Volume 8 Supplement 1

20th Annual Congress ESGE September 21-24, 2011 in London ICC-International Convention Center

Open Access

Abstracts

Gynecological SurgeryEndoscopic Imaging and Allied Techniques20118(Suppl 1):1

https://doi.org/10.1007/s10397-011-0694-4

Published: 14 August 2011

Table of Contents

Table of Contents 1

Session FC.01 * Free Communications_1 * 29

Abstract FC.01.1 - ABSCESSUS TUBOOVARIALIS AND ILEUS.LAPAROSCOPIC TREATMENT.- 30

Abstract FC.01.2 - MANAGEMENT OF BORDERLINE OVARIAN TUMOURS BY LAPAROSCOPY . CONSERVATIVE TREATMENT. - 31

Abstract FC.01.3 - MODERN DIAGNOSTIC ASPECTS OF BORDERLINE TUMOURS IN REPRODUCTIVE AGE PATIENTS - 32

Abstract FC.01.4 - REMOVAL OF ESSURE DEVICE - 33

Abstract FC.01.5 - REPEAT RESECTOSCOPIC ENDOMETRIAL RESECTION AFTER FAILED THERMAL BALLOON ENDOMETRIAL ABLATION: IS IT WORTH THE RISK? - 34

Abstract FC.01.6 - UNDERTAKING THE LAPAROSCOPIC REMOVAL OF OVARIAN DERMOID CYSTS CAN MINIMIZE RISK OF CHEMICAL PERITONTIS - 35

Abstract FC.01.7 - ADENOMYOSIS AND UTERINE JUNCTIONAL ZONE (JZ) BY 3D TRANSVAGINAL ULTRASOUND IN INFERTILE AND FERTILE PATIENTS WITH AND WITHOUT PELVIC ENDOMETRIOSIS - 36

Abstract FC.01.8 - DIAGNOSTIC ACCURACY OF TRANSVAGINAL ULTRASOUND FOR NON-INVASIVE DIAGNOSIS OF BOWEL ENDOMETRIOSIS – A SYSTEMATIC REVIEW - 37

Abstract FC.01.9 - DIAGRAM TO MAPP ENDOMETRIOSIS - 38

Abstract FC.01.10 - ENHANCED OPTICAL DIAGNOSIS OF ENDOMETRIOSIS USING TARGETED NANOPARTICLES – DEFINING A NEW PARADIGM FOR ENDOSCOPIC SURGERY? - 39

Abstract FC.01.11 - PRE-OPERATIVE MRI FOR ASSESSMENT OF BOWEL INVOLVEMENT IN PATIENTS WITH DEEP PELVIC ENDOMETRIOSIS – DOES TIMING OF MENSTRUAL CYCLE MAKE A DIFFERENCE? - 40

Abstract FC.01.12 - SIMPLIFIED APPROACH TO THE TREATMENT OF ENDOMETRIOSIS – ECO SYSTEM - 41

Abstract FC.01.13 - FOCAL ENDOMETRIAL ABLATION FOR THE TREATMENT OF MENORRHAGIA AND INTRERMENSTRUAL SPOTTING IN WOMEN WITH CESAREAN SCAR DEFECT - 42

Session FC.02 * Free Communications_2 * 43

Abstract FC.02.1 - A ROLE OF DIENOGEST AS POSTOPERATIVE RECURRENCE PREVENTION - 44

Abstract FC.02.2 - DEEP ENDOMETRIOSIS. THE IMPORTANCE OF A MULTIDISCIPLINARY UNIT. ACCURATE DIAGNOSIS PRIOR TO STANDARIZATION OF TREATMENT. - 45

Abstract FC.02.3 - DEEP INFILTRATING ENDOMETRIOSIS OF THE BLADDER AND THE URETER: SURGICAL STRATEGY AND RESULTS - 46

Abstract FC.02.4 - DEEP INFILTRATING ENDOMETRIOSIS WITH DIAPHRAGMATIC INFILTRATION: RETROSPECTIVE ANALYSIS OF 46 CASES. - 47

Abstract FC.02.5 - ENDOMETRIOMA WITH BROAD LIGAMENT INVOLVEMENT: COMPARISON BETWEEN STRIPPING TECHNIQUE WITH/WITHOUT PERITONEAL EXCISION - 48

Abstract FC.02.6 - LAPAROSCOPIC NERVE SPARING COLORECTAL RESECTION FOR BOWEL ENDOMETRIOSIS: SURGICAL OUTCOMES AND FOLLOW-UP - 49

Abstract FC.02.7 - LAPAROSCOPY TREATMENT OF DEEP ENDOMETRIOSIS - 50

Abstract FC.02.8 - ORIGINAL TECHNIQUE OF COMBINED LAPAROSCOPIC AND TRANSANAL EXCISION OF DEEP ENDOMETRIOSIS NODULES INFILTRATING THE LOW AND MIDDLE RECTUM - 51

Abstract FC.02.9 - OUTCOME OF CONSERVATIVE SURGICAL TREATMENT OF RECTOVAGINAL ENDOMETRIOSIS. - 52

Abstract FC.02.10 - THE KAYANI-KENT (K-K) MAP OF ENDOMETRIOSIS - 53

Abstract FC.02.11 - THE LONG TERM (>2 YEARS) EFFECT OF TREATMENT WITH GNRH ANALOGUES WITH ADD-BACK THERAPY IN PATIENTS WITH RELAPSING PELVIC PAIN SECONDARY TO ENDOMETRIOSIS. - 54

Abstract FC.02.12 - THE USE OF PLASMAJET ULTRA IN THE TREATMENT OF ENDOMETRIOSIS - 55

Abstract FC.02.13 - TOTAL PELVIC PERITONEAL EXCISION ALLOWS CONSERVATION OF OVARIES IN ALL WOMEN WITH ENDOMETRIOSIS UNDERGOING HYSTERECTOMY - 56

Session FC.03 * Free Communications_3 * 57

Abstract FC.03.1 - COMPLICATIONS AFTER LAPAROSCOPIC BOWEL SURGERY FOR DEEP INFILTRATING ENDOMETRIOSIS: A RETROSPECTIVE STUDY ON 1147 PATIENTS - 58

Abstract FC.03.2 - COMPLICATIONS AFTER LARGE BOWEL RESECTION FOR DEEP INFILTRATING ENDOMETRIOSIS (DIE), “EXPERIENCE IN A SERIES OF 110 CASES” - 59

Abstract FC.03.3 - GUM CHEWING STIMULATES EARLY RETURN OF BOWEL MOTILITY AFTER GYNECOLOGIC LAPAROSCOPIC SURGERY - 60

Abstract FC.03.4 - LAPAROSCOPIC ENTRY TECHNIQUES- ISSUES AROUND SAFETY - 61

Abstract FC.03.5 - LIMITED SEGMENTAL RECTAL RESECTION IN A TERTIARY REFERRAL UNIT FOR THE TREATMENT OF RECTOVAGINAL ENDOMETRIOSIS 2000-2010: PAIN AND COMPLICATIONS - 62

Abstract FC.03.6 - PAIN AS RISK FACTOR FOR RECURRENCE IN PATIENTS WITH ENDOMETRIOSIS - 63

Abstract FC.03.7 - COMPARING DEMOGRAPHICS AND OUTCOMES BY TYPE OF HYSTERECTOMY IN AN INNER LONDON UNIVERSITY HOSPITAL (LASH VS TLH) - 64

Abstract FC.03.8 - HYSTERECTOMY: 5-YEAR PERIOD TRENDS - 65

Abstract FC.03.9 - LAPAROSCOPIC ASSISTED VAGINAL HYSTERECTOMY: IMPACT OF BODY MASS INDEX ON OUTCOMES - 66

Abstract FC.03.10 - LONG TERM OUTCOMES FOLLOWING LAPAROSCOPIC SUPRACERVICAL HYSTERECTOMY PERFORMED WITH AND WITHOUT EXCISION OF THE ENDOCERVIX - 67

Abstract FC.03.11 - TYPE OF COLPORRAPHY AND RISK OF VAGINAL CUFF DEHISCENCE AFTER LAPAROSCOPIC AND ROBOTIC HYSTERECTOMY - 68

Abstract FC.03.12 - INTRODUCTION OF LAPAROSCOPIC HYSTERECTOMY IN A PRIVATE SETTING IN DENMARK - 69

Session FC.04 * Free Communications_4 * 70

Abstract FC.04.1 - A COMPARATIVE STUDY ASSESSING DIAGNOSTIC ACCURACY OF PRE-OPERATIVE TRANSVAGINAL ULTRASOUND AND LAPAROSCOPY IN THE MANAGEMENT OF PATIENTS WITH OVARIAN CYSTS - 71

Abstract FC.04.2 - A BETTER WAY TO MANAGE PATIENTS WITH PREGNANCIES OF UNKNOWN LOCATION (PUL)? - 72

Abstract FC.04.3 - HYSTEROSALPINGO-CONTRAST SONOGRAPHY (HYCOSY) WITH FOAM OR HYSTEROSALPINGO-FOAM SONOGRAPHY (HYFOSY):, FIRST EXPERIENCES WITH A NEW ULTRASONOGRAPHIC TECHNIQUE TO VISUALIZE TUBAL PATENCY. - 73

Abstract FC.04.4 - HYSTEROSCOPY COMBINED WITH MRI AND ULTRASOUND IN PREOPERATIVE ASSESSMENT OF TUMOR GRADE, MYOMETRIAL AND CERVICAL INVASION IN ENDOMETRIAL ATYPIA AND CANCER - 74

Abstract FC.04.5 - VISUALIZATION OF ESSURE IMPLANTS WITH INTRAUTERINE SONOGRAPHY FOR CONFIRMATION OF PLACEMENT - 75

Abstract FC.04.6 - CORRELATION OF ASPIRATED PERITONEAL FLUID FINDINGS AT LAPAROSCOPY &TUBAL PATHOLOGY - 76

Abstract FC.04.7 - DOES MONOPOLAR RESECTION OF UTERINE SEPTUM INCREASE THE OCCURRENCE OF ECTOPIC PREGNANCY? - 77

Abstract FC.04.8 - ISOBARIC GASLESS LAPAROSCOPIC MYOMECTOMY UNDER GENERAL OR SPINAL-EPIDURAL ANAESTHESIA: REPRODUCTIVE OUTCOME - 78

Abstract FC.04.9 - LAPAROSCOPIC CERVICAL CERCLAGE IN THE TREANTMENT OF WOMEN WITH CERVICAL INCOMPETENCE - 79

Abstract FC.04.10 - LAPAROSCOPYC SURGERY OF ADNEXAL MASS IN OBSTETRICS - 80

Abstract FC.04.11 - THE VALIDITY OF THE ENDOSCOPIC SURGICAL PROCEDURE FOR TUBAL RECANALIZATION - 81

Session FC.05 * Free Communications_5 * 82

Abstract FC.05.1 - LAPAROSCOPIC LYMPOCELE FENESTRATION AFTER RETROPERITONEAL LYMPH NODE DISSECTION IN 102 GYNECOLOGICAL CANCER PATIENTS: ASSESSMENT OF SAFETY, FEASIBILTY, EFFICACY AND RECURRENCE RATES - 83

Abstract FC.05.2 - LAPAROSCOPIC MANAGEMENT OF HUGE OVARIAN CYSTS - 84

Abstract FC.05.3 - NOVASURE IMPEDANCE CONTROL SYSTEM VERSUS MICROWAVE ENDOMETRIAL ABLATION (MEA) FOR TREATMENT OF DYSFUNCTIONAL UTERINE BLEEDING: A RANDOMIZED CONTROLLED TRIAL - 85

Abstract FC.05.4 - OUR EXPERIENCE FOR SURGICAL TREATMENT OF PELVIC ORGANS PROLAPSE. - 86

Abstract FC.05.5 - PAIN RELIEF BY CONTINUOUS INTRA-PERITONEAL NEBULIZATION OF ROPIVACAINE DURING GYNECOLOGICAL LAPAROSCOPIC SURGERY UNDER GENERAL ANESTHESIA USING SHORT ACTING OPIATES - 87

Abstract FC.05.6 - STANDARDIZATION OF LAPAROSCOPIC SACROCOLPOPEXY: “THE 6 POINTS TECHNIQUE” - 88

Session FC.06 * Free Communications_6 * 89

Abstract FC.06.1 - UTERINE ARTERY EMBOLIZATION FOR SYMPTOMATIC UTERINE MYOMAS USING GELFOAM PLEDGETS ALONE VERSUS EMBOSPHERES PLUS GELFOAM PLEDGETS: A RANDOMIZED COMPARISON - 90

Abstract FC.06.2 - ABSTRACT, SCHOLARLY SEARCH FOR MIS, PROF. PAUL ALAN WETTER, M.D., F.A.C.O.G., F.A.C.S. - 91

Abstract FC.06.3 - COMBINED TRANSURETRAL WITH VERSAPOINT® AND LAPAROSCOPIC TREATMENT IN THE MANAGEMENT OF BLADDER ENDOMETRIOSIS - 92

Abstract FC.06.4 - PAIN AFTER LAPAROSCOPIC SURGERY IS RELATED TO THE TYPE OF GAS USED -93

Abstract FC.06.5 - SURGICAL AND OBSTETRIC OUTCOME AFTER LAPAROSCOPIC CERCLAGE - 94

Session FC.07 * Free Communications_7 * 95

Abstract FC.07.1 - ADVANTAGES AND LIMITATIONS OF LAPAROSCOPIC PARA-AORTIC LYMPHADENECTOMY IN OUR PRACTICE: A SERIES OF 96 CONSECUTIVE PARA-AORTIC LYMPHADENECTOMY - 96

Abstract FC.07.2 - COMPARISON OF RETROPERITONEAL LAPAROSCOPIC PARAAORTIC LYMPHADENECTOMY WITH MRI/CT AND COMPLICATIONS IN ADVANCED CERVICAL CARCINOMA: IS IT USEFUL? - 97

Abstract FC.07.3 - FIRST REPORT OF TRANS VAGINAL ENDOSCOPIC MICROSURGERY (T.V.E.M.) IN A PATIENT WITH SQUAMOUS CARCINOMA OF THE VAGINAL VAULT - 98

Abstract FC.07.4 - LAPAROSCOPIC NERVE-SPARING RADICAL PARAMETRECTOMY FOR OCCULT INVASIVE CERVICAL CANCER AFTER SIMPLE HYSTERECTOMY - 99

Abstract FC.07.5 - LONG-TERM FOLLOW-UP AFTER LAPAROSCOPIC MANAGEMENT OF ENDOMETRIAL CANCER IN THE OBESE: A FIFTEEN-YEAR COHORT STUDY - 100

Abstract FC.07.6 - TOTAL LAPAROSCOPIC HYSTERECTOMY WITH BILATERAL SALPINGOOPHORECTOMY (TLH) VERSUS ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPINGOOPHORECTOMY IN ENDOMETRIAL CANCER SURGICAL STAGING. - 101

Abstract FC.07.7 - TOTAL LAPAROSCOPIC NERVE-SPARING RADICAL HYSTERECTOMY, THE TECHNIQUE AND PATIENTS FOLLOW UP - 102

Abstract FC.07.9 - A SIMPLE LAPAROSCOPIC KNOT-TRAINER - 103

Session FC.08 * Free Communications_8 * 104

Abstract FC.08.1 - RISK OF RECURRENCE AFTER LAPAROSCOPIC MYOMECTOMY - 105

Abstract FC.08.2 - A NEW GENERATION REUSABLE FLEXIBLE COAXIAL BIPOLAR HOOK ELECTRODE IN OFFICE HYSTEROSCOPY - 106

Abstract FC.08.3 - AN AUDIT OF USING THE H PIPELLE FOR ENDOMETRIAL SAMPLING AT OUT PATIENT HYSTEROSCOPY - 107

Abstract FC.08.4 - COST-EFFECTIVENESS OF HYSTEROSCOPY SCREENING FOR INFERTILE WOMEN - 108

Abstract FC.08.5 - EVALUATION OF NICKEL ALLERGY AFTER HYSTEROSCOPIC ESSURE® STERILISATION: RISK OR DAILY PRACTICE? PRELIMINARY RESULTS. - 109

Abstract FC.08.6 - HOW EFFECTIVE IS THE GYNAECOLOGY RAPID ACCESS CLINIC? - 110

Abstract FC.08.7 - INTRODUCTION OF SINGLE PORT LAPAROSCOPY IN A PRIVATE SETTING IN DENMARK - 111

Session FC.09 * Free Communications_9 * 112

Abstract FC.09.1 - FEASIBILITY OF OPERATIVE HYSTEROSCOPY AFTER ENDOMETRIAL PREPARATION: 1,25 MG NOMEGESTROL ACETATE VERSUS 20 MCG ETHINYL ESTRADIOL/ 75MCG GESTODENE - 113

Abstract FC.09.2 - HYSTEROSCOPIC MANAGEMENT OF AMENORRHEA AND HYPOMENORRHEA - 114

Abstract FC.09.3 - HYSTEROSCOPIC METROPLASTY UNDER TRANS-RECTAL THREE DIMENSIONAL ULTRASOUND GUIDANCE. - 115

Abstract FC.09.4 - OUTPATIENT NOVASURE ABLATION-OUTCOME MEASURES AND PATIENT SATISFACTION SURVEY - 116

Abstract FC.09.5 - PREVALENCE OF INTRA UTERINE ADHESIONS POST MISCARRIAGE: A SYSTEMATIC REVIEW. - 117

Abstract FC.09.6 - REMOVAL OF SUBMUCOSAL UTERINE LEIOMYOMAS BY OPERATIVE HYSTEROSCOPY. - 118

Abstract FC.09.7 - HYPERSPECTRAL HYSTEROSOCPY: TECHNOLOGY AND FIRST PILOT CLINICAL TRIAL. - 119

Abstract FC.09.8 - HYSTEROSCOPIC FEMALE STERILIZATION IN AN OUTPATIENT SETTING - 120

Abstract FC.09.9 - OPTIMUM INTRAUTERINE FILLING PRESSURE IN OUTPATIENT HYSTEROSCOPY— A DOUBLE BLIND RANDOMISED CONTROL TRIAL - 121

Abstract FC.09.10 - VALUE OF HYSTEROSCOPY PRIOR TO UTERINE ARTERY EMBOLISATION (UAE) - 122

Abstract FC.09.11 - SUCCESS RATE OF THE ADIANA® HYSTEROSCOPIC STERILIZATION TECHNIQUE. - 123

Session FC.10 * Free Communications_10 * 124

Abstract FC.10.1 - A COMPARATIVE STUDY OF MEA AND NEA IN OBESE WOMEN. - 125

Abstract FC.10.2 - COMPARISON OF TISSUE VOLUME AND WEIGHT FOLLOWING OUTPATIENT RESECTION OF FIBROIDS AND POLYPS UNDER LOCAL. - 126

Abstract FC.10.3 - GUIDED HYSTEROSCOPIC PROCEDURES: A SYSTEMATIC REVIEW - 127

Abstract FC.10.4 - NOVOSURE ENDOMETRIAL ABLATION IN WOMEN WITH HIGH BMI OR FAILED TREATMENT WITH MIRENA IUS - 128

Abstract FC.10.5 - THE EFFECT OF POSTOPERATIVE WITH / WITHOUT ADJUVANT THERAPY ON REPRODUCTIVE OUTCOME AFTER TRANSCERVICAL RESECTION OF SEPTA - 129

Abstract FC.10.6 - SUCCESS AND SATISFACTION EXPERIENCED WITH THERMAL BALLOON ABLATION - 130

Abstract FC.10.7 - THE NEXT GENERATION: NOVASURE® ENDOMETRIAL ABLATION AFTER UNCOMPLICATED ESSURE® STERILISATION IN THE SAME TIME, A FEASIBILITY STUDY. - 131

Abstract FC.10.8 - 22 FR AND 26 FR BIPOLAR OPERATIVE HYSTEROSCOPY: OUR EXPERIENCE - 132

Abstract FC.10.9 - EVALUATION OF HYSTEROSCOPICAL POLYPODECTOMY AND SUBMUCOSAL FIBROMYOMECTOMY WITH THE USE OF TRUCLEAR MORCELLATOR IN COMPARISON WITH CONVENTIONAL RESECTOSCOPY. THE GREEK EXPERIENCE. - 133

Abstract FC.10.10 - HOW TO TREAT SUBMUCOSAL MYOMAS WITH OFFICE HYSTEROSCOPY - 134

Session FC.11 * Free Communications_11 * 135

Abstract FC.11.1 - AN ELECTROMAGNETIC MOTION ANALYSIS SYSTEM TO ASSESS GYNAECOLOGISTS’ SURGICAL SKILLS IN-VITRO USING STRAIGHT STICK (SSL) AND SINGLE INCISION (SILS) LAPAROSCOPIC SURGERY – CONSTRUCT VALIDITY AND PSYCHOMOTOR COMPARISONS. - 136

Abstract FC.11.2 - LAPAROSCOPIC EXTRA PERITONEAL AORTIC DISSECTION: IS SINGLE PORT SURGERY OFFERS THE SAME POSSIBILITIES THAN CONVENTIONAL LAPAROSCOPY? - 137

Abstract FC.11.3 - DEVELOPMENT AND VALIDATION OF A GENERIC TOOL FOR ASSESSMENT OF LAPAROSCOPIC SKILLS IN GYNAECOLOGY USING VIDEOTAPED PROCEDURES - 138

Abstract FC.11.4 - FACE AND CONSTRUCT VALIDITY OF A VIRTUAL REALITY SIMULATOR FOR HYSTEROSCOPY ESSURE STERILIZATION - 139

Abstract FC.11.5 - GRADING SURGICAL SKILLS CURRICULA AND TRAINING FACILITIES FOR MINIMALLY INVASIVE SURGERY - 140

Abstract FC.11.6 - IMPLEMENTING THE TOTAL LAPAROSCOPIC ROUTE FOR HYSTERECTOMY IN A PRIVATE MATERNITY HOSPITAL SETTING - 141

Abstract FC.11.7 - IS OPEN SURGICAL TRAINING NECESSARY FOR LAPAROSCOPIC COMPETENCY. - 142

Abstract FC.11.8 - PROVING CONSTRUCT VALIDITY OF VIRTUAL REALITY HYSTEROSCOPY - 143

Abstract FC.11.9 - PSYCHOMOTOR SKILLS IN LAPAROSCOPY - 144

Abstract FC.11.10 - SPECIALIZED COURSE TO TEACH INTRACORPOREAL LAPAROSCOPIC SUTURING - 145

Abstract FC.11.11 - THE IMPACT OF THE LEARNING CURVE UPON ADHESION FORMATION IN A LAPAROSCOPIC MOUSE MODEL - 146

Abstract FC.11.12 - TRAINEE PERCEPTIONS OF ULTRASOUND TRAINING – A UK STUDY - 147

Session FC.12 * Free Communications_12 * 148

Abstract FC.12.1 - HOW CAN ARTICULATED INSTRUMENTS HELP IN ENDOSCOPIC SURGERY? - 149

Abstract FC.12.2 - DOCUMENTATION IN LAPAROSCOPIC SURGERY - 150

Abstract FC.12.3 - MULTIDISCIPLINARY GUIDELINE DEVELOPMENT IN MIS: A CHALLENGE FOR ALL? - 151

Abstract FC.12.4 - SURGICAL RISK PERCEPTION WITH LAPAROSCOPIC AND ABDOMINAL HYSTERECTOMY - 152

Abstract FC.12.5 - HIGH AORTO-CAVA LIMPHADENECTOMY BY TRANSPERITONEAL ROBOTIC APPROACH WITH DOUBLE DOCKING AND LESS THAN 7 PORTS. REPORT OF 14 INITIAL CASES - 153

Abstract FC.12.6 - AUDIT OF COMPLICATIONS OF LAPAROSCOPY - 154

Abstract FC.12.7 - ROBOTIC SURGICAL RECONSTRUCTION FOR COMPLETE LATERAL AND CENTRAL ANTERIOR PLUS POSTERIOR PELVIC FLOOR DEFECT USING A MODIFIED “Y” SHAPE MESH - 155

Abstract FC.12.8 - LAPAROSCOPIC MANAGEMENT OF ECTOPIC PREGNANCY: 10 YEARS EXPERIENCE IN A - 156

Session FC.13 * Free Communications_13 * 157

Abstract FC.13.1 - ALTERNATIVE CHEAP RETRIEVAL METHOD OF FIBROIDS IN LAPAROSCOPIC MYOMECTOMY - 158

Abstract FC.13.2 - PULSED ULTRASOUND FOR IMPROVED HAEMOSTASIS - 159

Abstract FC.13.3 - TECHNIQUES FOR LAPAROSCOPIC RE-ENTRY FOR POST-OPERATIVE BLEEDING - 160

Abstract FC.13.4 - THE “EASY LOAD” UNIVERSAL KNOT PUSHER - 161

Abstract FC.13.5 - THE TLH STRIPPED - 162

Abstract FC.13.6 - TRANS-UMBILICAL GLOVE PORT: A SIMPLE AND COST EFFECTIVE METHOD FOR SINGLE PORT LAPAROSCOPIC SURGERY FOR BENIGN ADNEXAL DISEASE. CASE REPORT AND VIDEO DEMONSTRATION - 163

Abstract FC.13.7 - USING FILEMAKER PRO TO DOCUMENT GYNAECOLOGICAL SURGERY - 164

Abstract FC.13.8 - REPORTED PREGNANCIES AFTER ESSURE® HYSTEROSCOPIC STERILIZATION: A RETROSPECTIVE ANALYSIS OF PREGNANCY REPORTS WORLDWIDE DURING COMMERCIAL DISTRIBUTION: 2001-2010 - 165

Session FC.14 * Free Communications_14 * 166

Abstract FC.14.1 - LAPAROSCOPIC SACROCOLPOPEXY (LSCP) VS TRANSVAGINAL MESH (TVM) REPAIR: COMPARISON OF ANATOMICAL AND FUNCTIONAL RESULTS IN THE MEDIUM TERM. BI-CENTER RETROSPECTIVE STUDY ABOUT 122 CASES. - 167

Abstract FC.14.2 - OUR EXPERIENCE IN TREATMENT OF RECURRENT STRESS URINARY INCONTINENCE -168

Abstract FC.14.3 - PRE-PUBIC TENDON / TRANS OBTURATORY ARCUS TENDINEUS INSERTION - ISCHIAL SPINE MESH ANCHORING FOR SIMULTANEOUS POP-REPAIR AND URINARY INCONTINENCE THERAPY USING ONLY ONE VAGINAL MESH. 169

NAZCA TC: ONE MESH THERAPY FOR TWO PATHOLOGIES? - 169

Abstract FC.14.4 - THE SURGICAL ANATOMY OF THE RECTOVAGINAL SEPTUM - 171

Abstract FC.14.5 - VAGINAL BURCH - 172

Session V.01 * Video Session_1 * 173

Abstract V.01.1 - A RARE CASE OF UNDESCENDED LEFT UTERINE HORN - 174

Abstract V.01.2 - CONSERVATIVE LAPAROSCOPIC APPROACH OF A PERFORATED PYOMYOMA AFTER UTERINE FIBROID EMBOLIZATION - 175

Abstract V.01.3 - EXTENSIVE LAPAROSCOPIC ADHESIOLYSIS AND SALPINGO-OOPHORECTOMY IN AN OBESE PATIENT WITH SIX PREVIOUS LAPAROTOMIES. - 176

Abstract V.01.4 - LAPAROSCOPIC MYOMECTOMY OF CYSTIC FIBROID WITH ABNORMAL TRACT TO UTERINE CAVITY - 177

Abstract V.01.5 - LAPAROSCOPIC PARTIAL CYSTECTOMY FOR BLADDER ENDOMETRIOSIS: REPORT OF THREE CASES THAT HAVE DESIRE FOR CHILDBEARING. - 178

Abstract V.01.6 - LAPAROSCOPIC REPAIR OF A UTERINE WALL DEFECT ON A CAESAREAN SCAR - 179

Abstract V.01.7 - LAPAROSCOPIC REPAIR OF UTERINE SCAR AFTER C SECTION - 180

Abstract V.01.8 - LAPAROSCOPIC SACROHYSTEROPEXY ON A UNICORNUATE UTERUS - 181

Abstract V.01.9 - LAPAROSCOPIC STAGING AND DEBULKING OF A UTERINE MALIGNANT MIXED MULLERIAN TUMOR. - 182

Abstract V.01.10 - PRESERVING FERTILITY ON CERVICAL CANCER – CASE REPORT - 183

Abstract V.01.11 - SILS FOR OVARIAN MALIGNANCY CASES - 184

Abstract V.01.12 - SYMPTOMATIC SUBSEROUS MULTICYSTIC UTERUS: CASE PRESENTATION. - 185

Abstract V.01.13 - UNUSUAL CAUSES OF FALLOPIAN TUBE ENLARGEMENT - 186

Abstract V.01.14 - VIDEO PRESENTATION: LAPAROSCOPIC RIGHT PARTIAL OOPHORECTOMY TO TREAT RUPTURED OVARIAN ECTOPIC PREGNANCY - 187

Session V.02 * Video Session_2 * 188

Abstract V.02.1 - INTESTINAL REPAIR USING SINGLE PORT LAPAROSCOPIC SURGERY - 189

Abstract V.02.2 - LAPAROSCOPIC REPAIR OF UTERINE SCAR DEHISCENCE FOLLOWING CAESAREAN SECTION - 190

Abstract V.02.3 - PEARLS OF LAPAROSCOPIC SURGERY, PART II – A FINE SELECTION OF INTRA-OPERATIVE COMPLICATIONS - 191

Abstract V.02.4 - TITLE: LAPAROSCOPIC REMOVAL OF MCCALL SUTURE FOLLOWING URETERIC INJURY - 192

Abstract V.02.5 - UTERINE INCARCERATION OF A FALLOPIAN TUBE - 193

Abstract V.02.6 - VAGINAL DEHISCENCE AND SMALL BOWEL PROCIDENCE AFTER LAPAROSCOPIC RADICAL HYSTERECTOMY - 194

Abstract V.02.7 - LAPAROSCOPIC BOARI FLAP- PSOAS HITCH METHOD FOR EXTENSIVE URETERAL ENDOMETRIOSIS - 195

Abstract V.02.8 - TOTAL LAPAROSCOPIC REMOVAL OF HUGE UTERUS USING THE LIGASURE™ DEVICE, CLASSICAL BIPOLAR AND BARBED V-LOC™ SUTURE - 196

Abstract V.02.9 - LAPAROSCOPIC EXCISION OF ENDOMETRIOSIS & LEFT URETERIC RE-IMPLANTATION -197

Abstract V.02.10 - LAPAROSCOPIC EXCISION OF SEVERE ENDOMETRIOSIS - 198

Abstract V.02.11 - RECTAL DISC EXCISION IN CASES OF DEEP INFILTRATING ENDOMETRIOSIS - 199

Abstract V.02.12 - BEST VIDEO SELECTION OF THE IBS (INTEGRATED BIGATTI SHAVER) IN ACTION - 200

Abstract V.02.13 - SINGLE PORT ACCESS SUBTOTAL HYSTERECTOMY: A FIRST CASE WITH A NEW DEVICE (X-CONE) - 201

Abstract V.02.14 - SINGLE-PORT ACCESS LAPAROSCOPIC HYSTERECTOMY USING STORZ EXCONE PORT - 202

Abstract V.02.15 - LAPAROSCOPIC EXCISION OF BLADDER NODULE IN A PATIENT WITH MULTIPLE PREVIOUS OPEN SURGERIES. - 203

Session V.03 * Video Session_3 * 204

Abstract V.03.1 - LAPAROSCOPIC SUTURING - TIPS, TRICKS AND TECHNIQUES - 205

Abstract V.03.2 - INTRAOPERATIVE ENDOSCOPIC AND SONOGRAPHIC INVESTIGATION OF THE LOWER URINARY TRACT: PERSONAL EXPERIENCE. - 206

