Azadeh Nezhat

Laparoscopic Appraisal of the Anatomic Relationship of the Umbilicus to the Aortic Bifurcation

STUDY OBJECTIVE To determine the cephalocaudal relationship among the umbilicus, aortic bifurcation, and iliac vessels by direct measurement during laparoscopy. DESIGN Prospective, consecutive study (Canadian Task Force classification II-1). SETTING Tertiary referral center. PATIENTS Ninety-seven women undergoing operative laparoscopy. INTERVENTIONS The distance from the aortic bifurcation relative to the umbilicus was measured in both the supine and Trendelenburg positions with a marked suction-irrigator probe. Patients were stratified into three groups based on body mass index (kg/m2). The anatomic location of the common iliac vessels and course of the left common iliac vein were identified in 68 women. MEASUREMENTS AND MAIN RESULTS The position of the aortic bifurcation ranged from 5 cm cephalad to 3 cm caudal to the umbilicus in the supine position, and from 3 cm cephalad to 3 cm caudal in the Trendelenburg position. In the supine position, the aortic bifurcation was located caudal to the umbilicus in only 11% of patients compared with 33% in the Trendelenburg position. This difference was statistically significant for the total study population (p <0.0001) and for the nonoverweight group (p <0.01). In both positions no significant correlation was found between the distance from the aortic bifurcation to the umbilicus and body mass index. Mean +/- SD distance of the aortic bifurcation from the umbilicus in the supine position was 0.1 +/- 1.2 cm for the nonoverweight group, 0.7 +/- 1.5 cm for the overweight group, and 1. 2 +/- 1.5 cm for the very overweight group. Respective values in Trendelenburg position were 1.0 +/- 1.1, -0.4 +/- 1.2, and -0.2 +/- 1.3 cm. The common iliac artery was caudal to the umbilicus in four women. The space between common iliac arteries was always at least partly occupied by the left common iliac vein, and was completely filled in 19 women (28%). CONCLUSIONS The cephalocaudal relationship between the aortic bifurcation and umbilicus varies widely and is not related to body mass index in anesthetized patients. Regardless of body mass index, the aortic bifurcation is more likely to be located caudal to the umbilicus in the Trendelenburg compared with the supine position. Its presumed location can be misleading during Veress needle or primary cannula insertion, and a more reliable guide is necessary for this procedure to avoid major retroperitoneal vascular injury.

Multidisciplinary Treatment for Thoracic and Abdominopelvic Endometriosis

Background and Objectives: Thoracic endometriosis is a rare form of extragenital endometriosis with important clinical ramifications. Up to 80% of women with thoracic endometriosis have concomitant abdominopelvic endometriosis, yet the surgical treatment is usually performed with separate procedures. This is the largest published series of the combination of video-assisted thoracoscopic surgery and traditional laparoscopy for the treatment of abdominopelvic and thoracic endometriosis. The objectives of this series are to further evaluate the manifestations of thoracic endometriosis, assess the multidisciplinary surgical approach, and discuss our institutions protocols. Methods: This is a retrospective, institutional review board–approved case series of 25 consecutive women who underwent combined video-assisted thoracoscopic surgery and traditional laparoscopy for the treatment of abdominopelvic, diaphragmatic, and thoracic endometriosis from January 1, 2008, to September 30, 2013. All surgeries were performed at a tertiary referral center by the same primary surgeons. Data were collected by chart review. Results: Twenty-five patients were included, with a mean age of 37.7 years. Eighty percent of patients had catamenial chest pain, and in 40% this was their only chest complaint. Shoulder pain was noted in 40% of patients, catamenial pneumothorax in 24%, and hemoptysis in 12%. One hundred percent of patients were found to have endometriosis in the pelvis, 100% in the diaphragm, 64% in the chest wall, and 40% in the parenchyma. There were 2 major postoperative complications: 1 diaphragmatic hernia and 1 vaginal cuff hematoma. Conclusion: Clinical suspicion and preoperative assessment are crucial in the diagnosis of thoracic endometriosis and allow for a multidisciplinary approach. The combination of video-assisted thoracoscopic surgery and traditional laparoscopy for the treatment of endometriosis optimally addresses the pelvis, diaphragm, and thoracic cavity in a single operation.

