Rosanne M. Kho

Strategies for Management of Colorectal Endometriosis

Abstract Endometriosis has clearly three distinct clinical presentations and deep endometriosis, especially compromising the rectosigmoid is probably the most concerning one for both patients and surgeons. Currently, with the available tools, it is mandatory to have a precise diagnostic of this type of disease prior to indication of treatment. Strategies to manage this form of endometriosis will take into account several involved aspects, such as age of the patient, reproductive desire or infertility, clinical symptoms, as well as the extension and localization of the disease. Treatment could vary from more conservative to more radical depending on those aspects. As we pointed out in this article, the key to manage colorectal endometriosis is to start with a good diagnosis. Knowing exactly what is the extension and localization of the disease and knowing the patients wishes as well as the clinical complaints, surgeons are able to define the best option for each patient. Critical points should always be discussed; for example, patients chosen to have clinical treatment should be aware of important issues regarding the follow‐up, while patients undergoing surgery must be advised about all surgical possibilities and related complications.

How Can We Increase the Percentage and Quality of Minimally Invasive Hysterectomy for Benign Disease Among Low/Intermediate-Volume Gynecologic Surgeons? A Perspective Piece From an Expert Panel Session at the 2017 Society of Gynecologic Surgeons Annual Meeting

Please cite this article as: Gutman RE, Morgan D, Levy B, Kho RM, Walter AJ, Mansuria S, How can we increase the percentage and quality of minimally invasive hysterectomy for benign disease among low/intermediate volume gynecologic surgeons? A Perspective Piece from Expert Panel Session at the 2017 Society of Gynecologic Surgeons Annual Meeting, The Journal of Minimally Invasive Gynecology (2017), doi: 10.1016/j.jmig.2017.05.012.

Ileum Endometriosis: a Cause of Bowel Obstruction

Bowel endometriosis can affect the ileum in 2-16% of women with endometriosis. Here we report a 37-year-old women with complaints of metrorrhagia, dysmenorrhea, noncyclic pelvic pain, and cyclic constipation for 10 years. Transvaginal ultrasound showed an ileum nodule compromising the muscular layer suggestive of endometriosis. At laparoscopy, it was observed two small lesions in ileum causing a severe horseshoe retraction of the small bowel submitted to surgery. Patient was submitted to enterectomy with complete resolution of symptoms.

Vaginal Hysterectomy, Salpingectomy, and Adnexectomy

Vaginal hysterectomy (VH) is the preferred route of hysterectomy for benign gynecological indications. The most recent Cochrane review (2015) [1] involving 47 studies and 5102 women concluded superiority of the vaginal route over abdominal, laparoscopic, and robotic-assisted hysterectomy. The vaginal approach provided faster return to normal activities, greater patient satisfaction and quality of life, fewer intraoperative visceral injuries, and less major long-term complications (such as fistula, pain, urinary and bowel, pelvic floor, and sexual dysfunction). Review of evidence revealed that VH should be performed in preference to abdominal hysterectomy (AH). When VH is not feasible, it is preferable to perform laparoscopic hysterectomy (LH) over AH. Considering changing demographics with a rising obese patient population, the American College of Obstetricians and Gynecologists (ACOG) in 2015 [2] recommended that vaginal hysterectomy be performed over other approaches for the obese patient in particular. The vaginal route with its single and concealed incision is associated with less serious adverse events such as wound infection and thromboembolism [3]. In the face of available evidence and recommendations, it is important that the surgeon conducts a thorough discussion with the patient to allow full participation in the decision-making.

Use of Vessel-Sealing Devices during Vaginal Hysterectomy

STUDY OBJECTIVE To demonstrate the proper use of vessel-sealing devices during vaginal hysterectomy. DESIGN Educational video (Canadian Task Force classification level III). SETTING University hospital. INTERVENTION The video reviews the principles on the use of energy in minimally invasive surgery. We focus on how vessel-sealing devices function and the benefits of their use in difficult vaginal hysterectomy. The video explains the 2 major types of complications, inadequate vessel sealing and undesired thermal injury, and demonstrates techniques to avoid these complications. MEASUREMENTS AND MAIN RESULTS Laboratory, intraoperative, and cadaveric recordings demonstrate proper use and the complications that may arise in the setting of improper use. CONCLUSION Vessel-sealing devices may be a useful tool for surgeons performing vaginal hysterectomy. This video demonstrates their use and underlines the importance of understanding the principles of energy devices and their proper usage in surgery.

Surgical treatment of different types of endometriosis: Comparison of major society guidelines and preferred clinical algorithms

Treatment options for patients with different types of endometriosis - superficial, ovarian, or deep - vary depending on the clinical presentation. New findings in the recent years regarding the role of preoperative imaging, efficacy of medical therapy, and effect of surgery on ovarian reserve have changed the way we understand the disease and subsequently the way we treat our patients. Practicing clinicians frequently refer to published recommendations from major societies for treatment guidelines. This paper aims to present and compare the varying major society guidelines on the indications and best surgical treatment approach for the management of the different types of endometriosis. We also present our preferred surgical treatment algorithm given the evidence in the literature and our cumulative 30-year clinical experience in a large tertiary referral center.