Abstract V.03.3 - ABLATION OF OVARIAN, PERITONEAL AND DIAPHRAGMATIC ENDOMETRIOSIS USING PLASMA ENERGY - 207

Abstract V.03.4 - HERLYN-WERNER-WUNDERLICH SYNDROME – A CASE REPORT - 208

Abstract V.03.5 - EFFECTIVE CONTROL OF BLOOD LOSS BY MISOPROSTOL ADMINISTRATION PRIOR TO LAPAROSCOPIC MANAGEMENT OF CORNUAL PREGNANCY - 209

Abstract V.03.6 - ORIGINAL TECHNIQUE OF COMBINED LAPAROSCOPIC AND TRANSANAL EXCISION OF DEEP ENDOMETRIOSIS NODULES INFILTRATING THE LOW AND MIDDLE RECTUM - 210

Abstract V.03.7 - TECHNICAL TRICKS IN LAPAROSCOPIC SACROCOLPOPEXY - 211

Abstract V.03.8 - THE USED OF NEW MINILAPAROSCOPIC INSTRUMENTAL IN MINOR VASCULAR YATROGENIC DAMAGE, IN PELVIC VESSELS, DURING GYNECOLOGIC LAPAROSCOPIC SURGERY. - 212

Abstract V.03.9 - USING ENSEAL® FOR LARGE-SIZED HYSTERECTOMY: A NEW TECHNOLOGY FOR GYNECOLOGICAL SURGERY - 214

Session V.04 * Video Session_4 * 215

Abstract V.04.1 - INTRAPERITONEAL LAPAROSCOPIC AORTIC LIMPHADENECTOMY. TIPS AND TRICKS - 216

Abstract V.04.2 - LAPAROSCOPIC EN BLOC ANTERIOR EXENTERATION FOR RECURRENT VULVAL CANCER - 217

Abstract V.04.3 - LAPAROSCOPIC EXTRAPERITONEAL TOTAL LYMPHADENECTOMY - 218

Abstract V.04.4 - PELVIC LYMPHADENECTOMY: STANDARD TECHNIQUE AND TIPS AND TRICKS - 219

Abstract V.04.5 - SINGLE SITE SURGERY FOR MALIGNANCY - 220

Abstract V.04.6 - TRANSVAGINAL RETROPERITONEAL LYMPHADENECTOMY - 221

Abstract V.04.7 - COMBINED LAPAROSCOPIC/ HYSTEROSCOPIC MANAGEMENT OF LARGE HEMATOCOLPOS FROM COMPLETE UTERINE SEPTUM - 222

Abstract V.04.8 - HYSTEROSCOPY AND RESCETION OF SUBMUCOUS FIBROIDS WITH AN INTRAMURAL COMPONENT - 223

Session V.05 * Video Session_5 * 224

Abstract V.05.1 - LAPAROSCOPIC SUSPENSION FOR UTEROVAGINAL PROLAPSE USING NEW TOOLS -225

Abstract V.05.2 - ENDOSCOPIC VAGINAL OOPHORECTOMY: A VIDEO PRESENTATION OF A NEW SURGICAL TECHNIQUE. - 226

Abstract V.05.3 - FOCUSING ON TRANSVAGINAL LAPAROSCOPY- HYBRID NOTES - 227

Abstract V.05.4 - HYBRID-NOTES ADNEXECTOMY – TRANSVAGINAL LAPAROSCOPY - 228

Abstract V.05.5 - LAPAROSCOPIC HYSTERECTOMY USING CINEMATOGRAPHIC 3D - 229

Abstract V.05.6 - LAPAROSCOPIC INTERVENTIONS DURING PREGNANCY - 230

Abstract V.05.7 - LAPAROSCOPIC PECTOPEXY - 231

Abstract V.05.8 - DIE: EGT ( ENDOGYNAETEAM) SURGICAL STEPS - 232

Abstract V.05.9 - NEW TECHNIQUE: LAPAROSCOPIC MODIFIED MOSCHCOWITZ MCCALL (MMM) FOR VAGINAL VAULT SUSPENSION AND ENTEROCOELE CLOSURE - 233

Abstract V.05.10 - OUR EXPERIENCE OF LAPAROSCOPIC MYOMECTOMY WITH TEMPORARY OCCLUSION OF INTERNAL ILIAC ARTERIES - 234

Abstract V.05.11 - THE BENEFITS OF CINEMATOGRAPHIC 3D IN LAPAROSCOPIC SUTURING - 235

Abstract V.05.12 - ORIFICE ASSISTED SMALL INCISION SURGERY (OASIS) - 236

Session V.06 * Video Session_6 * 237

Abstract V.06.1 - ROBOTIC HYSTERECTOMY FOR OBESE PATIENT- A POSSIBLE ADVANTAGE TO CONVENTIONAL LAPAROSCOPY? - 238

Abstract V.06.2 - ROBOTIC MYOMECTOMY OF A DIFFICULT DEGENERATED MYOMA. - 239

Abstract V.06.3 - ROBOTIC SURGICAL RECONSTRUCTION FOR COMPLETE LATERAL AND CENTRAL ANTERIOR PLUS POSTERIOR PELVIC FLOOR DEFECT USING A MODIFIED “Y” SHAPE MESH - 240

Abstract V.06.4 - WHAT IS THE PLACE OF LAPAROSCOPIC RICHTER SPINOFIXATION TO TREAT GENITAL PROLAPSE ? - 241

Abstract V.06.5 - NO MORE CONTROINDICATIONS IN LESS SURGERY: A COMPLEX CASE OF THL WITH BSO IN AN OBESE PATIENT, PREVIOUSLY SUBJECTED TO AN HYSTEROPEXY. - 242

Abstract V.06.6 - SINGLE ACCESS LAPAROSCOPIC SUPRACERVICAL HYSTERECTOMY FOR VERY LARGE UTERUS - 243

Abstract V.06.7 - A NOVEL APPROACH TO SACROHYSTEROPEXY - 244

Abstract V.06.8 - DA VINCI ASSISTED LAPAROSCOPIC SACROCOLPOPEXY - 245

Abstract V.06.9 - LAPAROSCOPIC SACROCERVICOPEXY - TIPS AND TRICKS - 246

Abstract V.06.10 - LAPAROSCOPIG CERVICO VESICAL FISTULA REPAIR - 247

Abstract V.06.11 - NERVE SPARING LAPAROSCOPIC SACROCOLPOPEXY – SURGICAL TECHNIQUE - 248

Abstract V.06.12 - EXTENDING THE SCOPE OF SINGLE SITE SURGERY- MYOMECTOMY TO RETROPERITONEAL LYMPHADENECTOMY - 249

Session V.07 * Video Session_7 * 250

Abstract V.07.1 - BLADDER LEIOMYOMA - 251

Abstract V.07.2 - ENDOMETRIOTIC NODULE RESECTION, MULTIPLE MYOMECTOMY USING BARBED V-LOC™ SUTURE, RIGHT OVARIAN CYSTECTOMY AND SPRAYSHIELD™ - 252

Abstract V.07.3 - DIRECT ENTRY AND TROCARS PLACEMENT: THE WAY TO DO IT SAFELY, ERGONOMICALLY, AND ESTHETICALLY - 253

Abstract V.07.4 - GEOMETRIC LAPAROSCOPIC SUTURING - 254

Abstract V.07.5 - STEEP AND DEEP - THE CHALLENGE OF STEEP HEAD DOWN (TRENDELENBURG) DURING SURGERY - 255

Abstract V.07.6 - SURGICAL MANAGEMENT OF THE ASYMPTOMATIC BRCA POSITIVE WOMAN - 256

Abstract V.07.7 - TOTAL LAPAROSCOPIC HYSTERECTOMY WITH BILATERAL ADNEXECTOMY: STANDARD TECHNIQUE - 257

Session P.01 * Case reports * 258

Abstract P.01.1 - ARGUMENT AGAINST “SUPRA-CERVICAL HYSTERECTOMY IS A TRENDY UNPROVEN FAD” - 259

Abstract P.01.2 - BOWEL HERNIATION AFTER LAPAROSCOPIC SACRAL MESH FIXATION - 260

Abstract P.01.3 - A CASE OF RECTUS SHEATH ENDOMETRIOSIS INFILTRATING THE LIVER PARENCHYMA: DIAGNOSIS AND SURGICAL MANAGEMENT - 261

Abstract P.01.4 - A RARE CASE OF BLADDER ENDOCERVICOSIS AND REVIEW OF LITERATURE. - 262

Abstract P.01.5 - A RARE CASE OF GASTRIC INJURY DURING ROUTINE LAPAROSCOPIC SURGERY - 263

Abstract P.01.6 - ACQUIRED UTERINE ARTERIOVENOUS MALFORMATION (UAVM) AFTER UTERINE ARTERY EMBOLISATION (UAE) AND UNSUCCESSFUL PREGNANCY. - 264

Abstract P.01.7 - AUDIT: SURGICAL MANAGEMENT OF ECTOPIC PREGNANCY - 265

Abstract P.01.8 - CASE REPORT: LAPAROSCOPIC OOPHORECTOMY: TREATMENT FOR ANTI-NMDAR ENCEPHALITIS - 266

Abstract P.01.9 - CERVICAL ECTOPIC PREGNANCY - 267

Abstract P.01.10 - CHRONIC PELVIC PAIN : THE ROLE OF LAPAROSCOPIC SURGERY AND ITS OUTCOMES - 268

Abstract P.01.11 - CORRECTION OF UTERO TUBAL JUNCTION AREA DAMAGES INDUCED BY POLYPS AS SINGLE CAUSES OF WOMEN SUBFERTILITY DETECTED DURING FERTILOSCOPIC EXAMINATION - 269

Abstract P.01.12 - DE-NOVO VAGINAL VAULT ENDOMETRIOSIS FOLLOWING PROLONGED USE OF OESTROGEN ONLY HORMONE REPLACEMENT THERAPY (HRT). - 270

Abstract P.01.13 - EFFECTIVENESS OF LAPAROSCOPIC SURGERY IN TWO CASES OF RUPTURED OVARIAN CYSTS WITH HIGHLY ELEVATED SERUM CA19-9 AND CA125 LEVEL - 271

Abstract P.01.14 - ENDOMETRIAL TUBERCULOSIS – ACCIDENTAL FINDING IN HYSTEROSCOPY - 272

Abstract P.01.15 - GENETIC PREDISPOSITION TO ENDOMETRIOSIS: THE RESULTS OF PILOT STUDIES IN UKRAINE - 273

Abstract P.01.16 - HYPERREACTIO LUTEALIS IN SPONTANEOUS TWIN PREGNANCY: A MANAGEMENT DILEMMA - 274

Abstract P.01.17 - HYSTEROSCOPIC FEMALE STERILIZATION - ESSURE® IN VIVO: AN IMAGE DESCRIPTION - 275

Abstract P.01.18 - IN VITRO FERTILIZATION-EMBRYO TRANSFER AND PREGNANCY OUTCOMES AFTER ESSURE® BILATERAL PLACEMENT FOR THE TREATMENT OF HIDROSALPINX AND ENDOMETRIOSIS: A CASE REPORT - 276

Abstract P.01.19 - INTRAOPERATIVE USE OF ULTRASOUND FOR ASSISTING THE DIAGNOSIS AND MANAGEMENT OF LOCALISED UTERINE ADENOMYOMA - 277

Abstract P.01.20 - IS AN INCIDENTAL FINDING OF A THICKENED ENDOMETRIAL LINING IN POST MENOPAUSAL WOMEN OF ANY CONSEQUENCE? - 278

Abstract P.01.21 - LAPAROSCOPIC APPROACH FOR DEEP ENDOMETRIOSIS - 279

Abstract P.01.22 - LAPAROSCOPIC GONADECTOMY FOR ANDROGEN INSENSITIVITY SYNDROME--CASE REPORT - 280

Abstract P.01.23 - LAPAROSCOPIC LIGATION OF MAJOR BLOOD SUPPLY TO THE UTERUS; A LIFE SAVING PROCEDURE IN A CASE OF ENDOMETRIAL CANCER - 281

Abstract P.01.24 - LAPAROSCOPIC MANAGEMENT OF ADNEXAL MASSES – OUR EXPERIENCE - 282

Abstract P.01.25 - LAPAROSCOPIC MANAGEMENT OF LARGE ADNEXAL MASSES - 283

Abstract P.01.26 - LAPAROSCOPIC MANAGEMENT OF TUBO-OVARIAN ABSCESSES - 284

Abstract P.01.27 - LAPAROSCOPIC MYOMECTOMY OF A GIANT UTERINE MYOMA - 285

Abstract P.01.28 - LAPAROSCOPIC OVARIOPEXI AT THE RECURRENT OVARIAN TORSION CASES:CASE REPORT - 286

Abstract P.01.29 - LAPAROSCOPIC PELVIC AND PARAAORTIC LYMPHADENECTOMY IN CERVICAL CANCER FIGO STAGE IV B - CASE REPORT - 287

Abstract P.01.30 - LAPAROSCOPIC RESECTION OF ECTOPIC URETER ENDED IN GARTNER’S CYST RESULTED IN EXTENSIVE INTRAABDOMINAL INFECTION IN AN INFERTILE WOMAN - 288

Abstract P.01.31 - LAPAROSCOPIC SURGERY IS THE BEST CHOICE FOR MANAGING OF PREGNANT WOMEN WHO HAVE BENIGN OVARIAN TUMORS AND TUMOR-LIKE OVARIAN FORMATIONS - 289

Abstract P.01.32 - MALIGNANT MIXED MULLERIAN TUMOR OF THE UTERUS: LAPAROSCOPIC STAGING, SAFE AND FEASIBLE. CASE AND LITERATURE REVIEW. - 290

Abstract P.01.33 - MANAGEMENT OF ECTOPIC PREGNANCIES: A RETROSPECTIVE OBSERVATIONAL STUDY IN A PRIVATE UNIVERSITY HOSPITAL IN BARCELONA (SPAIN). - 291

Abstract P.01.34 - OVARIAN DYSGERMINOMA MIMICKING AN ECTOPIC PREGNANCY: CASE REPORT AND LITERATURE REVIEW. - 292

Abstract P.01.35 - PELVIC SPLENOSIS IN INFERTILE PATIENT: AN UNUSUAL FINDING. - 293

Abstract P.01.36 - PORT SITE METASTASES IN STAGE 1B, G1, ENDOMETRIAL CANCER: A CASE REPORT -294

Abstract P.01.37 - RECURRENT ASCITES SECONDARY TO ENDOMETRIOSIS: A CASE REPORT - 295

Abstract P.01.38 - ROBERT'S UTERUS WITH MENSTRUAL RETENTION IN THE BLIND CAVITY: A CASE REPORT - 296

Abstract P.01.39 - ROBOTIC MYOMECTOMY OF HUGE MYOMA CASES IN THIN ASIAN WOMEN - 297

Abstract P.01.40 - SCOPING THE REALITY OF BECOMMING A NURSE HYSTEROSCOPIST IN THE UK - 298

Abstract P.01.41 - SMALL BOWEL OBSTRUCTION CAUSED BY A DUODENAL COMPRESSION OF A PARARAORTIC LYMPHOCELE: A CASE PRESENTATION AND REVIEW OF THE LITERATURE - 299

Abstract P.01.42 - SPONTANEOUS TUBAL EXTRAUTERINE PREGNANCY INTO HYDROSALPINX. - 300

Abstract P.01.43 - STORY OF THE MIGRATING COIL - 301

Abstract P.01.44 - SURGICAL MANAGEMENT OF LIVER AND DIAPHRAGMATIC ENDOMETRIOSIS. CASE REPORT ILLUSTRATING THE TREATMENT CHALLENGES - 302

Abstract P.01.45 - SURGICAL TECHNIQUE FOR REMOVING A GIANT OVARIAN CYST USING AN OCTO PORT COMBINED MINILAPAROTOMY AND SINGLE PORT LAPAROSCOPIC SURGERY - 303

Abstract P.01.46 - THE CASE OF SHANGHAI INTRA UTERINE COIL - 304

Abstract P.01.47 - THE CASE OF THE SHANGHAI COIL ? REVERSIBLE BUT/OR ?PERMANENT - 305

Abstract P.01.48 - THE ROLE OF THE TRANSCERVICAL EMBRIOSCOPY TO DEFINE A CASE OF TRISOMY 18 SUSPECTED BY ULTRASOUND IMAGING AND CONFIRMED BY EMBRIO CHROMOSOMAL STUDY (CVS) - 306

Abstract P.01.49 - THE USE OF DESOGESTREL 75MCGR/DAY PREVIOUS TO TUBAL STERILIZATION WITH ESSURE IMPLANTS - 307

Abstract P.01.50 - TITLE: CHRONIC PELVIC PAIN AND ADENOMYOSIS IN A PATIENT WITH ROKITANSKY SYNDROME. - 308

Abstract P.01.51 - TOTAL LAPAROSCOPIC HYSTERECTOMY FOR TREATMENT OF A BICERVICAL DIDELPHIC UTERUS WITH A MYOMA - 309

Abstract P.01.52 - TREATMENT OF PELVIC ORGAN PROLAPSE BY LAPAROSCOPIC LATERAL SUSPENSION USING MESH : A CONTINUOUS SERIES OF 293 PATIENTS - 310

Abstract P.01.53 - ULTRASOUND GUIDED HYSTEROSCOPIC TREATMENT OF ASHERMAN SYNDROME REPORT OF THREE CASES - 311

Abstract P.01.54 - URINOTHORAX AFTER LAPAROSCOPIC HYSTERECTOMY; A RARE COMPLICATION - 312

Abstract P.01.55 - UTERS DUPLEX WITH VAGINA ATRETICA FOLLOWED BY CONSECUTIVE UNILATERAL HEMATOCOLPOS – HYSTEROSCOPIC APPREOACH TO THE DIAGNOSIS - 313

Abstract P.01.56 - VAGINAL EXPULSION OF SUBMUCOSAL FIBROIDS POST EMBOLIZATION: A CURE OR A COMPLICATION? - 314

Session P.02 * Complications * 315

Abstract P.02.1 - ARE 12 CASES OF DEEPLY INFILTRATED PELVIC ENDOMETRIOSIS PER YEAR ASSOCIATED WITH HIGHER SHORT-TERM COMPLICATION RATES COMPARED TO LARGER ENDOMETRIOSIS CENTRE? - 316

Abstract P.02.2 - FEASIBILITY OF ADVANCED LAPAROSCOPIC GYNAECOLOGIC SURGERY IN OBESE WOMEN - 317

Abstract P.02.3 - MAJOR VASCULAR INJURIES IN A CLINICAL HOSPITAL OF LATINOAMÉRICA - 318

Abstract P.02.4 - PUBIC OSTEOMYELITIS FOLLOWING LAPAROSCOPIC RETROPUBIC SURGERY - 319

Abstract P.02.5 - THE DEFINITION FOR CONVERSION IN MIS: IS THERE CONSENSUS? - 320

Abstract P.02.6 - THE OBSTETRICAL COMPLICATIONS OF LAPAROSCOPIC SURGERY FOR ADNEXAL MASSES DURING PREGNANCY - 321

Abstract P.02.7 - THERMAL LEASIONS AFTER UNCOMPLICATED NOVASURE ENDOMETRIAL ABLATION -322

Abstract P.02.8 - UTERINE PERFORATION DURING HYSTEROSCOPY – SERBIAN EXPERIENCE - 323

Session P.03 * Endometriosis: Diagnosis * 324

Abstract P.03.1 - COMPUTED TOMOGRAPHY-BASED VIRTUAL COLONOSCOPY AND CONSERVATIVE SURGERY OF THE DEEP ENDOMETRIOSIS INFILTRATING THE RECTUM AND THE SIGMOID COLON: EFFECTS OF SHAVING AND DISC EXCISION ON THE DIGESTIVE TRACT STENOSIS - 325

Abstract P.03.2 - CONTINUOUS LOW-DOSE ESTRO-PROGESTIN COMBINATION IN THE TREATMENT OF COLORECTAL ENDOMETRIOSIS AS EVALUATED BY RECTAL ENDOSCOPIC ULTRASONOGRAPHY - 327

Abstract P.03.3 - DARE SOUTH AFRICAN WOMEN HAVE ENDOMETRIOSIS? - 328

Abstract P.03.4 - DIGESTIVE SYMPTOMS IN WOMEN PRESENTING WITH PELVIC ENDOMETRIOSIS AND THEIR RELATIONSHIP WITH THE LOCALISATION OF THE LESIONS - 329

Abstract P.03.5 - DOES LAPAROSCOPY CHANGE THE MANAGEMENT OF CHRONIC PELVIC PAN? 330

Abstract P.03.6 - EFFECTIVE TREATMENT FOR DYSFUNCTIONAL UTERINE BLEEDING WITHIN AN OUT-PATIENT SETTING - 331

Abstract P.03.7 - ENDOMETRIOSIS IN OMAN: EXPERIENCE IN A TERTIARY HOSPITAL - 332

Abstract P.03.8 - LAPAROSCOPIC TREATMENT OF ENDOMETRIAL CANCER VERSUS OPEN ABDOMINAL SURGERY: 15-YEARS EXPERIENCE AT THE JENA UNIVERSITY HOSPITAL - 333

Abstract P.03.9 - MINIMAL PERISIGMOIDAL ADHESIONS IN CASES WITH NORMALLY APPEARING PERITONEUM IS A SURE SIGN OF ENDOMETRIOSIS. - 334

Abstract P.03.10 - NURSE-LED SELF-REFERRAL SERVICE FOR WOMEN WITH ENDOMETRIOSIS AND PELVIC PAIN: - 335

Abstract P.03.11 - THE DESTRUCTION OF TIE2MACROPHAGES IN HUMAN ENDOMETRIOSIS REDUCES LESION’S GROWTH IN A MOUSE MODEL - 336

Session P.04 * Endometriosis: Surgery * 337

Abstract P.04.1 - ENDOMETRIOSIS IN ADOLESCENCE: ENDOMANS STUDY - 338

Abstract P.04.2 - COMBINED TREATMENT OF PATIENTS WITH GENITAL ENDOMETRIOSIS. - 339

Abstract P.04.3 - DIGESTIVE FUNCTIONAL OUTCOMES OF THE SURGICAL MANAGEMENT OF DEEP ENDOMETRIOSIS INFILTRATING THE RECTUM: RADICAL VERSUS SYMPTOM GUIDED APPROACH - 340

Abstract P.04.4 - GYNECOLOGICAL BOWEL RESECTION FOR DEEP ENDOMETRIOSIS - 341

Abstract P.04.5 - LAPAROSCOPIC APPROACH TO URETERAL ENDOMETRIOSIS. ANALYSIS OF A SURGICAL SERIE. - 342

Abstract P.04.6 - LAPAROSCOPIC BOWEL RESECTION FOR COLORECTAL ENDOMETRIOSIS: THE HUNGARIAN EXPERIENCE - 343

Abstract P.04.7 - LAPAROSCOPIC NEUROLISYS FOR DEEP ENDOMETRIOSIS INFILTRATING PELVIC WALL AND SOMATIC NERVES: A RETROSPECTIVE STUDY - 344

Abstract P.04.8 - LAPAROSCOPIC SURGICAL THERAPY OF ENDOMETRIMAS BEFORE IVF PROTOCOLS - 345

Abstract P.04.9 - OVARIAN ENDOMETRIOMA ABLATION USING PLASMA ENERGY : ABOVE ALL PRESERVING THE OVARIAN PARENCHYMA ! - 346

Abstract P.04.10 - PATHOPHYSIOLOGICAL APPROACH TO BOWEL DYSFUNCTION AFTER SEGMENTAL COLORECTAL RESECTION FOR DEEP ENDOMETRIOSIS INFILTRATING THE RECTUM - 348

Abstract P.04.11 - PATIENT LEVEL INFORMATION COSTING SYSTEMS (PLICS): COULD BE USED TO GET RIGHT TARIFFS FOR ENDOMETRIOSIS CASES? - 349

Abstract P.04.12 - PRE AND POSTOPERATIVE PELVIC PAIN. THE PATIENT EXPERIENCE - 350

Abstract P.04.13 - RECURRENCE RATE AND RECURRENCE RISK FACTORS OF OVARIAN ENDOMETRIOMAS - 351

Abstract P.04.14 - SAFETY OF USE OF HEMOSTATIC SUTURES FOR HEMOSTASIS OF THE OVARIAN BED AFTER OVARIAN CYSTECTOMY OF ENDOMETRIOMAS - 352

Abstract P.04.15 - THE IMPACT OF SURGERY ON THE QUALITY OF LIFE (QOL) & FERTILITY IN PATIENTS WITH STAGE 3 OR 4 ENDOMETRIOSIS - 353

Abstract P.04.16 - THE IMPORTANCE OF STRATEGY IN DEEP ENDOMETRIOSIS SURGERY - 354

Abstract P.04.17 - THE PLACE OF LAPAROSCOPIC GYNAECOLOGY IN THE UNITED KINGDOM - SURVEY OF UK CONSULTANTS - 355

Abstract P.04.18 - WHEN SURGERY IS INAPPROPRIATE OR INADEQUATE FOR ENDOMETRIOSIS-ASSOCIATED PAIN: BACK TO THE FUTURE! - 356

Abstract P.04.19 - SERUM ANTI-MULLERIAN HORMONE (AMH) AND ANTRAL FOLLICLE COUNT (AFC) AS PREDICTORS OF OVARIAN RESERVE AFTER LAPAROSCOPIC MANAGEMENT OF ENDOMETRIOTIC CYSTS. - 357

Session P.05 * Hysterectomy * 358

Abstract P.05.1 - ADVANTAGES OF LAPAROSCOPIC HYSTERECTOMY STANDARDIZATION - 359

Abstract P.05.2 - AUDIT OF INTRODUCTION OF LAPAROSCOPIC TOTAL AND SUBTOTAL HYSTERECTOMIES IN A DGH - 360

Abstract P.05.3 - CAN ALL HYSTERECTOMIES BE LAPAROSCOPIC? A FOUR-YEAR PROSPECTIVE STUDY OF HYSTERECTOMY IN AN UNSELECTED HOSPITAL POPULATION. - 361

TAH 361

VH 361

TLH 361

Total Hysterectomies 361

Year 361

1 361

2 361

3 361

4 361

Total 361

Abstract P.05.4 - CHARACTERISTICS INDICATING ADENOMYOSIS AT THE TIME OF HYSTERECTOMY: A RETROSPECTIVE STUDY OF 291 PATIENTS - 362

Abstract P.05.5 - CLINICAL EFFICACY OF TWO MINIMALLY INVASIVE HYSTERECTOMY TECHNIQUES FOR BENIGN PATHOLOGY: TLH VS. VH - 363

Abstract P.05.6 - EFFECTS OF PERIOPERATIVE STRATEGIES TO REDUCE POSTOPERATIVE PAIN IN PATIENTS UNDERGOING LAPAROSCOPIC HYSTERECTOMY - 364

Abstract P.05.7 - HIGH PREVALENCE OF ADENOMYOSIS IN HYSTERECTOMY AFTER NOVASURE ENDOMETRIAL ABLATION - 365

Abstract P.05.8 - INTRA AND POST OPERATIVE OUTCOME AFTER LAPAROSCOPIC INTRA-FASCIAL HYSTERECTOMY (LHI) IN WOMEN WITH BMI OVER 35. - 366

Abstract P.05.9 - LAPAROSCOPIC ASSISTED VAGINAL HYSTERECTOMY EXPERIENCE OF THE DEPARTMENT OF GYNECOLOGY, UNIVERSITY HOSPITAL OF MARRAKESH - 367

Abstract P.05.10 - LAPAROSCOPIC ASSISTED VAGINAL HYSTERECTOMY VERSUS VAGINAL HYSTERECTOMY - 368

Abstract P.05.11 - LAPAROSCOPIC HYSTERECTOMY FOR BIG UTERUS. TIPS AND TRICKS. - 369

Abstract P.05.12 - LAPAROSCOPIC HYSTERECTOMY FOR THE LARGE UTERUS AND ASSOCIATED COSTS -370

Abstract P.05.13 - VAGINAL HYSTERECOMY UNDER REGIONAL ANAESTHESIA WITH INTRATHECAL MORPHINE - 371

Abstract P.05.14 - LAPAROSCOPIC HYSTERECTOMY IN A DISTRICT GENERAL HOSPITAL- A LEARNING CURVE - 372

Abstract P.05.15 - LAPAROSCOPIC HYSTERECTOMY: OUR EXPERIENCE AND CRITERIA FOR CHOICE OF ROUTE - 373

Abstract P.05.16 - LAPAROSCOPIC SUBTOTAL HYSTERECTOMY: IMPLICATIONS AND COST-EFFECTIVENESS - 374

Abstract P.05.17 - OUTCOME OF SURGICAL MANAGEMENT OF DYSFUNCTIONAL UTERINE BLEEDING: AUDIT OF PRACTICE OF A NEW NHS CONSULTANT GYNAECOLOGIST. - 375

Abstract P.05.18 - OUTCOME OF TOTAL LAPAROSCOPIC HYSTERECTOMY - 376

Abstract P.05.19 - OUTCOMES OF LAPAROSCOPIC HYSTERECTOMY- AT INTRODUCTION AND 3 YEARS -377

Abstract P.05.20 - PERIOPERATIVE OUTCOMES AND FOLLOW-UP OF LAPAROSCOPIC SUPRACERVICAL HYSTERECTOMY - 378

Abstract P.05.21 - RCOG SPECIAL SKILLS MODULE GRADUATE: AUDIT OF HYSTERECTOMY PROCEDURES IN THE FIRST 30MONTHS AS NEW NHS CONSULTANT OBSTETRICIAN AND GYNAECOLOGIST. - 379

Abstract P.05.22 - REINVENTION OF MINIMAL INVASIVE HYSTRECTOMY IN DENMARK. RESULTS FROM A PRIVATE HOSPITAL. - 380

Abstract P.05.23 - SELF-ASSESSED PATIENT SATISFACTION SURVEY AFTER LAPAROSCOPIC HYSTERECTOMY - 381

Abstract P.05.24 - THE EFFECT OF PREVIOUS ABDOMINAL SURGERY TO TOTAL LAPAROSCOPIC HYSTERECTOMY FOR BENIGN GYNECOLOGIC CONDITION - 382

Abstract P.05.25 - THE FUTURE OF HYSTERECTOMY - 383

Abstract P.05.26 - THE IMPACT AND EFFECTIVENESS OF RCOG POST-OPERATIVE LEAFLETS FOR TOTAL LAPAROSCOPIC HYSTERECTOMY - 384

Abstract P.05.27 - TOTAL LAPAROSCOPIC HISTERECTOMY – THE EXPERIENCE OF 3 YEARS - 385

Abstract P.05.28 - TOTAL LAPAROSCOPIC HYSTERECTOMY (TLH) VERSUS TOTAL ABDOMINAL HYSTERECTOMY (TAH): A COMPARATIVE STUDY - 386

Session P.06 * Imaging * 387

Abstract P.06.1 - EMBRIOSCOPY: NEW CLINICAL AND DIAGNOSTIC PROSPECTIVES OF THE OFFICE HYSTEROSCOPY IN THE EMBRIO DESEASES - 388

