A. Cholkeri-Singh

Power Morcellation in a Specimen Bag

STUDY OBJECTIVE To show a technique of power morcellation within a rip-stop nylon specimen bag. DESIGN Step-by-step explanation of the technique. BACKGROUND The Food and Drug Administration recently warned against the use of electromechanical power morcellation for hysterectomy and myomectomy because of potential tissue dissemination within the abdomen and pelvis. If the tumor is malignant, this technique increases the staging of the patient and may further warrant re-operation and chemotherapy. If the tumor is benign, the patient is at risk for parasitic myomas that may lead to, but are not limited to, pain and/or bowel obstruction. INTERVENTION To reduce the preceding risks, we reviewed the techniques of power morcellation within a specimen bag used by other surgeons across the United States. This technique was modified to incorporate a more durable bag made out of rip-stop nylon. Laparoscopic supracervical hysterectomy during power morcellation was performed, along with an introduction to incorporating power morcellation of multiple myomas during a laparoscopic myomectomy. CONCLUSION This technique of power morcellation within a rip-stop nylon bag minimizes the risk of inadvertent tissue spread. This allows the patient an opportunity to undergo minimally invasive surgery for hysterectomy and myomectomy.

Persistent bleeding after laparoscopic supracervical hysterectomy.

Background and Objectives: In our clinical experience, there seemed to be a correlation between cervical stump bleeding and adenomyosis. Therefore, we wanted to conduct a study to determine whether there was an actual correlation and to identify other risk factors for persistent bleeding after a laparoscopic supracervical hysterectomy. Methods: The study included women who underwent laparoscopic supracervical hysterectomy from January 1, 2003, through December 31, 2012. Data were collected on age, postmenopausal status, body mass index (BMI), uterine weight, indication for hysterectomy, concomitant bilateral salpingo-oophorectomy (BSO), presence of endometriosis, surgical ablation of the endocervix, adenomyosis, presence of endocervix in the specimen, and postoperative bleeding. Results: The study included 256 patients, of whom 187 had no postoperative bleeding after the operation, 40 had bleeding within 12 weeks, and 29 had bleeding after 12 weeks. The 3 groups were comparable in BMI, postmenopausal status, uterine weight, indication for hysterectomy, BSO, surgical ablation of the endocervix, adenomyosis, and the presence of endocervix. However, patients who had postoperative bleeding at more than 12 weeks were significantly younger (P = .002) and had a higher rate of endometriosis (P < .001). Conclusions: Risks factors for postoperative bleeding from the cervical stump include a younger age at the time of hysterectomy and the presence of endometriosis. Therefore, younger patients and those with endometriosis who desire to have no further vaginal bleeding may benefit from total hysterectomy over supracervical hysterectomy. All patients who are undergoing supracervical hysterectomy should be counseled about the possible alternatives, benefits, and risks, including continued vaginal bleeding from the cervical stump and the possibility of requiring future treatment and procedures.

Intramural Fibroid Impinging on the Uterine Cavity

Women that have a multiple fibroid uterus can present with a variety of symptoms such as menorrhagia, pelvic pressure or pain, dyspareunia, infertility, and recurrent pregnancy loss. Definitive therapy is a hysterectomy. However, in the premenopausal patient who desires fertility, myomectomy is the current standard of care for treatment. Hysteroscopic, laparoscopic, robotic, and open techniques are all tools in a surgeon’s armamentarium that can be used to treat a fibroid uterus. There are emerging modalities that utilize imaging combined with a form of energy to treat fibroids. Ultimately, medical therapy may be used as an alternative to surgery for symptom relief. The management of a patient with a fibroid uterus must be made on a case-by-case basis depending upon what resources are available, patient’s fertility desire, and surgeon’s expertise.

Resectoscopic Surgery for Polyps and Myomas: A Review of the Literature

Resectoscopic surgery is routinely performed to remove endometrial polyps and uterine myomas. A search of Medline, PubMed, and the Cochrane Library was conducted through November 2016 for studies written in English, regardless of sample size or study type. The studies were then filtered by selecting those evaluating resectoscopic surgery. An analysis of peer-reviewed, published literature was performed to examine the clinical application of this treatment modality on patients requiring polypectomy and myomectomy. Different surgical techniques were also compared: hysteroscopy with scissors, forceps, or a cold loop; resectoscopy with radiofrequency energy; and mechanical resection. The literature finds that operative time during resectoscopic surgery is significantly longer than with mechanical resection. Resectoscopic myomectomy, however, may be necessary for removal of larger or more deeply embedded myomas. Ultimately, both techniques result in symptom resolution and a low recurrence rate.