Tm Walsh

Hand-Assisted Laparoscopic Hysterectomy for Large Uteri

Abstract Study objective To determine whether laparoscopic hand-assisted hysterectomy for a large uterus had different surgical outcomes compared with traditional open hysterectomy. Design Retrospective cohort study (Canadian Task Force classification II-2). Setting Academic tertiary care hospital. Patients Women who had undergone laparoscopic hand-assisted hysterectomy for a large uterus were included as the hand-assist group. The control group comprised patients with similar final specimen weight (>1 kg), characteristics (body mass index, age), and surgical history, who underwent open hysterectomy for a large uterus. Intervention Laparoscopic hysterectomy using a hand-assist port for laparoscopic portion of the case. Results The 2 groups were similar in terms of specimen weight (median, 1765.5 g for hand-assist vs 1215.50 g for controls; p = .29). In univariate analysis, the median operating time was longer in the hand-assist group compared with controls (241.5 minutes vs 185.0 minutes; p = .002), whereas median length of stay was shorter in the hand-assist group (1.0 day vs 3.0 days; p .05) between the 2 groups, although the change in hemoglobin was less in the hand-assist group compared with controls in multivariable analysis (adjusted mean.74 vs. 1.8; p = .04). Complications were divided into intraoperative complications (transfusion, consultation, bowel injury, bladder injury, ureter injury, and other), hospital postoperative complications (reoperation, transfusion, slow return of bowel function, ileus, poor pain control, fever of unknown origin, venous thromboembolism, pneumonia, and neuropathy), and complications after discharge (readmission, wound infection). The 2 groups had a similar low rate of complications (p > .05). Conclusion Laparoscopic hand-assist hysterectomy is a feasible alternative to open hysterectomy in patients with a large uterus.

Vaginal Tissue Extraction Made Easy

STUDY OBJECTIVE To demonstrate a new technique to improve vaginal morcellation. DESIGN This video demonstrates a step-by-step process for morcellation through the vagina in a contained environment (Canadian Task Force Classification III). SETTING When performing laparoscopic hysterectomy, difficulty arises when the tissue being extracted is larger than the incision made. To avoid extending an abdominal incision, the colpotomy tends to be the favorable location for removal. The difficulty with vaginal morcellation lies in retraction and keeping the specimen at the colpotomy site. INTERVENTION This 42-year-old gravida 0 female with abnormal uterine bleeding with leiomyoma had completed child-bearing and desired a hysterectomy. She had a 17-week sized uterus with enlarged bulky myomas. Total laparoscopic hysterectomy was performed using three 5-mm ports. After the hysterectomy completed, the specimen was placed in a bag for removal. Morcellation was performed, and the specimen was removed. This video demonstrates a simple technique for containing the specimen using a bag, an Alexis ring, and a stapler, and then removing it vaginally. This approach provides vaginal protection and retraction in a contained system. It also eliminates the need to close the abdominal fascia. CONCLUSION Morcellation performed through the vagina can be quick and easy using the technique shown in this video. Not only does the technique provide vaginal protection and retraction, but it also contains the specimen to prevent its loss during the morcellation process and to avoid the spread of any unforeseen malignancy. By eliminating the need to close the abdominal fascia, surgical time is reduced, and concerns about hernia formation from extended incisions are allayed.

Laparoscopic Single-Site Myomectomy of 11-cm Intramural Myoma

STUDY OBJECTIVE To demonstrate the feasibility of laparoscopic single-incision myomectomy using new technology. DESIGN A step-by-step video demonstrating our technique for accomplishing a laparoscopic single-site myomectomy of a large intramural myoma. SETTING Single institution. INTERVENTIONS Single-incision laparoscopic surgery (SILS) has been shown to have similar outcomes to multiport laparoscopy but with superior cosmetic results [1,2] but has traditionally been associated with an increased learning curve, primarily because of poor ergonomics and instrument collisions, lack of triangulation, and, until recently, inadequate instrumentation. MEASUREMENTS AND MAIN RESULTS We present a case of laparoscopic single-site myomectomy of an 11-cm intramural myoma. This video was exempt from institutional review board review at our institution. SILS has traditionally been associated with poor ergonomics; however, we found that the articulating Enseal G2 Articulating Tissue Sealer (Ethicon Endo-Surgery, Blue Ash, OH) enables completion of complex surgical procedures not traditionally associated with single-site laparoscopy. This video demonstrates our technique to successfully accomplish a single-site laparoscopic myomectomy including the importance of vertical closure with V-Loc (Covidien, New Haven, CT) at the surgical site. CONCLUSION We found that the articulating Enseal enables a single-incision laparoscopic myomectomy to be performed with only minimal modifications on multiport surgery techniques. We were able to successfully perform a myomectomy on an 11-cm intramural myoma with excellent cosmetic results.

Minimally Invasive Adnexal Mass Extraction: Considerations and Techniques (With Videos)

Adnexal masses are a common indication for surgery in the United States. This article reviews the clinical features that may suggest an underlying malignancy, including ultrasound and biomarkers. The decision regarding how to remove an adnexal mass involves consideration of several factors, including body habitus, intra-abdominal anatomy, concomitant procedures planned, characteristics of the adnexal mass, and concern for underlying malignancy. Minimally invasive techniques for removal of adnexal masses are discussed in detail, with a review of the risk of an unexpected underlying malignancy.