Abstract P.06.2 - PROGNOSTIC VALUE OF ADNEXAL MASSES SUBJECTIVE ULTRASONOGRAPHY ASSESSMENT IN QUALIFICATION FOR LAPAROSCOPY - 389

Abstract P.06.3 - SIGN GUIDELINES FOR THE MANAGEMENT OF POST MENOPAUSAL BLEEDING; A HOLY GRAIL OR A HARBINGER OF TROUBLE? - 390

Abstract P.06.4 - THE IMPROVEMENT OF OUTPATIENT DIAGNOSTICS OF BENIGN ENDOMETRIAL POLYPS - 391

Abstract P.06.5 - THE IMPROVEMENT OF THE OUTPATIENT DIAGNOSTICS OF INTRAUTERINE PATHOLOGY - 393

Abstract P.06.6 - 3D TRANSABDOMINAL ULTRASOUND. A NEW RELIABLE APPROACH TO LOCALIZE ESSURE® MICROINSERTS AFTER HYSTEROSCOPIC AMBULATORY STERILIZATION - 394

Abstract P.06.7 - DOES THREE-DIMENSIONAL SONOGRAPHY IMPROVE THE DIAGNOSTIC ACCURACY OF OVARIAN TUMORS WITH PREVIOUS INCONCLUSIVE IMAGING? - 395

Abstract P.06.8 - MRI IN DIFFERENTIAL DIAGNOSE OF EPITHELIAL OVARIAN CYSTS - 396

Session P.07 * Infertility and Reproductive Medicine * 397

Abstract P.07.1 - THYROID DYSFUNCTION IN INFERTILE PATIENTS AFTER LAPAROSCOPIC DRILLING OF OVARIES - 398

Abstract P.07.2 - A REVIEW ON LAPAROSCOPIC OVARIAN DIATHERMY (LOD) IN WOMEN WITH POLYCYSTIC OVARY SYNDROME (PCOS) - 399

Abstract P.07.3 - ANTIADHESION BARIERS APLICATION IN ADHESIONS PREVENTION - 400

Abstract P.07.4 - CLINICAL MARKERS FOR PELVIC ADHESIONS REFORMATION - 401

Abstract P.07.5 - DEMOGRAPHIC CHARACTERISTICS, CLINICAL PRESENTATIONS AND RISK FACTORS OF ECTOPIC PREGNANCIES IN 500 CONSECUTIVE SURGICALLY-MANAGED CASES - 402

Abstract P.07.6 - DETERMINATION OF THE ANXIETY LEVEL AND NEUROTIC DISORDERS IN PATIENTS WITH INFERTILITY. - 403

Abstract P.07.7 - DO SMALL UTERINE SEPTA, UTERUS ARCUATUS PLAY A ROLE IN SPONTANEOUS MISCARRIAGE RATE? - 404

Abstract P.07.8 - ESSURE FOR HYDROSALPINX: RESULTS AFTER 18 PATIENTS - 405

Abstract P.07.9 - HIGH CONCENTRATIONS OF IFN? IN INFERTILE PATIENTS WITH ENDOMETRIAL POLYPOSIS. - 406

Abstract P.07.10 - LAPAROSCOPIC OVARIAN DRILLING FOR OVULATION INDUCTION IN POLYCYSTIC OVARY SYNDROME - 407

Abstract P.07.11 - MANAGEMENT OF INTERSTITIAL PREGNANCIES:CONSERVATIVE TREATMENT AS A RELIABLE ALTERNATIVE TO SURGERY - 408

Abstract P.07.12 - MODERN WAY OF DIAGNOSIS AND TREATMENT OF PATIENTS WITH OVARIAN APOPLEXY FOR PREVENTION AND RESTORATION OF REPRODUCTIVE FUNCTION - 409

Abstract P.07.13 - OPERATIVE LAPAROSCOPY IN TUBAL INFERTILITY. A CLINICAL STUDY OF 49 CASES -410

Abstract P.07.14 - PGD : OUR EXPERIENCE IN SCREENING FOR ANEUPLOIDIES, CAUSES OF REPEATED FAILURES OF IMPLANTATION IN WOMEN UNDERGOING IVF-ET - 411

Abstract P.07.15 - PHOSPHOLIPIDS IN PELVIC ADHESIONS: THE NEW PARADIGM? - 412

Abstract P.07.16 - PREGNANCY OUTCOMES AND PERINATAL RESULTS AFTER UNINTENDED PREGNANCIES FOLLOWING ESSURE STERILIZATION: DESCRIPTIVE ANALYSIS OF 10 CASES - 413

Abstract P.07.17 - PREOPERATIVE EVALUATION OF ADHESIOLYSIS TECHNICAL DIFFICULTY (GRADE SCORE SYSTEM) - 414

Abstract P.07.18 - ROLE OF ENDOSCOPY IN TREATMENT OF PELVIC INFLAMMATORY DISEASES - 415

Abstract P.07.19 - SERUM AND FOLLICULAR FLUID ANTI-MULLERIAN HORMONE CONCENTRATIONS AT THE TIME OF FOLLICLE PUNCTURE AND REPRODUCTIVE OUTCOME IN PATIENTS UNDERGOING IN VITRO FERTILIZATION - 416

Abstract P.07.20 - THE EFFECT OF UTERINE ARTERY EMBOLISATION ON ANTI - MULLERIAN HORMONE LEVELS -417

Abstract P.07.21 - THE FAILURE OF UTERINE TRANSPORT FUNCTION IN PATIENTS WITH ENDOMETRIOSIS - 418

Abstract P.07.22 - THE FEATURES OF UTERINE PERISTALSIS FOR ADENOMYOSIS - 419

Abstract P.07.23 - THE IMPORTANCE OF GYNECOLOGIC LAPAROSCOPIC DAY SURGERY - 420

Abstract P.07.24 - THYROID DYSFUNCTION IN INFERTILE PATIENTS AFTER LAPAROSCOPIC DRILLING OF OVARIES - 421

Abstract P.07.25 - PATIENT SATISFACTION WITH SURGICAL MANAGEMENT OF ECTOPIC PREGNANCY - 422

Session P.08 * Innovation in Surgery * 423

Abstract P.08.1 - APPLICATIONS OF V-LOC BARBED SUTURE IN GYNECOLOGICAL LAPAROSCOPIC SURGERY - 424

Abstract P.08.2 - CASE REPORT OF MORE THAN 60 SINGLE PORT PROCEDURES IN ONE DEPARTMENT -425

Abstract P.08.3 - ENSEAL VS NORMAL BIPOLAR: COMPARED EFFICACY. - 426

Abstract P.08.4 - HOW CAN LAPAROSCOPIC SACROCOLPOPEXY BE A FASTER AND SAFER PROCEDURE? - 427

Abstract P.08.5 - LONG-TERM FOLLOW UP OF A RANDOMIZED CONTROLLED TRIAL COMPARING BIPOLAR RADIOFREQUENCY ENDOMETRIAL ABLATION WITH HYDROTHERM ABLATION FOR DYSFUNCTIONAL UTERINE BLEEDING - 428

Abstract P.08.6 - OUR EXPERIENCE OF PERFORMING LAPAROSCOPIC HYSTERECTOMY BY USING SILS-PORT. - 429

Abstract P.08.7 - TEN-YEAR FOLLOW UP OF A RANDOMIZED CONTROLLED TRIAL COMPARING NOVASURE AND THERMACHOICE ENDOMETRIAL ABLATION FOR DYSFUNCTIONAL UTERINE BLEEDING. - 430

Abstract P.08.8 - TWO-STEPS OFFICE HYSTEROSCOPY FOR THE TREATMENT OF ENDOMETRIAL POLYPS - 431

Abstract P.08.9 - FLUID ABSORPTION AFTER LAPAROSCOPIC SURGERY IS RELATED TO THE TYPE OF GAS USED - 432

Abstract P.08.10 - CO2 ABSORPTION DURING LAPAROSCOPIC SURGERY IS RELATED TO THE TYPE OF GAS USED - 433

Abstract P.08.11 - INTRODUCTION OF NEW TECHNOLOGY: A GUIDELINE FOR SURGEON AND MEDICAL COMPANY - 434

Session P.09 * Myomectomy * 435

Abstract P.09.1 - ARE THERE ANY LIMITATIONS FOR LAPAROSCOPIC POLYMYOMECTOMY? - 436

Abstract P.09.2 - FERTILITY AND PREGNANCY OUTCOME FOLLOWING LAPAROSCOPIC MYOMECTOMY - 437

Abstract P.09.3 - INTERLOCKING SUTURING IN LAPAROSCOPIC MYOMECTOMY ; A STATE OF ART - 438

Abstract P.09.4 - ISOBARIC GASLESS LAPAROSCOPIC MYOMECTOMY FOR MULTIPLE, MEDIUM OR LARGE UTERINE LEIOMYOMAS, UNDER GENERAL OR COMBINED SPINAL-EPIDURAL ANAESTHESIA: OPERATIVE OUTCOME - 439

Abstract P.09.5 - LAPAROSCOPIC MYOMECTOMIA: FACTORS THAT INFLUENCE THE COURSE OF OPERATION AND EARLY POSTOPERATIVE PERIOD - 440

Abstract P.09.6 - LAPAROSCOPIC MYOMECTOMY IN THE PERI- AND POSTMENOPAUSE - 441

Abstract P.09.7 - MYOMECTOMY THROUGH LAPAROSCOPICALLY ASSISTED ULTRAMINILAPAROTOMY -442

Abstract P.09.8 - PREDICTION OF POSTOPERATIVE ANEMIA FOLLOWING LAPAROSCOPIC MYOMECTOMY - 443

Abstract P.09.9 - PREGNANCY OUTCOMES AND LONG-TERM FOLLOW-UP AFTER TRANSVAGINAL MYOMECTOMY BY COLPOTOMY - 444

Abstract P.09.10 - REPRODUCTIVE OUTCOMES AFTER LAPAROSCOPIC MYOMECTOMY - 445

Abstract P.09.11 - RESULTS OF HYSTEROSCOPIC MYOMECTOMY FOR DIFFERENT TYPES OF SUBMUCOUS UTERINE FIBROIDS - 446

Abstract P.09.12 - THE EFFECTIVENESS OF HYSTEROSCOPIC MYOMECTOMY FOR YOUNG PATIENTS WITH LARGE SUBMUCOUS FIBROIDS AND INFERTILITY - 447

Abstract P.09.13 - UTERINE ARTERIES EMBOLIZATION AS A PRETREATMENT BEFORE HYSTEROSCOPIC MYOMECTOMY OF LARGE SUBMUCOUS FIBROIDS - 448

Abstract P.09.14 - UTERINE RUPTURE RATE DURING PREGNANCY AFTER LAPAROSCOPIC MYOMECTOMY ACCORDING TO THE SUTURING TECHNIQUE - 449

Session P.10 * Office & Diagnostic Hysteroscopy * 450

Abstract P.10.1 - A PILOT STUDY: HISTOLOGICAL CHANGES IN PREMENOPAUSAL WOMEN AGED 41 TO 44 YEARS - 451

Abstract P.10.2 - A PROSPECTIVE AUDIT EXAMINING WOMEN'S EXPERIENCE OF PAIN DURING OUT-PATIENT HYSTEROSCOPY - 452

Abstract P.10.3 - A REVIEW OF PAIN AND SATISFACTION WITH OUTPATIENT HYSTEROSCOPIC STERILIZATION. - 453

Abstract P.10.4 - AN OUTPATIENT HYSTEROSCOPY AUDIT AT WHIPPS CROSS HOSPITAL, LONDON - 454

Abstract P.10.5 - ARE WE ABLE TO DIAGNOSE MALIGNANT ENDOMETRIAL PATHOLOGY BY HYSTEROSCOPY? CURRENT SITUATION IN OUR AREA. - 455

Abstract P.10.6 - AUDIT OF OUTPATIENT HYSTEROSCOPY IN A DGH SETTING - 456

Abstract P.10.7 - CAN WE IMPROVE THE MANAGEMENT OF PATIENTS WITH POSTMENOPAUSAL BLEED (PMB)? - 457

Abstract P.10.8 - CONFIRMATION OF ESSURE® PLACEMENT USING TRANSVAGINAL ULTRASOUND - 458

Abstract P.10.9 - CORRELATION BETWEEN ENDOSCOPIC IMAGE AND PATHOLOGICAL ANATOMY IN ENDOMETRIAL CANCER - 459

Abstract P.10.10 - DIAGNOSTIC ACCURACY OF HYSTEROSCOPY IN THE DIAGNOSIS OF INTRAUTERINE PATHOLOGY - 460

Abstract P.10.11 - DIAGNOSTIC HYSTEROSCOPY AND BREAST CANCER - 461

Abstract P.10.12 - DO POST-MENOPAUSAL WOMEN WITH ABNORMAL TRANS-VAGINAL ULTRASOUND SCAN BUT NO VAGINAL BLEEDING NEED HYSTEROSCOPIC ASSESSMENT? - 462

Abstract P.10.13 - DON’T MISS A HORN! A TECHNIQUE TO BIOPSY BOTH UTERINE HORNS IN A UTERUS BICORNIS OR SEPTATE UTERUS - 463

Abstract P.10.14 - ENDOMETRIAL ASSESSMENT IN PATIENTS WITH BREAST CANCER TREATED WITH TAMOXIFEN - 464

Abstract P.10.15 - ENDOMETRIAL ASSESSMENT IN PATIENTS WITH BREAST CANCER TREATED WITH TAMOXIFEN - 465

Abstract P.10.16 - HISTEROSCOPIC POLIPECTOMY PERFORMED IN OFFICE: STUDYING THE POSSIBLE INFLUENCE OF SEVERAL FACTORS IN THE DURATION OF THE PROCEDURE. - 466

Abstract P.10.17 - HYSTEROSCOPIC EVALUATION IN PATIENTS WITH THICKENED ENDOMETRIUM ON ULTRASOUND - 467

Abstract P.10.18 - HYSTEROSCOPIC STERILIZATION: PREDICTIVE FACTORS OF ESSURE DEVICE PLACEMENT FAILURE. - 468

Abstract P.10.19 - HYSTEROSCOPIC TUBAL OCCLUSION – THE EXPERIENCE OF CENTRO HOSPITALAR DA PÓVOA DE VARZIM/VILA DO CONDE - 469

Abstract P.10.20 - HYSTEROSCOPIC TUBAL STERILIZATION WITH ESSURE DEVICE: WHAT HAPPEN AFTER? - 470

Abstract P.10.21 - IMPORTANCE OF DIAGNOSTIC HYSTEROSCOPY ON THE EVALUATION OF INTRACAVITARY POLYPS - 471

Abstract P.10.22 - MANAGEMENT OF POST-MENOPAUSAL BLEEDING (PMB) IN A RAPID ACCESS CLINIC - 472

Abstract P.10.23 - ONE STOP CARE PATHWAY IN GYNAECOLOGY - FROM GOOD TO BETTER? - 473

Abstract P.10.24 - OUTPATIENT HYSTEROSCOPY: THE ABERDEEN ROYAL INFIRMARY EXPERIENCE - 474

Abstract P.10.25 - OUTPATIENT HYSTEROSCOPY:OUTCOME STUDY - 475

Abstract P.10.26 - PAIN EVALUATION IN OFFICE HYSTEROSCOPY - 476

Abstract P.10.27 - POSTMENOPAUSAL BLEEDING: FINDINGS AND ACCURACY OF HYSTEROSCOPY AND HISTOPATHOLOGY IN THE DIAGNOSIS OF ENDOMETRIAL CANCER - 477

Abstract P.10.28 - PROSTAGLANDINS PRIOR TO HYSTEROSCOPY: A RANDOMIZED CONTROLLED TRIAL. - 478

Abstract P.10.29 - RELIABILITY OF OUT-PATIENT HYSTEROSCOPY IN ONE-STOP CLINIC FOR ABNORMAL UTERINE BLEEDING ATEF M. DARWISH MD PHD, EZZAT H. SAYED MD, SAFWAT A. MOHAMMAD MD, IBRAHEEM I. MOHAMMAD MSC, HOIDA I HASSAN*, PHD - 479

Abstract P.10.30 - THE DEVELOPMENT OF A NURSE CONSULTANT LED ONE STOP PROCEDURE CLINIC -480

Abstract P.10.31 - THE ROLE OF HYSTEROSCOPY IN THE ANALYSIS OF POSTMENOPAUSAL PATIENTS WITHOUT HORMONE TERAPY THAT HAD ENDOMETRIAL THICNESS - 481

Abstract P.10.32 - THE USE OF SELF-ADMINISTERED VAGINAL MISOPROSTOL BEFORE OFFICE HYSTEROSCOPY: NO PAIN OR NO GAIN? - 482

Abstract P.10.33 - UNINTENDED PREGNANCIES AFTER ADIANA® STERILIZATION. - 483

Abstract P.10.34 - AS WOMEN ACCEPT OFFICE HYSTEROSCOPY - 484

Session P.11 * Oncology * 485

Abstract P.11.1 - ASSESSMENT OF THE RADICAL IN THE MANAGEMENT OF THE HIGH RISK OF ENDOMETRIAL CANCERS - 486

Abstract P.11.2 - CERVICAL CANCER REVIEW IN OUR COMMUNITY HOSPITAL IN THE LAST TEN YEARS -487

Abstract P.11.3 - CERVICAL CANCER’S SCREENING IN THE POPULATION OF “ESPAÇO JOVEM” - 488

Abstract P.11.4 - CONDITIONAL LAPAROSCOPIC STAGING IN INTERMEDIATE RISK ENDOMETRIAL CANCERS - 489

Abstract P.11.5 - CONTRIBUTION OF THE LAPAROSCOPYC TECHNIQUE IN THE OVARIAN CANCER - 490

Abstract P.11.6 - COULD LAPAROSCOPIC LYMPHADENECTOMY BE AVOIDED IN EARLY STAGES OF ENDOMETRIUM CANCER? - 491

Abstract P.11.7 - DEFINITIVE LAPAROSCOPIC SURGICAL TREATMENT IN PATIENTS WITH EARLY OVARIAN CANCER - 492

Abstract P.11.8 - DISCORDANCE IN THE PRE-SURGICAL STAGING AND FINAL HISTOLOGIC STUDY IN ENDOMETRIOIDES ADENOCARCINOMAS OF LOW RISK - 493

Abstract P.11.9 - ENDOMETRIAL CANCER - THE GOLD STANDARD INVESTIGATION?? - 494

Abstract P.11.10 - ENDOMETRIUM CANCER AND LAPAROSCOPIC APPROACH IN ELDER - 495

Abstract P.11.11 - FAILURE OF MINIMAL INVASIVE PIPELLE ENDOMETRIAL SAMPLING IN WOMEN PRESENTING WITH POSTMENOPAUSAL BLEEDING - 496

Abstract P.11.12 - INFLUENCE OF SYSTEMATIC PELVIC LYMPHADENECTOMY ON THE OUTCOME OF PATIENTS WITH EARLY STAGE - 497

Abstract P.11.13 - LAPAROSCOPIC OVARIAN TRANSPOSITION IN TREATMENT OF CERVICAL CANCER OF LOCALLY ADVANCED STAGES - 498

Abstract P.11.14 - LAPAROSCOPIC APPROACH IN PATIENTS WITH ENDOMETRIUM CANCER AND BMI OVER 35 - 499

Abstract P.11.15 - LAPAROSCOPIC CONTRIBUTION TO CERVICAL CANCER TREATMENT IN A DISTRICT UNIVERSITARY HOSPITAL - 500

Abstract P.11.16 - LAPAROSCOPIC CYSTECTOMY-IN-A BAG OF AN INTACT CYST: IS IT FEASIBLE AND ONCOLOGICALY SAFE AFTER ALL? - 501

Abstract P.11.17 - LAPAROSCOPIC DETECTION OF SENTINEL LYMPH NODES IN PATIENTS WITH ENDOMETRIAL CANCER: PRELIMINARY RESULTS - 502

Abstract P.11.18 - LAPAROSCOPIC PARAORTIC AND PELVIC LYMPHADENECTOMY AND RADICAL HYSTERECTOMY IN A PATIENT WITH CERVICAL CANCER 6 MONTHS AFTER PRIMARY CHEMO – RADIATION. - 503

Abstract P.11.19 - LAPAROSCOPIC RADICAL SURGERY IN INITIAL STAGES OF THE CERVICAL CANCER - 504

Abstract P.11.20 - LAPAROSCOPIC SALPINGOOHRECTOMY IN MANAGEMENT OF BREAST CANCER ; NOVEL RESURGENCE - 505

Abstract P.11.21 - LAPAROSCOPIC TECHNIQUES IN THE TREATMENT OF ENDOMETRIAL CANCER - 506

Abstract P.11.22 - LAPAROSCOPY HYSTERECTOMY IN ENDOMETRIAL CARCINOMA: IS IT POSSIBLE TO AVOID THE UTERINE MANIPULATOR? 2 YEARS REPORT. - 507

Abstract P.11.23 - LAPAROTOMY STAGING OF EARLY-STAGE ENDOMETRIAL CANCER - 508

Abstract P.11.24 - OVARAIN TRANSPOSITION :FUNCTIONAL OUTCOMES - 509

Abstract P.11.25 - RADICAL VAGINAL TRACHELECTOMY (DARGENT’S OPERATION): INITIAL EXPERIENCE IN NORTH OF PORTUGAL - 510

Abstract P.11.26 - RETROPERITONEAL LAPAROSCOPIC LYMPHADENECTOMY AND GYNAECOLOGICAL MALIGNANCIES. - 511

Abstract P.11.27 - ROLE OF LAPAROSCOPIC SURGERY IN THE MANAGEMENT OF ENDOMETRIAL CANCER. A MULTI-CENTRE AUDIT - 512

Abstract P.11.28 - SENTINEL LYMPH NODE DETECTION IN EARLY STAGE CERVICAL CANCER PATIENTS: COMPARISON OF MINIMALLY INVASIVE AND OPEN PROCEDURE - 513

Abstract P.11.29 - SHORT TERM RESULTS OF LAPAROSCOPIC RADICAL HYSTEROCTOMY FOR ENDOMETRIAL ADENOCARCINOMA - 514

Abstract P.11.30 - SHOULD WE CENTRALIZE CARE FOR THE PATIENT SUSPECTED OF HAVING OVARIAN MALIGNANCY? - 515

Abstract P.11.31 - THE EFFECTIVENESS OF LAPAROSCOPIC OVARIAN TRANSPOSITION IN PATIENTS TREATED WITH PELVIC RADIOTHERAPY AND CHEMOTHERAPY - 516

Abstract P.11.32 - THE OUTCOME OF LAPAROSCOPIC RADICAL HYSTERECTOMY (LRH) AND PELVIC LYMPHADENECTOMY IN PATIENTS WITH EARLY INVASIVE CERVICAL CANCER - 517

Abstract P.11.33 - TOTAL LAPAROSCOPIC HYSTERECTOMY – PROVIDING EFFICIENCY WITHIN AN ONCOLOGY SERVICE - 518

Abstract P.11.34 - UTROSCT: 2 CASES REPORT - 519

Abstract P.11.35 - VAGINAL RADICAL TRACHELECTOMY - RECURRENCE AND PREGNANCY RATES - 520

Abstract P.11.36 - WHICH IS THE MEANING OF ASC-US IN THE POPULATION OF ESPAÇO JOVEM? - 521

Abstract P.11.37 - INCIDENTAL ADNEXAL MALIGNANCIES DURING ROUTINE LAPAROSCOPIC SURGERY -522

Session P.12 * Operative Hysteroscopy * 523

Abstract P.12.1 - AN ANALYSIS ON 409 CASES OF REMOVAL IUDS FOR POSTMENOPAUSAL WOMEN - 524

Abstract P.12.2 - BIPOLAR ENDOMETRIAL ABLATION COMPARED WITH HYDROTHERMABLATION FOR DYSFUNCTIONAL UTERINE BLEEDING: IMPACT ON LONG TERM PATIENTS’ HEALTH RELATED QUALITY OF LIFE. - 525

Abstract P.12.3 - COMPARATIVE ASSESSMENT OF EFFICACY AND COMPLIANCE OF HYSTEROSCOPIC METROPLASTY USING A 16 FR. (5.4 MM) MINI RESECTOSCOPE VERSUS A 24 FR. MONOPOLAR RESECTOSCOPE IN A POPULATION OF INFERTILE WOMEN - 526

Abstract P.12.4 - COMPLICATIONS OF HYSTEROSCOPY. RETROSPECTIVE STUDY. - 527

Abstract P.12.5 - ENDOMETRIAL ABLATION: COMPARATIVE STUDY OF NOVASURE© AND THERMACHOICE© USING THE OUTCOME MEASURE OF HYSTERECTOMY ONE YEAR AFTER PROCEDURE - 528

Abstract P.12.6 - ENDOMETRIAL ABLATION: A SERVICE EVALUATION OF TREATMENT OUTCOMES AT THREE YEARS - 529

Abstract P.12.7 - ENDOMETRIAL THERMOCOAGULATION BY CAVATERM COMBINED WITH HYSTEROSCOPIC STERILISATION BY ESSURE® IN THE TREATMENT OF FUNCTIONAL UTERINE HAEMORRHAGE, AN ALTERNATIVE TO HYSTERECTOMY? ABOUT 40 CASES. - 530

Abstract P.12.8 - HYSTEROSCOPIC REMOVAL OF INTRAUTERINE FOREIGN BODIES - A TEN YEARS EXPERIENCE - 531

Abstract P.12.9 - HYSTEROSCOPIC STERILIZATION WITH ESSURE® - 5 YEARS OF OUR EXPERIENCE. - 532

Abstract P.12.10 - OPERATIVE HYSTEROSCOPY WITH BIPOLAR RESECTOSCOPE: EFFICACY AND SAFETY -533

Abstract P.12.11 - OUTPATIENT OPERATIVE HYSTEROSCOPY SERVICE UNDER LA USING CONVENTIONAL RESECTOSCOPES: DEVELOPMENT OF PERSONNEL AND POLICIES. - 534

Abstract P.12.12 - REPRODUCTIVE OUTCOME AFTER HYSTEROSCOPIC SEPTOPLASTY IN PATIENTS WITH COMPLETE SEPTATE UTERUS - 535

Abstract P.12.13 - SUCCESS RATE OF THE ADIANA® PERMANENT CONTRACEPTION SYSTEM IN CLINICAL PRACTICE - 536

Abstract P.12.14 - THE ACUPUNCTURE AS AUXILIARY HYSTEROSCOPIC SURGERY IN CASES OF STERILIZATION INTRATUBAREA - ESSURE - 537

Abstract P.12.15 - THE NUMBER OF CURETTAGES AND UTERINE EVACUATIONS AS A PREDISPOSING FACTOR FOR THE SEVERITY OF INTRAUTERINE ADHESIONS - 538

Abstract P.12.16 - SMALL DIAMETER HYSTEROSCOPIC MORCELLATOR FOR OPERATIVE HYSTEROSCOPY: A FIRST CASE SERIES. - 539

Session P.13 * Operative Risk Management * 540

Abstract P.13.1 - AN AUDIT ON THE CONSENT PROCESS FOR LAPAROSCOPIC SURGERY - 541

Abstract P.13.2 - LAPAROSCOPIC COMPLICATION EVALUATION FROM 1990 TO 2010 - 542

Abstract P.13.3 - LAPAROSCOPY AND BODY MASS INDEX: DO THE OBESE HAVE A HIGHER RISK? - 543

Abstract P.13.4 - OUTCOME OF HYSTEROSCOPIC MYOMECTOMY AND POLYPECTOMY-A CASE SERIES -544

Abstract P.13.5 - SAFETY OF THE OPTICAL ACCESS TROCAR IN GYNECOLOGIC LAPAROSCOPIC SURGERY - 545

Abstract P.13.6 - THERMAL ENDOMETRIAL ABLATION, TO REPEAT OR NOT TO REPEAT? - 546

Session P.14 * Robotics * 547

Abstract P.14.1 - IMPROVING PATIENT TURNOVER WITH ROBOTIC SURGERY - 548

Abstract P.14.2 - LPS ROBOTIC-ASSISTED SURGERY FOR ENDOMETRIAL CANCER: PRELIMINARY RESULTS OF THE SIDE-DOCKING APPROACH - 549

Abstract P.14.3 - ROBOTIC HYSTERECTOMY LEARNING CURVE OF TWO LAPAROSCOPIC EXPERIENCED GYNECOLOGISTS - 550

Abstract P.14.4 - THE INTRODUCTION OF ROBOTIC SURGERY INTO A DISTRICT GENERAL HOSPITAL. - 551

Session P.15 * Single Access Surgery * 552

Abstract P.15.1 - A CASE OF SALPINGECTOMY IN LESS SURGERY FOR GEU IN OBESE WOMAN: NO MORE LIMITS? - 553

Abstract P.15.2 - BILATERAL ADNEXECTOMY IN AN ANIMAL MODEL COMPARING CONVENTIONAL LAPAROSCOPY AND SINGLE PORT ACCESS. - 554

Abstract P.15.3 - DIRECT INSERTION OF PRIMARY TROCAR BY RAILROAD METHOD AT GYNAECOLOGICAL LAPAROSCOPY, A STUDY OF 7000 CASES. - 555

Abstract P.15.4 - FEASIBILITY OF SINGLE-PORT ACCESS LAPAROSCOPIC-ASSISTED VAGINAL HYSTERECTOMY COMPARED WITH CONVENTIONAL LAPAROSCOPIC-ASSISTED VAGINAL HYSTERECTOMY: A SYSTEMIC REVIEW - 556

Abstract P.15.5 - TRANSUMBILICAL SINGLE-INCISION LAPAROSCOPIC ADNEXAL SURGERY - 557

Abstract P.15.6 - MINIMALLY INVASIVE MANAGEMENT OF A HUGE OVARIAN CYST BY LAPAROSCOPIC EXTRACORPOREAL APPROACH THROUGH A SINGLE-SITE INCISION - 558

Abstract P.15.7 - SIMULTANEOUS OPERATIONS USING SINGLE-PORT LAPAROSCOPY - 559

Abstract P.15.8 - SINGLE ACCESS LAPAROSCOPY: ANALYSIS OF INITIAL EXPERIENCE. - 560

Abstract P.15.9 - SINGLE INCISION LAPAROSCOPIC SURGERY (SILS) IN EARLY ENDOMETRIAL CANCER: TECHNIQUE AND INITIAL REPORT - 561

Abstract P.15.10 - SINGLE PORT ACCESS LAPAROSCOPY ASSISTED VAGINAL HYSTERECTOMY(SPA-LAVH) FOR BENIGN GYNECOLOGICAL DISEASES: OUR INITIAL CLINICAL EXPERIENCES. - 562

Abstract P.15.11 - SINGLE–PORT ACCESS HAND-ASSISTED LAPAROSCOPIC SURGERY (SPA-HALS) FOR BENIGN LARGE ADNEXAL TUMOR - 563

Abstract P.15.12 - SINGLE-PORT LAPAROSCOPY: WHEN IS IT INDICATED? - 564

Abstract P.15.13 - SINGLE-PORT VERSUS THREE-PORT LAPAROSCOPIC SURGERY FOR BENIGN ADNEXAL TUMOR - 565

Abstract P.15.14 - SINGLE-PORT VERSUS THREE-PORT LAPAROSCOPIC-ASSISTED VAGINAL HYSTERECTOMY FOR BENIGN OR PRECANCEROUS UTERINE DISEASE - 566

