This video outlines the approach to radiofrequency ablation of uterine fibroids through the Acessa Procedure. The procedure begins with the preparation of the patient’s thighs and the insertion of a Foley catheter into the bladder. The surgeon then makes an incision in the patient’s left upper quadrant to insufflate the abdomen and insert a laparoscope. The location for the intra-abdominal ultrasound port is determined, and all fibroids are identified using ultrasound mapping. The surgeon then deploys the handpiece to ablate the fibroids and uses the coagulation page to minimize bleeding. The procedure is completed with the use of a suction irrigator to lavage the abdominal cavity, and any defects are checked for bleeding before closing.
The Acessa Procedure Summary:
- Prepare thighs with alcohol and place return electrodes above patellae
- Insert Foley catheter into the bladder
- Place single tooth tenaculum on cervix at 6 and 12 o’clock
- Use left upper quadrant approach for insufflation and visualization of anterior abdominal wall
- Make left upper quadrant incision and insert 3-mm port after lidocaine injection
- Place 3-mm laparoscope for supraumbilical port placement
- Insert 5-mm port and laparoscope; remove 3-mm port after checking for bleeding
- Decide on 10/12-mm port placement for intra abdominal ultrasound
- Introduce ultrasound transducer and begin mapping procedure to identify fibroids
- Insert handpiece approx. 1-2 cm away from ultrasound transducer
- Move into the center of the fibroid and confirm position by rotating transducer
- Deploy handpiece and begin treatment, ramping up to 100 degrees centigrade
- Retract array after treatment and switch to coagulation page for bleeding control
- Repeat treatment and coagulation steps for different areas of the fibroid
- Introduce suction irrigator to lavage abdominal cavity and check for bleeding
- Close 10/12-mm defect with suture to prevent hernia
Mercy Hospital, St. Louis MO
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What is the Acessa Procedure?
- The Acessa procedure is a minimally invasive outpatient treatment for fibroids using radiofrequency ablation technology.
- The procedure requires only two small incisions in the abdomen.
- Controlled radiofrequency energy is utilized to generate heat and induce coagulative necrosis of fibroid tissue.
- Fibroid symptoms alleviate as the treated tissue gradually softens and diminishes.
- There is no need for suturing uterine tissue during the procedure.
- The Acessa procedure enhances uterine imaging by concurrently displaying the laparoscopic camera and ultrasound views in real-time.
- This allows physicians to identify and address almost all fibroid locations, including those outside the uterine cavity and within uterine walls.
- Following the procedure, women typically experience minimal discomfort.
- Women can return to normal activities within 4-5 days after the procedure.
- The procedure provides long-lasting satisfaction and relief.
What are some risks the Acessa Procedure?
- The Acessa procedure is generally considered safe but complications can arise.
- Complications associated with the Acessa procedure include:
- Skin burns due to radiofrequency energy dispersion
- Minor intraoperative bleeding
- Temporary urinary retention or urinary tract infections may occur after the procedure
- Adhesion development
- Post-procedure discomfort, such as cramping and pelvic pain, may occur
- Temporary amenorrhea
- damage to nearby structures
- Vaginal bleeding
- short-term anemia
- In some cases, blood loss may necessitate transfusion or hysterectomy
- wound separation
- deep vein thrombosis
- pulmonary embolism
- Treatment failure
- Complications stemming from laparoscopy and/or general anesthesia, including the possibility of death, are also potential risks
Video Transcript: Radiofrequency Ablation of Symptomatic Uterine Fibroids: The Acessa Procedure
As you see, this is a typical setup for the Acessa procedure. The thighs need to be prepared with alcohol before the return electrodes are placed equidistant above both patellae. A Foley catheter is then placed into the bladder. The single tooth tenaculum will be placed on the cervix at six and 12 o’clock. I prefer a left upper quadrant approach for insufflation as well as visualization of the anterior abdominal wall. The left upper quadrant incision is made in the midline between the anterior axillary line and the sternum.
Just below the left costal margin, the patient is injected with lidocaine and a 3-mm port is directly inserted. Obviously, the stomach is emptied before this is performed. And she’s not had a splenectomy. Once the abdomen is adequately insufflated, a 3-mm laparoscope is placed into the abdomen for the placement of the umbilical or, in this case, supraumbilical port. Initially, the injection was made into the umbilicus. However, we realized that she had had a hernia repair, so we came above the mesh with our supraumbilical port.
Now we would not have seen that had we not used the left upper quadrant approach to identify the anterior abdominal wall. The 5-mm port is placed. A 5-mm laparoscope is now placed. And we will first look to see where the 3 mm port entered to be sure there is no bleeding. The 3-mm laparoscopic port is removed. And now we’re going to look into the abdomen and actually see the uterus that we’re going to treat. Once we’ve done that, now the decision is where to place the 10/12-mm port for the intra abdominal ultrasound.
And normally, it’s placed right at the fundus of the uterus so that the uterus can be scanned from all angles. If you were to place the laparoscopic port too low, it would be impossible to adequately scan the fundus of the uterus, nor would it be possible to support the uterus and manipulate it in such a way so that the procedure could be performed adequately. The ultrasound transducer is now introduced into the abdomen, and the mapping procedure has begun.
You want to identify all fibroids before you begin your treatment. There are two large fibroids. One in the left fundal area and one posteriorly. Now the question is how best to support this so that when we insert the probe, the uterus will be helping us rather than hurting us. Now you’re ready to insert the handpiece, which is placed approximately a centimetre to 2 cm away from the ultrasound transducer. Now I’m going to move into the center of the fibroid, about a centimetre.
Now the idea is to try to see whether we really are in the center of the fibroid. To prove that, once you can see your needle, if you’re in the center of the fibroid, you can prove that by rotating the transducer from side to side. If you lose the image equally, then you know that you’re in the center of the fibroid. We want to deploy the handpiece and get a picture, and you want to gently push down as you deploy. What you’ll see is the arms open. Now you’re ready to treat.
The image on the generator reflects the ablation page. This will show us the time to ramp to get to 100 degrees centigrade so we can begin our treatment. Once the treatment is completed, the array is retracted. The ablation page is changed to a coagulation page, and you slowly retract the handpiece to coagulate and minimize the amount of bleeding.
Now I’m looking for an area that’s a little more anterior so that I can complete the treatment of this fibroid. Again, I’m going to push down and deploy. Now we’re ready to treat the second portion of the fibroid. Again, we’re going to ramp up. And this time, we should ramp up a lot faster because the fibroid has been previously heated. Once the treatment has been completed, the array is retracted. The screen is changed to the coagulation screen.
You place your foot on the pedal, and you slowly remove the handpiece so that you can coagulate out and minimize the amount of bleeding from the fibroid and serosal surface. Once we finish the procedure, we introduce a suction irrigator so we can lavage the abdominal cavity. Look at all the defects. Be sure there is no bleeding. The only defect that needs to be closed with a suture is the 10/12 to prevent a hernia.