Mallory Stuparich

Anatomic vascular considerations in uterine artery ligation at its origin during laparoscopic hysterectomies

Pelvic pathology such as fibroids, endometriosis, adhesions from previous pelvic surgeries, or ovarian remnants can distort anatomy and pose technical challenges during laparoscopic hysterectomies. Retroperitoneal dissection to ligate the uterine artery at its vascular origin can circumvent these obstacles, resulting in a safer procedure. However, detailed anatomic knowledge of the course of the uterine artery and understanding of vascular variations are essential for optimal dissection. We frequently encounter a C-shaped uterine artery variation during retroperitoneal dissection. We describe the key steps in identification and isolation of this variant, approaching the uterine artery origin either from the pararectal space or by utilizing the medial umbilical ligament coursing through the paravesical space. We also review other known uterine artery configurations. These techniques allow for safe completion of complex laparoscopic hysterectomies performed for various gynecologic diseases.

Endometriosis in the Adolescent Patient

Abstract The recognition and management of endometriosis in the adolescent patient is challenging. A strong clinical suspicion for endometriosis should be maintained in the adolescent who suffers from acyclic pelvic pain as well as absenteeism from school and lack of participation in daily activities. Risk factors include the presence of an obstructive Mullerian anomaly, a family history of endometriosis, and conditions that prolong exposure to endogenous and exogenous estrogens. Empiric medical therapy with nonsteroidal anti‐inflammatory drugs and combined oral contraceptive pills may be considered in most adolescents with endometriosis. Failure of empiric therapy may warrant diagnostic laparoscopy, which affords a concomitant opportunity for treatment via excision of endometriosis. Endometriotic implants in the adolescent tend to be more atypical, appearing red/flame‐like, clear/polypoid, or vesicular. Endometriosis tends to recur more often in adolescents when compared with adults, and the role of postoperative medical therapy for the suppression of disease progression is not entirely clear. Current knowledge on the impact of adolescent endometriosis on future fertility is limited but overall reassuring.

The Prolapsed Myoma

A 37-year-old patient presented to the emergency department with heavy bleeding, cramping, lightheadedness, and dizziness. She appeared pale and fatigued, with tachycardia to a heart rate of 119 bpm and normal blood pressure and temperature. Upon speculum examination, she was noted to be actively bleeding with moderate amount of blood in the vagina. She was noted to have a large fungating mass protruding from the cervical os, which was quite dilated to about 4–5 cm. The cervical rim itself appeared normal without focal lesions. On bimanual examination, the uterus was enlarged to approximately10 weeks in size, difficult to assess due to the likely prolapsed mass. No Pap or endometrial biopsy was obtainable in the presence of the mass.

Discoid Resection of Rectosigmoid Endometriotic Nodules

STUDY OBJECTIVE To show various techniques to perform laparoscopic anterior discoid resection of rectosigmoid endometriotic nodules. DESIGN A step-by-step explanation of the techniques using video with narration (educational video). SETTING Segmental bowel resection and reanastomosis are treatment options for larger rectosigmoid endometriotic nodules. However, laparoscopic anterior discoid resection of rectosigmoid endometriotic nodules is feasible and potentially less morbid in the appropriate candidate. Detailed knowledge of the avascular planes of the pelvis, particularly the pararectal and rectovaginal spaces, is crucial when approaching these nodules, which may initially present within an obliterated posterior cul-de-sac. Resection begins with determination of the nodule size followed by enucleation of the nodule itself. A 2-layer closure with barbed suture is then performed using a rectal probe as a template. Our institution previously demonstrated that barbed suture is safe to use in bowel repair and did not result in major complications [1]. An air leak test assesses the integrity of the repair and may be completed with air insufflation or with a methylene blue or povidone-iodine enema. With larger nodules, a V-shaped closure may be necessary. The patients provided consent to use images and videos of the procedure. Institutional review board approval was not required for this procedure. INTERVENTIONS Laparoscopic anterior discoid resection of a rectosigmoid endometriotic nodule. CONCLUSION Laparoscopic anterior discoid resection avoids the need for segmental bowel resection and reanastomosis. Barbed suture is a safe option for 2-layer bowel closure [1].

Tips and Tricks for Performing Salpingectomy at the Time of Laparoscopic Hysterectomy

STUDY OBJECTIVE To demonstrate various techniques to perform salpingectomy efficiently at the time of laparoscopic hysterectomy. DESIGN Step-by-step explanation of the techniques by video with narration (educational video) (Canadian Task Force Classification III). INTERVENTION Salpingectomy at the time of laparoscopic hysterectomy. MEASUREMENTS AND MAIN RESULTS Ovarian cancer is the deadliest gynecologic malignancy and has no effective screening strategies for average-risk women. After recognizing that the origin site for pelvic serous carcinomas may be the fallopian tube, the Society of Gynecologic Oncology published a practice statement in November 2013 addressing the role of salpingectomy at the time of hysterectomy or other pelvic surgery in average-risk women. (https://www.sgo.org/clinical-practice/guidelines/sgo-clinical-practice-statement-salpingectomy-for-ovarian-cancer-prevention). They now recommend that these women consider opportunistic salpingectomy to reduce their risk of fallopian tube and ovarian cancers. Various techniques allow the surgeon to complete the salpingectomy in a highly efficient manner. CONCLUSION Salpingectomy at the time of laparoscopic hysterectomy or other pelvic surgery should be considered in women at average risk of ovarian cancer. Salpingectomy can be performed either before or after control of the uterine blood supply. The surgical approach must also consider the coexisting pelvic pathology. Efficient dissection occurs if the surgeon maximizes exposure to the fallopian tube, optimizes presentation of the tissue to the working instrument, and provides gentle yet constant traction with accompanying countertraction. The fallopian tube specimen should be removed immediately to prevent its loss in the pelvis.