Session P.16 * Teaching and Training * 567

Abstract P.16.1 - APPENDICECTOMIES IN GYNAECOLOGY - 568

Abstract P.16.2 - DEDICATED CONSULTANT-LEAD EPAU SERVICE REDUCES SURGICAL INTERVENTION IN ECTOPIC PREGNANCIES - 569

Abstract P.16.3 - EFFECTIVENESS OF A HANDS-ON EDUCATION PROGRAM IN IMPROVING GYNAECOLOGICAL RESIDENTS' LAPAROSCOPIC SKILLS. - 570

Abstract P.16.4 - ETIOLOGY AND MANAGEMENT OF HEAVY MENSTRUAL BLEEDING: PREVALENCE RESULTS FROM A SINGLE CLINIC - 571

Abstract P.16.5 - FIRST YEAR OF ENDOSCOPIC PROCEDURES IN OUR HOSPITAL. REVIEW. - 572

Abstract P.16.6 - IMPLEMENTATION OF LAPAROSCOPIC VIRTUAL REALITY SIMULATION (VRS) TRAINING - 573

Abstract P.16.7 - INTRODUCING ENHANCED RECOVERY INTO GYNAECOLOGICAL SURGERY AT A DISTRICT GENERAL HOSPITAL - 574

Abstract P.16.8 - LAPAROSCOPIC SIMULATION MODELS FOR ADVANCED LAPAROSCOPIC TRAINING- INNOVATIVE TECHNIQUES - 575

Abstract P.16.9 - OPINIONS ON LAPAROSCOPIC SURGICAL SKILLS TRAINING IN MEDICAL STUDENTS - 576

Abstract P.16.10 - SEE AND TREAT HYSTEROSCOPY: OUR TEACHING EXPERIENCE WITH RESIDENTS. - 577

Abstract P.16.11 - SURGICAL MANAGEMENT OF ECTOPIC PREGNANCY - 578

Abstract P.16.12 - SURGICAL MANAGEMENT OF ECTOPIC PREGNANCY IN NI – A MULTI-CENTRE ANALYSIS - 579

Abstract P.16.13 - THE BENEFITS OF A TAKE-HOME TRAINER ON THE DEVELOPMENT OF LAPAROSCOPIC SURGICAL SKILLS - 580

Abstract P.16.14 - THE PROFILING OF A LAPAROSCOPIST - 581

Abstract P.16.15 - THE USEFULNESS OF THE APPRENTICESHIP MODEL IN GYNAECOLOGICAL ONCOLOGY TRAINING - 582

Abstract P.16.16 - ULTRASOUND EDUCATION FOR TRAINEES IN OBSTETRICS AND GYNAECOLOGY IN SOUTH EAST WALES - 583

Session P.17 * Technical Tricks and New Instrumentation * 584

Abstract P.17.1 - A SHAVER-LIKE SYSTEM (SLS) FOR INTRAUTERINE PATHOLOGY TREATMENT, PRECLINICAL INVESTIGATION. - 585

Abstract P.17.2 - MINIMIZING ABDOMINAL INCISIONS IN LAPAROSCOPIC REPRODUCTIVE SURGERY - 586

Abstract P.17.3 - MINI-SITE PRACTICE IN GYNECOLOGICAL ENDOSCOPY - 587

Abstract P.17.4 - OVARIAN ENDOMETRIOMA ABLATION USING PLASMA ENERGY VS. CYSTECTOMY : A STEP TOWARD A BETTER PRESERVATION OF THE OVARIAN PARENCHYMA IN WOMEN WISHING TO BECOME PREGNANT - 588

Abstract P.17.5 - PREVALENCE AND POSSIBLE TREATMENT MODALITIES OF LIPOMESOSALPNIX IN INFERTILITY: A PRELIMINARY STUDY - 589

Abstract P.17.6 - SAFETY FOR PREGNANT PATIENTS WITH ACUTE APPENDICITIS OF LAPAROSCOPIC APPENDECTOMY PERFORMED BY AN EXPERT GYNECOLOGIC LAPAROSCOPIST. - 590

Session P.18 * Urogynaecology * 591

Abstract P.18.1 - DO ANATOMICAL DEFECTS AFTER IMMEDIATE REPAIR OF OBSTETRIC ANAL SPHINCTER INJURIES CORRELATE WITH URINARY AND BOWEL SYMPTOMS? - 592

Abstract P.18.2 - PREVALENCE AND PERCEPTION OF URINARY PROBLEMS AMONG WOMEN WITH HIGH BMI - 593

Abstract P.18.3 - TENSION FREE VAGINAL TAPE - ABBREVO FOR TREATMENT OF STRESS URINARY INCONTINENCE: PRELIMINARY RESULTS - 594

Abstract P.18.4 - THE OUTCOME OF THE TRANSOBTURATOR TAPE (TOT) PROCEDURE DURING THE FOLLOW-UP OF 6.5 YEARS. - 595

Abstract P.18.5 - THE ROLE OF GYNEMESH IN VAGINAL MESH REPAIR OF ANTERIOR PARAVAGINAL GENITAL PROLAPSE DEFECTS - 596

Authors' Index 598

Session FC.01

* Free Communications_1 *

Case reports - Endometriosis: Diagnosis

FC.01.1

Abscessus tuboovarialis and ileus. Laparoscopic treatment

Radojicic V.*[1]

[1] Health Center Valjevo Valjevo Serbia

17 patients with tuboovarial abscessus and ileus were treated with laparoscopic procedures within 48–72 h of illness onset. All were treated with antibiotics (cephalosporins + amynogliosides + metronidasole) initially. Adhaesiolysis, punction and pus evacuation, adnexectomy, were performed respectivly. Antibiotherapy was administred 2–3 weeks after operation. No reintervention was performed.

PID with propagation into a abscessus tuboovarialis and consequent ileus is very common in a third world countries. There are too many risk factors. Most often irregular use of intrauterine devices(IUD), and/or lack of using other contraceptive methods are risk factors. Treatment could be done with or without operative methodes. Our experiencies with initial laparoscopic treatment are very promissing.

Clinical retrospective evaluation. Visualisation of anatomic features. Postoperative clinical and laboratory findings, comparation between transabdominal and laparoscopic approach.

No reoperation after laparoscopic approach was needed. Average CRP was twofold lower in a comparison with transabdominal approach. Patient stays in hospital 3–5 days.

It seems that laparoscopic approach provides good results even with bowel occlussion caused by PID. Smooth removing adhaesions with blunt and aqua dissection are way to avoid major tissue collateral damage.

FC.01.2

Management of borderline ovarian tumours by laparoscopy. Conservative treatment

Guerra T.*[1], Suarez E.[1], Mañalic L.[1], Puig O.[1], Xercavins J.[1]

[1] Hospital Valle De Hebron Barcelona Spain

To assess the efficacy and safety of laparoscopy sugery in the management of adnexal tumors with no sings of malignancy

Retrospective study.

A total of 2.844 adnexal tumors were removed by laparoscopy from 2.522 women. The mean age was 39.1 years (range: 17–79 yrs.).

The procedures performed were total cystectomy, and ovariectomy or adnexectomy in those beyond menopause. Preoperative assessment was the same as for as conventional surgery. Transvaginal ultrasonography was performed to evaluate the size and internal characteristics of masses to exclude malignancy, also was evaluate the IR by Doppler-colour. Serum CA 125 and CA 19.9 level was measured in all women at disagnóstic laparoscopy, visual inspection, cytologic examination, and if necessary, biopsy and frozen section were performed. If cytology of the frozen section indicated malignancy, the procedure was converted to ovarian cancer protocol by oncological team. Eighteen patiens (0.64%) required to change the procedure because of unexpected malignancy, and from twenty five patiens (0.72%) that had a Borderline tumors, six were stadificated by laparoscopic because of the results of patology study

Laparoscopic management of adnexal tumors is a safe and beneficial method in selected patiens when are performed by experienced laparoscopic surgeons. The approach to complex ovarian masses is posible in most patiens, however, it should be performed only in centers where an oncologic back-up is immediately available.

FC.01.3

Modern diagnostic aspects of borderline tumours in reproductive age patients

Chugunova N.*[1], Kovaleva M.[1]

[1] South District Medical Center Of Federal Medico-Biological Agency Of Russia Novorossiysk Russian Federation

Research and use of organ-sparing treatment methods encouraged to preserve fertility in women of young age. Still, the problem of menstrual-ovarian function reinstatement in women with borderline ovarian tumours remains urgent and not yet totally resolved.

Multiple scholar works and fundamental scientific research focused on diagnostic problems and management of ovarian tumours reveal that borderline ovarian tumours generally affect women of young age.

The aim of this study was to evaluate chances to preserve and reinstate menstrual-ovarian function in women of childbearing age who underwent organ-sparing surgery on uterine adnexa due to borderline ovarian tumours (BOTs); the surgeon was diagnostically focusing on tumour-associated markers CA-125 and CA-19-9. The research conducted within 2008–2010 covered 142 women, 69 of them with BOTs. The age varied from 25 to 45 years old. All patients were divided into 3 groups based on nosological tumours forms:
  1. 1)

    48 patients suffering serous BOTs

     
  2. 2)

    21 patients suffering mucinous BOTs

     
  3. 3)

    73 patients suffering non-malignant serous tumours.

     

The research showed that it was expedient to evaluate the level of secretion of tumour markers CA-125 and CA-19-9 in blood plasma of patients belonging to groups with various morphological tumour structures. The statistics revealed that marker CA-125 was significantly higher in the 1st group, while CA-19-9 was mostly present in group No. 2.

According to the side-research the rise of CA-125 level may occur in patients with epithelial tumours of non-gynaecological localisation, inflammatory processes of abdominal organs, cirrhosis, pregnancy and endometriosis. Therefore, analysis of CA-125 and CA-19-9 marker level demonstrates a high specificity of tumour markers at diagnostics of serous and mucinous ovarian tumours which are one of the prognostic indicators of ovarian disorders but still not a definite predictor.

FC.01.4

Removal of Essure device

Van Meer T.*[1], Veersema S.[1], Graziosi P.[1]

[1] St Antonius Hospital Nieuwegein Netherlands

We describe a case series of 14 patients in which Essure devices were removed hysteroscopically or laparoscopically because of perforation, pelvic pain, incorrect placement and bilateral salpingo-oophorectomy after Essure sterilisation.

More than 10000 women underwent an Essure sterilisation in the Netherlands. In less than 1% a tubal perforation has been reported. In certain cases women request a removal of the devices because of pelvic pain.

Little literature has been published regarding the removal of Essure devices.

Since 2004 we have done approximately 1000 Essure sterilizations with the vaginoscopic approach in St. Antoinius Hospital, Nieuwegein, the Netherlands (University-affiliated teaching hospital). We performed a retrospective review of all patients who underwent removal of Essure devices in our hospital (n = 14). The interval between placement of the devices and removal was between 10 days and 3 years.

If the devices were still protruding in the uterine cavity they were removed hysteroscopically otherwise they were removed laparoscopically by cutting the tube just distal from the device and pulling it out of the tube with a forceps.

In all 14 cases the devices were successfully removed. In total 19 devices were removed of which 13 were removed laparoscopically and 6 hysteroscopically. The mean operation time was 46 minutes (variation 20–70 min). All patients were released from our clinic the same day. No late or short term complications were registrated.

Removal of Essure devices is incidentally necessary or requested. It can be done either laparoscopically or hysteroscopically depending of the position of the device. It is a safe procedure which can be done in a day care setting.

We experienced it is feasible to remove the devices beyond 12 weeks after placement.

If sterilisation is still requested we perform a laparoscopic sterilisation by Filshie clips.

We conclude that it’s safe to remove Essure devices if indicated.

FC.01.5

Repeat resectoscopic endometrial resection after failed thermal balloon endometrial ablation: is it worth the risk?

Vilos G.[1], Garcia-erdeljan M.[2], Abu-rafea B.*[3], Vilos A.[2]

[1] St. Joseph’S Health Care London Canada - [2] The University Of Western Ontario London Canada - [3] King Saud University Riyadh Saudi Arabia

To examine the characteristics of women who failed TBEA, their uterine cavity and clinical outcomes following repeat REA after 5 years of follow-up.

Thermal balloon endometrial ablation (TBEA) was introduced in the 1990s as an easier, safer and equally effective treatment to resectoscopic endometrial ablation (REA), introduced in the 1980s, to treat women with abnormal uterine bleeding (AUB) from benign causes. Long-term results indicate that approximately 30% of women treated with TBEA require additional treatment for various indications. In these women, some physicians advocate repeat TBEA contrary to manufacturer’s instruction for use (IFU) manual. With repeat TBEA bowel thermal injuries have been experienced (one after failed Thermachoice, one after Thermablate).

Patients: 84 women treated with TBEA (ThermaChoice, n = 17 or Thermablate, n = 67) from 1994 through 2006 by the senior author (GAV). The corresponding average age was 40.2 and 41.3 years, and time to repeat REA 35.7 and 26.5 months, respectively.

Intervention: Following failed TBEA, all women received repeat REA using 1.5% glycine irigant solution, a 26 F resectoscope with an 8 mm diameter monopolar loop electrode at 120 W of cut waveform.

The most common indication for repeat REA was abnormal uterine bleeding +/− pain (ThermaChoice-64%, Thermablate-82%). At hysteroscopy, the uterine cavity appeared normal in 23.2% v. 25.3% and contracted or obliterated in the rest of women. There was one resectoscopic uterine perforation with no intra-abdominal injury. Following repeat REA, 16.6% of women in both groups were still symptomatic and received vaginal hysterectomy. Adenomyosis was identified in all specimens.

1. Following TBEA the uterine cavity is distorted in approximately 75% of women. 2.Repeat REA obviates hysterectomy in 83% of women.

FC.01.6

Undertaking the laparoscopic removal of ovarian dermoid cysts can minimize risk of chemical peritontis

Godinjak Z.*[1], Bilalović N.[1], Idrizbegović E.[1]

[1] Obstetrics And Gynaecology Hospital- University Clinical Centre Of Sarajevo department Of Clinical Pathology And Cytology-University Clinical Centre Of Sarajevo

The aim of the study was to analyze the use of laparoscopy in ovarian dermoid cysts treatment, the operative outcome, complications and possible factors that could lead to the development of chemical peritonitis.

In this study we presented 78 patients whom were diagnosed with ovarian dermoid cysts and treated laparoscopically.

In 65 patients we performed cystectomy, in 13 salpingo-oophorectomy. We used a 15 mm diameter trocar for evacuation of the cysts. Before evacuation of cyst, we evacuated contents of the cysts to reduce size of cysts. We did not use the bag to pull out the cyst. Immediately after the dermoid cyst ruptured we performed aspiration of the content spilled from the cyst and peritoneal cavity thorough washing out with a Ringer lactate. All extracted material was submited for a histopathological examination.

Dermoid cysts were composed of tissue that developed from three germinative layers in 52% patients, from two germinative layers in 38% and in 10% patients from one germinative layer. In 74% of patients we found several types of tissues developed from the ectoderm which is significantly more than tissues developed from mesoderm or endoderm. (p < 0,05) No intra or postoperative complications occured. No case of chemical peritonitis was noted.

Using strict adherence to guidelines for preoperative clinical assesment and intraoperative management, laparoscopic treatment of ovarian dermoid cysts appears to be a safe procedure and no complications were noted. Controled intraperitoneal spillage of cyst contents does not increase postoperative morbiditi, and the peritoneal cavity thorough woshing out might reduce risk of chemical peritonitis.

FC.01.7

Adenomyosis and uterine junctional zone (JZ) by 3D transvaginal ultrasound in infertile and fertile patients with and without pelvic endometriosis

Exacoustos C.*[1], Zupi E.[1], Luciano D.[2], Romeo V.[1], Corbett B.[2], Luciano A.[2], Arduini D.[1]

[1] Dept Ob Gyn Università degli Studi di Roma ‘Tor Vergata’ Rome Italy - [2] Dept Ob Gyn University Of Connecticut New Britain, Ct United States

3D TVS evaluation of uterine JZ in infertile patients is useful in identifying those women affected by endometriosis with or without infertility when there are no other sonographic signs of the disease.

The aim of this study is to assess the efficacy of 3D TVS to detect morphological alterations of the JZ in infertile patients affected by pelvic endometriosis and to correlate the findings to the laparoscopic stage of endometriosis.

We evaluated JZ on the uterine coronal section obtained by 3D volume acquisition in patients scheduled for laparoscopy. Measurements of JZ thickness (min and max), infiltration and disruption of the JZ were compared in patients with infertility or pelvic pain with and without endometriosis documented at laparoscopy and histology. Four groups of patients were considered for statistical analysis, patients with infertility or pain and with or without endometriosis.

The mean age of the 77 patients in this study who underwent laparoscopy was 34.6 (range 20–40) and did not differ among the 4 groups. Pelvic endometriosis was documented in 55 patients, and of these 40 had infertility. Of the 22 patients without endometriosis 10 were infertile. The JZ maximum in patients with endometriosis was significantly (p < 0.05) greater than in patients without endometriosis (6.3 ± 1.2 vs 4.5 ± 1.0 mm). Infertile patients with endometriosis had a JZ max significantly larger than infertile patients without endometriosis (6.3 ± 1.2 vs 4.8 ± 0.83 mm). Infiltration of JZ was statistically more evident in patients with endometriosis (40% vs 0%).

3D TVS of the coronal section of the uterus permits an accurate evaluation of the JZ. Non invasive assessment of the JZ may be useful in identifying those women affected by endometriosis with or without infertility when there are no other sonographic signs of the disease.

FC.01.8

Diagnostic accuracy of transvaginal ultrasound for non-invasive diagnosis of bowel endometriosis—a systematic review

Hudelist G.*[1], English J.[2], Thomas A.[3], Tinelli A.[4], Singer C.[5], Keckstein J.[6]

[1] Endometriosis & Pelvic Pain Clinic, Wilhelminen Hospital Endometriosis & Pelvic Pain Clinic, Wilhelminen Hospital Austria - [2] Dpt. Ob/gyn Brighton University Hospital, Nhs United Kingdom - [3] Institute Of Psychology; Dpt. Of Methodological Research And Statistics, Alpe Adria University Klagenfurt Austria Austria - [4] Dpt. Of Obstetrics & Gynaecology, Lecce Hospital Lecce Italy - [5] Dpt. Of Obstetrics & Gynaecology, University Of Vienna Vienna Austria - [6] Center For Endometriosis, Dpt. Obstetrics & Gynaecology, Villach Hospital Villach Austria

TVS with or without the use of prior bowel preparation is an accurate test for non-invasive, presurgical detection of deep infiltrating endometriosis of the rectosigmoid.

The aim of this study was to critically analyze the diagnostic value of TVS for non-invasive, presurgical detection of bowel endometriosis.

MEDLINE (1966–2010) and EMBASE (1980–2010) databases were searched for relevant studies investigating the diagnostic accuracy of TVS for diagnosing deep infiltrating endometriosis (DIE) involving the bowel. Diagnosis was established by laparoscopy and/or histopathological analysis. Likelihood ratios (LHR’s) were recalculated in addition to traditional measures of effectiveness.

Out of 188 papers, a total of 10 studies fulfilled predefined inclusion criteria involving 1106 patients with suspected endometriosis. The prevalence of bowel endometriosis varied from 14% to 73.3%. Positive LHR’s ranged from 4.8 to 48.56, negative LHR’s ranged from 0.02 to 0.75 with wide confidence intervals (CI’s). Pooled estimates of sensitivities and specificities were 91% and 98%; positive and negative LHR’s 30.36 and 0.09, respectively. Three of the studies used bowel preparations to enhance the visibility of the rectal wall; one study directly compared the use of water contrast (RWC-TVS) versus no prior bowel enema (TVS). The negative LHR was 0.04 for RWC-TVS versus 0.47 for TVS.

TVS with or without the use of prior bowel preparation is an accurate test for non-invasive, presurgical detection of deep infiltrating endometriosis of the rectosigmoid.

FC.01.9

Diagram to mapp endometriosis

Lasmar R.*[1], Lasmar B.[1]

[1] Universidade Federal Fluminense Rio De Janeiro Brazil

setting: University Center Brazil, Fluminense Federal University, Rio de Janeiro Ricardo Bassil Lasmar MD, PhD and Bernardo Portugal Lasmar, MD.

Was formulated a proposal to create a diagram to correlate the graphical view of the graphical view of endometriosis mapping with the description of the findings of patients with endometriosis.

Objective: To Demonstrate a high correlation between a graphic demonstration of the endometriosis location in the diagram, with the description of the case by the auditorium at the 20th annual congress of ESGE.

It was observed, from extensive literatures in this subject that, the discussion about the approach to endometriosis is related to the suspected endometriosis location: peritoneal, ovarian, deep.

For appropriate treatment of patients with endometriosis is fundamental to know the correct location of the disease and its extension.

Another important finding is the association of clinical findings with the imaging exams findings.

After being referred 10 cases of patients with endometriosis by five expert’s professors in treating patients with endometriosis, the diagram was presented to other 100 doctors and gynecology residents to describe the clinical cases.

Three different modifications were made from the first proposal.

After the third amendment the same cases were subjected to 50 physicians and residents, who had no previous contact with the diagram. The correlation was 98% with the description of the 10 cases referred.

To map the patient with endometriosis enables a direct and objective view of the case and a comparison between the preoperative findings with those of post-op.

FC.01.10

Enhanced optical diagnosis of endometriosis using targeted nanoparticles—defining a new paradigm for endoscopic surgery?

Newman T.[1], Shreeve N.[1], Bailey J.[1], Zisimopoulou K.[1], Sadek K.[1], Cheong Y.*[2]

[1] University Of Southampton Southampton United Kingdom - [2] Complete Fertility Centre Southampton, University Of Southampton Southampton United Kingdom

This pilot work demonstrates that targeted, reporter nanoparticles can enhance the diagnosis of endometriosis, thus defining a new paradigm for endoscopic surgery.

Surgical removal of endometriosis is often required. Currently, only macroscopic lesions can be removed. The treatment of endometriosis requires techniques that can identify both early and late stage disease. Here we investigate the interaction between endometrial cells and polymersome NPs; this approach when combined with a novel optical system that is under development, will demonstrate the enhanced diagnosis of diseased tissue.

Freshly collected endometrial tissue was incubated ex vivo with NPs labelled with fluorescein (FITC) and TAT peptide for 10 mins. The tissue was washed to remove unbound NPs and processed for immunohistochemisty using 7 μm thick sequentially cut cryostat sections. Sections were fluorescently labelled using markers of the luminal surface of endometrial glandular cells and antibodies against FITC to label the NPs. The optical visualisation of diseased tissue was studied.

Nanoparticles labelled with FITC and TAT peptide are taken up into glandular epithelial cells. Fluorescence microscopy identified that nanoparticles labelled with TAT efficiently labelled glandular epithelial cells. MUC-1 labelling allowed the lumen of the glandular epithelial cells to be defined. We also demonstrated co-localisation of the NPs with the surfaces of the columnar epithelia cells. Visualisation of fluorescein loaded NPs in fresh ex vivo endometriotic tissue using a novel optical system was demonstrated.

This preliminary data shows that TAT tagged NPs are taken up by glandular epithelial cells of endometriotic lesions. Using this paradigm, reporter NPs could be used in a complementary fashion to enhance the diagnosis and treatment of endometriosis.

FC.01.11

Pre-operative MRI for assessment of bowel involvement in patients with deep pelvic endometriosis—does timing of menstrual cycle make a difference?

Jagasia N.[1], Cameron M.[1], Mcilwaine K.[1], Readman E.[1], Maher P.*[1]

[1] Mercy Hospital For Women Melbourne Australia

MRI has proven to be sensitive and specific for detection of bowel lesions and is an invaluable tool for planning multidisciplinary approach to surgery with colorectal involvement.

The primary objective of this study was to prospectively assess MRI pattern during phases of the menstrual cycle and determine if it made a difference to recognition of deep pelvic endometriosis deposits involving bowel. We also evaluated the overall accuracy of pelvic MRI in diagnosing bowel involvement with endometriosis.

This was a prospective study. 25 patients with clinical evidence or suspicion of deep infiltrating endometriosis involving the bowel or recto-vaginal septum were recruited and underwent a menstrual and mid-cycle MRI scans. MRI findings were compared with surgical and histopathology diagnosis.

MRI has high sensitivity (100%) and specificity (83%) for diagnosis of deep infiltrating endometriosis involving the recto-sigmoid. There was no statistically significant difference in the detection rate of bowel lesions between menstrual and mid-cycle MRI however there was a trend towards mid-cycle MRI scans having greater accuracy for detection of bowel lesions (accuracy of menstrual MRI 80% versus accuracy of mid-cycle MRI 95%).

Pre-operative MRI scanning has proven to be an invaluable tool for planning multidisciplinary approach to surgery including predicting the need for a potential bowel resection or risk of bowel injury and hence allows for having the appropriate colorectal expertise available at the time of surgery.

FC.01.12

Simplified approach to the treatment of endometriosis—ECO system

Ricardo L.*[1], Abraão M.[2], Bernardo L.[1], Dewilde R.[3]

[1] Universidade Federal Fluminense = Uff Rio De Janeiro Brazil - [2] Universidade De São Paulo - Usp São Paulo Brazil - [3] University Of Goettingen Germany Germany

Objective: To develop a system to facilitate the approach for patients with endometriosis.

Interventions: To correlate three known parameters for endometriosis, qualifying and quantifying their importance in terms of disease severity and treatment complexity.

Main Outcome Measure(s): To score each parameter from 0 to 2 in order to determine medical or surgical management for endometriosis based on the clinical and imaging results.

Results: The total score from three parameters: Anatomical extent of infiltration, Complaints and Objective of the patient can be helpful in deciding on management of patients with endometriosis, by dividing them into two groups, where the total score of 0 to 2 is for medical treatment, while a score of 3 to 6 is for surgical intervention.

Conclusion: The ECO system demonstrated to be a qualified and helpful tool in the approach to patients with suspected endometriosis

The objective of this study was to develop a system to facilitate the decision-making process, a choice of medical or surgical approach that is applicable to patients suspected with endometriosis.

The ECO aims are to balance these three variables; extent of disease, complaints and patient’s objectives to make the approach more accurate, uniform and less subjective.
  1. 1.

    Location and extent of endometriosis lesions.

     
  2. 2.

    Type and severity of symptoms.

     
  3. 3.

    Desire and patient’s objective.

     

The ECO system demonstrated to be a qualified and helpful tool in the approach of patients suspected with endometriosis

This ECO system may also help gynecologists who are not qualified in complex endometriosis surgery, supporting decision making when referring the patient to a specialized endometriosis center.

Prospective data collection and review may provide a larger clinical base to evaluate this new system.

FC.01.13

Focal endometrial ablation for the treatment of menorrhagia and intrermenstrual spotting in women with cesarean scar defect

Cohen S.*[1], Schiff E.[1], Seidman D.[1], Goldenberg M.[1]

[1] Department Of Obstetrics And Gynecology, Sheba Medical Center, Affilated With The Sackler School Of Medicine, Tel-Aviv University, Israel

Investigation the role of focal endometrial ablation in symptomatic patients with CSD

Cesarean Scar Defect (CSD) is a common finding in women who underwent cesarean section. This finding could be encountered during routine ultrasound or during hysterosalpingography (HSG). However, some of the patients with this finding report of new onset menorrhagia or intermenstrual bleeding which could not be explained otherwise.

48 consecutive patients arriving to our gynecological service with symptoms of menorrhagia and or intermenstrual bleeding. All patient underwent cesarean section and a CSD was demonstrated in transvaginal ultrasound. First18 (37.5%) patients were treated by using the rollerball while the last 30 (62.5%) were treated by performing resctopscopic treatment.

In 10/18 (55.5%) symptoms had relapsed post the procedure in the group who underwent focal rollerball ablation. In the group who underwent focal resectoscopic ablation, 6/30 (20%) symptoms had relapsed. This finding was significant with p < 0.01.

Symptomatic patients with CSD can benefit from focal resectoscopic ablation. Menstrual flow in these patients can regain normal pattern post such procedure. Larger cohorts with randomized assignments should be performed to enforce these fingings.

Session FC.02

* Free Communications_2 *

Endometriosis: Surgery

FC.02.1

A role of dienogest as postoperative recurrence prevention

Ota Y.*[1], Hada T.[1], Kanao H.[1], Andou M.[1], Ota I.[2]

[1] Kurashiki Medical Center Okayama Japan - [2] Kurashiki Heisei Hospital Okayama Japan

Our retrospective study into the role of postoperative progestin therapy shows how dienogest and LEP (low dose estrogen progestin) can help patients prevent the recurrence of endometriotic lesions.

Endometriosis is typically seen during the reproductive years, and it is a common finding in women with infertility. As a result fertility-sparing laparoscopic surgery is on the rise. After fertility-sparing laparoscopic surgery, it is necessary to prevent a recurrence of endometriosis until the patient become pregnant. To maintain the positive effects of surgery, we used dienogest and LEP for postoperative recurrence prevention. We will report the effect of postoperative dienogest use by retrospective study.

A total of 349 women underwent fertility-sparing laparoscopic excision of deeply infiltrating endometriosis between January, 2008 and July, 2010. These women could be divided into 3 groups. Women who didn’t use postoperative medication (group1:control), women who used dienogest (group2), women who use LEP post operative (group3) were compared by the VAS, serum CA125 and cumulative recurrence rate for 2 years. In group2, metrorrhagia rate and continuance rate, metrorrhagia rate by dosage were analysed using Kaplan-Meier analysis.

Postoperative VAS and serum CA125 levels were decreased in all groups, however after 2 years, VAS and serum CA125 levels were increased in only the control group. Postoperative recurrence rate of group1 over 2 years was 30% in women with deep endometriosis, 15% in women with no deep endometriosis. There was no recurrence in groups 2 and 3 over the same period. In addition, the group which used 2 mg of dienogest had significantly lower frequency of metrorrhagia in comparison with the group of women which took only 1 mg of dienogest. (log-lank test; P < 0.01)

Our study showed that postoperative recurrence prevention was aided by dienogest and LEP in endometriosis cases for 2 years.

FC.02.2

Deep endometriosis. The importance of a multidisciplinary unit. Accurate diagnosis prior to standarization of treatment

Barri-soldevila P. N.*[1], Pascual M. A.[1], Cusidó M. T.[1], Ubeda A.[1], Rodriguez I.[1]

[1] Instituto Universitario Dexeus Barcelona Spain

The aim of our multidisciplinary unit, created in 2008, is to avoid unexpected surgical findings and to achieve good clinical symptoms control with a low complication rate.

Deep endometriosis requires clinical and surgical skills similar to oncology. The main difference is that the patient is the first to perceive the results of our technique. The outcome may depend more on medical decisions taken rather than on the biology of the disease.

The first requirements were to set up guidelines and select the members of the multidisciplinary team. The learning curve was suitable due to the fact that we soon had the possibility to perform deep endometriosis surgery on a weekly basis. Surgical training was based on prior surgical fellowship and later continuous education. The second step was to validate our own diagnostic tools compared to surgical and pathological findings. As a whole, the overall preoperative work-up was reduced to physical exam, 3D-ultrasound and MRI. (Ref: Pascual MA et al. Diagnosis of endometriosis of the rectovaginal septum using introital three-dimensional ultrasonography. Fertil Steril. 2010 Dec; 94(7):2761–5).

Although none of the available diagnostic tools prevent us from taking final intraoperative decisions, the application of our protocol leads us to rarely have unexpected surgical findings (none in the last year) with a lower average complication rate related to that compared in literature. (n = 46 cases in the last two years, 7% urinary and 9% bowel major complications, respectively.

