Dec 11, 2018 | 1078 Views
This video discusses tips and tricks in dissecting an adherent bladder safely at the time of total laparoscopic hysterectomy.
Apr 15, 2019 | 338 Views
This video presents the laparoscopic management of a large cervical fibroid through subtotal hysterectomy. If highlights the importance of access, visualization, anatomy, and hemostasis
Apr 15, 2019 | 203 Views
This video highlights the use of the STRATAFIX Symmetric PDS Plus Knotless Tissue Control Device is used to reapproximate the myometrium following myomectomy.
Apr 15, 2019 | 205 Views
This video depicts an interesting case of round ligament varicocele and discusses the technique used to surgically manage it laparoscopically.
Apr 15, 2019 | 297 Views
Through a single surgical case, this video discusses technical tips in restoring anatomy in the setting of deep infiltrating endometriosis.
Apr 15, 2019 | 242 Views
This video provides an up to date review of the literature around risk-reducing salpingo-oophorectomy and outlines the procedural steps in performing RRSO in BRCA mutation carriers.
Apr 15, 2019 | 355 Views
Vasopressin administration can be an effective method of reducing blood loss during gynecological procedures. This video outlines the physiology of vasopressin and clinical scenarios in which its administration can help mitigate blood loss.
Jul 5, 2019 | 301 Views
This video demonstrates the excision of a uterine horn and the subsequent confined morcellation technique used for specimen extraction.
Jul 5, 2019 | 274 Views
This video demonstrates a technique for contained power morcellation in a bag during TLH for symptomatic fibroids. It also highlights tips and tricks to make the procedure easier.
Jul 5, 2019 | 525 Views
This video outlines the indications for appendectomy during gynecologic surgery, discusses the surgical technique, and is presented in the context of clinical case scenarios.
Jul 5, 2019 | 300 Views
This video outlines the management options for cesarean scar ectopic pregnancies and highlights a case of laparoscopic surgical management.
Jul 8, 2019 | 433 Views
This video outlines tips and tricks to help navigate an enlarged uterus at the time of laparoscopic hysterectomy.
Jul 8, 2019 | 1534 Views
This video outlines two approaches to the suspension of the vaginal vault following total laparoscopic hysterectomy.
Jul 12, 2019 | 302 Views
This video demonstrates an approach to laparoscopic cervical cerclage at the cervico-isthmic junction in a patient prior to conception. The risks and benefits of laparoscopic and vaginal cerclage are also compared.
Jul 12, 2019 | 291 Views
This video outlines techniques the optimize visualization during gynecologic surgery. It focuses on techniques to suspend the ovaries, navigate excess adipose tissue, and retract sigmoid colon.
Sep 26, 2019 | 430 Views
BRCA 1 and BRCA 2 account for 15-20% of all ovarian cancers. Risk-reducing salpingo-oophorectomy (RRSO) is the only proven method to decrease mortality in BRCA mutation carriers. No screening method has been shown to reduce mortality. The objectives of this video are to clarify the risk of ovarian cancer in women carrying a BRCA mutation, assess the advantages associated with minimally invasive RRSO and establish a step-by-step surgical approach to RRSO in BRCA carriers. The 5-Step RRSO approach includes: abdominal exploration, peritoneal washings, retro-peritoneum and ureter visualization, infundibulopelvic ligament dissection 2 cm away from the ovary as well as complete dissection of the fallopian tubes. With the increasing awareness of BRCA 1 and BRCA 2 gene mutations and genetic testing, more and more gynecologists will be faced with surgical management of patients with these mutations. Following the 5-Step RRSO approach will allow efficient and reproducible surgical management.
Sep 26, 2019 | 306 Views
We present a laparoscopic surgical approach for hysterectomy in Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome with cervicovaginal agenesis. Laparoscopic approaches for removal of uterine remnants have been published with only reports of laparotomy described for hysterectomy with cervicovaginal agenesis. We discuss the diagnosis, management considerations and preoperative planning for definitive surgical treatment of a patient with MRKH with cervicovaginal agenesis presenting initially with hematometra and pain. We show that laparoscopic hysterectomy is a viable and safe option in patients with cervicovaginal agenesis. The importance of preoperative imaging to rule out associated anomalies and assist in surgical planning is stressed. We highlight necessary alterations in surgical technique to overcome the lack of traction, identify potential anomalous vasculature and ultimately maintain hemostasis, clear delineation of surgical anatomy, and avoid injury. Tissue extraction through laparoscopic in bag morcellation is performed thus avoiding mini laparotomy altogether.