Bowel Endometriosis: Diagnosis and Management

&NA; The most common location of extragenital endometriosis is the bowel. Medical treatment may not provide long‐term improvement in patients who are symptomatic, and consequently most of these patients may require surgical intervention. Over the past century, surgeons have continued to debate the optimal surgical approach to treating bowel endometriosis, weighing the risks against the benefits. In this expert review we will describe how the recommended surgical approach depends largely on the location of disease, in addition to size and depth of the lesion. For lesions approximately 5‐8 cm from the anal verge, we encourage conservative surgical management over resection to decrease the risk of short‐ and long‐term complications.

Strong Association Between Endometriosis and Symptomatic Leiomyomas.

Background and Objectives: The relationship between leiomyoma and endometriosis is poorly understood. Both contribute to considerable pain and may cause subfertility or infertility in women. We conducted this retrospective study to assess the rate of coexistence of endometriosis in women with symptomatic leiomyoma. The primary outcome measured was the coexistence of histology-proven endometriosis in women with symptomatic leiomyoma. Methods: This is a retrospective review of a data-based collection of medical records of 244 patients treated at a tertiary medical center, who were evaluated for symptomatic leiomyoma from March 2011 through December 2015. Of those, 208 patients underwent laparoscopic or laparoscopic-assisted myomectomy or hysterectomy. All patients provided consent for possible concomitant diagnosis and treatment of endometriosis. The remaining 36 patients underwent medical therapy and were excluded from the study. All patients who had myomectomy or supracervical hysterectomy underwent minilaparotomy for extracorporeal morcellation and specimen removal beginning in April 2012. Results: Of the 208 patients with the presenting chief concern of symptomatic leiomyoma and who underwent surgical therapy, 181 had concomitant diagnoses of leiomyoma and endometriosis, whereas 27 had leiomyoma. Of the 27 patients, 9 also had adenomyosis. Patients with only fibroid tumors were, on average, 4.0 years older than those with endometriosis and fibroids (mean age, 44 vs 40 ± SD). Patients with both pathologies were also more likely to present with pelvic pain and nulliparity than those with fibroid tumors alone. Conclusions: In our patient population, 87.1% of patients with a chief concern of symptomatic fibroids also had a diagnosis of histology-proven endometriosis, which affirms the need for concomitant diagnosis and intraoperative treatment of both conditions. Overlooking the coexistence of endometriosis in women with symptomatic leiomyoma may lead to suboptimal treatment of fertility and persistent pelvic pain. It is important for physicians to be aware of the possibility of this association and to thoroughly evaluate the abdomen and pelvis for endometriosis at the time of myomectomy or hysterectomy in an effort to avoid the need for reoperation.

Robotic-Assisted Laparoscopic Hysterectomy and Endometriosis

Leonardo da Vinci sketched the first prototype of a robot in 1464 when he was 12 years old (Fig. 74.1). His life-sized armored robot knight was not realized until 1495 when it was built for the entertainment of his patron, the Duke of Sforza, at a celebration in the Court of Milan [1]. Five hundred years later, the field of robotics is not limited to entertainment, but has improved many aspects of everyday life. In medicine, for example, robotics has brought advancements to minimally invasive surgery.

Diagnostic and treatment guidelines for gastrointestinal and genitourinary endometriosis

Endometriosis is commonly misdiagnosed, even among many experienced gynecologists. Gastrointestinal and genitourinary endometriosis is particularly difficult to diagnose, and is commonly mistaken for other pathologies, such as irritable bowel syndrome, interstitial cystitis, and even psychological disturbances. This leads to delays in diagnosis, mismanagement, and unnecessary testing. In this review, we will discuss the diagnosis and management of genitourinary and gastrointestinal endometriosis. Medical management may be tried first, but often fails in cases of urinary tract endometriosis. This is particularly important in cases of ureteral endometriosis because silent obstruction can lead to eventual kidney failure. Thus, we recommend complete surgical treatment in these cases. Bladder endometriosis may be managed more conservatively, and only if symptomatic, because these rarely lead to significant morbidity. In cases of bowel endometriosis, we recommend medical management first in all cases, and the least invasive surgical management only if medical treatment fails. This is due to the extensive nervous and vasculature supply to the lower rectum. Injury to these nerves and vessels can cause significant complications and postoperative morbidity.