Preliminary clinical results are promising, but still need to be evaluated. Longer follow-up and more cases are needed to stress our hypothesis. Experience and a multidisciplinary unit seem to support our good results. All conditions have met to settle a clinical outcome monitoring register in terms of quality of life and, later on fertility.

FC.02.3

Deep infiltrating endometriosis of the bladder and the ureter: surgical strategy and results

Wattiez A.[1], Gabriel B.[3], Trompoukis P.[1], Barata S.[1], Nassif J.*[2]

[1] Department Of Gynecologic Surgery, Strasbourg University Hospital Hautepierre And Cmco And Ircad Department Of Gynecologic Surgery, Strasbourg University Hospital Hautepierre And Cmco And Ircad France - [2] American Hospital Of Beirut, Lebanon Beirut, Lebanon Lebanon - [3] Universitäts-Frauenklinik Freiburg, Germany Freiburg, Germany Germany

In severe pelvic endometriosis, involvement of the urinary tract is not uncommon. The laparoscopic approach is feasible and safe.

The aim of this study was to report on the surgical management and outcome of patients with bladder and ureteral endometriosis and to discuss potential intraoperative strategies. To evaluate the prevalence of deep infiltrating endometriosis of the urinary bladder and the ureter following laparoscopic surgery for moderate and severe pelvic endometriosis.

Consecutive patients undergoing laparoscopic surgery for deep infiltrating endometriosis between 2007 and 2010 and presenting involvement of the urinary bladder and the ureter were eligible for this retrospective clinical case series.

In most cases a deep infiltrating endometriosis including bowel, bladder or ureteral infiltration was present. In addition, most patients were diagnosed with uni- or bilateral uterosacral ligament involvement. Whenever possible, a complete resection of endometriotic nodules was performed including bowel or bladder wall resection, partial excision, or mucosal skinning. Ureteral endometriosis was managed by ureterolysis, superficial excision of nodules, or resection with uretero-ureterostomy.

We evaluated the prevalence of urinary tract endometriosis. Pre- and postoperative pain scores and symptoms were assessed using visual analogous scale. Postoperative follow-up data including the assessment of bladder function are presented. The intra- and postoperative complications are evaluated. Results are still ongoing.

The preliminary data analysis revealed a considerable rate of bladder and ureter involvement in patients suffering from severe pelvic endometriosis. Laparoscopic management is feasible and appears to be safe. We discuss potential operative strategies for the management of bladder and ureteral endometriosis.

FC.02.4

Deep infiltrating endometriosis with diaphragmatic infiltration: retrospective analysis of 46 cases

Ceccaroni M.[1], Roviglione G.*[1], Clarizia R.[1], Giampaolino P.[2], Bruni F.[1], Ruffo G.[3], Minelli L.[4], De Placido G.[2]

[1] Sacred Heart Hospital, Gynecologic Oncology Division, International School Of Surgical Anatomy Negrar (Verona) Italy - [2] Department Of Obsetrical And Gynecological Sciences, Urology And Reproductive Medicine, University Of Naples “federico Ii” Naples Italy - [3] Sacred Heart Hospital, General Surgery Division, International School Of Surgical Anatomy Negrar (Verona) Italy - [4] Sacred Heart Hospital, Department Of Gynecology And Obstetrics Negrar (Verona) Italy

Aim of this retrospective analysis is to define clinical aspects and surgical treatment of diaphragmatic endometriosis in a long-experience series of an Italian Endometriosis Unit.

Diaphragmatic endometriotic involvement was documented in literature in about 0.6% of patients who underwent laparoscopy for deep infiltrating endometriosis. Symptomatic involvement of the diaphragm by endometriosis is rare and can cause ipsilateral chest, shoulder, arm and neck pain which can be aggravated during menses.

A retrospective analysis of all consecutive patients affected by diaphragmatic endometriosis treated by complete or incomplete laparoscopic eradication in our Institution from February 2004 to March 2011, was performed.

46 women with diaphragmatic endometriosis were reviewed, over a total of 2180 laparoscopies performed for suspected endometriosis (2%). 70% of diaphragmatic nodules were multiple and 75% of them were defined as superficial; however, in 12 patients (26%) nodules had diameter = 1 cm. Six (13%) patients had hepatic, one (2.1%) pericardial and pleural nodules. Surgical procedures included diathermocoagulation (36.9%), argon plasma coagulation (28.2%), excision (23.9%) and stripping in one case, (2.1%) with conversion to abdominal route because of massive left diaphragmatic, pleural and pericardial involvement. Intra-operative opening of the diaphragm occurred in 5 patients (10.8%), three of which were sutured laparoscopically and two had intrathoracic drainage positioned. Two patients had intraoperative pneumothorax, spontaneously sort out in the early post-operative period.

Diaphragmatic endometriosis is a rare entity, often asymptomatic and mostly present in case of severe pelvic involvement. Laparoscopic surgery, when performed by expert surgeons, can be safe and completely eradicative, with complete resolution of symptoms.

FC.02.5

Endometrioma with broad ligament involvement: comparison between stripping technique with/without peritoneal excision

Mereu L.[1], Carri G.*[1], Albis Florez E. D.[1], Giunta G.[1], Prasciolu C.[1], Cofelice V.[1], Florio P.[1], Mencaglia L.[1]

[1] Centro Oncologico Fiorentino Sesto Fiorentino (Fi) Italy

To evaluate if surgical endometrioma treatment with resection of posterior broad ligament influences the rate of ovarian recurrence and adhesions formation.

Endometrioma occurs in 17–44% of patients with endometriosis and it often associates with (PBL) adhesion.

Retrospective, two-center, case-control study on 100 consecutive patients affected by endometrioma without other evident localization of disease, who underwent to laparoscopic endometrioma excision by stripping tecnique. Group A (50 patients) underwent to concomitant sistematic PBL resection; group B (50 patients) just underwent to endometrioma excision. Data on patients’ characteristics, surgical and anatomopathological findings and follow up were collected

Among group A patients, 49/50 had a posterior broad ligament involvement, which correlates to the presence of preoperative pain symptoms. Endometrioma recurrence occurred in 2 cases (4%) among group A patients and 5 cases (10%) among group B patients. Comparing patients’ symptomatology one month and 12 months after surgery, recurrence in term of pain symptoms has been: dysmenorrhea 1/50 (2%) vs. 3/50 (6%); dyschezia 1/50 (2%) vs. 2/50 (4%); dyspareunia 3/50 (6%) vs. 5/50 (10%); dysuria 1/50 (2%) vs. 1/50 (2%); middle cycle pain 7/50 (14%) vs. 3/50 (6%) in group A and B, respectively.

Even if surgical endometrioma treatment with resection of PBL seems to reduce the rate of ovarian recurrence, it has to be taken in consideration the possibility of adhesion formation with subsequent middle cycle pain that can be explained by ovarian adhesion formation after surgery.

FC.02.6

Laparoscopic nerve sparing colorectal resection for bowel endometriosis: surgical outcomes and follow-up

Amato N. A.*[1], Caputo A.[1], Del Corso A.[1], Faticato A.[1], Fiaccavento A.[1], Zaccoletti R.[1]

[1] Casa di Cura Dr. Pederzoli Peschiera Del Garda (Vr) Italy Italy

A prospective study to evaluate the efficacy and the safety of laparoscopic colorectal resection with nerve sparing surgical technique in rectosigmoid obstruction caused by endometriosis.

Rectosigmoid junction is the most common intestinal endometriotic lesion. In these cases can be necessary a bowel resection that can cause a damage of the pelvic autonomic nerves with important consequences on bowel and bladder functions.

Between August 2008 and July 2010, 29 patients underwent laparoscopic colorectal resection with nerve sparing surgical technique for D.I.E. with documented bowel stenosis of 40% or more with a median stenotic intestinal tract length of 3.13 cm. 20 (69%) patients had anterior and lateral parametrial involvment; 7 (24.1%) of them had urinary tract endometriosis.We analyzed changes in gynaecological disorders, non-specific symptoms, bowel and urinary functions by a symptom questionnaire completed befor and after the surgery. We also assessed patients satisfaction, intraoperative and postoperative data and any complications.

20 (68,9%) patients had already undergone at least one surgical procedure for endometriosis.

Median follow up duration after surgery was 21.4 months (range 8–34). A statistically significant improvement in dysmenorrhoea (p < 0.0001), dysparaeunia (p < 0.0001), stypsi (p > 0.0006), diarrhoea (p < 0.0001), dyschezia (p < 0.0001) and lower back pain (p < 0.001) were registered.The patients satisfaction was detected as total in 20 cases (69%), medium in 6 (20.7%), low in 2 (6.9%); no satisfaction was reported in 1 case (3.4%). Major postoperative complications developed in 3 (10,3%) cases, including 1 recto-vaginal fistula, 1 ureteral fistula and 1 anastomosis dehiscence.

Colorectal resection with nerve sparing technique in rectosigmoid obstruction caused by endometriosis is a valid and safe procedure.

FC.02.7

Laparoscopy treatment of deep endometriosis

Popov A.*[1], Krasnopol’skaya K.[1], Ramazanov M.[1], Manannikova T.[1], Fedorov A.[1], Slobodyaniuyk B.[1], Krasnopol’skaya I.[1], Perfilev A.[1], Zemskov Y.[1]

[1] Moscow Regional Institute O\g Moscow Russian Federation

Endometriosis surgery was carried out in 126 patients.

To determine the best treatment modality in treatment of deep infiltrative endometriosis (DIE) complicated by involvement of adjacent structures in women planning pregnancy.

Endometriosis surgery was carried out in 126 patients. We define DIE as minimum 5 mm endometriosis invasion histologically confirmed. Median age was 32. All patients had DIE and invasion to adjacent structures of various degrees. The basic complaints of patients were chronic pelvic pain, bowel problems and infertility. Depending on degree of affection of adjacent organs the surgery was different in all patients. All cases were treated with laparoscopic approach with no conversion. Some of them include: excision of nodules 63 (50.8%), segmental resection of sigmoid or rectum 8 (6.4%), stapler resection of sigmoid or rectum 8 (6.4%), ureterolisis 24 (19.4%), bladder resection 1 (0.4%), ureterocystostomy 2 (0.8%). In 120 cases (95%) DIE was combined with unilateral or bilateral endometriomas. All patients receive postoperative hormonal therapy including agonist GnRH during 3–6 month. Median follow-up was 4 years (1–7).

After surgery 123 (97.6%) patients noted improvement of quality of a life and absence of a pain syndrome during period of observation. Pregnancy has come in 38 (30%) cases, in 25 (20%)—successful delivery. IVF was performed in 20 (80%) of successful delivery.

We propose two stage treatment modality: 1. destruction of the endometriosis nodules, 2. pharmacotherapy. We believe that this concept is pathologically valid. First stage include destruction of all visible endometriotic lesions, while the second stage inactivates ectopic endometrioid tissue which might cause infertility, pregnancy lost and pain, moreover consequently it’s reasonable to perform super-long protocol of ovarian stimulation.

FC.02.8

Original technique of combined laparoscopic and transanal excision of deep endometriosis nodules infiltrating the low and middle rectum

Roman H.*[1], Bridoux V.[1], Tuech J.[1]

[1] University Hospital Rouen France

Disc excision using the Contour 30 stapler is feasible in nodules infiltrating the rectal wall which diameter and height from the anus are respectively inferior to 5 and 10 cm, and allows complete relief of both digestive complaints and rectal stenosis, and avoids unfavourable functional outcomes following the removal of low and middle rectum.

The Contour® 30 Transtar stapler performs at the same time both the rectal wall excision and suture. We report a series of women presenting with deep endometriosis nodules infiltrating the rectum and having undergone transanal disc excision using this device.

Seven nulliparas which age varied from 25 to 33 years benefited for this technique from April 2009 to October 2010.

Rectal nodules measured from 20 to 50 mm in diameter, and they infiltrated at least the rectum muscularis at 5 to 10 cm from the anus.

Rectal wall discs removed measured from 40 × 45 mm to 60 × 50 mm. In 5 cases the limits were microscopically safe, while in 2 cases microscopic foci were found on one of limits. During our first procedure, the stapler caught both the anterior and the posterior rectal wall leading to the obliteration of the tract and requiring segmental rectal resection.

Other 6 women having benefited for this technique have a follow up varying from 5 to 21 months, have no digestive complaint, and their postopeartive computed tomography and virtual colonoscopy showed regular diameter of the rectum.

Our technique is feasible in nodules infiltrating the rectal wall which diameter and height from the anus are respectively inferior to 5 and 10 cm. This original technique allows complete relief of both digestive complaints and rectal stenosis, and avoids the occurrence of postoperative unfavourable functional outcomes du to the removal of low and middle rectum.

FC.02.9

Outcome of conservative surgical treatment of rectovaginal endometriosis

Gordts S.*[1], Campo R.[1], Puttemans P.[1], Valkenburg M.[1], Gordts S.[1]

[1] Leuven Institute For Fertility And Embryology Leuven Belgium

The aim of this study was to evaluate complications, recurrence rate after laparoscopic resection of rectovaginal endometriosis by shaving technique.

Rectovaginal endometriosis, frequently associated with pain, is diagnosed at clinical examination and with indirect imaging techniques like ultrasound and MRI.

Between January 2004 and December 2010, 74 procedures for rectovaginal endometriosis were performed in patients with pain and/or infertiltity. The adenomyotic plaques were resected laparoscopically using scissors and bipolar and/or unipolar current. If rectosigmoidal invasion was present, a shaving of was performed. With this technique as much as possible of the endometriotic tissue is removed without opening the intestine or sigmoidal resection. Only in 1 patient a discoid resection was performed and 2 appendectomies were carried out. Only 2 patients received preoperatively GnRH analogues. Mean age was 30,9 years (SD ±4,4).

The vaginal nodule was a solitary lesion in 4% of the patients without involvement of ovaries, rectum or bladder. In 91% of cases the rectosigmoid was involved as well. 9 patients were lost of follow-up and excluded for further analysis. Mean follow-up was 640 days (SD 498). 10 patients received GnRH- agonist treatment for 3 months postoperatively. One patient developed postoperatively a severe complication with intestinal perforation secondary to thermal necrosis (1%). In 4 patients recurrence of endometriosis was noted(5%): in those patients a recurrence of the sympotms was noted, only in 1 patient a second intervention was performed.

Conservative surgery for rectovaginal endometriosis resulted in a relief of pain, with a low postoperative complication rate (1%). This shaving technique also resulted in limited risk of recurrence of symptoms (5%).

FC.02.10

The Kayani-Kent (K-K) map of endometriosis

Kayani S.*[1], Kent A.[2]

[1] Benenden Hospital Trust Kent United Kingdom - [2] Royal Surrey County Hospital Surrey United Kingdom

Our aim is to develop a system of recording findings of endometriosis at laparoscopy which is reproducible and has low intra and inter observer variability.

Translating the extent of endometriosis seen at laparoscopy into a diagram which is simple yet logical and ‘decodeable’ is difficult. Taking images is very helpful, however, this can be expensive and not many units are able to give high quality images to patients. This becomes important when patients are transferred between hospitals or change gynaecologists. We have developed a simple yet effective method that allows translation of the appearance of endometriosis seen at laparoscopy to a diagrammatic record.

This is a prospective study to assess validity of mapping of endometriosis found at laparoscopy.

SK and AK, collected 25 cases of endometriosis each. They undertook videos of the pelvic survey, marked them according to this mapping technique, exchanged the videos with each other and marked again.

SK and AK then mapped their original videos again after an interval to assess intra observer validity. Thus each video was marked thrice and the mapping of the two gynaecologists was compared.

Each video was mapped. In total 50 videos were mapped thrice. The mapping sequence was as follows:

SK videos: SK, AK, SK

AK videos: AK, SK, AK

The mapping was compared. There was high inter and intraobserver validity.The results will be presented.

We have developed a universal diagrammatic tool for logging the extent and depth of endometriosis. This method of mapping of endometriosis is simple, reproducible and demonstrates high inter and intra observer validity.

We would recommend the KK Map of Endometriosis to be used as a standard tool by laparoscopic gynaecologists to log the extent of endometriosis.

We will now widen the assessment of the inter and intraobserver validity with the aim of developing a simple yet effective classification of endometriosis.

FC.02.11

The long term (>2 years) effect of treatment with GnRH analogues with add-back therapy in patients with relapsing pelvic pain secondary to endometriosis

Sahu B.*[1], Kapoor D.[2], Powell M.[3]

[1] Banchhita Sahu Nottingham United Kingdom - [2] Deepanwita Kapoor Nottingham United Kingdom - [3] Martin C Powell Nottingham United Kingdom

Long term(>2 years)GnRH analogues with add-back therapy allows the treatment of women with relapsing pelvic pain secondary to endometriosis for a longer period; with reduced bone mineral density loss, good control of pain symptoms and a better quality of life.

GnRH analogues are effective in relieving symptoms of pain secondary to endometriosis. Unfortunately there use is restricted due to acceleration in bone mineral density(BMD) loss and hypo-estrogenism. Even with add back therapy, the Royal college of Obstetrician and Gynaecologists recommends a use for a maximum of 1 year.

40 women with relapsing pelvic pain after previous endometriosis surgery, treated with GnRH analogue plus add-back therapy for more than 2 years were observed prospectively.

Outcome measure(s)- Quality of life in treated patients according to the SF-36 questionnaire, pain evaluation by a visual analogue scale and occurrence of adverse effects such as BMD loss at pre-treatment, after 1 year, 2 years and at the last visit(maximum of 5 years).

Patient treated with GnRH analogues with add-back therapy showed a significant improvement in quality of life as assessed with the SF-36 questionnaire. There was significant reduction in pelvic pain, dyspareunia and dysmenorrhoea. There was no significant difference in percentage change of BMD from baseline after 1 and 2 years of treatment and at last visit.

GnRH analogues with add-back therapy allows the treatment of women with relapsing pelvic pain secondary to endometriosis for a longer period; with reduced BMD loss, good control of pain symptoms and a better quality of life. This study results suggest that GnRH analogues with add-back therapy can be used for a longer period in this group of women than the current recommendation of maximum of 1 year.

FC.02.12

The use of PlasmaJet ultra in the treatment of endometriosis

Hill N.*[1], Erian J.[1]

[1] The Princess Royal University Hospital London United Kingdom

PlasmaJet was first used in the treatment of endometriosis in 2008. We report the results of the first cohort of patients treated with the new second generation PlasaJet Ultra. The presentation will be in conjunction with the European launch of PlasmaJet Ultra as the ESGE meeting in London.

PlasmaJet was introduced for the treatment of Endometriosis in 2008. It has been used in over 3000 patients worldwide and is now available in 5 countries. The device can be used for both excision and ablation of endometriosis. The second generation PlasmaJet Ultra is now available and we report the results of the first cohort of patients treated with this device.

Plama Jet Ultra has been designed to incorporate a new low powered settings combined with a new pulse mode of action. It will be available for treatment in July. The first generation PlasmaJet has been in use at Chelsfield Park & the Sloane hospitals for over 6 months. No major complications have been reported and it is now used routinely for the treatment of endometriosis. The patients reported in this abstract will be the first cohourt of patients treated with the new device.

Awaited.

The advantages of the new second generation PLasmaJet Ultra will be discussed. The new low power settings & new pulse mode of action will be demonstrated. This presentation is designed to accompany the European launch of PlasmaJet Ultra at ESGE>.

FC.02.13

Total pelvic peritoneal excision allows conservation of ovaries in all women with endometriosis undergoing hysterectomy

Trehan A.[1], Dadi H.*[1], Jones B.[1]

[1] Dewsbury And District Hospital Dewsbury United Kingdom

Aim of the study was to evaluate the safety and long-term outcome of laparoscopic total pelvic peritoneal excision and hysterectomy with ovarian conservation in women with endometriosis.

The RCOG guideline 24 on the management of endometriosis suggests that bilateral oophorectomy may result in improved pain relief and reduced chance of further surgery¹. We have demonstrated that total pelvic peritoneal excision² for endometriosis at the time of hysterectomy allows conservation of ovaries in all women with greatly improved outcome.

Retrospective case notes review and postal patient satisfaction questionnaires of 103 consecutive patients from 2001–2010.

103 consecutive patients undergoing surgery had mean age of 41 years, parity 2 and duration of symptoms 4.5 years (range of 2–15 years). 22 women had chocolate cysts ranging from 3–10 cm, 86% of which had cystectomy with conservation of both ovaries whilst the remaining underwent unilateral oophorectomy. Following surgery, mean pain scores improved from 3–8 to 0–1 whilst quality of life scores improved from 3 to 9. Detailed analysis from questionnaires will be available for presentation. No major intra or post-operative complications were reported although one patient did require a 2-unit blood transfusion. 85% of patients were discharged following an overnight stay. One patient was readmitted for suspected pulmonary embolism. 14 patients underwent further surgery, with 79% requiring only ovarian adhesiolysis.

Based on our long-term data showing marked improvement of quality of life, pain scores and patient satisfaction, we believe that ovaries with or without cyst can always be conserved in all women with endometriosis who undergo total pelvic peritoneal excision at the time of hysterectomy. Bilateral oophorectomy is not necessary.

Session FC.03

* Free Communications_3 *

Endometriosis: Surgery—Complications—Hysterectomy

FC.03.1

Complications after laparoscopic bowel surgery for deep infiltrating endometriosis: a retrospective study on 1147 patients

Ceccaroni M.[1], Ruffo G.[2], Bruni F.*[1], Clarizia R.[1], Roviglione G.[1], De Placido G.[3], Minelli L.[4]

[1] Sacred Heart Hospital, Gynecologic Oncology Division, International School Of Surgical Anatomy Negrar (Verona) Italy - [2] Sacred Heart Hospital, General Surgery Division, International School Of Surgical Anatomy Negrar (Verona) Italy - [3] Department Of Obsetrical And Gynecological Sciences, Urology And Reproductive Medicine, University Of Naples “federico Ii” Naples Italy - [4] Sacred Heart Hospital, Department Of Gynecology And Obstetrics Negrar (Verona) Italy

Aim of this retrospective study is to report the incidence of various complications after laparoscopic bowel surgery for deep infiltrating endometriosis in a cohort of 1147 patients.

Laparoscopic excision of deep infiltrating endometriosis with segmental bowel resection is commonly performed in our structure in cases of pelvic endometriosis with bowel involvement.

We hereby report complications rate and tipology in a cohort of 1147 women who underwent laparoscopic excision of deep infiltrating endometriosis with segmental or discoid bowel resection.

Between January 3, 2001 and June 2, 2011 1147 consecutive patients referred to our Centre and underwent laparoscopic excision endometriosis with segmental (n = 1022) or discoid (n = 125) bowel resection performed by a Gynecologist and a general Surgeon.

Dehiscence of the anastomosis was reported in 11 patients (1%) who underwent segmental bowel resection and in 1 patients (0.8%) who underwent discoid bowel resection. Stenosis of the anastomosis occurred in 46 patients (4.5%) after segmental bowel resection and in no patient after discoid bowel resection. Occlusion occurred in 9 patients (0.9%) after segmental bowel resection and in no patient after discoid bowel resection.

Bleeding from the anastomosis was reported in 4 patients (0.4%) after segmental bowel resection and in 13 patients (10%) after discoid bowel resection.

Recto-vaginal fistula was reported in 11 cases (1%) after segmental bowel resection and in 0 cases after discoid resection.

In our experience we report a progressive reduction of the complication rates (global complication rate = 21% in 2002 versus 5.2% in 2010), probably due to a improvement of the surgical skills and standardization of the laparoscopic approach to deep infiltrating endometriosis with segmental or discoid bowel resection.

FC.03.2

Complications after large bowel resection for deep infiltrating endometriosis (die), “experience in a series of 110 cases”

Saska G.*[2], Jean-christophe N.[3], Alexis B.[1], Vincent A.[2]

[1] Department Of Colorectal Surgery, Erasme Hospital Brussels Belgium - [2] Department Of Gynecology, Erasme Hospital, Université Libre De Bruxelles Brussels Belgium - [3] Departement Of Pathology, Erasme Hospital Brussels Belgium

Laparoscopic assisted rectosigmoid resection for DIE is safe intervention and has good outcomes. In this series the most frequent complication was anastomotic stenosis, which can be responsible for considerable functional discomfort. The appropriate treatment is endoscopic dilatation. It is highly recommended preoperatively to inform patients about the risk of potential complications.

Evaluation of complications following large bowel resection for DIE of the colon in a consecutive series of 110 cases severe pelvic endometriosis with symptomatic large bowel involvement.

Retrospective study on a prospective database on complications after large bowel resection for highly symptomatic DIE, performed in Erasme Hospital between October 1997 and October 2010. A total of 110 patients underwent surgical management for DIE. 96 patients had laparoscopically assisted large bowel resection and 14 laparotomy. 79 had anterior rectal resection, 27 segmental sigmoid resection and 4 ileocaecal resections. 3 patients had two resections.

Median age was 33 ± 6 years. Mean operating time was: 250 ± 64 min. Mean follow-up was 64 ± 44 months. 19 patients (17%) had complications. Complications were: anastomotic fistulae (n = 2), rectovaginal fistulae (n = 2), small bowel occlusion (n = 1) and anastomotic stenosis (n = 12). All cases occurred after mechanical end-to-end low anastomosis with a large diameter (31 millimeters) and required dilatation under general anesthesia.

In this series, the most frequent complication after colonic resection for DIE was anastomotic stenosis which can be responsible for considerable functional discomfort. It seems to occur mainly after mechanical low EEA anastomosis even when a large diameter (31 mm) stapling device is used. No cases were observed after handsewn lateroteminal anastomosis.

FC.03.3

Gum chewing stimulates early return of bowel motility after gynecologic laparoscopic surgery

Lu D.*[1], Liu Q.[1], Shi G.[1]

[1] West China Second University Hospital, Sichuan University Chengdu China

Use of chewing gum did not increase complications and owing to its simplicity, efficacy, safety and low cost, it should be considered for use in routine practice for patients undergoing gynecologic laparoscopic surgery.

The laparoscopic approach to gynecologic surgery has important benefits on postoperative recovery and complications, which results the further postoperative enhanced recovery program has not been addressed. To assess the effects of gum chewing on postoperative bowel function after gynecologic laparoscopic surgery.

Women who underwent gynecologic laparoscopic surgery were randomized to either a gum-chewing group (n = 53) or a non-gum-chewing group (n = 56). The two groups were compared with respect to the return of bowel activity, postoperative pain, postoperative complications and postoperative hospital stay.

Bowel sounds appeared in a significantly shorter duration of time in the study group, the mean being 8.26 h as compared to 12.70 h in the control group (p < 0.001). The first passage of flatus postoperatively was 22.43 h in the gum-chewing group and 28.12 h in the control group (p = 0.001). The postoperative length of hospital stay was longer in the gum-chewing group (2.85 days) than in the control group (2.66 days), but it was not statistically significant (p > 0.05). Postoperative pain in both groups was similar. The postoperative ileus was fewer, but not significantly, in gum-chewing group as compared to the control group (3.8% vs. 7.1%, p = 0.441).

There is still a place to enhance the postoperative bowel recovery for gynecologic patients underwent laparoscopic surgery. On the basis of the tolerability and results on bowel function, gum chewing provides a simple method for early recovery of bowel function after laparoscopic surgery for gynecologic patients.

FC.03.4

Laparoscopic entry techniques- issues around safety

Ahmad G.[1], Ahmad G.*[1], O Flynn H.[2], Duffy J. M.[3], Watson A.[4], Phillips K.[5]

[1] Pennine Acute Trsut Manchester United Kingdom - [2] South Manchester University Hospital Manchester United Kingdom - [3] Queen Charlotte & Chelsea Hospital Imperail College Health Care Nhs Trust United Kingdom - [4] Tameside General Hospital Manchester United Kingdom - [5] Hull And East Yorkshire Nhs Trust Hull United Kingdom

On the basis of evidence investigated in this review, the rate of major complications in the included trials was low. There appears to be no evidence of benefit with respect to major complications of one entry technique over another.

Background

Laparoscopy is a common procedure in gynaecology. Complications associated with laparoscopy are often related to entry. The life-threatening complications include injury to the bowel, bladder, major abdominal vessels, and anterior abdominal-wall vessel. This is an update of a Cochrane review first published in 2008.

The objective of this study was to compare the different laparoscopic entry techniques in terms of their influence on intra-operative and post-operative complications.

This review has drawn on the search strategy developed by the Menstrual Disorders and Subfertility Group. In addition MEDLINE, EMBASE, CENTRAL and PsychInfo were searched through to February, 2011.

Randomised controlled trials were included when one laparoscopic entry technique was compared with another.

Results for each study were expressed as odds ratio (Peto version) with 95% confidence intervals

The 29 included randomised controlled trials concerned 4,860 individuals undergoing laparoscopy. Overall there was no evidence of advantage using any single technique in terms of preventing major complications. There were three advantages with direct-trocar entry when compared with Veress-Needle entry, in terms of avoiding extraperitoneal insufflation, failed entry and omental injury with OR of 0.18 (95%Cl 0.13 to 0.26), 0.21 (95%Cl 0.14 to 0.31), 0.28 (95% CI 0.14 to 0.55) respectively.

On the basis of evidence investigated in this review, the rate of major complications in the included trials was low. There appears to be no evidence of benefit with respect to major complications of one entry technique over another.

FC.03.5

Limited segmental rectal resection in a tertiary referral unit for the treatment of rectovaginal endometriosis 2000–2010: pain and complications

English J.*[1], Lo J.[2], Hudelist G.[3], Miles A.[2], Baig M. K.[2]

[1] Royal Sussex County Hospital Brighton United Kingdom - [2] Worthing Hospital Worthing United Kingdom - [3] Hospital Vienna Austria

This retrospective cohort study from a tertiary referral unit assesses the clinical results in women requiring segmental anterior rectal resection for deeply infiltrating rectal endometriosis (DIE) performed over a ten year period from 2000 to 2010.

Debate continues as to the appropriate treatment for deeply infiltrating endometriosis in the rectum. As experience increases more units appear to be undertaking radical excision of the disease. This presentation assesses one tertiary unit’s experience going back over ten years

A questionnaire was sent to 106 women who had had a segmental anterior rectal resection for symptomatic rectal DIE and assessed the response to surgery in terms of pain and fertility. Notes were reviewed to assess operative complications. Follow up was from 1 to 5 years.

35% of women had a concomitant hysterectomy and 85% had ovarian conservation. Mean hospital stay was 7 days Range 4–23 days). The mean age at operation was 37.2 years (range 23–49).

Of 106 patients some 99 responded. 82% reported that pain had gone or was greatly improved; 8% reported some improvement and 10% no improvement. 17 women had had at least one successful pregnancy (range 1–5).

Complications included: 5 anastomotic leaks, 9 rectal strictures which required balloon dilatation, 3 DVTs, 4 fistulae (2 closed spontaneously), 2 peroneal neuropraxias.

Histology confirmed DIE in 98 specimens, severe fibrosis in another 7 specimens and diverticular disease in one case.

Women with DIE in the rectum may obtain excellent pain relief following surgery to remove severe disease. Complications are significant and patients must be made aware of these risks.

FC.03.6

Pain as risk factor for recurrence in patients with endometriosis

Renner S.*[1], Rix S.[1], Lermann J.[1], Thiel F.[1], Oppelt P.[2], Beckmann M. W.[1], Fasching P.[1]

[1] Department Of Gynecology And Obstetrics University Clinic Erlangen Germany - [2] Department Of Gynecology And Obstetrics Akh Linz Austria

There is little evidence regarding the recurrence risk in patients with endometriosis. The rASRM-classification doesn’t show a strong correlation to pain symptoms nor to recurrence rate. Aim of this study was to asses risk factors to identify patients that are at a higher risk of recurrence.