Sep 26, 2019 | 289 Views
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.
Sep 26, 2019 | 317 Views
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.
Sep 26, 2019 | 347 Views
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.
Sep 26, 2019 | 621 Views
Didelphys uterus occurs with incomplete fusion of the Mullerian ducts, generating two uterine cavities, two cervices and a longitudinal vaginal septum. The incidence of Mullerian anomalies is 0.5-5% in the general population with didelphys uterus representing 8.3% of all Mullerian anomalies.Our surgical case is a 41 year old G2P2 female with Lynch syndrome. Upon completion of childbearing, she elected to undergo a risk-reducing hysterectomy and bilateral salpingo-oophorectomy. She had a known didelphys uterus and had 2 previous cesarean sections. An approach to a total laparoscopic hysterectomy for didelphys uterus is not widely described in literature. This video highlights surgical techniques to overcome unique challenges associated with a didelphys uterus. We demonstrate identification of renal anomalies associated with didelphys uterus, ligation of the uterine artery at the origin and techniques for dissection of the bladder flap after two previous cesarean sections to facilitate a wider colpotomy.
Sep 26, 2019 | 340 Views
Transvaginal hydro-laparoscopy is a minimally invasive technique that allows direct visual examination of the pelvic structures through the vaginal wall of the posterior fornix as opposed to going through the abdominal wall during the traditional laparoscopy.Insertion of the hydro-laparoscopy trocar is accomplished through a puncture done under sedation passing through the vaginal wall posteriorly and directly into the cul-de-sac. Approximately, 200-300 cc of normal saline are used to facilitate navigation between pelvic structures allowing excellent, close-up visualization of the pelvic organs and peritoneal surfaces including the posterior wall of the uterus, fallopian tubes, ovaries, pelvic sidewalls and the cul-de-sac. Fimbrioscopy is also feasible assessing the mucosal folds of the distal tube.The operative capabilities of that approach are limited to simple lysis of adhesions, ovarian drilling and ablation of surface endometriosis. There is also promising potential to collect cytology samples from ovarian surfaces and from the distal tubal mucosa which can be of interest to oncologists aiming to offer screening for early diagnosis of epithelial ovarian tumours.The video illustrates the examination of the reproductive system during TVHL. It captures the appearance and orientation of pelvic structures when entering the pelvis from a direction opposite to what gynecologists are accustomed to during traditional laparoscopy.
Sep 27, 2019 | 320 Views
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.
Sep 27, 2019 | 305 Views
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.
Sep 27, 2019 | 442 Views
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.
Sep 27, 2019 | 281 Views
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.
Sep 27, 2019 | 323 Views
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.
Sep 27, 2019 | 438 Views
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.
Sep 27, 2019 | 365 Views
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.
Sep 28, 2019 | 392 Views
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.
Sep 28, 2019 | 605 Views
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.
Sep 29, 2019 | 489 Views
Intracorporeal knot tying is an essential skill for a laparoscopic surgeon. Acquiring this ability may be intimidating for learners. There are numerous methods available, many of which can be confusing to the learner. This video presents a straight-forward, easily replicable technique with related suturing pitfalls and tips. We highlight several advantages to this technique over others: 1) The surgeon holds the suture versus the needle, decreasing inadvertent visceral injury. 2) It involves switching hands, ensuring square knots, and ease in lying knots flat. 3) It is particularly useful when there is a large defect to close and a long suture is needed (ie. Vaginal vault), vs a single knot. 4) It is easy to learn and teach regardless of handedness because both hands are used equally.
Oct 26, 2019 | 332 Views
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.
