A. Kent

A Prospective, Randomized, Controlled, Double-Masked, Multi-Center Clinical Trial of Medical Adhesives for the Closure of Laparoscopic Incisions

STUDY OBJECTIVE To compare LiquiBand Surgical S (LB) (Advanced Medical Solutions Ltd, Plymouth, UK) with High Viscosity Dermabond (DB) (Ethicon Inc., Kirkland, Scotland) for the closure of laparoscopic wounds. DESIGN Prospective, multicenter, randomized, controlled trial (Canadian Task Force classification I). SETTING Multiple district hospitals. PARTICIPANTS A total of 433 subjects were enrolled between 2006 and 2009 at 4 investigational sites. INTERVENTIONS In this study, LB, an octyl/butyl cyanoacrylate blend, and DB, an octyl-based cyanoacrylate, were compared for topical skin closure of laparoscopic port sites (www.clinicaltrials.gov; study identifier NCT00762905). MAIN RESULTS High dermal apposition and cosmesis scores resulted from the use of both adhesives along with low rates of wound dehiscence and suspected infections. Masked evaluators and patients favored DB in the healing of the incisions (98.3% DB vs 93.9% LB, p < .05) and (97.2% DB vs 89.4% LB, p < .05). However, there was no difference in the overall satisfaction of the appearance of the wounds. LB was found to be significantly (p < .05) faster (LB = 32.1 seconds; DB, 50.3 seconds) and easier to use than DB, and surgical users were significantly more satisfied with using LB for wound closure. CONCLUSION The results of this trial show the efficacy of LB for the closure of topical skin incisions; LB was significantly faster, easier to use, and resulted in greater user satisfaction compared with DB.

Demonstration of Laparoscopic Resection of Uterine Sacculation (Niche) With Uterine Reconstruction

STUDY OBJECTIVE To demonstrate a technique of laparoscopic excision of uterine sacculation (niche) with uterine reconstruction. DESIGN Narrated video presenting a step-by-step explanation of a laparoscopic technique for excision of uterine sacculation (niche) with uterine reconstruction using a narrated video (Canadian Task Force classification III). SETTING Laparoscopic excision of uterine sacculation (niche) is a fertility-sparing technique for use in a selected group of patients who do not respond to medical treatment and in whom definitive treatment via hysterectomy is not an option. INTERVENTIONS Laparoscopic excision of uterine sacculation (niche) is performed by excising the uterine defect after initial reflection of the uterovesical fold. The area of uterine defect is identified preoperatively using flexible hysteroscopy. Once the margins of the defect are identified laparoscopically, it is circumferentially excised. The uterine manipulator helps to identify the cervical canal. Reconstruction is performed using interrupted 1 Vicryl sutures using an extracorporeal technique for secure tissue apposition. An adhesion barrier is then applied around the reconstructed area. CONCLUSION Excision of uterine sacculation (niche) with uterine reconstruction is a conservative surgical laparoscopic technique that should be considered in a selected group of patients in whom fertility sparing is desired and after medical therapy including progestogens, combined contraceptive pills, or the Mirena coil has failed to resolve symptoms.

Technical Video: Modified Laparoscopic Colposuspension

BACKGROUND Laparoscopic colposuspension has been shown in some studies to have equivocal results as open colposuspension, and in addition to treating stress incontinence can also reduce anterior vaginal wall compartment prolapse, as described by Burch in 1961 [1]. STUDY OBJECTIVE To demonstrate a novel modified technique for laparoscopic colposuspension. DESIGN Narrated step-by-step video demonstration of the modified laparoscopic colposuspension technique. SETTING Department of Obstetrics and Gynecology, Royal Surrey County Hospital. INTERVENTION Initially, 180 mL methylene blue with saline solution is instilled into the bladder for clear identification. Incision and dissection bilaterally, directly onto the ileopectineal ligament (Coopers ligament) are performed. By using the Kent dissecting knotter, dissection down the space of Retzius to the paravaginal tissues is easily performed. Two 0 Ethibond sutures (Ethicon, Inc., Somerville, NJ) are then placed on each side, between the Coopers ligament and the paravaginal tissues. These are tied via an extracorporeal knot using the other end of the Kent dissecting knotter. The peritoneal defects are then closed sequentially using 2/0 polyglactin 910 sutures (Vicryl; Ethicon) in a figure-of-eight intracorporeal surgical slip knot technique. MAIN RESULTS The patient had second-degree anterior wall prolapse with proved stress incontinence and descent of the bladder neck observed on video urodynamics. At 8 months after surgery she has no symptomatic or measurable prolapse and no stress incontinence. CONCLUSION This modified laparoscopic colposuspension procedure can be used in most cases because it is a transperitoneal technique. It requires substantially less dissection than the traditional techniques do, which results in a markedly reduced operative time.

Ovaries do not float

Hydrofloatation anti-adhesion solutions are often used to try to prevent adhesion formation around the ovary following surgery for endometriosis. Adhesions between the ovary and the ovarian fossa are very common following this surgery, and to be effective in preventing these, the hydrofloatation solution should separate the ovaries from the side wall. We demonstrate that ovaries do not float in either Hartmann’s solution, normal saline or 4% icodextrin. It is unlikely therefore that any of these solutions would be effective in preventing sub-ovarian adhesions.

Technical Video: Bilateral Tubal Adhesiolysis With Cuff Salpingostomy

STUDY OBJECTIVE To show the steps involved in a bilateral tubal adhesiolysis and cuff salpingostomy. DESIGN Technical video showing tubal adhesiolysis and cuff salpingostomy in a step-by-step approach. SETTING Minimal Access Therapy Training Unit, Royal Surrey County Hospital, Guildford, UK, a tertiary referral unit for complex gynecologic endoscopic surgery. INTERVENTIONS A 38-year-old woman presented with left-sided pelvic pain and primary infertility for 13 years. An ultrasound scan showed bilateral hydrosalpinges with suspected adnexal adhesions. Hysterosalpingography did not show spill of dye. After counseling, she opted to have tubal adhesiolysis and bilateral cuff salpingostomy. CONCLUSION Tubal surgery for occlusion has become less popular because of the superior success rates of assisted reproductive techniques. As a result, tubal surgery may eventually become a historic operation. However, in cases of distal tubal blockage after adhesionlysis and cuff salpingostomy or neosalpingostomy, pregnancy rates up to 35% have been reported in the literature. Furthermore, performing a bilateral salpingectomy instead in these cases renders a patient entirely dependent on assisted reproductive techniques for tubal factor infertility. Therefore, a bilateral cuff salpingostomy should be considered in a select group of patients.

Laparoscopic Hysterectomy Intrafascial (LHi) Following Pelvic Vein Embolization With Coils

Intra-operative rupture of the uterine mass occurred with drainage of serous fluid. Intra-operative pathology favored leiomyomawith cystic degenerative changes and hemorrhage. Final pathology confirmed a leiomyoma with cystic degeneration weighing 232 gm and revealed a uterus with leiomyoma, proliferative endometrium, and benign fallopian tubes weighing 180 grams. Her post-operative course was unremarkable with discharge home after 23 hour observation. Conclusion: Degenerating leiomyoma can have variable appearance on imaging and intra-operatively, mimicking potential malignancy.

A new method of quantifying endometriosis using digital photography

The revised American Fertility Society scoring system for quantifying endometriosis is a relatively insensitive tool when assessing peritoneal endometriosis. We describe a new technique that can be used to quantify endometriosis which uses digital photography and a specifically designed computer analysis package to calculate lesion surface area. Using this we were able to demonstrate good intra-observer reproducibility, although inter-observer variability was relatively poor.