To asses risk factors a total number of 150 patients with pain that presented in the gynecologic and obstetric department of the University hospital in Erlangen were included in the study. All patients had surgery done with a complete removal of the endometriosis.

The patients were interviewed retrospectively to obtain information about pain levels during the course of the disease. All patients included had a reduction in pain or no pain at all 3 months after surgery. Recurrence was defined as an increase of pain after the 3 months survery.

High preoperative pain levels were associated with a higher risk of recurrence after 4 years of follow-up. The hazards ratio was 2.30 (95% CI, 1.22 to 4.31; p = 0.009). None of the other parameters assessed for medical history, reproductive history, or lifestyle was associated with the recurrence risk.

Knowing risk factors for recurrence of endometriosis is crucial when talking about (medical) prophylaxis after surgery. Neither rASRM nor histological classifications have shown clear evidence about a higher or lower recurrence rate. Other risk classifications are nonexistent. As risk might be increased by the pain and pain perception of the patients maybe sensory testing for pain perception could help estimating the risk and improve further treatment and/or prophylaxis.

FC.03.7

Comparing demographics and outcomes by type of hysterectomy in an inner London university hospital (LASH vs TLH)

Arambage K.*[1], Odejinimi F.[1]

[1] Whipps Cross University Hospital London United Kingdom

A comparison of LASH (Laparoscopic Assisted Supracervical Hysterectomy) and TLH (Total Laparoscopic Hysterectomy) was carried out to determine the operative and demographic characteristics at Whipps Cross University Hospital. There is a significant difference in uterine weights and BMI without any significance in other parameters.

It has been reported that LASH and TLH are comparable. This study would compare the characteristics of women undergoing LASH and TLH.

A prospective cohort study to compare LASH and TLH was carried out using 168 patients (2005–2011). The specific operative characteristics include BMI, operative time, blood loss, uterine weight, post-operative stay and complications.

The average operating time for LASH and TLH was 74 min (range 25–180) and 82 min (range 40–180) respectively. Mode of estimated blood loss in both groups was 200 ml (range 50–800). BMI and uterine weight were significantly different between two groups (P < 0.05 and p < 0.01 respectively). Average uterine weight of LASH and TLH groups were 373 g (range 60–1940) and 172 g (range 46–780). Patients who underwent TLH had no complications. In the LASH group 3 (3/109) 2.7% complications noted.

Of the patients who sustained bladder injuries (LASH), one had an anterior cervical fibroid (997 g) whilst the other had two previous LSCS with the bladder adherent to the fundus of uterus and anterior abdominal wall and a uterine weight of 444 g, this is not consistent with published data which suggests an increase risk of bladder injury among TLHs. Interestingly, they had BMI between 18–25. There were no complications in women with larger BMI. We conclude that there is no significant difference between these two methods in this cohort apart from larger uteri with LASH. However, the outcome of these surgical approaches may also be influenced by the surgical competency and patient factors.

FC.03.8

Hysterectomy: 5-year period trends

Gladchuk I.[1], Rozhkovska N.*[1], Kozhakov V.[1], Petrovskiy Y.[1]

[1] Odessa National Medical University Odessa Ukraine

Every type of hysterectomy has the individual learning curve, which affects complication rate and patient’s quality of life after the operation. Modern technologies greatly affect surgeon’s choice of specific hysterectomy type for each patient.

Hysterectomy remains one of the most frequently performed operations in gynecologic clinics. The indications for different techniques of hysterectomy are still a topic for discussion.

Study objective was to compare indications, advantages and disadvantages of different hysterectomy types.

Case history and clinical outcomes were compared in patients who had undergone hysterectomy during 2006–2010 period at the Department of obstetrics and gynecology, Odessa National Medical University Hospital. We had compared results of different hysterectomy types.

881 cases of hysterectomies were analyzed. Among them abdominal hysterectomy (AH)—12 (1,4%), subtotal abdominal hysterectomy (SAH)—20 (2,3%), radical abdominal hysterectomy with lymphadenectomy (RAH)—49 (5,6%), laparoscopy-assisted vaginal hysterectomy (LAVH)—99 (11,2%), laparoscopic subtotal hysterectomy (LSH)—19 (2,2%), laparoscopic hysterectomy (LH)—53 (6,0%), total laparoscopic hysterectomy (TLH)—57 (6,5%), laparoscopic radical hysterectomy with lymphadenectomy (LRH)—32 (3,6%) and vaginal hysterectomy (VH)—540 (61,3%).

We observed no significant hysterectomy type ratio changes during last 5 years, except increasing frequency of TLH and LSH while decreasing rate of LAVH. The longest postoperative hospital stay (4,5 + 0,8) days was observed after AH, shortest after LSH (2,8 + 0,3) days. Mean operating time ranged from (40,7 + 19,5) min with VH to (77,5 + 10,4) min for TLH and (64,6 + 7,2) min with LAVH. Serious complications were registered in 5 (0.6%) cases. Postoperative pain syndrome was more intensive after AH and VH as compared to LAVH, LH and TLH. We observed best patient satisfaction after LSH.

FC.03.9

Laparoscopic assisted vaginal hysterectomy: impact of body mass index on outcomes

Nellore V.*[1], Flanagan V.[1], Hawthorn R.[1], Bjornsson S.[1], Pringle S.[1], Hardwick C.[1], Ghim Poh P.[1]

[1] Southern General Hospital Glasgow United Kingdom

We evaluated the effect of body mass index on intra and postoperative complications in patients undergoing laparoscopic assisted vaginal hysterectomy.

The incidence of obesity has been increasing worldwide. Obesity is generally known to increase the risk of intra- and postoperative complications. However, several studies show that obesity, formerly precluding keyhole surgery, seems now to be an indication for the laparoscopic approach. The objective of our study was to compare intra operative and postoperative complication rates for laparoscopic-assisted vaginal hysterectomy (LAVH) between women classified as normal weight, over weight and obese based on body mass index (BMI).

A total of 142 patients underwent Laparoscopic assisted vaginal hysterectomy for various benign gynaecological conditions between April 2009 and March 2011.The women were identified from theatre records an independent clinician performed a case notes review. The data was analysed using Pearson and Spearman correlations, ANOVA and Fisher’s Exact test with significance at p < 0.05,stratifying by BMI (kg/m2): ideal (18.5–24.9 kg/m2), overweight (25 to 29.9 kg/m2), obese(30 to 39.9 kg/m2) and morbidly obese (40 kg/m2 or more).

Of 142 patients having LAVH over 3 years, BMI ranged from 18 to 48 kg/m2, with 46 patients having ideal, 51 having overweight and 45 having obese BMI There were no significant differences in mean duration of surgery (135 ± 28 min),blood loss (200 ± 60) and duration of hospital stay (2.2) for all BMI groups. Complications occurred in 9 patients (6.0%): Bladder injury in one, conversion to laparotomy in 6 and in two patients laparotomy for post operative bleeding.

Laparoscopic assisted vaginal hysterectomy is feasible and safe for women with benign gynaecological diseases for every BMI category and extends the benefits of minimally invasive hysterectomy to more women, regardless of BMI.

FC.03.10

Long term outcomes following laparoscopic supracervical hysterectomy performed with and without excision of the endocervix

Berner E.*[1], Qvigstad E.[1], Lieng M.[1]

[1] Oslo University Hospital Oslo Norway

Prospective randomized trial. The objective was to compare the occurrence of vaginal bleeding as well as patient satisfaction after laparoscopic supracervical hysterectomy (LSH) performed with and without excision of the endocervix in a reverse cone pattern.

Main arguments aganist LSH is cervical stump symptoms such as vaginal bleeding after the prosedure. It has been claimed that removal of the endocervix at the time of the hysterectomy may reduce the occurrence of vaginal bleeding. This study was conducted in order to evaluate the occurrence of vaginal bleeding and patient satisfaction following LSH.

The hypothesis of the study was that there is no significant difference in occurrence of vaginal bleeding or patient satisfaction following LSH performed with excision of the endocervix in a reverse cone pattern compared to after traditional LSH.

Prospective randomized trial performed in a Norwegian university teaching hospital. 140 premenopausal women who were referred to the Department due to a benign condition requiring hysterectomy were enrolled in the study.

The study participants were randomized to LSH performed with peroperative electrocoagulation of the upper cervical canal (n = 70) or performed by excision of the endocervix in a reverse cone pattern followed by electrocoagulation of the remnant cervical canal (n = 70). Study patients were followed up 12 months after the operation. The intervention was blinded both for the patient and the examinating physician during follow-up.

The main outcomes of the study were occurrence of vaginal bleeding and patient satisfaction 12 months after LSH.

The 12 months follow-up is compleded in June 2011.

The results of the study will be presented and evaluated during the presentation.

FC.03.11

Type of colporraphy and risk of vaginal cuff dehiscence after laparoscopic and robotic hysterectomy

Uccella S.*[1], Ghezzi F.[1], Bogani G.[1], Cromi A.[1], Formenti G.[1], Casarin J.[1], Bolis P.[1]

[1] University Of Insubria Del Ponte Hospital Italy

After description of our experience (527 cases) and systematic review of the literature (32 studies for 10,889 cases), we conclude that transvaginal colporraphy at the end of endoscopic hysterectomy for benign indications is associated with a lower risk of vaginal dehiscence, compared to both laparoscopic and robotic colporraphy.

We report our series of total laparoscopic hysterectomies (TLHs) with trans-vaginal colporraphy. We then conducted a systematic review of published series, to evaluate which (among robotic, laparoscopic and transvaginal colporraphy) is the best approach to close the vaginal cuff after endoscopic hysterectomy.

All women who underwent TLH for benign indication at our institution (2002–2010) were included. We then searched PubMed database up to May 2011, using the keywords: “laparosc*”, robot*” and “hysterectomy”. All series describing type of colporraphy and incidence of vaginal dehiscence were included.

In our series, vaginal cuff dehiscence occurred in 1/527 (0.19%) patient. The literature search identified 32 articles (10,889 cases; N = 11,416 when including our series). In total, 58 cases of vaginal dehiscence were observed (0.51%). Vaginal dehiscences were lower for transvaginal (0.19%) vs. laparoscopic (0.52%;OR:0.36;95%CI:0.15–0.84) and robotic (1.3%;OR:0.14;95%CI:0.05–0.36) colporraphy. Need for vaginal cuff resuture was lower for transvaginal vs. laparoscopic (OR:0.43;95%CI:0.19–0.96) and robotic (OR:0.18;95%CI:0.07–0.44) approach, with no increase in vaginal infection. Laparoscopic is better than robotic closure in terms of risk of dehiscence (OR:0.4;95%CI:0.22–0.72) and need for resuture (OR:0.41;95%CI:0.22–0.77).

Transvaginal colporraphy after endoscopic hysterectomy for benign disease is associated with a 2.5-fold and 6.5-fold reduction in the incidence of dehiscence compared with laparoscopic and robotic vault suture, respectively.

FC.03.12

Introduction of laparoscopic hysterectomy in a private setting in Denmark

Istre O.*[1], Springborg H.[1]

[1] Division Of Minimal Invasive Gynecology Privathospital Hamlet, Copenhagen Denmark

Introduction of Laparoscopic procedures in a country with low endoscopic experience is positive received among patients and will hopefully influence other hospital to reduce their numbers of TAH.

Abdominal hysterectomy TAH is the main treatment for enlarged uterus in Denmark. Laparoscopic hysterectomy is only performed in 9% and the vaginal route is utilized in 30% in the smaller uterus.

At our hospital we have offered TLH, LSH and VH as standard operation to all patients with no exception since November 2010. Registration of operative parameters, postop complications, return to work. And as main outcome we have interviewed the patient about their expectation and their reaction to these new offers.

Experience of our consecutive series of 100 hysterectomies will be presented based on our preliminary 60 procedures with no abdominal conversion or operative complication. All patient was discharged within 24 hours. The mean procedure time was with TLH 68 minutes, 20% of the cases, , LSH 73 minutes, 70% of the cases, and VH 78 minutes, 10% of the cases. The weight of specimen 35–1700 grams. Patients returned to regular in activities after 10 days. The initial reaction from the patients were extremely positive to these new possibilities.

Introduction of an alternative operating routine in a country with low tradition of laparoscopic procedures creates both admiration and suspicion among colleagues. However among patients the new routine is highly appreciated and will in the long end change routine gynecology surgery to minimal invasive.

Session FC.04

* Free Communications_4 *

Imaging—Infertility and Reproductive Medicine

FC.04.1

A comparative study assessing diagnostic accuracy of pre-operative transvaginal ultrasound and laparoscopy in the management of patients with ovarian cysts

Narang L.*[1], Ofuasia E.[1]

[1] Croydon University Hospital Croydon United Kingdom

The aim of this study was to assess the diagnostic accuracy of pre-operative transvaginal ultrasound in detecting ovarian cysts and comparing the findings with laparoscopic findings.The preoperative ultrasound assessment predicted the operation to be technically easy/ moderate or difficult in all 29 patients which correlated with the feasibility and findings at laparoscopy in 28 patients giving a sensitivity of 96%.

Ultrasound plays an important role in the detection of ovarian cysts and masses. It helps to differentiate between benign and malignant lesions.

This was a prospective study including a total of 29 women. The age range was 14–54 years (mean age 33.18). Inclusion criteria were the presence of ultrasonologically diagnosed benign ovarian cysts. All women underwent operative laparoscopy. All cysts removed were examined histologically.

29 women with 30 cysts were included in the study. The ovarian volume ranged between 16 mls and 2079 mls. All women were considered suitable for laparoscopic surgery. Of these, 27 (93%) were booked for laparoscopic ovarian cystectomy and 2(7%) for laparoscopic oopherectomy. The operation needed to be converted to a laparotomy in 3 (10%) patients. In all 3 of these patients the ultrasound had predicted the procedure to be difficult.

The preoperative ultrasound assessment predicted the operation to be technically easy/ moderate or difficult in all 29 patients which correlated with the feasibility and findings at laparoscopy in 28 patients giving a sensitivity of 96%. Histology was available for 19 (65%) patients and it corresponded to scan diagnosis in all of them.

In conclusion this study demonstrates the diagnostic accuracy of ultrasound assessment in women with ovarian cysts. Bigger studies are needed to confirm the above findings.

FC.04.2

A better way to manage patients with pregnancies of unknown location (PUL)?

Singh R.*[1], Majumder K.[2], Sule M.[3], Boto T.[4], Leather A.[4]

[1] Palmerston North Hospital Palmerston North New Zealand - [2] John Radcliffe Hospital Oxford United Kingdom - [3] Norfolk & Norwich University Hospital Norwich United Kingdom - [4] Ipswich Hospital Ipswich United Kingdom

S.ßhcG ratio & S.Progesterone are helpful in predicting the clinical outcome in PUL. A mathematical model incorporating these & other features, & clear guidelines on management are essential to improve the standards of care provided & patient satisfaction.

PUL is an important problem facing trainees in hospitals with potential for missed diagnosis. ßhcG ± transvaginal ultrasound (TVS) is usually used to help in management of these patients. Often these are insufficient & inefficient causing anxiety & potential morbidity to patients.

A retrospective, observational study. Over 15000 records assessed to determine women with PUL presenting to the Ipswich Hospital, Ipswich, UK. These patients had been followed up with TVS, S.ßhcG & S.Progesterone until a diagnosis was established. Management was expectant until the pregnancy was identified, the condition resolved spontaneously or an intervention was required. Notes were analyzed to determine management strategies used.

Most patients were 25–34 years old & Para 0/1. 50/80 patients presented to the early pregnancy assessment unit (EPAU) and 75/80 were seen by trainees. PV Bleeding, S.ßhcG & S.Progesterone were strongly predictive of outcome while previous risk factors, presence of pain & endometrial thickness were not. 41 were managed conservatively, 17 needed dilatation & evacuation, 14 needed laparoscopy & 2 patients needed laparotomy. 3 patients developed molar pregnancy and were successfully treated with chemotherapy. Quality of communication & documentation have also been analyzed.

PUL needs a multipronged approach to be managed efficiently. S.ßhcG ratio & S.Progesterone are helpful in predicting the clinical outcome in PUL. A mathematical model incorporating these with other features & clear guidelines on management are essential to improve the standards of care provided & patient satisfaction.

FC.04.3

Hysterosalpingo-contrast sonography (HyCoSy) with foam or hysterosalpingo-foam sonography (HyFoSy):, first experiences with a new ultrasonographic technique to visualize tubal patency

Emanuel M. H.*[1], Exalto N.[2]

[1] Spaarne Hospital Hoofddorp Netherlands - [2] Erasmus Medical Center Rotterdam Netherlands

Foam infusion offers a stable filling and visibility of the uterine cavity, Fallopian tubes and peritoneal cavity in case of tubal patency. It seems to be an attractive alternative for hysterosalpingography with minimal inconveniences for the patient.

Objective: To describe the first experieces with a new ultrasonographic technique to visualize tubal patency.

Design: A prospective cohort study.

Setting: A university affilliated teaching hospital

Intervention: Hysterosalpingo-Foam Sonography (HyFoSy): Hysterosalpingo-Contrast Sonography (HyCoSy) with foam infusion was performed with a hydroxymethylcellulose and glycerol containing non toxic foam through a cervical applicator. Transvaginal Ultrasonography was performed and dispersion of foam in the Fallopian tube and or peritoneal cavity to demonstrate tubal patency was observed. In case patency could not be demonstrated a hysteropsalpingography (HSG) was performed as control.

Main outcome measures: Number of successful HyFoSy procedures, number of cases with no need for HSG, disconcordance between HyFoSy and HSG and number of pregnancies afterwards.

Results: In 67 out to 73 (92%) patients a successful procedure was perfomed. In 57 out of 67 (85%) cases there was no need for a HSG. In 5 out of 67 (7%) patients there was discordance between HyFoSy and HSG. 14 (19%) patients conceived within a median of three months after the procedure.

Conclusion: HyFoSy is a successful procedure to demonstrate tubal patency. In a high number of patients it is suggested that HSG can be avoided. Further comparison to HSG will be needed to demonstrate whether this conclusion can be drawn

FC.04.4

Hysteroscopy combined with MRI and ultrasound in preoperative assessment of tumor grade, myometrial and cervical invasion in endometrial atypia and cancer

Ørtoft G.[1], Dueholm M.*[1], Mathiasen O.[1], Hansen E. S.[1], Marinovskij E.[1], Lundorf E.[1], Møller C.[1], Pedersen L. K.[1]

[1] Aarhus University Hospital Aarhus Denmark

Preoperative staging with hysteroscopic biopsy and MRI can accurately predict 82% of patient with intermediate to high risk features. The accuracy of hysteroscopic biopsies for cervical involvement was 95%.

The Danish Gynecology Cancer Group suggests pelvic lymph node resection for intermediate-high risk stage I and radical hysterectomy for stage II patients. The aim was to evaluate and compare the efficiacy of stading endometrial cancer (tumour grade, myometrial invasion, cervical involvement) by endometrial biopsy, resectoscopic hysteroscopic biopsies in combination with transvaginal ultrasound(TVS) or Magnetic resonance imaging (MRI).

156 patients referred with hyperplasia with atypia or endometrial cancer participated in this prospective study. Patients were offered TVS, MRI and hysteroscopic biopsies from the tumor and the cervix. Final pathology at operation was the golden standard.

At final pathology 83% had cancer, 7% atypia and 10% no residual tumor.

Tumor grade: Hysteroscopic biopsy determined tumor grade with an accuracy of 80% (Kappa = 0.67) compared with 41% (Kappa = 0.26) for endometrial biopsy.

Myometrial invasion could be estimated with 82% accuracy by MRI (SE = 81%, SP = 83%,) and 74% by TVS (SE = 78%, SP = 71%).

Cervical involvement could be estimated with 95% accuracy by hysteroscopic biopsy (SE = 67%, SP = 98%,), 85% by MRI (SE = 56%, SP = 91%) and 82% by TVS (SE = 45%, SP = 89%).

Identification of intermediate to high risk patients:

The accuracy were: TVS & endometrial biopsy 72% (SE = 56%, SP = 81%, PPV = 74%, NPV = 66%), MRI & hysteroscopy 82% (SE = 82%, SP = 82%, PPV = 82%, NPV = 82%).

Hysteroscopy had highest diagnostic efficacy for identification of tumor grade, and cervical involvement. MRI combined with hysteroscopy seems very effective for preoperative staging of endometrial cancer.

FC.04.5

Visualization of Essure implants with intrauterine sonography for confirmation of placement

Veersema S.*[1], Varma R.[2], Toub D.[3]

[1] St. Antonius Ziekenhuis Nieuwegein Netherlands - [2] Guy’S And St. Thomas’ Nhs Foundation Trust London United Kingdom - [3] Gynesonics, Inc. Redwood City, Ca United States

We examined the potential use of intrauterine sonography to confirm proper placement of Essure intratubal implants.

Once inserted through the tubal ostium, the distal portion of an Essure device is not visible via hysteroscopy. Confirmation of placement at 3 months often requires hysterosalpingography, which is associated with false positive results. Intrauterine sonography has a higher resolution than transvaginal sonography, uses a single anatomic orientation and may be performed at the time of hysteroscopy. We aimed to determine if intrauterine sonography reliably visualizes Essure implants to demonstrate correct placement at the time of insertion.

Women who desire permanent sterilization at 2 hospitals in The Netherlands and UK. Immediately after insertion of Essure implants, the hysteroscope was removed and a 3.2 mm Gynesonics™ Intrauterine Ultrasound Probe was inserted transcervically; additional saline was infused with a catheter for slight dilatation of the cavity if desired. The ultrasound probe was rotated at each cornu to localize and characterize tubal implants.

This case series is ongoing and currently consists of 4 women who underwent successful Essure placement. In all cases, the intrauterine sonography probe was able to readily visualize the Essure implants and they appeared in their expected locations. In all cases to date, the implants appeared to have been inserted appropriately and with no evidence of tubal perforation.

This ongoing study demonstrates that intrauterine sonography at the time of insertion can provide reassurance regarding the correct placement of Essure implants. Several patients will undergo repeat intrauterine sonography at three months in conjunction with tubal patency testing to confirm that this imaging modality can verify adequate placement and tubal occlusion in lieu of hysterosalpingography and/or transvaginal sonography.

FC.04.6

Correlation of aspirated peritoneal fluid findings at laparoscopy & tubal pathology

Nabag W.[1], Murwan O.[2], Eshraga F.[1], Abdullahi N.[1], Salwa E.[3], Mohamed E.[4], Nabag W.*[1]

[1] Alzaem Alazhari University Sudan Khartoum Sudan - [2] Omdurman Maternity Hospitals Khartoum Sudan - [3] Soba Research Laboratory Center. Khartoum Sudan - [4] University Of Khartoum Khartoum Sudan

Cytological studies of peritoneal fluid are of value when correlate to tubal pathology in infertile women while sterile fluid in cul- de –sac does not exclude PID either in acute or chronic stage.

Infertility remains a major clinical and social problem, the majority being residents of developing countries; the most common cause of infertility is tubal blockage.

A hospital based prospective study was conducted at the Minimal Access Gynecology Surgery (MAGS) unit at Omdurman Maternity hospital from June 2007-_August 2008 to look into peritoneal fluid bacteriological and cytological findings in infertile women and correlate the results to the tubal pathology. The study included 205 infertile women attending this centre. The peritoneal fluid was aspirated from cul-de-sac at laparoscopy and sent to the laboratory.

Tubal blockage was found in 90(43.9%) women. The bacteriological studies showed sterile aspirate with no growth while the cytological studies revealed inflammatory cells in the fluid mainly macrophages, lymphocytes and plasma cells. The incidence of tubal blockage was found to be significantly higher in patients with inflammatory cells indicating chronic inflammation.

In this study search for Gonorrhea, Chlamydia G. vaginalis, aerobic and anaerobic bacteria from the fluid aspirated from cul de-de-sac of infertile women at laparoscopy were studied but no organisms were isolated. This result might be explained by the fact that if there are no organisms it does not rule out an infection; they may be present in small number. The organisms that give rise to acute PID are usually isolated in the first 48 hours but sometimes one third of these organisms can not be isolated in this period, also in chronic PID micro organisms are not usually present.

FC.04.7

Does monopolar resection of uterine septum increase the occurrence of ectopic pregnancy?

Tomazevic T.*[1], Ban Frangez H.[1]

[1] University Clinical Center Women Hospital Slajmerjeva 3 Ljubljana Slovenia

Monopolar resection of uterine septum does not increase the occurrence of ectopic pregnancy. On contrary it reduces the risk of ectopic pregnancy.

To evaluate the influence of monopolar resection of uterine septum on the occurence of ectopic pregnancy.

The retrospective study: We included 975 pregnancies in women before and 564 pregnancies after monopolar hysteroscopic resection of uterine septum. The ectopic pregnancy rate before and after surgery was compared. Data were also compared according to the septum length: women with a larger septum (AFS 5) vs. women with an arcuate uterus (AFS6). Chi sqare test was used for statistics.

Among 975 pregnancies before hyteroscopic resection there were 881 (92%) intrauterine pregnancies (713 spontaneous abortions and 168 deliveries) and 8% ectopics. Among 564 pregnancies after surgery there were 536 (95%) intrauterine pregnancies (113 spontaneous abortions, 518 deliveries) and 28 (5%) ectopics. The 8% ectopic pregnancy rate before surgery was higher compared to 5% ectopic pregnancy rate after surgery (P < 0.01). In women with a larger uterine septum (AFS 5) the 8% ectopic pregnancy rate before surgery was higher compared to 6% ectopic pregnancy rate after surgery (P < 0.2) while in women with small uterine septum (AFS6) the 8% ectopic pregnancy rate before surgery was higher compared to 4% ectopic pregnancy rate after surgery (P < 0.03).

Monopolar hysteroscopic resection of uterine septum does not increase the risk of ectopic pregnancy. On contrary after surgery the risk of ectopic pregnancy has been significantly reduced (P < 0.01).

FC.04.8

Isobaric gasless laparoscopic myomectomy under general or spinal-epidural anaesthesia: reproductive outcome

Cammareri G.[1], Macalli E. A.*[1], Cirillo F.[1], Lanzani C.[1], Di Francesco S.[1], Turri A.[1], Zampogna G.[2], Rehman S.[1], Ferrazzi E. M.[1]

[1] Ospedale Vittore Buzzi Milano Italy - [2] University Medical Center, Richmond Staten Island, New York United States

Retrospective analysis of reproductive outcome after 109 isobaric laparoscopic myomectomies between October 2005 and September 2010 in Obstetrics and Gynaecology University Department.

To investigate reproductive outcome after isobaric laparoscopic myomectomy.

One hundred-nine women aged less than 43 years, with 1 or more intramural or subserosal leiomyomas measuring more than 4 cm, symptomatic or enlarging underwent gasless laparoscopic myomectomy using a subcutaneous abdominal lifting system and laparotomic instruments under general or spinal-epidural anaesthesia. A six months waiting period after surgery was suggested for uterine scar reparation.

The average number of myomas removed per patient was 2.1 ± 1.6. The mean diameter of the biggest fibroid was 7.0 ± 2.4 cm. The median operating time and blood loss were respectively 90 minutes and 200 mL. Fifty-three interventions were performed under spinal-epidural anaesthesia and 56 under general anaesthesia. No conversions to laparotomy were required. After intervention 76 women used contraceptive methods. Of 33 women wishing to conceive after surgery 25 became pregnant. There were no significant differences in clinical and demographic characteristics between women who conceived and women who did not conceive. Early miscarriage occurred in 3 cases. Eleven patients delivered by elective Caesarean Section. Ten women underwent a trial of labour. Among these 8 births took place by vaginal delivery and 2 by Caesarean Section, after a median period of 26 months from the intervention. The average fetal weight after vaginal and abdominal surgical birth was 3509 ± 186 gr and 3199 ± 424 gr respectively. No uterine rupture occurred. One patient is currently pregnant.

Isobaric gasless myomectomy is a safe and reliable procedure, it has good reproductive outcome and it is possible to be performed under spinal-epidural anaesthesia.

FC.04.9

Laparoscopic cervical cerclage in the treatment of women with cervical incompetence

Yao S. Z.*[1]

[1] Chen Shu Qin Guangzhou China

Laparoscopic cervical cerclage is a safe and effective method to manage women with cervical incompetence.

Objective: To investigate a new method for the management of women with cervical incompetence.

Methods: A laparoscopic cervical cerclage was performed before pregnancy under general anesthesia. A 5-mm Mersilene tape with straight needle in both end of the tape were used for cervical cerclage. First we dissected the bladder flap of peritoneum and exposed the uterine isthmus. At this part we can see the uterine artery in both side of the uterus. The needle pass through the uterine wall at the level of uterine isthmus just lateral in the uterine artery. The needle pass through the uterine wall in both side of the uterine isthmus from anterior to posterior. The tip of the needle come out just above the uterine- sacral ligament. Hysteroscopy examination was carried out to exclude the exposure of tape in the uterine canal when the tape was placed in position. The tape was than tied posteriorly with double throws of an intracorporeal knot after hysteroscopy examination.

Result: 11 women who has unsuccessful vaginal cervical cerclage accept laparoscopic cervical cerclage. No intraoperative or postoperative complications were experienced. The average operating time is 45 minute(20–75 min).The average blood loss during surgery is 30 ml(20–50 ml).7 women became pregnancy spontaneously after surgery.5 of them have a term pregnancy and deliver a healthy baby by cesarean section. 2 women had spontaneous abortion. 4 of them are still not conceived.

Conclusion: Laparoscopic cervical cerclage is feasible and effective. Outcomes are good in a particularly high-risk group of women with cervical incompetence who have had failed vaginal cerclage and have a history of recurrent pregnancy loss.

FC.04.10

Laparoscopyc surgery of adnexal mass in obstetrics

Popov A.[1], Logutova L.[1], Manannikova T.[1], Fedorov A.*[1], Ramazanov M.[1], Krasnopolskaya I.[1], Zemskov Y.[1], Chechneva M.[1], Abramyan K.[1], Kolesnik N.[1]

[1] Moscow Regional Institute O\g Moscow Russian Federation

Adnexal cysts situated on the 2 place, among all tumors of women reproductive system and often leads to abnormal pregnancy.

Adnexal cysts situated on the 2 place, among all tumors of women reproductive system and often leads to abnormal pregnancy. Usual surgical technique for these patients is laparotomy.

377 pregnant patients were divided on 4 groups: 1 group include 241 patients who was undergoing surgical laparoscopy in 16–18 weeks of gestation; 2 group include 41 patients with laparotomy in 16–34 weeks; 58 patients from group 3 were delivered abdominal by cesarean section and tumor removement; laparoscopical procedures at 74 patients from 4 group were done on 5–9 day after vaginal delivery. Gestation period at 16–18 weeks is optimal for surgery, because placental formation is finished already and small uterine size makes laparoscopy possible.

Laparoscopy in pregnant patients have several characteristic: «open » laparoscopyc metod by 2 cm. minilaparotomy without Veress needle, low level of pneumoperitoneum, untypical troacar port places, only short-term relaxation is possible. 2–3 days preoperative period tocolytic therapy were done.

268 patients from group 1 and 2 were successfully vaginal delivered, 5 patients are still pregnant, 9 patients were delivered by caesarian section. In 3 group adnexal mass became an indication for abdominal delivery in 26(45%) cases.

