E. Soto

Comparison of Long-Term Fertility and Bleeding Outcomes after Robotic-Assisted, Laparoscopic, and Abdominal Myomectomy

Background/Aims. To compare long-term fertility and bleeding outcomes of women who underwent robotic-assisted, laparoscopic, and abdominal myomectomy at our institution over a 15-year period. Methods. This was a retrospective cohort study of myomectomy patients 18–39 years old that had surgery between January 1995 and December 2009 at our institution. Long-term follow-up on fertility and bleeding outcomes was collected from the patient directly. The uterine fibroid symptom and quality of life survey was also administered to assess current bleeding patterns. Baseline characteristics were compared across groups. Univariable comparisons of fertility and bleeding outcomes based on surgical approach were made using analysis of variance, Kruskal-Wallis analysis of ranks, and Chi-square tests as appropriate. Results. 134/374 (36%) subjects agreed to participate in the study. 81 subjects underwent an open procedure versus 28 and 25 subjects in the laparoscopic and robotic groups, respectively. Median follow-up after surgery was 8 years. 50% of patients desired pregnancy following surgery and, of those, 60% achieved spontaneous pregnancy; the spontaneous pregnancy rate did not differ between groups. Additionally, UFS-QOL scores and/or subscores did not differ between groups. Conclusion. There is no significant difference in long-term bleeding or fertility outcomes in robotic-assisted, laparoscopic, or abdominal myomectomy.

Minimally-Invasive Myomectomy Using Unidirectional Knotless Barbed Suture

STUDY OBJECTIVE To demonstrate the technique for closure of the uterine wall defect during minimally invasive myomectomy using unidirectional knotless barbed suture. DESIGN Step-by-step explanation of the technique using videos and pictures (educational video). SETTING Women have a 70% to 80% lifetime risk of developing uterine leiomyomas. Myomectomy is a common procedure performed for conservative treatment of leiomyomas that is frequently performed using a minimally invasive technique. Knotless barbed sutures have recently been used successfully in minimally invasive myomectom procedures. Advantages of using barbed sutures in this setting include the ability to perform knotless suturing and rapid suture deployment, which may result in decreased operative time and blood loss. In addition, the tensile strength of the suture is maintained by the barbs, which facilitates the operative procedure and may potentially lead to a more even distribution of tension along the closure. INTERVENTIONS Closure of the uterine wall defect using unidirectional knotless barbed suture during minimally invasive myomectomy. CONCLUSION The use of unidirectional knotless barbed suture substantially facilitates closure of uterine defects during minimally invasive myomectomy and may offer additional advantages such as minimizing operative time.

Supraumbilical primary trocar insertion for laparoscopic access: the relationship between points of entry and retroperitoneal vital vasculature by imaging

OBJECTIVES Advances in laparoscopy have demonstrated that supraumbilical primary ports can be desirable in complex cases with large masses. This study evaluated distances to vital retroperitoneal vasculature that were encountered with 45- and 90-degree angle entry from the umbilicus and 2 commonly described supraumbilical entry points at 3 and 5 cm cephalad from the umbilicus. STUDY DESIGN Retrospective analysis of computed tomography scans of the abdomen and pelvis from 100 randomly selected women who were 18-50 years old with normal anatomy was performed. Three-dimensional models of sagittal sections were generated using IMPAX software. Measurements from the abdominal wall at the umbilicus and 3 and 5 cm cephalad with 45- and 90-degree angles to retroperitoneal structures were performed. RESULTS With 90-degree angle entry, the abdominal wall thickness (AWT) was thinnest at the umbilicus; however, the thickness at 3 and 5 cm was similar. AWT increased at all sites with 45-degree angle entry, and the same pattern was observed. AWT and intraperitoneal distance positively correlated with body mass index and supraumbilical entry points. With 90-degree angle entry, the aorta was 1.9 cm (95% confidence interval [CI], 1.4-2.4) and 2.5 cm (95% CI, 2.0-2.9) farther away at 3 and 5 cm cephalad compared with umbilical entry. In one-third of the cases, regardless of port placement, a vascular structure other than the aorta was the most anterior vessel. With 45-degree angle entry at the umbilicus, no vessels were encountered. With 45-degree angle entry at 3 and 5 cm cephalad, the aorta was the most anterior vessel in 1% and 2% of cases, respectively, and was noted to be 1.0 cm (95% CI, 1.0-1.0) and 2.3 cm (95% CI, 1.2-3.3) farther away than with 90-degree angle entry. A vessel other than the aorta was encountered in 4% and 7% of cases at 3 and 5 cm, respectively. CONCLUSION According to theoretic modeling, supraumbilical primary port placement can be implemented safely in laparoscopy. With supraumbilical entry, the distance to retroperitoneal vessels was greater than at the umbilicus. Compared with a 90-degree angle, with a 45-degree angle entry, it was uncommon to encounter vasculature, and all measured distances were greater.

