F. Shakir

The perforated uterus

Key content Uterine perforation is an uncommon but potentially serious complication of uterine manipulation, evacuation of retained products of conception or termination of pregnancy (TOP), hysteroscopic procedures and during coil insertion. Factors that increase the risk of uterine perforation include uterine anomalies, infection, recent pregnancy and postmenopause. TOP is the most common procedure associated with uterine perforation. Prevention of uterine perforation is favoured, although if it occurs, initial recognition together with immediate and ongoing management is key to reducing morbidity, mortality and long-term consequences. It is important that surgeons performing surgical TOP are adequately trained. The experience of the surgeon results not only in fewer perforations but also in the early recognition of uterine injury. Uterine perforation is a complication that is well recognised by all gynaecologists, although subsequent assessment and management needs to be standardised. Learning objectives To be aware of the incidence of uterine perforation and the potential serious complications that can result. To identify the risk factors of uterine perforation, the mechanism of injury and how to potentially prevent it from occurring. To increase awareness of this complication and to propose a standardised management protocol if a uterine perforation occurs, together with risk management issues. Ethical issues Are women at increased risk of uterine perforation counselled adequately about the complications and consequences? Are women at increased risk given the full range of alternative treatment options?Uterine perforation is an uncommon but potentially serious complication of uterine manipulation, evacuation of retained products of conception or termination of pregnancy (TOP), hysteroscopic procedures and during coil insertion. Factors that increase the risk of uterine perforation include uterine anomalies, infection, recent pregnancy and postmenopause. TOP is the most common procedure associated with uterine perforation. Prevention of uterine perforation is favoured, although if it occurs, initial recognition together with immediate and ongoing management is key to reducing morbidity, mortality and long‐term consequences. It is important that surgeons performing surgical TOP are adequately trained. The experience of the surgeon results not only in fewer perforations but also in the early recognition of uterine injury. Uterine perforation is a complication that is well recognised by all gynaecologists, although subsequent assessment and management needs to be standardised.

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.

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.