Early diagnostics of ovarian cysts during pregnancy, detection optimal period for surgery, gently surgical technique, rational obstetrical tactic of pregnancy treating may decrease pregnancy abnormalities and rate of cesarean section.

FC.04.11

The validity of the endoscopic surgical procedure for tubal recanalization

Castelli A.[1], Valenti G.[1], Piazza A. M.[1], Scozzaro A.*[1]

[1] Genesi Centre Palermo Italy

In our Centre to evaluate tubal patency we first perform hysterosalpingography and then laparoscopy. Laparoscopy can first have a diagnostic role to confirm what seen at hysterosalpingography or it can diagnose some obstruction not seen by hysterosalpingography but the most important is that by laparoscopy it’s possible to treat tubal obstruction. For the prossimal tubal damage we use tranhysteroscopic Wallace catheter with a combined hysteroscopic-laparoscopic approach, for the distal tubal damage we usually perform salpingoplastic and adhesiolysis if necessary.

Fallopian tube disease represents the 30% of sterility problems. In our Centre each woman with tubal sterility performs both hysterosalpingography and laparoscopy.

Women who came to us for tubal sterility first performed hysterosalpingography and then laparoscopy.

For the prossimal damage we prefer to use transhysteroscopic Wallace ET catheter that come from the cervix to the tubal ostium without any dilatation of the cervical canal and it’s seen by laparoscopic view. If satisfactory dye is injected. As in the study of Valle and Rimbach et al. we have good results. For the distal damage we perform salpingoplastic and adhesiolysis if necessary. Controindications are florid infections, long tubal obliteration and sometimes previously performed tubal surgery.

If laparoscopy confirms the hysterosalpingography tubal obstruction, before using IVF, we introduce ET Wallace catheter from the cervix for the prossimal damage. Distal damage is correct by salpingoplastic. We have 68% pregnancy rate and 30% long-standing restoration of fertility.

Laparoscopy treatment often represents the first step for the women who have sterility problems, before IVF. Laparoscopic recanalization is useful if tubal mucosa is healthy and gives long-standing restoration of fertility, but an accurate selection of the cases is necessary.

Session FC.05

* Free Communications_5 *

Infertility and Reproductive Medicine—Innovation in Surgery

FC.05.1

Laparoscopic lympocele fenestration after retroperitoneal lymph node dissection in 102 gynecological cancer patients: assessment of safety, feasibilty, efficacy and recurrence rates

Radosa M.*[1], Camara O.[1], Winzer H.[1], Mothes A.[1], Diebolder H.[1], Anschuetz J.[1], Runnebaum B.[1]

[1] Jena University Hospital Jena Germany

Laparoscopic lympocele fenestration after retroperitoneal lymph node dissection in 102 gynecological cancer patients: assessment of safety, feasibilty, efficacy and recurrence rates

The occurrence of lymhpoceles is a notorious complication occurring after retroperitoneal lymph node dissection (LND). We evaluated the technique of laparoscopic lympocele fenestration in gynecologic cancer patients with history of a precedent retroperitoneal LND regarding safety and efficacy.

From January 2001 to December 2010, surgical outcome was analyzed for 102 consecutive patients who underwent laparoscopic lymphocele fenestration for a symptomatic lymphocele, following a retroperitoneal LND with retroperitoneal drainage at our department.

A total of 132 lymphoceles were fenestrated. Mean duration of surgery was 115.6 minutes and the average intra-operative blood loss per patient was 145.6 ml. Overall conversion rate to laparotomy was 7.8%. The rate of major intraoperative or postoperative complication rate was 15.7%, being significantly higher (21.1%) in patients after pelvic and paraaortic LND compared to those after pelvic LND. Mean follow-up of the patients was 60.4 months. Two-year cumulative risk of lympohcele recurrence was 4.2% with a total of 7 recurrences of lymphoceles observed.

Laparosopic lymphocele fenestration is a safe and effective surgical treatment option for symptomatic lymhphocele following pelvic or paraaortic LND in gynecological cancer patients with an acceptable recurrence rates.

FC.05.2

Laparoscopic management of huge ovarian cysts

Alobaid A.*[1], Momen A.[1], Aldakhil L.[2]

[1] King Fahad Medical City Riyadh Saudi Arabia - [2] King Saud University Riyadh Saudi Arabia

We present 5 cases of patients with huge ovarian cysts managed by Laparoscopy without complications.

There is ample data suggesting that laparoscopy is the gold standard treatment in managing small to moderate size ovarian cysts. Extremely large ovarian cysts posses challenge to the gynecologic laparoscopic surgeons due to technical difficulties related to removal of the cyst like cyst rupture, space constrains and risk of malignancy. Therefore huge ovarian cysts are conventionally managed by laparotomy. We present 5 cases of patients with huge ovarian cysts managed by Laparoscopy without complications

Case series of five patients, describing patient’s presentation, surgeries performed and the final pathology.

The patient’s age ranged between19–69 years. The maximum diameter of all cysts ranged between 18–42 cm as measured by ultrasound, the tumor makers were normal for all patients. Ultrasound showed unilocular cysts, there were fine or no septations and no solid component in all patients.

All patients had open laparoscopy, after evaluation of the cyst capsule, the cysts were drained under laparoscopic guidance, 1–12 liters were drained from the cysts, and then the patients had laparoscopic oopherectomy using the convential technique. One patient had LAVH and BSO as she was 69 years of age. The procedures were done using three ports only except for the LAVH, where four ports were introduced.

The final pathology confirmed benign serous cystadenoma in four patients and one patient had a benign mucinous cystadenoma.

There was minimal blood loss and no complications for all the patients.

Although there is no size limit of ovarian cyst ever been decided to be contraindicated for laparoscopy. The only thing that is needed is expertise in laparoscopic surgery and proper selection of patients. With advancing techniques and availability of experts in gynecologic endoscopy, it is possible to remove giant cyst by laparoscopy.

FC.05.3

Novasure impedance control system versus microwave endometrial ablation (MEA) for treatment of dysfunctional uterine bleeding: a randomized controlled trial

Pados G.*[1], Athanatos D.[1], Venetis C.[1], Stamatopoulos P.[1], Roussos D.[2], Tsolakidis D.[1], Tarlatzis B.[1]

[1] 1st Dept. Of Obgyn, “papageorgiou” Hospital, Aristotle University Of Thessaloniki, Greece Thessaloniki Greece - [2] 3rd Dept Of Obgyn, “hippocration” Hospital, Aristotle University Of Thessaloniki, Greece Thessaloniki Greece

In this randomized controlled trial the efficacy and safety of two different second generation ablation devices in cases of severe DUB was examined. It was found that endometrial ablation with Novasure presents significantly higher probability of amenorrhea at 12-months post-ablation when compared with MEA.

The aim of this randomized controlled trial is to compare the efficacy and safety of two different second generation ablation devices, Novasure impedance control system and Microwave Endometrial Ablation, in cases of severe DUB.

Sixty six premenopausal women (FSH < 20 mIU/L), aged <50 years, diagnosed with DUB, unresponsive to medical therapy, were recruited in the trial. They were randomly allocated in two groups (Novasure: n = 33—MEA: n = 33). Endometrial pretreatment, although not necessary in cases of Novasure device, was performed in all patients for proper randomization, with administration of GnRH-a for 3 months. The main outcome of our study was amenorrhea rates at 12-months post-ablation.

There was no statistically significant difference between the two groups regarding age (p = 0.99), body mass index (p = 0.22), parity (p = 0.50), duration and blood loss during menstrual period (p = 0.56 and p = 0.12 respectively) and hemoglobin (p = 0.81) in the time of ablation.

The probability of amenorrhea at 12-months post ablation was increased by 51.6% in the Novasure group (75.8%) when compared to the MEA group (24.2%) (95% CI: +27.8 to +67.7; NNT 2).

Based on the results of the first randomized control trial, endometrial ablation with Novasure presents significantly higher probability of amenorrhea at 12-months post-ablation when compared with MEA in patients with severe DUB. For every two patients subjected to ablation with Novasure instead of MEA, one extra case of amenorrhea at 12-months is gained.

FC.05.4

Our experience for surgical treatment of pelvic organs prolapse

Shaparnev A.[1], Vardanyan S.[1], Tsivyan B.*[1]

[1] State City Hospital # 40 Sestroretsk, Saint-Petersburg Russian Federation

Retrospective study of 82 cases of surgical treatment of pelvic organs prolapse.Traditional and new technologies were used for surgery. In 2 years follow up recurrency and complications rates are discribed. The preferable types of operations for more effective surgical treatment are suggested.

The aim of our study was to evaluate outcomes following surgical management of pelvic organs prolapse (POP).

82 women with III–IV prolapse (POP-Q), who underwent surgical treatment of POP with 2 years follow up were included in our retrospective study. 39 (47,6%) were operated traditionally, 43 (52,4%)—using different new technologies: Sacrocolpopexy (SCP) was performed in 24(29,3%) cases, in 17 (20,7%) combined with vaginal hysterectomy (VH), laparoscopic subtotal hysterectomy (LSH) and Prolift anterior, in 12 (14,6%) cases Prolift anterior and in 7 (8,5%) cases—Prolift posterior was performed.

Mean operation time for traditional operations was 1 h 35 m + _ 23 min, for SCP 3 h 40 m + _48 min, and for prolift—1 h 24 m + _ 12 min.Mean blood loss was 180,0 + _ 25, and 80,0 + _ 15 and 75 + _ 10,0 Mean post\operation stay 6,3 , 5,2 and 3,2 days respectively.Complications: In group of traditional operations no intraoperative complications were mentioned. In group of new technologies there were 2 blind bladder injuries which were treated immediately. Among postoperative complications 2 cases of prolapse of vaginal vault and 2 cases of recurrence of cystocele occured in traditional group. In new technologies group 3 cases of de novo stress urinary incontinence (SUI) occured, successfully treated by TVT-O procedure 1 year later.

The use of meshes for surgical treatment is effective and can be reliable alternative to traditional surgery. In our opinion, cystoceles are treated better by vaginal approach, retropexies are preferable to be performed laparoscopically.

FC.05.5

Pain relief by continuous intra-peritoneal nebulization of ropivacaine during gynecological laparoscopic surgery under general anesthesia using short acting opiates

Kaufman Y.*[1], Ostrovsky L.[1], Klein O.[1], Shnaider I.[2], Pizov R.[2], Lissak A.[1]

[1] Department Of Obstetrics And Gynecology, The Lady Davis Carmel Medical Center Affiliated To The Technion Institute Of Technology Medical School Haifa Israel - [2] Departments Of Anesthesiology And Critical Care, The Lady Davis Carmel Medical Center Affiliated To The Technion Institute Of Technology Medical School Haifa Israel

A double-blinded randomized cotrolled trial assessing the efficacy of intraperitoneal nebulization of ropivacaine on pain relief during and following gynecological laparoscopic procedures under general anesthesia using short acting opiates.Results showed that using short-acting opiates combined with nebulization of 100 mg ropivacaine does not improve patients’ outcome in terms of post-operative pain as well as usage of opiates post-operatively.

Our objective was to evaluate the efficacy of intraperitoneal nebulization of ropivacaine on pain relief during and following gynecological laparoscopic procedures under general anesthesia using short acting opiates.

A double-blinded, randomized, controlled, clinical trial (Canadian Task Force classification I) including 40 patients undergoing elective gynecological outpatient laparoscopy. Study group patients received 10 ml of 1% ropivacaine and the control group received 10 ml of sterile water by intraperitoneal nebulization. During surgery, short acting opiates were used while under general anesthesia. Post-operatively patients were followed-up for 24 hours including Visual Analogue Scale (VAS) scores and analgesic usage

Following laparoscopy there was no difference between the groups in terms of morphine consumption (p = 0.74). There was also no significant difference between the groups in post-operative VAS scores.

Our study is a follow-up to a previous study on the effects of intraperitoneal neublization of ropivacaine throughout laparoscopic gynecological procedures. The previous study was done using long acting opiates. The current study, using short-acting opiates combined with nebulization of 100 mg ropivacaine, showed no improvement in patients’ outcome in terms of post-operative pain as well as usage of opiates post-operatively.

FC.05.6

Standardization of laparoscopic sacrocolpopexy: “the 6 points technique”

Wattiez A.[1], Vazquez A.*[1], Maia S.[1], Alcocer J.[1]

[1] Ircad Strasbourg France

Due to the difficulty and technicity of laparoscopic sacrocolpopexy a standardization is needed.

The use of Standardization is to implement guidelines, a design, or measurements in order to obtain solutions to a disorganized system.

Laparoscopic sacrocolpopexy for female organ prolapse is a long and complex procedure that requires good knowledge of the anatomy and surgical technique and advanced laparoscopic suturing skills.

N/A

We describe the key steps of laparoscopic sacrocolpopexy standard technique that we call “the six points technique” due to the only 6 points we use for the mesh fixation.

Long learning curves are reported in the literature for this procedure (Akladios CY et al 2010). Nevertheless the enormous changes over the past 15 years have contributed to a better understanding of this surgery, to simplify it, and to make it much more reproducible (Gabriel B et al 2011). To conclude is important to remember that laparoscopic sacrocolpopexy is the “gold standard” procedure for POP repair and its standardization is justified by the difficulty.

Session FC.06

* Free Communications_6 *

Innovation in Surgery

FC.06.1

Uterine artery embolization for symptomatic uterine myomas using gelfoam pledgets alone versus embospheres plus gelfoam pledgets: a randomized comparison

Vilos G.*[1], Korakianitis E.[1], Abu-rafea B.[2], Garvin G.[3], Vilos A.[1], Kozak R.[3]

[1] Department Of Ob/gyn, The University Of Western Ontario London Canada - [2] King Saud University Riyadh Saudi Arabia - [3] Department Of Radiology, The University Of Western Ontario London Canada

To evaluate the efficacy and clinical outcomes following UAE using G-alone (n = 31) vs. E + G (n = 28). UAE with G-alone was equally effective to E + G in reducing uterine, by 41%, and fibroid volume by 56% and normalizing menstrual blood loss.

Uterine artery embolization (UAE) with Embospheres +/− gelfoam pledgets (E+/−G) has been very effective in treating fibroids. However, Embospheres cause unintended embolization of ovaries, endomyometrium, and other organs/tissues, resulting in unwelcome sequellae. We hypothesized that UAE using G-only is equally effective to E + G and may minimize above sequellae.

Prospective, pilot, patient blinded, IRB approved RCT. (Level I). University-affiliated teaching hospital. Women received trans-catheter UAE under fluoroscopy, local anesthesia and overnight patient-controlled-analgesia, using G-pledgets-alone or E(500–700mic) + G-pledgets. At baseline, groups were similar in age, parity, BMI, uterine & dominant fibroid volume, and menstrual blood loss determined by the Aberdeen menorrhagia severity scale (AMSS/Ruta).

At baseline, 3, 6, 12 months, means(SD) were: uterine volume; 801 cm3 (538) vs.565 (370), 535 (226) vs. 426 (322), 485 (401) vs. 401 (249), 467 (438) vs. 343 (227), fibroid volume; 268 (291) vs. 227 (213), 190 (290) vs. 137 (168), 132 (168) vs. 93 (101), 118 (169) vs. 81 (99), Ruta; 19.2 (6.8) vs.21.6 (6.1), 11.5 (7.2) vs. 8.1 (5.2), 13.2 (8.3) vs. 6.4 (4.0, p < .001), 10.5 (7.9) vs. 5.8 (3.6, p < .01) for G-alone & E + G, respectively. At 12 months, 71% & 79% were satisfied/ very satisfied, respectively.

UAE with G-alone was equally effective to E + G in reducing uterine, by 41%, and fibroid volume by 56% and normalizing menstrual blood loss.

FC.06.2

Abstract, scholarly search for MIS, Prof. Paul Alan Wetter, M.D., F.A.C.O.G., F.A.C.S.

Wetter P.*[1]

[1] Society Of Laparoendoscopic Surgeons Miami United States

The presentation is an overview of the Scholarly Search for MIS.

There is a powerful and easy to use resource, available for free on the internet, at www.SLS.org, that is the only place on the web where you can find out what is being said about an MIS topic at National and International meetings, peer review, index medicus journal, textbooks on surgery and surgical history. Includes powerful search features along with text and video.

A team of dedicated non-profit publishers, part of the Society of Laparoendoscopic Surgeons Staff have been working for over fifteen years to develop a free, open access, education and information site for minimally invasive surgery. Extensive information is now available to all MIS Surgeons and surgical and minimally invasive surgical societies worldwide at www.SLS.org.

Features of the Scholarly Laparoscopy Search.
  • Search multiple sources from one convenient place

  • Find papers, abstracts, articles, research material and MIS Information

  • Locate complete journal articles from JSLS, Journal of the Society of Laparoendoscopic Surgeons

  • Learn about key advancements in MIS

Fast one-click search is easy to use.

What is the Scholarly Laparoscopy Search? ?The Scholarly Laparoscopy Search provides a simple way to search for information and literature on a wide range of laparoscopic and MIS topics. From one place, you can search across many sources using the subset of MIS search topics by specialty.

FC.06.3

Combined transuretral with Versapoint® and laparoscopic treatment in the management of bladder endometriosis

Litta P.*[1], Saccardi C.[1], Cosmi E.[1], Borghero A.[1], D’agostino G.[1], Borgato S.[1], Berton S.[1]

[1] Department Of Gynecological Sciences And Human Reproduction Padova Italy

We present a new endoscopic technique for the management of bladder endometriosis combining cystoscopic approach with Versapoint® and laparoscopic removal of endometriotic nodule in the bladder.

Urinary tract endometriosis is a rare condition affecting 1–2% of women with endometriosis, and in 84% of cases can involve the bladder. Some recent reports show as combined transurethral and laparoscopic approach is safe and ensure complete removal of the lesion minimizing ureteral injuries.

For the first time we utilize a transurethral way using a 5.2 mm endoscope with 30 degrees optic and operative channel of 5 F, that permits passage of a bipolar electrode of 0.6 mm diameter and 3 mm length (Gynecare Versapoint, Ethicon women’s health and urology). We just delimit via cystoscopy the edges of the lesion, penetrating transmurally at 3 or 9 without trespassing the broad ligament peritoneum, and then (second time), starting from the lateral window, we excise the nodule by laparoscopy with ultrasonic scalpel (Ultracision, Ethicon Endo-Surgery). The bladder hole is repaired with continuous 3–0 monofilament two layer suture, and the bladder integrity is tested with diluted methylene blue.

Operating time of the 12 patients underwent surgery ranged from 115 to 167 min, mean blood loss ranged from 10 to 200 ml. We had no intra-operative complications and at 12 months follow.

The reduced diameter of the endoscope lowers the risk of uretral damage, allowing in the same time easy and complete visualization of bladder cavity and the relation between endometriotic nodule and ureteral ostia, permitting to decide the best surgical strategy. The small dimension of the electrode allows a precise section of nodule edge, reducing tissue damage. Prepared in such way transuretrally the site of incision, the laparoscopic removal of the lesion is safe and easy, with proper margins.

FC.06.4

Pain after laparoscopic surgery is related to the type of gas used

Verguts J.*[1], Corona R.[1], Declerck S.[2], Craessaerts M.[1], Koninckx P. R.[1]

[1] Uz Leuven Leuven Belgium - [2] Esaturnus Leuven Belgium

Addition of 4% of oxygen to the pneumoperitoneum will prevent mesothelial hypoxia and decrease post-operative inflammation and pain.

It is not clear what the exact mechanism of pain is after laparoscopic surgery and why pain is less when a similar type of surgery is performed by laparoscopy than performed by laparotomy, as demonstrated for hysterectomy or cholecystectomy.

This was a randomized, double-blind, controlled study. Randomization 1:1 into one of the two groups (CO2 or CO2 + 4% oxygen). The envelope was opened and the appropriate gas was used for the laparoscopy. The details of the study were kept blinded to the investigator that collected the post-operative data. VAS scores and White blood cells (WBC) and C-reactive protein (CRP) were measured on every post-operative day.

Patients (n = 24) were randomized. Pain-scores in the groups where oxygen was added to the CO2 pneumoperitoneum was significantly lower (p < 0.03) compared to the control group on the day of surgery (day 0). Inflammatory reaction as defined by CRP and WBC showed no significant decrease in the group where oxygen was added to the CO2 pneumoperitoneum. The means for CRP were however twice as high in the control group. The use of pain killers after surgery was not significantly different, although less pain medication was used by the study group receiving oxygen. The difference was the greatest for the use of paracetamol at the day of the surgery (p < 0.09) and at the second day after surgery for ketorolac (p < 0.16).

We can hypothesis that as the peritoneal lining will lose its integrity during laparoscopy, the ECM will come in contact with the peritoneal cavity and produce different cytokines, which will induce an inflammatory cascade, resulting in elevated CRP and post-operative pain. The effect of the oxygen on the inflammatory cascade can also be direct through mediation of reactive oxygen species.

FC.06.5

Surgical and obstetric outcome after laparoscopic cerclage

Saridogan E.*[1], Rodeck C.[1]

[1] University College London Hospitals London United Kingdom

Eleven patients underwent interval laparoscopic cerclage between 2005 and 2011 and eight conceived postoperatively. Six patients (75%) had term deliveries by caesarean section and two second trimester losses occurred. Our experience suggests that laparoscopic cerclage offers similar success to transabdominal cerclage and should be offered instead of it.

Transabdominal cerclage was first described in 1965 and in the last 13 years a number of reports described laparoscopic method for this procedure.

Eleven patients underwent pre-pregnancy laparoscopic cerclage procedure. Two patients had had second trimester pregnancy losses and a further two had had premature deliveries despite transvaginal cerclage. Seven had had repeated/large cone biopsies removing all of ectocervix. Laparoscopic cerclage suture using a mersilene tape was inserted at the isthmic level and it was tied behind the uterus for possible removal via colpotomy in case of pregnancy failure.

Laparoscopic cerclage suture was inserted in all patients successfully without any complications. Eight of the 11 patients conceived and three patients are trying to conceive. Six patients had full term pregnancies and all were delivered by caesarean section. One of the six patients also had a late first trimester miscarriage. One had premature rupture of membranes at 22 weeks and the suture was removed via colpotomy. Another had fetal death at 18 weeks and uterus was evacuated by hysterotomy at another hospital.

Procedure was technically feasible in all patients with good safety record. The method used in this small case series was the exact replication of open transabdominal approach and the success rates achieved were identical to it. It was possible to manage the first trimester miscarriage without removing the suture, however management of second trimester losses after abdominal suture remains a challenge.

Session FC.07

* Free Communications_7 *

Innovation in Surgery—Oncology

FC.07.1

Advantages and limitations of laparoscopic para-aortic lymphadenectomy in our practice: a series of 96 consecutive para-aortic lymphadenectomy

Akladios C. Y.*[1], Dautun D.[1], Wattiez A.[1]

[1] Strasbourg University Hospital Strasbourg France

A retrospective multicentre study including 96 patients having para-aortic lymphadenectomy for gynaecologic malignancies. 75 by laparotomy and 21 by laparoscopy. Laparoscopy was associated with shorter duration of surgery, less blood loss, shorter hospital stay, and less post operative complications. It gives however a lower number of lymph node than laparotomy.

Classically para-aortic lymphadenectomy is realised by laparotomy. Advancement of laparoscopy allowed it to replace the open approach. The aim of the study was to evaluate in our practice, it’s advantages and the limitations.

A retrospective multicentre study including 96 patients having para-aortic lymphadenectomy. 75 by laparotomy and 21 by laparoscopy. Patient files were reviewed for demographic, tumour, operative and post-operative data. Statistical analysis was realised by the student test and difference in-between variables was considered to be significant when p < 0,05.

The mean age was:54,3 years (15–79), BMI: 25 (16–45). The mean duration of surgery was 220 minutes (180–240) versus 171 (120–270), mean hospital stay :12 days versus 6 days (p < 0,0001), average haemoglobin gradient: 3,7 and 1,7 g/dl (p < 0,001), the percentage of Dindo level II post-operative complications was of 16% and 9,5% for laparotomy and laparoscopy respectively. The mean number of lymph node was 19,7 by laparotomy and 13,5 by laparoscopy.

Laparoscopy is getting a predominant place in the realisation of para-aortic lymphadenectomy. In well selected cases, it seems providing a reduced: duration of surgery, blood loss, hospital stay, and post operative complications. It gives however a lower number of lymph node than laparotomy, this shows a steady increase with the surgeon experience.

FC.07.2

Comparison of retroperitoneal laparoscopic paraaortic lymphadenectomy with MRI/CT and complications in advanced cervical carcinoma: is it useful?

Rodríguez E.[1], Fuster S.*[1], Gurrea M.[1], Romaguera E.[1], Domingo S.[1], Boldó A.[1], Pellicer A.[1]

[1] La Fe Hospital Valencia Spain

It is known the bad prognosis of advanced cervical carcinoma in the cases with lymph nodes affection. The standard treatment in this advanced stage is chemo-radiotherapy. Radiotherapy should be performed with extended fields to aortic area if there is a suspicious of aortic lymph node involvement. It is discussed the therapeutic impact of this attitude.

We have compared the profitability of surgical nodes dissection with a retroperitoneal laparoscopic approach versus radiological images, studying the anatomy pathological concordance and the surgical complications.

Retrospective study in our institution between June 2009 and December 2010. We have identified 11 patients with advanced cervical carcinoma suitable for surgical staging.

We have compared the MRI and CT report in the cases with suspicious of retroperitoneal affection with the pathologist report after surgery. We have also studied the rate of intraoperative complications with the next items: changes of hemoglobin, major complications and conversion rate, including technical pitfalls.

There were 4 out of eleven cases with paraaortic positive nodes. None of the radiologist reports suggested aortic affection, although a patient had suspicious of pelvic adenopathies. There were no significant changes in hemoglobin levels, and no major complications were reported. Mean surgical time was one hour and fifty-four minutes. In one case there was a disruption of the peritoneum that had to be sutured from an intraperitoneal approach; in this case the retroperitoneal dissection could be finalized.

Retroperitoneal aortic lymph node dissection laparoscopically is feasible, and it should be performed in all cases of advanced cervical carcinoma with a negative radiological report.

FC.07.3

First report of trans vaginal endoscopic microsurgery (T.V.E.M.) in a patient with squamous carcinoma of the vaginal vault

Hermans R.*[1], Luyer M.[1], Smink M.[1], Schoot D.[1]

[1] Catharina Hospital Eindhoven Netherlands

The first use of Transvaginal Endoscopic Microsurgery (analogues to Transanal Endoscopic Microsurgery; T.E.M.) is described in a patient with squamous vaginal carcinoma. This novel technique was used successfully to perform a partial vaginectomy.

In endoscopic surgery, TEM is used to excise deep positioned rectal tumours in a precise way with excellent view. In case of a deep localized sharply defined local intravaginal lesion, clean surgical excision will be hampered by vaginal atrophy, radiation effects and a narrow vagina. TEM was used for the vaginal approach.

In a 62 yr old woman with previous hysterectomy, squamous carcinoma (cT3N1M0; FIGOIII) was diagnosed. After treatment with local brachytherapy (25 times, 7 modulated photon beams 6 MV of 45 Gy) and chemotherapy (Cisplatin 40 mgr/ kg as radio sensitizer weekly for 5 weeks), incomplete remission was seen after 6 month. Sonography showed no tumour infiltration in the rectum. Partial vaginectomy was chosen using TEM (Video Surgical Rectoscope for Transanal Endoscopic Operations (TEO®) KARL STORZ, Germany) due to deep positioning of the lesion in the vaginal vault. The 3 cm lesion, as well as the complete top of the vagina was excised using Harmonic Scalpel (Ethicon endosurgery, New Brunswick, New Jersey, USA). The intactness of the rectum was evaluated using the intravaginal CO2.

Pathology report showed complete excision of the tumour. The patient was discharged after 2 days and recovered with no signs of complications.

Deep vaginal surgery is often troublesome due to difficult exposure. Especially in the postmenopausal atrophic vagina and following radiation the exactness of the procedure is limited. In addition, the magnification of the vaginal image using the endoscope provides the opportunity to follow tumour margins more precise. A Lesion of the rectum can easily be detected.

FC.07.4

Laparoscopic nerve-sparing radical parametrectomy for occult invasive cervical cancer after simple hysterectomy

Liang Z.*[1], Xu H.[1], Chen Y.[1]

[1] Department Of Gynecology And Obstetrics, Southwest Hospital, The Third Military Medical University, Chongqing 400038 Chongqing China

Laparoscopic nerve-sparing radical parametrectomy for 28 patients with occult invasive cervical cancer after simple hysterectomy.

To investigate the feasibility and effectiveness of laparoscopic nerve-sparing radical parametrectomy (LNSRP), upper vaginal resection, and lymphadenectomy for treatment of unexpected invasive cervical cancer discovered after simple hysterectomy.

From 2006 to 2010, 28 patients who were discovered to have unexpected invasive cervical cancer after a simple hysterectomy for cervical in situ carcinomas or benign disease underwent laparoscopic nerve-sparing radical parametrectomy, upper vaginal resection, and pelvic lymphadenectomy. A retrospective analysis of these cases was performed.

All patients underwent successful laparoscopic nerve-sparing radical parametrectomy, and pelvic and/or para-aortic lymphadenectomy. There was no conversion to laparotomy. The mean operation time was 173.30 ± 56.20 min. The mean estimated blood loss was 230.00 ± 109.55 ml. Two intraoperative complications were recorded. The median number of extracted pelvic and para-aortic lymph nodes was 23 (range 12–36) and 7 (range 3–15), respectively. The mean time before Foley catheter removal was 10.6 ± 2.74 d (7–17 d), and bladder voiding function recovery to 0-I grade was observed in 25 (89.3%) patients. The median follow-up period was 38 (4–62) months. No patient presented with any evidence of late complications related to LNSRP that required further management.

Our experience suggests that a laparoscopic nerve-sparing radical parametrectomy including a pelvic and/or para-aortic lymphadenectomy is a safe, feasible and effective alternative to conventional radiotherapy in patients with occult invasive cancer detected at the time of simple hysterectomy or after extrafascial hysterectomy.

FC.07.5

Long-term follow-up after laparoscopic management of endometrial cancer in the obese: a fifteen-year cohort study

Rabischong B.*[1], Larrain D.[1], Canis M.[1], Le Bouedec G.[2], Pomel C.[2], Jardon K.[1], Kwiatkowsski F.[2], Bourdel N.[1], Achard J.[2], Dauplat J.[2], Mage G.[1]

[1] Chu Clermont-Ferrand, Service De Gynécologie A, Chu Estaing Clermont-Ferrand, 63003 France - [2] Crlc Jean Perrin Clermont-Ferrand, 63058 France

Most studies regarding laparoscopic management of endometrial cancer (EC) in obese women has been focused on technical aspects, but its oncological safety is not well documented. We sought to assess the surgical outcomes and long-term results of laparoscopic treatment of EC in obese patients.

The objective is to assess the surgical outcomes and long-term results of laparoscopic treatment of endometrial cancer in obese patients, and compare these results with those of non-obese women.

The records of 207 consecutive patients with clinical stage I EC managed by laparoscopy from 1990–2005 in two referral centres were reviewed. We identified 52 obese women for further analysis. Data collected included: Sociodemographic characteristics, surgical outcomes, follow-up, recurrence, and survival data. These results were then compared with 155 non-obese patients with EC managed laparoscopically during the same period.

