Danny Chou

Prediction of pouch of Douglas obliteration in women with suspected endometriosis using a new real‐time dynamic transvaginal ultrasound technique: the sliding sign

To evaluate preoperative real‐time dynamic transvaginal sonography (TVS) in the prediction of pouch of Douglas (POD) obliteration in women undergoing laparoscopy for suspected endometriosis.

Home Within 24 Hours of Laparoscopic Hysterectomy

We assessed the feasibility of safe discharge home within 24 hours following laparoscopic hysterectomy in 30 patients who met the inclusion criteria and consented to be enrolled in the study group. Patients were admitted on the day of their surgery with the expectation of discharge within 24 hours. Appropriate home nursing follow‐up and phone contact by the surgical team were organized preoperatively. Inclusion criteria were: age 30–65 years, absence of any major medical history that would require prolonged hospitalization, availability of home support for the first 48 hours after discharge and presence of a working telephone line and an address within the area of the Community Home Nursing service. All 30 operative procedures were completed without incident. Six patients underwent total laparoscopic hysterectomy (TLH) (all the procedures of hysterectomy being performed laparoscopically including the suturing of uterine arteries, colpotomy and closure of the vaginal vault. The uterus was removed vaginally) and 24 patients underwent laparoscopic hysterectomy (LH) (this techniques differs from TLH in that the colpotomy was performed laparoscopically but the uterosacral ligaments were divided vaginally and the vault also was closed vaginally after the uterus was removed vaginally). The average operating time was 115 minutes (range 85–150 minutes) and the average blood loss was 97 mL (20–250 mL). There were no intraoperative complications, no requirement for transfusion and no readmission to hospital for any of the patients in the study. Postoperative complications were minor (umbilical cellulitis (1), intestinal colic (1)) and both were treated with resolution of the symptoms. Ninety per cent of patients in the study were discharged within 24 hours of their surgery, the average duration of stay being 22.9 hours (20–24 hours). Three patients were not fit for discharge at 24 hours postoperatively due to general lethargy, migraine and nausea; their average discharge time was 53.5 hours. The study showed that laparoscopic hysterectomy can be associated with a reduction in length of in‐patient stay compared to traditional laparotomy. Furthermore this reduction could be safely reduced to 24 hours following laparoscopic hysterectomy. There was also an associated cost saving in terms of inpatient bed days. Patient satisfaction with this protocol was high in this selected and motivated group.

Is Hysterectomy Necessary for Laparoscopic Pelvic Floor Repair? A Prospective Study

STUDY OBJECTIVE To evaluate whether the addition of hysterectomy to laparoscopic pelvic floor repair has any impact on the short-term (perioperative) or long-term (prolapse outcome) effects of the surgery. DESIGN A controlled prospective trial (Canadian Task Force classification II-1). SETTING Private and public hospitals affiliated with a single institution. PATIENTS A total of 64 patients with uterovaginal prolapse pelvic organ prolapse quantification system stage 2 to 4 had consent for laparoscopic pelvic floor repair from January 2005 through January 2006 (32 patients in each treatment arm). Patients self-selected to undergo hysterectomy in addition to their surgery. INTERVENTIONS Patients were divided into group A (laparoscopic pelvic floor repair with hysterectomy) or group B (laparoscopic pelvic floor repair alone). All patients had laparoscopic pelvic floor repair in at least 1 compartment, whereas 52 patients had global pelvic floor prolapse requiring multicompartment repair. Burch colposuspension and/or additional vaginal procedures were performed at the discretion of the surgeon in each case. MEASUREMENTS AND MAIN RESULTS Symptoms of prolapse and pelvic organ prolapse quantification system assessments were collected preoperatively, perioperatively, and at 6 weeks, 12 months, and 24 months postoperatively. Validated mental and physical health questionnaires (Short-Form Health Survey) were also completed at baseline, 6 weeks, and 12 months. No demographic differences occurred between the groups. Time of surgery was greater in group A (+35 minutes), as was estimated blood loss and inpatient stay, although the latter 2 results had no clinically significant impact. No difference between groups was detected in the rate of de novo postoperative symptoms. At 12 months, 4 (12.9%) patients in group A had recurrent prolapse as did 6 (21.4%) patients in group B. At 24 months these figures were 6 (22.2%) and 6 (21.4%), respectively. These differences were not statistically significant (p=.500 at 12 months and .746 at 24 months). In the group not having hysterectomy, 4 (14.3%) of 28 patients had cervical elongation or level-1 prolapse by the 12-month assessment. CONCLUSION The addition of total laparoscopic hysterectomy to laparoscopic pelvic floor repair adds approximately 35 minutes to surgical time with no difference in the rate of perioperative or postoperative complications or prolapse outcome. Leaving the uterus in situ, however, is associated with a risk of cervical elongation potentially requiring further surgery. Laparoscopic pelvic floor repair is successful in 80% of patients at 2 years.

A review of total laparoscopic hysterectomy: role, techniques and complications.