Surgical anatomy of supraumbilical port placement: implications for robotic and advanced laparoscopic surgery

OBJECTIVE To describe the surgical anatomy of the supraumbilical region and to provide guidelines for insertion technique. DESIGN Educational video. SETTING Tertiary university hospital. PATIENT(S) A study population of 92 women. INTERVENTION(S) Abdominal thickness was measured from the skin to the anterior peritoneum. Distance to the aorta and the IVC was measured from the anterior peritoneum to the most superficial border of the vessel. Mean values are presented for the distances from the umbilicus to the aorta and the IVC and at 1-cm increments cephalad to the umbilicus. Pearson correlation coefficients and 95% confidence intervals were calculated to describe the association between BMI and the distance and thickness measurements. MAIN OUTCOME MEASURE(S) Abdominal wall thickness, distance to the aorta and inferior vena cava. RESULT(S) Abdominal wall thickness increases the more cephalad above the umbilicus. The distance to the great vessels decreases at 1-cm increments above the umbilicus until 2 cm. The greatest distance from the entry point to the aorta and the IVC is at 5 cm above the umbilicus. However, the abdominal wall is also the thickest at this point, particularly in obese patients. Thus, the overall distance from the skin to the great vessels is reduced as BMI increases. The distal end of the falciform ligament, which is a fold of the peritoneal ligament, is on average 6.5 cm from the umbilicus. CONCLUSION(S) It is prudent for the surgeon to be cognizant of distance variations and risk of vessel injury with obese patients. If the supraumbilical entry is necessary, it is recommended to do so at 5 cm cephalad to the umbilicus. These anatomical relationships should be considered to avoid injury to the aorta and the IVC as well as intraligamentary preperitoneal insufflation.

Endometriomas and assisted reproductive technology.

Endometriomas in the assisted reproductive technology patient present a challenging clinical scenario for the infertility specialist. Although surgical management is often pursued in cases of pain or large cyst diameter, patients without such factors must be counseled regarding surgical versus expectant management. Decisions to pursue surgery must be viewed in the context of potentially decreased ovarian reserve and more difficult stimulation for in vitro fertilization. In this article, three distinct cases are presented along with a summary of the most current literature available to guide clinicians in the optimal management of in vitro fertilization patients with endometriomas.

Endometriosis and Cancer: Is There an Association?

Endometriosis currently affects 200 million women worldwide and is associated with an increased risk of ovarian cancer (OC). The pathophysiology of endometriosis-associated ovarian cancer (EAOC) is poorly understood with multiple theories proposed. Currently, there are no guidelines for screening or risk reduction strategies in this at-risk population; meanwhile, ovarian cancer remains the most lethal gynecological malignancy. This chapter reviews the current literature on the association of endometriosis and cancer, possible pathways to malignancy, prevention mechanisms, and treatment options for patients with endometriosis.