus was mobile. <h3>Patients or Participants</h3> Singular patient who consented for this demonstration video. <h3>Interventions</h3> The patient underwent an uncomplicated robotically assisted total laparoscopic hysterectomy and bilateral salpingectomy. This was accomplished using a two-port technique. A multi-channel port system and a second robotic trocar were used. <h3>Measurements and Main Results</h3> Effective dissection of the adnexal structures and ligaments of the uterus was accomplished. Isolation, coagulation, and transection of blood vessels was optimally done with the vessel sealer. Despite the size of the uterus and leiomyoma, the specimen was completely removed transvaginally, without morcellation. Vaginal cuff closure was done with delayed absorbable barbed suture with ease. The three-centimeter fascial incision was re-approximated. There were no intra-operative complications. Estimated blood loss was 150 ml. She was discharged home on the same day. Her final histopathology was benign. <h3>Conclusion</h3> The two-port robotic hysterectomy with the gel-capped multi-channel laparoscopic port afforded the use of additional necessary laparoscopic instruments to safely complete the procedure while avoiding the usual three to five port incisions most gynecological surgeons use. This approach utilized the advantages of robotic laparoscopy: superior operative visualization, improved instrument mechanics and stabilization, and upgraded ergonomics for the surgeon. Our robotic hysterectomy technique is a feasible alternative for the appropriately selected patients.

Vaginal Cuff Dehiscence: Tips for Laparoscopic Repair and Prevention

<h3>Study Objective</h3> To define vaginal cuff dehiscence, identify risk factors for dehiscence, understand steps needed for laparoscopic cuff revision, and review techniques for cuff closure. <h3>Design</h3> Vaginal cuff dehiscence, defined as a full thickness separation of the vaginal cuff, is a rare but morbid complication after hysterectomy. After a total laparoscopic hysterectomy, the incidence of vaginal cuff dehiscence is 0.7% (range 0.64 – 1.27%). Risk factors include poor vaginal cuff closure technique, smoking, low body mass index, conditions that cause poor wound healing such as infection, hematoma, prior radiation, or immunosuppression, and increased pressure on the vaginal incision line such as trauma, pelvic organ prolapse, or excessive valsalva. In this video we will demonstrate a laparoscopic repair of a vaginal cuff dehiscence. <h3>Setting</h3> Patients should be positioned in lithotomy position in the operating room. Standard GYN laparoscopic setup should be used. The authors prefer placing the camera via a 5mm trocar in the umbilicus, with 2 accessory 5mm ports laterally and a 5mm suprapubic port. <h3>Patients or Participants</h3> N/A. <h3>Interventions</h3> In this video we describe the 5 steps of a laparoscopic repair of a vaginal cuff dehiscence. We also discuss tips and tricks to optimize cuff closure. • Identify and normalize anatomy • Identify the vaginal cuff defect • Mobilize the cuff • Excise cuff edges • Close the cuff <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Although vaginal cuff dehiscence is rare, knowledge of safe and effective laparoscopic repair technique is crucial for the gynecologic surgeon, both for repair and for prevention of future cuff dehiscence.