Oct 26, 2019 | 591 Views
Ligating the uterine arteries is a key step in successfully performing a total laparoscopic hysterectomy. However, in the presence of pelvic pathology, the anatomy can be significantly distorted making visibility and accessibility difficult. Securing the uterine arteries at the origins of the internal artery is a useful technique for any gynecologists performing hysterectomies. In this total laparoscopic hysterectomy, we encountered an obliterated anterior cul-de-sac from the previous Caesarean section scar and an inaccessible posterior cul-de-sac from a large posterior fibroid. Since it was not possible to ligate the uterine arteries at the level of the internal cervical os, we decided to use the lateral approach to ligate the uterine arteries by dissecting the pararectal fossa. This video aims to highlight the importance of identifying landmarks, hemostatic dissection, and adaptive intraoperative planning.
Sep 24, 2020 | 160 Views
The purpose of this educational video is to provide an overview of the guidelines and indications for laparoscopy in pregnancy. We will review preoperative, intraoperative and postoperative considerations for laparoscopy in this patient population. Although historically contraindicated in pregnancy, laparoscopy is now the preferred treatment approach to surgical conditions in pregnancy and is considered safe in all trimesters. In this video, we review topics such as patient positioning, recommendations for venous thromboembolism prophylaxis and appropriate monitoring for preterm labor. We also review and demonstrate options for safe laparoscopic port entry and surgical techniques to aid with visualization. We aim to provide a thorough approach to laparoscopy in this unique patient population.
Sep 24, 2020 | 112 Views
The patient was a 29-year-old G1P0 female presenting with a live 11-week extrauterine pregnancy. Radiologic work-up with both pelvic ultrasound and MRI could not fully ascertain diagnosis. Differential diagnosis included tubal ectopic, horn pregnancy of a bicornuate uterus, interstitial pregnancy, and broad ligament pregnancy. Given this was a wanted pregnancy, intra-sac potassium chloride was not administered pre-operatively and the patient was consented for a diagnostic laparoscopy and possible removal of ectopic pregnancy. Laparoscopy revealed a large left rudimentary horn pregnancy. Our video demonstrates a stepwise approach for the excision of such pregnancies including isolation of the ureter retroperitoneally, bladder dissection, use of peritoneal landmarks to ensure safe transection of the fibrous band, and use of hemostatic techniques such as vasopressin and advanced bipolar devices. In addition, we demonstrate a simple technique for oophoropexy where we stabilize a hypermobile ovary to the round ligament pedicle using a laparoscopic ligature device.
Sep 24, 2020 | 266 Views
The purpose of this educational video is to provide a brief overview of interstitial ectopic pregnancy, describe a rare case of a recurrent interstitial ectopic pregnancy after previous ipsilateral cornuectomy and demonstrate a minimally invasive surgical approach to management. We describe the case of a 38 year old G5P2 woman who presented with imaging concerning for a left interstitial ectopic pregnancy. She had previously undergone a left salpingectomy and left uterine wedge resection for separate pregnancies making the case complex and clinically fascinating. While recurrent interstitial ectopic pregnancy does pose a high risk to patients, it can be safely managed with a minimally invasive surgical approach when techniques focused on surgical planning, blood conservation, vigilant post operative care and extensive patient counseling are implemented
Sep 24, 2020 | 129 Views
This is the third video of a series introducing the concept of parametrial endometriosis (PE) and describing our surgical approach in treating this particular disease presentation. The objective of this video is to review the anatomy and innervation of the parametrium and introduce the surgical technique and efficacy of the Laparoscopic Nerve-Sparing Ultralateral Resection (LaNSURe) of PE. This educational video introduces the nerve-sparing surgical treatment of PE and reviews initial results of a retrospective review of these patients. It is a compilation of anatomy schematics and surgical video clips demonstrating the novel LaNSURe surgical technique in patients diagnosed with PE. PE is a unique presentation of endometriosis with a specific constellation of signs and symptoms. This video introduces the surgical technique of our novel LaNSURe surgical technique of PE which has demonstrated encouraging initial results improving pain and quality of life. Long-term follow up will be completed in the future.
