Laparoscopic Myomectomy in the 2nd Trimester of Pregnancy

Sep 26, 2019 | 356 Views

Anjali Kulkarni, Carmen McCaffrey, Janet Bodley, Rose Kung

The purpose of this video is to demonstrate surgical management of a large symptomatic fibroid in the 2nd trimester of pregnancy. This patient is a 26 year old G1P0 who presented to a tertiary care centre at 18 weeks and 3 days gestational age with severe abdominal pain, not controlled with intravenous and oral narcotics. She was otherwise healthy and incidentally was diagnosed with a fibroid during her dating ultrasound. An MRI of her abdomen and pelvis delineated this to be a pedunculated fundal uterine fibroid, measuring 19.4 by 13.2 by 16.2cm, retroplacental in location. Ultimately, she was consented for a laparoscopic myomectomy, with mini-laparotomy and morcellation. Post-operatively, this patient’s pregnancy progressed well and was uncomplicated. She underwent an uncomplicated spontaneous vaginal delivery at 40 weeks gestational age.

Challenges when Performing Laparoscopic Hysterectomy in Women with BMI ≥ 40

Sep 26, 2019 | 302 Views

Tina Ngan, Julie Vermeer, Darrien Rattray, John Thiel

Obesity has become a worldwide epidemic. In 2016, 15% of women aged 18 and over were obese. The prevalence of obesity in Canada has doubled since 1985. It is estimated that by the end of 2019, 21% of the Canadian population will be obese. In this video, we will review a total of seven potential challenges encountered when performing laparoscopic hysterectomy in women with BMI above 40. These include comorbidities, patient positioning, insufflation of the abdomen, accessory ports placement suboptimal exposure of surgical field, bladder dissection and vaginal cuff closure. Management options and technical tips will be discussed.

Management of Adnexal Torsion in Advanced Pregnancy

Sep 26, 2019 | 333 Views

Tina Ngan, Peter Thiel, Huse Kamencic

Adnexal torsion is a common gynecological pathology representing 2.7% of all gynecological emergencies. The management of adnexal torsion presents a unique challenge when encountered in advanced pregnancy. This challenge is further complicated by a paucity of literature discussing management approaches and outcomes in pregnancy. The objective of this video is to review the risk factors, perioperative planning and management of adnexal torsion in advanced gestation. The stepwise minimally invasive approach consists of identification of the anatomy, determination of accessory port placement, detorsion of the adenexa, and finally removal of the specimen. This surgical approach will be demonstrated by a case of adnexal torsion in pregnancy with a focus on pearls to utilize and pitfalls to avoid. Furthermore, general tips for laparoscopic surgery in pregnancy will be covered and demonstrated in the video.

Routine Anterior Colpotomy Prior to Ligation of the Uterine Artery at the Time of Laparoscopic Hysterectomy

Sep 27, 2019 | 375 Views

Angela Deane, Liane Belland

We present an alternative approach to securing the uterine pedicle during laparoscopic hysterectomy by initiating the colpotomy prior to uterine artery ligation. We review the traditional approach to securing the uterine pedicle and then demonstrate our alternative approach in a simple laparoscopic hysterectomy and in complex cases involving endometriosis and fibroidsCreation of the colpotomy prior to securing uterine arteries has several advantages. It improves surgical technique through clear delineation of anatomy, improving patient outcomes based on limited data and our experience. This technique improves surgical education and comfort with anatomy for learners. It is easy to teach and versatile for use in both simple and complex cases.

Creation of a Neovagina: A Modified Davydov Approach

Sep 27, 2019 | 338 Views

Ari Sanders, Sari Kives, Lisa Allen

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

Deep Endometriosis of the Bowel: A Surgical Approach

Sep 27, 2019 | 313 Views

Cici Zhu, Michael Suen, Shaheer Tadros, Sukhbir Sony Singh

The objectives of this video are to define bowel endometriosis and to explore various surgical parameters for the different types of surgical excision. Then, a specific surgical approach will be demonstrated. When planning a surgical approach to deep endometriosis of the bowel, patient characteristics such as age and BMI, as well as their specific symptoms and level of pain, quality of life and fertility goals must be considered. As well, the actual lesion must be investigated with respect to size, number, location, depth of infiltration, and amount of intestinal wall circumference involved. Then, various surgical techniques can be performed depending on these specific characteristics, such as nodule shaving, nodular resection and segmental resection and re-anastomosis. A surgical case is then utilized to demonstrate a nerve sparing and blood supply conserving technique of segmental resection after intra-operative sigmoidoscopy demonstrated luminal obstruction.

A Step-wise Approach to Laparoscopic Cystectomy of Ovarian Endometrioma

Sep 27, 2019 | 463 Views

Caroline Lee, Catherine Allaire

A 37-year-old G1P0 woman presented with dysmenorrhea and pelvic pain in the context of known bilateral endometriomas. She was being treated with dienogest as suppressive therapy. She requested conservative surgery for treatment of her endometriosis due to the presence of persistent pelvic pain despite medical therapy. Here, we present a step-by-step approach to laparoscopic cystectomy of ovarian endometriomas.