Purpose of review The following review examines the current role of total laparoscopic hysterectomy, which is a hysterectomy completed entirely laparoscopically. Recent advances in equipment, surgical techniques and training have made total laparoscopic hysterectomy a well tolerated and efficient technique. It is increasingly being adopted around the world because of the benefits to patients and surgeons. This study discusses the role of total laparoscopic hysterectomy, provides some technical suggestions about how to perform a total laparoscopic hysterectomy and how to avoid possible complications. Recent findings Only a few surgeons performing total laparoscopic hysterectomy have published their techniques and results. The terminology and techniques for total laparoscopic hysterectomy used by different surgeons, such as energy sources, the use of uterine manipulators, vaginal tubes, the method for uterine artery ligation and method of vault closure, vary. This makes objective comparison of the literature, techniques and complication rates difficult. Summary As more surgeons become trained in advanced laparoscopic surgery, the role of total laparoscopic hysterectomy will increasingly take over indications for total abdominal hysterectomy. It remains important that surgeons share their experience and publish their techniques, results and complications. Advanced laparoscopic training and supervision are paramount before embarking on total laparoscopic hysterectomy, so that complications are minimized.

Sydney Contained in Bag Morcellation for Laparoscopic Myomectomy

STUDY OBJECTIVE To demonstrate a new technique of contained in bag morcellation of a myoma after laparoscopic myomectomy. DESIGN Step-by-step explanation of the technique in a narrated video. INTERVENTION Contained In Bag Morcellation of myoma after laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS Recent controversy regarding the risk of disseminating occult leiomyosarcomatous tissue during morcellation means we need to revise our current approach to tissue extraction at laparoscopic myomectomy and morcellation in general. Herein we present a novel technique, conceived by Dr. Danny Chou, called the Sydney Contained In Bag Morcellation technique for laparoscopic myomectomy. In this technique an EndoCatch bag (EndoCatch II Auto Suture Specimen Retrieval Pouch; Covidien, Mansfield, MA) is introduced in the typical fashion, the myoma is retrieved, and the mouth of the bag is exteriorized onto the abdominal wall. A 12-mm trocar is then introduced within the bag, and pneumoperitoneum is created before introducing an optical balloon tip port (KII Balloon Blunt Tip System; Applied Medical, Rancho Santa Margarita, CA) and the power morcellator device. Morcellation is then performed within the bag, under direct vision. This technique may offer a safer approach to morcellation because the bowel is not within the morcellation field and there is lower risk of disseminating occult leiomyosarcomatous tissue during morcellation. Subsequent to the morcellation process, suctioning of the bag removes any aerosolized particles of myoma, further minimizing the risk of possible dissemination. CONCLUSION This technique may enable a minimally invasive approach to myomectomy to continue as a viable option in the era since the warning by the US Food and Drug Administration.

Laparoscopic sacrocolpopexy: how low does the mesh go?

Laparoscopic sacrocolpopexy is becoming an increasingly popular surgical approach for repair of apical vaginal prolapse. The aim of this study was to document the postoperative anterior mesh position after laparoscopic sacrocolpopexy and to investigate the relationship between mesh location and anterior compartment support.

Laparoscopic Ovarian Transposition with Potential Preservation of Natural Fertility

Radiotherapy doses greater than 6 Gy lead to irreversible ovarian damage by reducing the number of primordial follicles [1]. Ovarian transposition preserves fertility potential and prevents premature menopause in 83% to 88.6% of patients undergoing pelvic irradiation [2,3]. In contrast to conventional ovarian transposition with hysterectomy, this technique mobilizes the fallopian tube and ovary without tubal transection (Fig. 1). This is achieved by dividing the ovarian ligament while maintaining the vessels of the mesovarium intact. The anatomical proximity

Sonographic evaluation of immobility of normal and endometriotic ovary in detection of deep endometriosis

To examine the association between ovarian immobility and presence of endometriomas and assess the diagnostic accuracy of transvaginal sonographic (TVS) ovarian immobility in the detection of deep infiltrating endometriosis (DIE).

Anterior approach to laparoscopic uterine artery ligation.

Herein is described an anterior approach to uterine artery ligation during laparoscopic myomectomy and total laparoscopic hysterectomy. The anterior leaf of the broad ligament is opened and the uterine artery is clipped lateral to its crossing over the ureter. Outcome measures were completion of the procedure laparoscopically and the need for transfusion postoperatively. Thirty-eight myomectomies and 28 difficult total laparoscopic hysterectomies (primarily uteri with large myomas) were performed, with 1 conversion to laparotomy during myomectomy and 1 during hysterectomy, and 1 transfusion after total laparoscopic hysterectomy. The anterior approach to uterine artery ligation is an alternative method for treatment of uterine artery occlusion during laparoscopic myomectomy or hysterectomy performed to treat large myomas.

Uterine perfusion following laparoscopic clipping of uterine arteries at myomectomy

Laparoscopic clipping of uterine arteries facilitates laparoscopic myomectomy with minimal blood loss. This paper shows the return to normal myometrial perfusion following this procedure with literary evidence of the safety and efficacy of this technique.