Sep 24, 2020 | 153 Views
This is the second video of a series introducing the concept of parametrial endometriosis (PE) and describing our approach to diagnosing and treating this particular disease presentation. The objective of this video is to discuss the presenting signs and symptoms associated to this condition as well as provide an approach for clinical workup and diagnosis. It is a compilation of anatomy schematics, medical imaging and surgical video clips demonstrating the anatomy, clinical and diagnostic findings, and describing the infiltration patterns of PE. We then present some pictorial cases correlating the clinical, imaging and surgical findings. PE is a unique presentation of endometriosis with a specific constellation of symptoms and clinical findings. This video series introduces this concept and teaches the approach to clinical diagnosis setting the bases for the next video in the series, which describes the surgical technique and results of the Laparoscopic Nerve-Sparing Ultralateral Resection (LaNSURe) of PE.
Sep 24, 2020 | 197 Views
This is the first video of a series introducing the concept of parametrial endometriosis (PE) and describing our approach to diagnosing and treating this particular disease. The objective of this video is to discuss anatomy and innervation of the parametrium and explain presenting signs and symptoms associated to this condition. This educational video includes a compilation of anatomy schematics, surgical video clips, and cadaveric dissections demonstrating the anatomy in the innervation of the parametrium and its correlation with the specific symptoms and signs of PE. This is part of an ongoing retrospective-prospective study that currently includes 28 patients who underwent surgical parametrectomies for the treatment of PE. PE is a unique presentation of endometriosis with a specific constellation of symptoms. This video introduces this concept and sets the fundamental anatomic bases for the next videos in the series which describe diagnosis, as well as the LaNSURe surgical technique.
Sep 24, 2020 | 167 Views
Adnexal torsion in the third trimester of pregnancy is rare but associated with significant risk of maternal and fetal morbidity if left untreated. Laparoscopy is considered the preferred surgical approach for treatment of adnexal torsion but has not been described beyond 34 weeks’ gestation. Here we illustrate a case of right adnexal torsion in the setting of a known ovarian cyst successfully treated with laparoscopic detorsion and cystectomy at 35+5 weeks gestational age. Pre-operative consultations, port placement, surgical steps and post-operative monitoring with the help of a multidisciplinary team are presented.
Sep 24, 2020 | 188 Views
An interstitial ectopic refers to the implantation of a pregnancy in the proximal fallopian tube where it passes through the myometrium. This type of ectopic offers a distinct surgical challenge, as they often present with rupture, and carry a significant risk of hemorrhage at time of resection. This video demonstrates a four-step approach to resection of interstitial ectopic pregnancies with a laparoscopic cornuostomy. This includes isolating the pregnancy by salpingectomy and ligation of the utero-ovarian ligament, ensuring hemostasis with a novel purse string suture around the pregnancy at its equatorial line and injection of vasopressin, resection using a linear incision, and a layered repair of the uterine defect. The purse-string suture is shown to be a useful tool in minimizing bleeding, and this sequential approach allows for interstitial ectopic pregnancies to be excised with a minimally invasive cornuostomy, even in cases of significant anatomical distortion.
Sep 24, 2020 | 217 Views
In this video, we present an approach to previously described suprapubic laparoscopic-assisted myomectomy that we feel mitigates some of the disadvantages of traditional myomectomy - increased operative time, increased blood loss and surgical expertise in laparoscopic suturing. Using footage from our own procedures of this kind, we propose a method by which a fibroid is just partially dissected free of the myometrium, is tagged with a unique suture and morcellated while still within the myometrium.
Sep 24, 2020 | 104 Views
Neuropathic pain refractory to other modalities of treatment is an indication for surgical management. This video follows a case of neuropathic pain in the distribution of the ilioinguinal nerve, as demonstrated with short-term resolution of symptoms after a nerve block. Relevant neuroanatomy will be reviewed, and laparoscopic excision of the ilioinguinal nerve will be demonstrated in a stepwise fashion. Resolution of her symptoms on post-operative pain mapping will also be shown.