Vaginal Length After Laparoscopic Versus Vaginal Closure: A Randomized Trial [1K]

INTRODUCTION: Despite the increasing numbers of total laparoscopic hysterectomies (TLH) being performed each year, randomized comparisons between laparoscopic versus vaginal cuff closure are lacking. The purpose of this study is to determine the change in vaginal length after TLH with laparoscopic cuff closure (LC) versus vaginal cuff closure (VC). METHODS: Randomized study of women undergoing TLH. Vaginal length was measured pre-operatively and then 6–12 weeks and 6–12 months postoperatively. The primary outcome was change in vaginal length. Secondary outcomes were vaginal vault dehiscence and cuff closure operative time. Analysis was per-protocol using Mann-Whitney U test and Wilcoxon signed rank test. RESULTS: 68 patients were randomized, 34 patients were excluded due to inadequate follow-up, malignancy or alternative closure. No significant differences in age, BMI or parity were found. The median preoperative vaginal lengths were similar: LC 9.0 cm vs VC 9.25 cm; P=.23. The difference in median vaginal lengths at 6–12 weeks were: LC 9.0 cm versus VC 8.9 cm (P=.68). The median vaginal lengths at 6–12 months were both 9.5 cm (P=.94). When compared to the preoperative lengths, there were no significant differences at the 6–12 evaluation. The cuff closure time was significantly longer in the LC group (20 min versus 8 minutes, P<.05). There were no cases of vaginal cuff dehiscence. CONCLUSION: After total laparoscopic hysterectomy, the vaginal length at 12 months did not differ based on method of vaginal closure. Laparoscopic cuff closure times are longer than vaginal cuff closures and neither method had cases of vaginal cuff dehiscence.

Surgical Endoscopic Diagnosis of Infertility

Conception requires a series of coordinated, well-timed steps: ovulation, coitus, fertilization, implantation, and gestation. These steps require the cooperation of multiple systems and organs in the body as well as a healthy male sperm and female egg. Disruption at any of these points can contribute to infertility. Advances in surgical technique have enabled surgeons to treat more challenging cases of infertility with less risk than in the past. An infertility workup begins with a good history and physical exam. Blood and semen samples, as well as imaging studies, often provide additional information. When no obvious diagnosis is elucidated from this initial work-up, videolaparoscopy may be considered for direct view of the abdomen and pelvis using a small telescope-like camera through small abdominal incisions. Treatment of any structural causes of infertility may be performed using specialized instruments that require small incisions and minimal recovery time. As a result of videolaparoscopy, there are more opportunities and less invasive approaches for physicians to intervene on behalf of patients facing infertility (Nezhat et al., 2013).

Comment on "Unravelling the ovarian endometrioma pathogenesis: “The long and winding road” across the various theories"

We have received your Journal of Endometriosis and Pelvic Pain Disorders, which we enjoyed reading. In your most recent issue, we read the article by Viganò et al titled “Unravelling the ovarian endometrioma pathogenesis: “The long and winding road” across the various theories” (1). While we believe it is important to review the most common theories of endometriosis, it is also important to accurately give credit to those who initially presented the theory and not to the clinician who most recently republished that theory. The initial theory of retrograde menstruation is cited as “Hughesdson-Brosen’s theory.” This was in fact first described by Schron and Ruysh over 2 centuries ago and was further delineated by Sampson in 1927 (2, 3). The second theory mentioned, “Vercellinis theory,” is also inaccurately cited. This theory was suggested as early as 1921 by Sampson (4), yet the authors give credit to Vercellini et al, who published in 2009. Sampson initially described the theory of an endometrioma being formed after invasion functional ovarian follicules. Later, in 1992, Nezhat et al confirmed this theory and expanded on it by looking at the histology of these cysts (Type 2 endometriomas) (5). Nezhat et al further described another subtype of endometrioma (Type I) caused by invagination of ectopic tissue (5). Finally, the last theory, “Donnez’s theory,” is the theory of coelomic metaplasia. This was not initially suggested by Donnez in 1996, but was theorized as early as 1898 by Dr Iwanoff, then confirmed by multiple other authors including Dr Gruenwald in 1942 (6, 7). Again, we believe it is important to review the theories and present the new data, but credit should be given to the pioneers of those theories. Thank you for your consideration.