D. Lum

Utilization of and charges for robotic versus laparoscopic versus open surgery for endometrial cancer.

To analyze the utilization and hospital charges associated with robotic (RS) versus laparoscopic (LS) versus open surgery (OS) in endometrial cancer patients.

Impact of the 2014 Food and Drug Administration Warnings Against Power Morcellation.

STUDY OBJECTIVE To determine whether members of the AAGL Advancing Minimally Invasive Gynecologic Surgery Worldwide (AAGL) and members of the American College of Obstetricians and Gynecologists Collaborative Ambulatory Research Network (ACOG CARN) have changed their clinical practice based on the 2014 Food and Drug Administration (FDA) warnings against power morcellation. DESIGN A survey study. SETTING Participants were invited to complete this online survey (Canadian Task Force classification II-2). PATIENTS AAGL and ACOG CARN members. INTERVENTIONS An online anonymous survey with 24 questions regarding demographics and changes to clinical practice during minimally invasive myomectomies and hysterectomies based on the 2014 FDA warnings against power morcellation. MEASUREMENTS AND MAIN RESULTS A total of 615 AAGL members and 54 ACOG CARN members responded (response rates of 8.2% and 60%, respectively). Before the FDA warnings, 85.8% and 86.9%, respectively, were using power morcellation during myomectomies and hysterectomies. After the FDA warnings, 71.1% and 75.8% of respondents reported stopping the use of power morcellation during myomectomies and hysterectomies. The most common reasons cited for discontinuing the use of power morcellation or using it less often were hospital mandate (45.6%), the concern for legal consequences (16.1%), and the April 2014 FDA warning (13.9%). Nearly half of the respondents (45.6%) reported an increase in their rate of laparotomy. Most (80.3%) believed that the 2014 FDA warnings have not led to an improvement in patient outcomes and have led to harming patients (55.1%). CONCLUSION AAGL and ACOG CARN respondents reported decreased use of power morcellation during minimally invasive gynecologic surgery after the 2014 FDA warnings, the most common reason cited being hospital mandate. Rates of laparotomy have increased. Most members surveyed believe that the FDA warnings have not improved patient outcomes.

Brush Cytology of the Fallopian Tube and Implications in Ovarian Cancer Screening

STUDY OBJECTIVE To determine whether fallopian tube epithelial cells adequate for cytopathology can be obtained via a minimally invasive approach using brush cytology. DESIGN Prospective feasibility study (Canadian Task Force classification II-1). SETTING Tertiary-care university-based teaching hospital. PATIENTS Ten patients who underwent laparoscopic hysterectomy, with or without adnexal surgery, because of benign indications. INTERVENTIONS Attempted hysteroscopic and laparoscopic brush cytologic sampling of the fallopian tubes. MEASUREMENTS AND MAIN RESULTS ThinPrep slides and cell blocks were prepared and analyzed. P53 and KI-67 immunostaining was performed on cell block specimens if adequate cellularity was present. The first 5 patients underwent attempted hysteroscopic sampling of the fallopian tube, with successful collection only in 1 patient. The protocol was then modified to enable sampling of the fallopian tube laparoscopically as well as hysteroscopically. In the other 5 patients sampling of the fallopian tubes was successful laparoscopically, including successful sampling hysteroscopically in 1 patient. The brush biopsy catheter could not be passed through the entire length of the fallopian tube in either the hysteroscopic or laparoscopic approach. All cytologic findings were interpreted as benign, although findings of nuclear overlapping, crowding, and small nucleoli were initially considered benign atypia. Immunohistochemistry for P53 and KI-67 yielded uniformly negative findings. CONCLUSION To our knowledge, this is the first study to describe endoscopic brush cytology of the fallopian tubes with correlated cytologic narrative. In the future, cytologic sampling of the fallopian tube may have implications for an ovarian cancer screening test.

Cytologic Findings in Experimental in vivo Fallopian Tube Brush Specimens

Objective: The fallopian tube is now recognized as a primary source of precursor neoplastic lesions for pelvic serous adenocarcinomas. Cytologic features of fallopian tube brushings from low-risk patients have not been well described. Study Design: We describe the cytomorphology of tubal epithelium from prospectively collected experimental in vivo brushings from normal fallopian tubes of 7 low-risk patients. Liquid-based cytology slides and cell blocks were prepared and reviewed on all specimens. Results: Fifteen brush cytology specimens were obtained, ten by laparoscopy, four by hysteroscopy and one following hysterectomy and bilateral salpingo-oophorectomy on an ex vivo specimen. Variable cytologic features were documented for background, cellularity, cellular architecture, cilia, nuclear overlap, mitoses, nuclear pleomorphism, nuclear membrane changes and nucleoli. Negative P53 and Ki-67 stain results were documented in available cell blocks. Histopathologic salpingectomy findings and clinical follow-up were benign. Conclusion: Moderate nuclear pleomorphism and nuclear overlap, prominent single and multiple nucleoli and background granular debris were common challenging cytologic findings in fallopian tube brushings from low-risk patients. With experience, cellular changes can be recognized as benign. Recognition of the range of normal fallopian tube cytology should help to minimize false-positive interpretations of cytology specimens obtained in association with risk-reducing salpingo-oophorectomies.

Techniques in minimally invasive surgery for advanced endometriosis.

Purpose of review Surgery can be an important treatment option for women with symptomatic endometriosis. This review summarizes the recommended preoperative work up and techniques in minimally invasive surgery for treatment of deeply infiltrating endometriosis (DIE) involving the obliterated posterior cul-de-sac, bowel, urinary tract, and extrapelvic locations. Recent findings Surgical management of DIE can pose a challenge to the gynecologic surgeon given that an extensive dissection is usually necessary. Given the high risk of recurrence, it is vital that an adequate excision is performed. With improved imaging modalities, preoperative counseling and surgical planning can be optimized. It is essential to execute meticulous surgical technique and include a multidisciplinary surgical team when indicated for optimal results. Summary Advanced laparoscopic skills are often necessary to completely excise DIE. A thorough preoperative work up is essential to provide correct patient counseling and incorporation of the preferred surgical team to decrease complications and optimize surgical outcomes. Surgical management of endometriosis is aimed at ameliorating symptoms and preventing recurrence.

73: Clinical characteristics and outcomes of patients undergoing contained extracorporeal manual tissue extraction

DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Erin Inman: Nothing to disclose; Emily Kobernik: Nothing to disclose; Kate Zahn: Nothing to disclose; Carolyn Swenson: Nothing to disclose; Neil Kamdar: Nothing to disclose; Kenneth Piehl: Nothing to disclose; John O. DeLancey: Nothing to disclose; Daniel M. Morgan: Up To Date , author, royalties; Michigan Surgery Quality Collaborative, physician lead, salary support.

Laparoscopic Management of Rectus Sheath Hematomas

Introduction: Rectus sheath hematomas can result from shearing of rectus muscle fibers or injury to the inferior epigastric vessels, which is the most common vascular injury to occur at the time of laparoscopic surgery. Case Description: We describe a case of a rectus sheath hematoma that was diagnosed 5 days after operative laparoscopy. We review the clinical presentation, diagnostic criteria, and therapeutic options of managing rectus sheath hematomas, and we describe the innovative use of laparoscopy for hematoma drainage after failed conservative management. Discussion: Rectus sheath hematomas that fail conservative management can be effectively drained laparoscopically. This minimally invasive approach provides rapid symptom relief and patient recovery.