Sep 24, 2020 | 103 Views
Cervical myomectomy is a surgical challenge and the risk of subsequent cervical incompetence is unknown. We presented the case of a 30-year-old woman, nulligravida, with a 12 cm cervical leiomyoma, who consulted for heavy menstrual bleeding and pelvic pain. After failure of multiple medical therapies, a laparoscopic cervical myomectomy was successfully performed. Adjuvant pre-operative uterine artery embolization with gelatin sponges was used to reduce surgical blood loss, as an alternative to intra-operative ligation of uterine arteries when access to the retroperitoneum is limited by the size and location of leiomyomas. In order to prevent cervical incompetence, a concomitant laparoscopic cerclage was achieved since the integrity of the cervix has been compromised by the myomectomy.
Sep 24, 2020 | 160 Views
This video reviews techniques to recreate pelvic supports and mitigate long term surgical complications of laparoscopic hysterectomy including: (1) ophoropexy and (2) vault suspension.
Sep 24, 2020 | 116 Views
This video reviews the surgical management of adnexal torsion in early and late pregnancy. We discuss imaging and diagnosis, and present an approach focusing on the preoperative, intraoperative, and postoperative considerations.
Sep 24, 2020 | 210 Views
Bowel injuries complicate 0.13% of laparoscopic gynecologic surgeries. Intraoperative diagnosis is critical to preventing mortality. A high index of suspicion should be maintained when patients present postoperatively with signs and symptoms suggesting bowel injury, and these patients should be promptly evaluated with imaging. The general approach to bowel injury includes involving consultants early if needed, intraoperative antibiotics if appropriate, thorough evaluation of the injury, surgical repair, and monitoring for possible postoperative complications. The specific approach to repair depends on the type of bowel injury. Veress needle injuries can be managed expectantly. Superficial, small thermal and partial thickness injuries can be oversewn or repaired with a one layer closure. Full thickness injuries should be closed in one or two layers. Large or infected injuries often require bowel resection with re-anastomosis and a possible diverting stoma. Considerations for postoperative care are also reviewed.
Sep 24, 2020 | 255 Views
This video presents a five-step approach to the laparoscopic excision of pericardial and diaphragmatic endometriosis. Clinically, endometriosis affects the thoracic cavity in less than 1% of cases, most commonly involving the diaphragm and treated using a VATS approach. Pericardial endometriosis is an even rarer entity, with only 4 case reports published to date. We present the case of a 35-year-old in order to illustrate the approach to a laparoscopic excision of diaphragmatic and pericardial endometriosis. In consultation with the Thoracic team, she is consented for a completion surgery of thoracic endometriosis identified at a prior laparoscopy, symptomatic for right shoulder and mid-chest pain, and unresponsive to medical therapy. The surgical approach consists of 5 reproducible steps: 1. Upper abdominal survey 2. Liver mobilization 3. Excision of diaphragmatic and pericardial lesions 4. Intra-thoracic laparoscopic exploration 5. Closure of the diaphragmatic defect
Sep 24, 2020 | 237 Views
Deeply infiltrating endometriosis can involve the bladder and ureters; this educational video demonstrates the steps for a laparoscopic ureteroureterostomy for ureteric obstruction and highlights the advantages of a multi-disciplinary approach. A 29-year-old G0 was referred to Urology with right sided flank pain, with a past history of surgically-excised endometriosis. Imaging showed a 6.6 cm right adnexal mass, with proximal hydroureter and hydronephrosis. A multi-disciplinary surgical approach was planned with Urology and Gynecology. Excision of endometriosis was initially performed, which included superficial endometriosis, a rectovaginal nodule and endometrioma cystectomy. Complete ureteric stricture due to endometriosis was confirmed; a laparoscopic ureteroureterostomy was performed, with closure using a barbed suture. Her post-operative recovery was uncomplicated, and follow-up imaging and ureteroscopy showed decreased hydroureter, and no evidence of obstruction. This video demonstrates the surgical steps and collaborative surgical decision-making during a complicated case.
Sep 24, 2020 | 286 Views
Management of interstitial ectopic pregnancy has traditionally been performed via cornual wedge resection. We present a minimally invasive approach using a four step process: (1) identify the location of the interstitial pregnancy, (2) utilize hemostatic measures such as vasopressin, vessel occlusion, or tranexamic acid, (3) create a circumferential linear incision over the specimen leaving a tissue pedicle, and (4) complete a double layer running closure for re-approximation and hemostasis.