Temporary Uterine Artery Occlusion at Laparoscopic Myomectomy - A Simple Technique to Reduce Blood Loss

Sep 27, 2019 | 289 Views

Fatemah Alhadhoud, Cici Zhu, Sukhbir Sony Singh

The objective of this video is to demonstrate a simple, temporary and reversible method for uterine artery occlusion at the time of laparoscopic myomectomy. A 42 yo G0 presented with a solitary, vascular uterine fibroid. her signs & symptoms were heavy menstrual bleeding, pressure symptoms and abdominal bloating.Because the patient desired fertility, laparoscopic myomectomy was done with intra-operative approaches to minimize blood loss; including reversible uterine artery occlusion using bulldog clamps, vasopressin, tranexamic acid and misoprostol.

Genitofemoral Nerve Sparing Adhesiolysis

Sep 27, 2019 | 334 Views

Tina Ngan, John Thiel, Darrien Rattray

The Genitofemoral nerve originates from the ventral rami of L1-L2. Its injury is uncommon in benign minimally invasive gynecologic surgery. However, when there is distorted anatomy due to adhesions or severe endometriosis, the risk of injury is higher. Therefore, it is important to recognize the anatomical landmarks early in the surgery to prevent injury. In this video, the genitofemoral nerve location, innervation, and mechanisms of injury will be reviewed. The points will be illustrated by demonstrating dissection of this nerve in a case with significant adhesions.

Manual Tissue Extraction: Approach to Vaginal Morcellation

Sep 27, 2019 | 470 Views

Alysha Nensi, Jennifer Liu, Deborah Robertson

Vaginal morcellation is a manual tissue extraction technique used to remove large specimens following robotic, laparoscopic, or vaginal hysterectomy. This procedure allows the surgeon to offer minimally invasive options to select patient populations and circumvents the need for laparotomy for specimen extraction. In recent years, there have been concerns regarding morcellation and the potential for inadvertent dissemination of malignant tissue. However, with appropriate patient selection and thorough pre-operative evaluation, the risks are low, particularly when the specimen is morcellated vaginally. The objective of this video is to describe the technique and equipment required for vaginal morcellation following laparoscopic hysterectomy. The case is a 43-year-old G3P3 female with abnormal uterine bleeding due to a multi-fibroid uterus, who underwent a total laparoscopic hysterectomy, bilateral salpingectomy, cystoscopy and vaginal morcellation. In this video, we demonstrate a safe and effective vaginal morcellation technique performed with bisection of the uterus, sequential wedge resections and myomectomy.

Tubal Re-Implantation Following Hysteroscopic Tubal Sterilization

Sep 28, 2019 | 402 Views

Tina Ngan, Cornell Smith, John Thiel, Darrien Rattray

Approximately 450 000 hysteroscopic tubal sterilization with micro-inserts have been performed worldwide. The Essure™ hysteroscopic tubal occlusion system is a micro-coil system that is placed at the uterotubal junction. Benign tissue in-growth is stimulated within the Essure™ coil resulting in tubal occlusion. Considering the cornual site of occlusion , in-vitro fertilization is the best treatment option offered to patients who desire pregnancy following this procedure. However, due to a variety of personal reasons, patients may not choose assisted reproductive technology and other options are required. In this video, we propose a novel laparoscopic technique of tubal re-implantation following hysteroscopic tubal sterilization. The surgical steps, technical tips along with postoperative management will be discussed.

Keep Your Landmarks Close, and the Hypogastric Nerve Closer: An Approach to Nerve-sparing Endometriosis

Sep 28, 2019 | 627 Views

Andrew Zakhari, Mohamed Mabrouk, Diego Raimondo, Manuela Mastronardi, Renato Seracchioli, Benedetta Mattei, Jessica Papillon-Smith, Meir Jonathon Solnik, Ally Murji, Nucelio Lemos

Extensive resections for endometriosis can cause damage to the autonomic nervous system of the pelvis resulting in urinary, anorectal, and sexual dysfunction. This educational video seeks to describe the autonomic neuroanatomy of the pelvis, illustrate the predictable location of the hypogastric nerve in relation to other pelvic landmarks, and demonstrate a technique for identifying, dissecting, and ultimately sparing the hypogastric nerve and consequently, the inferior hypogastric plexus. With laparoscopic footage, we detail: 1) transperitoneal identification of the hypogastric nerve, assisted by the pulling maneuver 2) Opening of the retroperitoneum at the level of the pelvic brim and retroperitoneal identification of the ureter 3) Medial dissection and identification of the hypogastric nerve 4) Lateralization of the hypogastric nerve, allowing for safe peritoneal resection.The hypogastric nerve follows a predictable course and can identified, dissected, and spared during pelvic surgery and is an important landmark for the preservation of pelvic autonomic innervation.

Laparoscopic Cerclage

Oct 26, 2019 | 351 Views

Chandrew Rajakumar

This video outlines cervical insufficiency and an approach to laparoscopic cerclage using 5mm Mersilene suture.

Surgical Management of a Fused Non-Communicating Rudimentary Uterine Horn with Significant Myometria

Oct 26, 2019 | 341 Views

Sari Kives, Jenna Kaiserman, Lisa Allen

In this video we present the surgical management of a fused non communicating, rudimentary uterine horn with significant myometrial connection. The objectives of this video are to review the diagnostic imaging features that are suggestive of surgical complexity with non communicating fused rudimentary horn resections. And review the steps involved in their resection.