Abstract:

Laparo-endoscopic single site (LESS) surgery has recently gained broader acceptance as a less-invasive approach to traditional multi-port laparoscopic procedures. LESS hysterectomy represents the gynecologic surgeon's progression toward this goal of performing minimally invasive hysterectomy procedures through increasingly fewer incisions. Although this procedure offers improved cosmesis and potentially decreased post-operative pain, there are also many challenges to adoption of this surgical procedure. LESS hysterectomy is associated with a steep learning curve and the need for the gynecologic surgeon to adopt new technologies and develop a new set of surgical skills. Following the basic principles of LESS surgery is essential for the gynecologic surgeon to safely and efficiently adopt this surgical procedure. Advances in surgical instrumentation will continue to allow surgeons to perform increasingly complex LESS surgical procedures in the future.

Authors:

Stuart Hart, MD, FACOG, FACS, Patrick Yeung Jr., MD, FACOG, Craig J. Sobolewski, MD, FACOG

For Direct IP Access please click this link

Abstract:

Abnormal uterine bleeding (AUB) is a significant health problem for many women. Surgical treatment of AUB often follows failed attempts with first-line medical therapy. Hysterectomy, while being a definitive treatment, is a major surgical procedure with potential for significant complications and economic costs. Endometrial ablation was developed as an alternative to hysterectomy. The first-generation endometrial ablation devices required extensive training and experience to be performed effectively and safely. As a result, newer ablative devices were developed addressing the need for less technical knowledge and improved safety. Since 1997, the United States FDA has approved 5 global endometrial ablation devices for treatment of AUB attributable to benign causes. This review will focus on the technical aspects of these second-generation devices and their applications for treatment of AUB.

Authors:

Shan Biscette, MD, FACOG, Jessica Shepherd, MD, Resad P. Pasic, MD, PhD

For Direct IP Access please click this link

Abstract:

As the number of conventional laparoscopic and robot-assisted gynecologic surgeries continues to rise, efficient and safe uterine manipulation has become increasingly important. Currently described uterine manipulation techniques require constant manual manipulation by the surgeon or surgical assistant. This often necessitates extra operating room personnel, increases fatigue levels, and decreases efficiency. There are two new uterine manipulation devices that can improve these measures: the Uterine Positioning System® (UPS) (Cooper Surgical, Trumbull, CT) and the ViKY UP® "Vision Control for endoscopY" Uterine Positioner (EndoControl Medical, La Tronche, France). Both provide accurate and secure uterine positioning. The UPS can manipulate the uterus with minimal bedside involvement from the surgical team while the ViKY UP provides uterine manipulation through a robotic arm controlled by the surgeon remotely. These two devices can facilitate a multitude of conventional laparoscopic and robot-assisted gynecologic surgeries.

Authors:

Kimberly Swan, MD, John Kim, MD, Arnold P. Advincula, MD

For Direct IP Access please click this link

Abstract:

The modified suspension technique for reanastomosis of the fallopian tube enables safer and more accurate placement of sutures at the anastomotic site. For all of the primary sutures, this technique enables careful inspection of the tissue layers prior to final approximation of the two tubal segments, thereby significantly reducing the possibilities of technical errors, such as posterior wall inclusion. This approach does not require the use of approximating clamps, and is an organized, well-staged approach.

Authors:

William A.C. Greene Jr., MD, FACOG, Zoltan Szabo, PhD, FICS

For Direct IP Access please click this link

Abstract:

Laparoscopy was considered marginal to surgical specialties before 1990. Rare innovations in instruments were done. With the realization of the first laparoscopic hysterectomy, this surgical route gained wide acceptance during the 1990s. Technical advances were made by instrument companies offering a wide variety of instruments to surgeons and by surgeons themselves to cope with problems during laparoscopic procedures. Manipulators are among the first instruments that surgeons suggested to ameliorate laparoscopic performance. Instruments that have multiple functions (i.e., grasping, cutting, coagulating) are more and more appreciated because surgeons can avoid changing instruments during surgery. Manipulators offer multifunctional assistance during gynecologic surgical procedures. They are useful for exposure purposes and also for reproductive surgery (and hysterectomy). This article explains the benefits and help that a manipulator can provide, especially in total laparoscopic hysterectomy. In the latter intervention, the manipulator will help to expose the pelvis by moving the uterus in any direction, to identify structures and find anatomical landmarks such as the vaginal fornices for culdotomy, and to avoid complications by pulling the ureter away from the operative field. Also, it is useful to avoid carbon dioxide leakage at the vaginal opening and to retrieve the surgical specimen. Each step is shown in a photograph with the specific hand movements corresponding to the manipulator's handling. We think that the use of manipulators during laparoscopic surgery is very useful and helps to reduce operative time.

Authors:

Joseph Nassif, MD, Arnaud Wattiez, MD

For Direct IP Access please click this link

Abstract:

Colposacropexy is the gold standard operation for repair of apical vaginal support defects. Although it is feasible to perform this operation using conventional laparoscopic techniques, a limited number of surgeons have mastered the advanced minimally invasive skills that are required. Introduction of the da Vinci® robotic system (Intuitive Surgical, Sunnyvale, CA) with instruments that have improved dexterity and precision and a camera system with three-dimensional imaging presents an opportunity for more surgeons treating women with pelvic organ prolapse to perform the procedure laparoscopically. This chapter outlines a technique that is exactly modeled after the open procedure for completion of a robotic-assisted colpo- and cervicosacropexy using the da Vinci® surgical system.

Authors:

Catherine A. Matthews, MD

For Direct IP Access please click this link