Median BMI among obese patients was 34.2 Kg/m2. The conversion rate was independent from the BMI of the patient (3.8% vs 4.5%, p = .80). Neither mean operative time (187.5 vs 172 min, p = .11) neither hospital stay (5.2 vs 4.9 days, p = .44) were related with BMI. Lymphadenectomy was considered not feasible in 7 obese (17%) and 8 nonobese (7%) women (p = 0.09). Fewer lymph nodes were retrieved among obese women (8 versus 11, p < .0002). No differences were found between the groups in terms of perioperative complications. Median follow-up was 69 and 71 months for the obese and nonobese, respectively (p = .59). Overall and disease-free 5-year survival rates did not differ between obese and nonobese patients (90.3% and 87.5% versus 88.5% and 89.8%, respectively).

Despite some limitations, laparoscopic approach seems to be particularly useful for obese patients with EC, without more complications and similar survival and recurrence rates than in non-obese population.

FC.07.6

Total laparoscopic hysterectomy with bilateral salpingoophorectomy (TLH) versus abdominal hysterectomy with bilateral salpingoophorectomy in endometrial cancer surgical staging

Malinowski A.*[1], Maciolek-blewniewska G.[1], Antosiak B.[1], Majchrzak D.[1], Wojciechowski M.[1]

[1] Polish Mothers’ Memorial Hospital Lodz Poland

The study presents our experience with surgical staging of endometrial cancer performed by the same surgical team, both experienced in abdominal and laparoscopic procedures. According to our results laparoscopy seems feasible and safe technique of surgical staging of endometrial cancer.

Laparoscopy is gaining more and more field in gynecological oncology. Endometrial cancer is one of the most common indications for laparoscopic procedure. Our aim was to compare laparoscopy and laparotomy performed by an experienced team of surgeons, given an increasing body of evidence in favor of laparoscopy.

The study was a retrospective analysis of 31 (42,5%) consecutive cases of patients with endometrial cancer randomly qualified to the TLH with pelvic lymphadenectomy group and 42 patients (57,5%) who underwent the same procedure abdominally. Groups were compared according to: age, BMI, comorbidities, surgical history, parity, operative time, blood loss, length of hospitalization, size of the uterus and complications rate.

The patients operated laparoscopically were significantly younger (54,3 vs. 64,7 years) and had less comorbidities (20,5% vs. 47.9%). There were no significant differences concerning BMI, parity, size of the uterus, surgical history. The mean operating time was shorter in the TLH group (130,6 min. vs. 151,77 min.). Laparoscopy was associated with significantly less blood loss and shorter hospitalization. There were 2 perioperative complications after laparoscopy and 12 in the laparotomy group.

Total laparoscopic hysterectomy with pelvic lymphadenectomy in endometrial cancer is a safe and feasible procedure. It is associated with a significantly lower risk of complications, shorter hospitalization, less blood loss and better cosmetic outcome.

FC.07.7

Total laparoscopic nerve-sparing radical hysterectomy, the technique and patients follow up

Kavallaris A.*[1], Zygouris D.[2]

[1] 4th Department Of Obstetrics And Gynecology University Of Thessaloniki Greece - [2] Attikon University Athens Athens Greece

We describe the technique of laparoscopic nerve-sparing radical hysterectomy and patient’s outcome.

The radical hysterectomy type three can be accompanied by postoperative morbidity, such as dysfunction of the lower urinary tract with loss of bladder or rectum sensation. We describe the technique of laparoscopic nerve-sparing radical hysterectomy and patient’s outcome.

32 patients underwent laparoscopic nerve-sparing radical hysterectomy with pelvic lymphadenectomy. Both the hypogastric and the splanchnic nerves were identified bilaterally during pelvic lymphadenectomy.

The median age of the patients was 52 years, the average operating time was 221 min. There were no intra- or postoperative complications considering the nerve-spring radical hysterectomy. Postoperatively, in all patients spontaneous voiding was possible on the third postoperative day with a median residual urine volume of <50 ml.

Laparoscopic identification (neurolysis) of the inferior hypogastric nerve and inferior hypogastric plexus is a feasible procedure for trained laparoscopic surgeons who have a good knowledge not only of the retroperitoneal anatomy but also of the pelvic neuro-anatomy as this qualification could prohibit long-term bladder and voiding dysfunction during nerve-sparing radical hysterectomy.

FC.07.8

A simple laparoscopic knot-trainer

Tsimpanakos I.*[1], Krishnamurthy G.[1], Moustafa M.[1], Dacco M.[2], Petrakis P.[1], Magos A.[1]

[1] Minimally Invasive Therapy Unit And Endoscopy Training Centre, University Department Of Obstetrics And Gynaecology, Royal Free Hospital Hampstead London United Kingdom - [2] Universita’ di Pavia Irccs Fondazione San Matteo Pavia Italy - Royal Free Hospital London United Kingdom -

We demonstrate a simple and cost-effective laparoscopic trainer for intracorporeal and extracorporeal knots that can be self-assembled and be used for personal practice or for wider training purposes.

We demonstrate a simple and cost-effective laparoscopic trainer for intracorporeal and extracorporeal knots that can be self-assembled and be used for personal practice or for wider training purposes

We developed a tool for training in laparoscopic knots without the need to use a rigid box, camera, TV-monitor or expensive software. It consists of two wooden boards on a fixed angle, two metal hooks and a metal ring to simulate the trocar. Along with the use of a knot pusher they can be used for training in extracorporeal knots. For practicing intracorporeal knots two of these devices are used in conjunction, along with laparoscopic needle holders. We demonstrate its assembly and use in video.

The device has been used for training in our “hands on” workshops on minimally invasive surgery. Trainees practiced their knot-skills before attempting “real life” laparoscopic suturing during the workshop, with positive results in short time.

We encourage trainees and surgeons who lack laparoscopic suturing skills to construct their own laparoscopic knot trainer in order to practice the correct techniques in an inexpensive and easy way. This will then unable them to maintain their skills and perform laparoscopic knots in real life.

Session FC.08

* Free Communications_8 *

Myomectomy - Office & Diagnostic Hysteroscopy - Single Access Surgery

FC.08.1

Risk of recurrence after laparoscopic myomectomy

Radosa M.[1], Winzer H.*[1], Mothes A.[1], Camara O.[1], Diebolder H.[1], Runnebaum I.[1]

[1] Jena University Hospital Jena Germany

Aim of this study was to estimate the risk of recurrence after laparoscopic myomectomy and to evaluated if factors, traditionally associated with myomagenesis influence this risk.

Laparoscopic myomectomy (LM) is associated with low intra-operative morbidity and short hospitalization. Comparably limited data is available regarding the long-term outcome of this therapeutic approach.

From 1996 to 2003, 331 Patients underwent laparoscopic myomectomy in our department. All patients were re-contacted 2009 and 224 patients consented in our follow-up. Cumulative risk of recurrence for the study population was calculated by using a Kaplan-Meier test. Further, cumulative risk of recurrence rates were compared by using a Cox regression model for multivariate analysis for the following factors: (1) age at time of surgery, (2) deliveries prior and after inital LM, (3) pregnancy after LM, (4) number of fibroids and (5) seize of leading fibroid removed, (6) anatomical localization of fibroid, (7) duration of surgery, (8) indication for LM and (8) BMI at time of surgery.

The mean duration of follow-up in this study was 108 months (range: 74–163 months). In 224 patients, we observed 75 recurrences (crude rate of recurrence: 36.77%). The cumulative risk of recurrence was 4.9% at 24 months, 21.4% at 60 months and 31.7% at 96 months.

Age and severity of uterine myoma affiliation at time of surgery were identified as main factors influencing the risk of recurrence after LM.

An advanced myoma affiliation of the uterus emerged as main risk factor for the occurrence of a symptomatic recurrence after LM. An early intervention in the course of a myometrial disease might therefore be associated with a lower risk for a post-operative relapse. Patients with a severe uterine myomatous affiliation should be counseled thoroughly about the risk of a symptomatic recurrence.

FC.08.2

A new generation reusable flexible coaxial bipolar hook electrode in office hysteroscopy

Cammareri G.*[1], Di Francesco S.[1], Lanzani C.[1], Turri A.[1], Rehman S.[1], Cirillo F.[1], Macalli E.[1], Ferrazzi E.[1]

[1] Children’s Hospital Vittore Buzzi, University Of Milan, Milan Italy

This is a prospective study performed on 82 women with intrauterine focal lesions.Hysteroscopy was performed with a reusable flexible coaxial bipolar hook electrode. The cutting quality and integrity of the reusable device was maintained for an average of 6.83 procedures.

Office hysteroscopy is a procedure for the diagnosis and treatment of uterine pathologies. The coaxial bipolar electrodes usually used are disposable devices. A possible argument against this procedure is the high cost of each single device. The aim of this study was to evaluate the average number of operative procedures with a reusable bipolar hook electrode produced by Karl Storz.

This is a prospective study performed on 82 women with intrauterine focal lesions. Hysteroscopy was performed using the vaginoscopic approach with a 30° lens (4.5 mm, Karl Storz, Germany) equipped with an operative channel of 1.8 mm. Operative procedures were performed with a reusable flexible coaxial bipolar hook electrode. The number of efficacy procedures and the overall duration of each single reusable device was calculated.

Median age of study group was 50 (i.r. 40–58). Fifty patients were fertile and 32 postmenopausal. Forty-six patients (56%) had a history of vaginal delivery.

We used 12 reusable bipolar electrodes. We performed 57 polypectomies, 19 myomectomies, 3 lysis of adhesions, 1 extended biopsy, 2 removal of residual placental tissue. The average dimension of polyps and submucous myomas was 19 mm (i.r. 11–28). The average duration of the polypectomy and myomectomy was respectively 11 min (i.r. 10–15) and 13 min (i.r. 10–15). The average duration of each device was 75.8 min (20–165). The device was reused on an average of 6.83 times (i.r. 5–8). No case of hysteroscopy failure was reported.

The cutting quality and integrity of the reusable device was maintained for an average of 6.83 procedures.

FC.08.3

An audit of using the H Pipelle for endometrial sampling at out patient hysteroscopy

Dacco’ M. D.*[1], Petrakis P.[2], Tsimpanakos I.[2], Moustafa M.[2], Krishnamurthy G.[2], Magos A.[2]

[1] Universita’ di Pavia Irccs Fondazione San Matteo Pavia Italy - Royal Free Hospital London United Kingdom - [2] Royal Free Hospital London United Kingdom

We analysed the efficiency of the H Pipelle endometrial sampler at diagnostic hysteroscopy in terms of biopsy adequacy for histological diagnosis in 200 premenopausal women. We found that the biopsy was adequate in 82% of cases overall, rising to 87% in those without submucous fibroids or polyps.

Endometrial sampling after hysteroscopy is more problematic because of the use of uterine irrigant with the result that suction biopsy devices tend to aspirate fluid rather than tissue. We wanted to assess the efficiency of the H Pipelle in this setting.

We looked at the clinical records of all premenopausal women who had an endometrial sampling done along with their outpatient hysteroscopy between June 2008 and April 2011. All hysteroscopies were done using a “No touch” technique with a 2.9 mm rigid single flow diagnostic hysteroscope (Karl Storz) and N/Saline for uterine distension. At the end of the hysteroscopy the optic was removed and an H Pipelle was used to obtain an endometrial sample via the diagnostic sheath.

200 patients fulfilled our study criteria with an average age of 41.8 years. 74 (37%) women had focal lesions in the uterine cavity and 3 had IUCDs. 154 (77%) of the endometrial biopsies were reported as normal, 10 (5%) showed evidence of atypia, and 36 (18%) were inadequate. The chance of a biopsy being inadequate was not influenced by age or menstrual cycle day, but was more likely in the presence of an intrauterine focal lesion (focal lesion present 27% inadequate, focal lesion not present 13% inadequate, p = 0.0214).

There is very little data showing the efficiency of suction type endometrial samplers when used after diagnostic hysteroscopy. The H Pipelle appears to be as effective as traditional endometrial samplers even after hysteroscopy. As with all endometrial samplers, it is less efficient in patients with focal lesions such as endometrial polyps and submucous fibroids.

FC.08.4

Cost-effectiveness of hysteroscopy screening for infertile women

Kasius J.*[1], Eijkemans R.[2], Mol B.[3], Fauser B.[1], Fatemi H.[4], Broekmans F.[1]

[1] University Medical Center Utrecht Netherlands - [2] Julius Center For Health Sciences And Primary Care Utrecht Netherlands - [3] Academic Medical Center Amsterdam Netherlands - [4] Academic Hospital At The Dutch-Speaking Brussels Free University Brussels Belgium

Mainly depending on the degree of increase in live birth rate by performing a HY, application of a HY prior to IVF seems to be costs-effective.

Minor intrauterine pathology is considered to have a negative impact on IVF outcome. It is advocated to diagnose and treat this pathology by hysteroscopy (HY) in order to optimize IVF treatment. The aim of this study was to assess the cost-effectiveness of office HY prior to IVF.

Decision analysis was performed for two models. Model I, based on the current literature, assumed that all patients who underwent HY prior to IVF, encountered thereby an increase in pregnancy rate. Model II -more hypothetical- assumed that the pregnancy rate solely increased in patients with intrauterine abnormalities after hysteroscopic treatment. The cost-effectiveness of 3 strategies were compared: strategy [NoHY] (no HY); strategy [FailedHY] (HY after 2 failed IVF cycles); and strategy [RoutineHY] (HY prior to IVF). Detected, intrauterine pathology (polyps, myoma, adhesions, septa) was treated during the HY procedure. For the 3 strategies the total costs and live birth rate after a total of 3 IVF cycles were assessed. Also, sensitivity analysis was performed.

For Model I, strategy [RoutineHY] was always cost-effective over strategy [NoHY] or [FailedHY]. It was found to give a monetary profit in case HY would increase the live birth rate after IVF by >4%. In Model II, the 3 strategies showed much less divergence. [RoutineHY] dominated [FailedHY], however HY performance was accompanied with extensive costs. Sensitivity analysis showed, that variation in increase in live birth rate by performing HY was the only model variable that influenced the cost-effectiveness considerably.

As the cost-effectiveness of a strategy is most influenced by the variance in increase in live birth rate by performing a HY, high quality data on this subject is crucial to recommend a strategy for daily practice.

FC.08.5

Evaluation of nickel allergy after hysteroscopic essure® sterilisation: risk or daily practice? preliminary results

Peter I.*[1], Michael V.[2], Hugo V. E.[1]

[1] Isala Klinieken Zwolle Zwolle Netherlands - [2] Ziekenhuis Rivierenland Tiel Tiel Netherlands

To evaluate the possible role of Essure micro-inserts in sensibilisation to nickel, skin tests before and after sterilisation were performed. The results of this study demonstrated that the Essure micro-inserts are not related to nickel sensibilisation.

We designed a prospective study to analyse whether or not the nickel-titanium alloy (Nitinol) of the Essure® device is related to sensibilisation to nickel.

Patients: 200 females, eligable for Essure® sterilisation.

Methods: All patients received two patches; one with a nickel solution and one control patch. Results were scored after 72 hours according to the score criteria for contact dermatitis [Fregert S. Manual of contact dermatitis]. Irrespectively of the outcome of this test, all patients underwent an Essure sterilisation. Subsequently, after three-months, the skin tests were repeated. All patients completed a questionnaire about possible allergic reactions.

Preliminary results of 50 women show that 25% had a positive nickel skin test before procedure. None of the patients with an initial negative skin test developed a positve skin test after the procedure. All patients whit a positive reaction pre-operatively demonstrated less or equal skin reaction after sterilisation. No clinical symptoms of allergy were recorded in both groups.

Our results demonstrate that the Essure micro-inserts are not related to (de novo) nickel sensibilisation. We conclude that nickel allergy is not a contra-indication for Essure sterilisation.

FC.08.6

How effective is the gynaecology rapid access clinic?

Littlechild S.*[1], Dinsdale M.[1], Khan R.[2], Bhalla R.[2], Ragavan M.[2]

[1] University Of Manchester Manchester United Kingdom - [2] University Hospital Of South Manchester Manchester United Kingdom

Prospective audit of 85 patients attending the gynaecology Rapid Access Clinic at the University Hospital of South Manchester (UHSM) between 1st June and 31st August 2011. The audit looked at the effeciecy of the clinic and highlighted areas where improvements could be made.

National Targets recommend that patients referred to Rapid Access Clinics should be seen within 2 weeks and receive their first treatment within 62 days. Appropriate referrals to gynaecology Rapid Access Clinics include post-menopausal bleeding (PMB), any suspicious cervical or vaginal lesion and any suspicious palpable abdominal mass. Guidelines predict that 10 to 15% of patients with PMB will have endometrial carcinoma.

Prospective audit, carried out from 1st June to 31th August 2010, looked at how effective the gynaecology Rapid Access Clinic is at UHSM.

The audit aimed to evaluate efficiency in three main ways:
  1. 1.

    Is the clinic meeting the National Targets?

     
  2. 2.

    Are the referrals appropriate?

     
  3. 3.

    Are there any areas requiring improvement?

     

Of the 85 patients, 76% were seen in the clinic within 2 weeks and 79% were treated within 62 days. The audit showed that 89% of referrals to the clinic were appropriate, with the most common presentation being PMB (65%) and 9% of these patients having endometrial carcinoma. The results from this audit have also revealed that only 25% of patients have an ultrasound scan organised by their GP before attending clinic, which delays their treatment time. It has also highlighted how few endometrial samplings are being carried out in clinic (32%) and how unsuccessful these are (63% failure rate). Consequently, many hysteroscopies (51%) had to be carried out.

As a result of this audit, we have recommended that the unit start up a ‘one stop clinic’ in order to provide a more efficient service. We intend to re-audit this clinic when the service is up and running in order to evaluate its efficiency.

FC.08.7

Introduction of single port laparoscopy in a private setting in Denmark

Istre O.*[1], Springborg H.[1]

[1] Division Of Minimal Invasive Gynecology Private Hospital Hamlet, Copenhagen Denmark

Introduction of Single port Laparoscopic procedures in a country with a relatively low endoscopic experience is positively received among patients. The procedure is highly encouraged due to better cosmetic result. The procedure is comparable to regular laparoscopy in operating time as well cost of equipment.

Single port procedures are relatively newly introduced as treatment tools in gynecology practice. In Denmark, as the only hospital we have been able to offer the patients this modality since 2011.

Patients was informed about the new offer benefits, risk and limitations. Primarily patients with no previous surgery and a low to moderate BMI was chosen for this new surgical approach. But later it was a part of our offer in a private setting in Denmark. The indication, operating parameters, postoperative course, videos of the procedures will be presented.

After the first 40 consecutive single port procedures our experience will be presented. The procedures range from hysterectomies to simple ovarian cyst removal. Mean procedure time based on our first 20 procedures where 35 minutes ranging from 25 to 60 minutes with no complications. The reaction and expectation from the patients of having an single procedure instead of an traditional strait stick laparoscopy will be presented and discussed.

Introduction of an alternative new operating modality like LESS in a country with low tradition of laparoscopic procedures creates both admiration and suspicion among colleagues. However among patients the new routine is highly appreciated.

Session FC.09

* Free Communications_9 *

Office & Diagnostic Hysteroscopy—Operative Hysteroscopy

FC.09.1

Feasibility of operative hysteroscopy after endometrial preparation: 1,25 mg nomegestrol acetate versus 20 mcg ethinyl estradiol/ 75 mcg gestodene

Mereu L.[1], Giunta G.*[1], Carri G.[1], Prasciolu C.[1], Albis Florez E. D.[1], Cofelice V.[1], Mencaglia L.[1]

[1] Centro Oncologico Fiorentino Sesto Fiorentino, Firenze Italy

To assess the antiproliferative effect on the endometrium of a brief treatment with 1,25 mg of Nomegestrol Acetate versus 20 mcg of Ethinyl Estradiol/75 mcg Gestodene before operative hysteroscopy.

The best condition for hysteroscopic procedure is the presence of a thin endometrium in order to achieve a clear visibility.

Between February and May 2011, 26 fertile women, referred to CFO in order to undergo hysteroscopic surgery, were prospectively enrolled in the study. On day 1 of the menstrual cycle, patients were randomized to receive 4 weeks therapy with 1,25 mg of Nomegestrol acetate daily (group A, n 14), or 20 mcg of Ethinyl Estradiol/75 mcg Gestodene daily (group B, n 12). Before treatment and after 4 weeks of therapy, each women received a transvaginal ultrasound evaluation to measure endometrial thickness, ovarian size, number of ovarian follicles. During hysteroscopy it was evaluated the endometrial features, the visibility of the uterine cavity, the success of surgery. One month after surgery women underwent a diagnostic hysteroscopy to confirm the completeness of the treatment.

The mean percentage reduction in endometrial thickness, ovarian size, number of ovarian follicles in group B was statistically significantly greater than in the group A. Surgeon satisfaction in terms of endometrial features was also greater with group B. No difference in intraoperative time, intraoperative complications and intraoperative bleeding was noticed.

The endometrial preparation with 1,25 mg Nomegestrol Acetate appears to be less comfortable for the surgeon in terms of visibility of the uterine cavity and in terms of difficulty to perform hysteroscopic surgery than 20 mcg Ethinyl Estradiol/ 75 mcg Gestodene endometrial preparation. No differences in completeness of surgery, operative time and intraoperative complications.

FC.09.2

Hysteroscopic management of amenorrhea and hypomenorrhea

Trivedi S.*[1]

[1] Lady Hardinge Medical College New Delhi India

Hysteroscopy proved valuable in management of intracavitary lesions causing amenorrhea & hypomenorrhea & also in detecting endometrial disease with high specificity and acceptable sensitivity.

Amenorrhea and hypomenorrhea need thorough evaluation to rule out any underlying pathology. Restoration of normal periods is important for psychological reasons This study was conducted to assess the role of hysteroscopy in management of amenorrhea & hypomenorrhea.

50 cases, 18 with amenorrhea & 32 with hypomenorrhea were studied. Hysteroscopic evaluation of uterine cavity & endometrium was done & hysteroscopic surgery performed if indicated. Endometrial findings on hysteroscopy were compared with histopathology.

Normal uterine cavity with normal endometrium was found in 20 , intra-uterine adhesions in 11, endometritis in 9, atrophic endometrium in 7 & osseous material in one. In two cases there was slight blood found on introduction of hysteroscope, both resumed menstrual cycles following hysteroscopy. Of 11 cases of IUA, adhesiolysis was done in 10 In one case with dense IUA hysteroscopy could not be performed. Normal menstrual flow was restored in 2, improvement occurred in 6, in 2 there was no improvement. 2 cases of tubercular endometritis confirmed on histopathology, resumed their menstruation following anti-tubercular treatment. Sensitivity, specificity, positive predictive value & negative predictive value of hysteroscopy in diagnosing endometrial pathology was 75%, 95%, 90% & 86.4%.respectively.

Uterine causes of amenorrhea and hypomenorrhea are common especially in developing countries. Visualization of cavity and endometrium can detect abnormalities which are amenable to hysteroscopic surgery in least invasive manner. Evaluation of endometrium especially with chromohysteroscopy can detect abnormalities with high specificity and sensitivity.

FC.09.3

Hysteroscopic metroplasty under trans-rectal three dimensional ultrasound guidance

Moustafa K.*[1]

[1] Alexandria Faculty Of Medicine Alexandria Egypt

Study the role of intra-operative trans-rectal 3D ultrasound in minimizing the contradictory risk of residual septum formation and uterine perforation during hysteroscopic metroplasty.

Hysteroscopic metroplasty under trans-rectal 3D US guidance. The intermittent trans-rectal 3D US imaging allowed intra-operative refinement of the metroplasty to ensure completeness with safety. All cases had post-operative HSG one month later. Comparing of pre and post HSG images for each patient was done.

A feasibility study, evaluating the efficacy of 3D ultrasound—guided hysteroscopic metroplasty.

Design classification: ? 2

Patients: 11 patients (with infertility and recurrent pregnancy loss problems) diagnosed to have uterine septum by HSG.

No uterine perforation occurred (0%). HSG images showed no residual septum formation (0%). In two cases in which the sonographer recommended further resection on the left side of the septum base and was done accordingly, the HSG images showed correct smooth restoration of the fundal integrity. But, one case of overcorrection (9%) was encountered.

Trans-rectal 3D US guided hysteroscopic metroplasty provides a perfect non-invasive tool to avoid both uterine perforation and residual septum formation. The confidence provided by trans-rectal US during metroplasty should be utilized cautiously to avoid the possibility of overcorrection giving a weak uterine point in future pregnancy.

FC.09.4

Outpatient Novasure ablation-outcome measures and patient satisfaction survey

Moloney S.*[1], Rao R.[1], Vindla S.[1]

[1] The Kings Mill Hospital Sutton In Ashfield United Kingdom

Patient satisfaction survey on 22 women who presented with heavy menstrual bleeding and underwent Novasure endometrial ablation under local anaesthesia. The procedure was well tolerated in most women (81%) and offers women a choice in ablation procedures. Study shows that Novasure ablation is a safe, effective and feasible outpatient procedure that is generally well accepted by patients.

Menorrhagia remains a widespread and lifestyle-altering women’s health care problem, with as many as 1 in 5 women suffering from this often painful and embarrassing condition. The main aim of the study was to evaluate the safety, feasibility and efficacy of Novasure endometrial ablation as an outpatient procedure.

Novasure endometrial ablation was carried out at King’s Mill Hospital , Sutton-In-Ashfield from 2007 to 2008 under local anaesthesia. Patient satisfaction survey was undertaken on women who underwent 22 consecutive Novasure procedures performed by a single operator. A four-month follow up was undertaken to establish the effectiveness and feasibility of the procedure.

The effectiveness of the pre-medication on pain during the procedure was scored on a verbal rating score from 0 to 10. Average score was 6.95. All patients had follow-up 4 months after treatment. Ninety one percent of women showed improvement in menstrual symptoms with 11 (50%) women developing post-ablation amenorrhea.

Our study is a patient satisfaction survey on 22 women who presented with heavy menstrual bleeding and underwent Novasure endometrial ablation under local anaesthesia. The procedure was well tolerated in most women (81%) and offers women a choice in ablation procedures.

FC.09.5

Prevalence of intra uterine adhesions post miscarriage: a systematic review

Hooker A.*[1], Thurkow A.[1], Huirne J.[2], Scheele F.[1], Brolmann H.[2]

[1] Sint Lucas Andreas Hospital Amsterdam Netherlands - [2] Vu Medical Centre Asmterdam Netherlands

To establish the prevalence of intra uterine adhesions by hysteroscopy in patients post miscarriage, a systematic review is perfomed.

Adhesion are encounter in 20% of patients post miscarriage. Reccurent curettage has been identified as a risk factor for adhesions formation.

Approximately 15–20% of all clinically recognised pregnancies in women of reproductive age will end in a miscarriage. (2, 3, 4) Spontaneous resolution occurs but commonly a surgical approach (dilatation and evacuation) is applied.Intrauterine adhesions (IUA) a possible complication, mainly after surgical procedure.

To evaluate the prevalence of IUA a systematic literature search was carried out in Medline, Embase and the Cochrane library for published articles in which women were systematically evaluated by hysteroscopy for adhesions after a miscarriage. For purpose of analysis the extent of the adhesions were extracted from the different classification systems and grouped in three clinical categories; minimal, moderate and severe.

In 19 articles women, after one or more spontaneous, incomplete or missed miscarriages were evaluated by hysteroscopy. Intrauterine adhesions or synechiae were identified in 20% of the patients. The majority of the adhesions were categorized as minimal, but in 30–40% moderate or severe.

Recurrent curettage is identified as a risk factor.

Trauma to the uterine cavity, with destruction of the basal layer of the endometrium constitutes the essential condition for the development of adhesions. The gravid uterus seems to be highly predisposed to adhesion formation. Other treatment possibilities, like a waiting period and medical evacuation should be discussed as treatment options. Strategies, to prevent or reduce adhesions while performing a (recurrent) curettage should be considered.

FC.09.6

Removal of submucosal uterine leiomyomas by operative hysteroscopy

Grigoriadis C.*[1], Papadakis E.[1], Sofoudis C.[1], Kalampokas T.[1], Kondi-pafiti A.[1], Gregoriou O.[1]

[1] National University Of Athens, 2nd Department Of Obstetrics-Gynecology, Aretaieion Hospital. Athens Greece

Hysteroscopy offers easy and safe approach into the uterine cavity, while access to submucosal leiomyomas is limited during transabdominal procedures.

Hysteroscopic myomectomy is considered to be a safe minimally invasive method which is preferred in order to avoid the morbidity of laparotomy and to provide a more rapid recovery for the patient.

This was an one-year retrospective study in our Department between April 2010 and March 2011. All medical records of patients who underwent hysteroscopic myomectomy during this period where analyzed. Firstly, diagnostic hysteroscopy was performed using a 4-mm outer-diameter hysteroscope with a 30-degree direction of view (Karl Storz Endoscopy) and normal saline 0.9% as distension medium. The removal of the submucosal leiomyomas was attempted through the resectoscope by use of bipolar hysteroscopical loop (Versapoint system) under direct view.

Twenty patients (31–65 y. mean age 46.4 years) with submucosal leiomyomas were treated in our Department during this period. The maximum diameter of leiomyomas ranged from 2.5 to 6 cm. 14 (70%) patients presented because of symptoms of menorrhagia/menometrorrhagia, 4 (20%) because of infertility and 2 (10%) women because of abnormal ultrasound findings. Final hysteroscopy was very satisfactory as there were not remnants from the base of leiomyomas in 19 cases accounting for a total therapeutic success of 95%. In the vast majority histology diagnosed typical uterine leiomyomas. In only one case that was lead to hysteroscopy after GnRH agonist treatment, the presence of bizarre (atypical) leiomyoma was detected. No intra- or postoperative complications occurred and hospitalization time was less than 12 hours in all cases.

Our method seems to be safe, with sufficient diagnostic-therapeutic outcome and rapid recovery for the patients.

FC.09.7

Hyperspectral hysterosocpy: technology and first pilot clinical trial

Gkrozou F.*[1], Lavasidis L.[1], Vrekoussis T.[1], Georgiou N.[2], Kavvadias B.[2], Mpalas C.[2], Paschopoulos M.[1]

[1] University Hospital Of Ioannina Ioannina Greece - [2] Department Of Electronic And Computer Engineering, Technical University Of Crete, Chania Greece

We present results from the clinical validation of a novel hyperspectral hysteroscope, conducted in the context of a pilot study.Our findings suggest that this technology has great potential in objectifying clinical diagnosis,in guiding biopsy sampling and in clinical monitoring.

We present results from the first pilot clinical validation of the recently developed High Definition,Hyper-Spectral (HDHS) hysteroscopy.

HDHS hysteroscopy captures and displays several narrow band live images, spanning both visible and non visible bands of the spectrum.In an automated operation this system captures more than 15 narrow band images in 2 s time and calculates a full spectrum per image pixel.The total number of collected spectra in each (2 s) scan is 2.5 millions.The HDHS system was used as an investigational platform in order to display high definition color images for visualization and identification of spectral bands of normal and pathologic conditions.One hundred women refereed on the basis of different indications for hysteroscopy were examined.The procedure was the same as the regular hysteroscopy.

During the pilot study,HDHS hysteroscopy provided crisp color and black and white, narrow band spectral imaging.No change in patient’s comfort was observed.The user could scan the entire spectrum investigating suspicious areas.The visualization of vascular pattern is enhanced at about 560 nm. Moreover subsurface hematomas or cysts can be visualized in the band 700–750 nm.Spectral analysis showed that different spectrae were collected from polyps displaying similar color/clinical appearance and atypical hyperplasia demonstrated a certain spectral pattern that assists the identification of the lesion.

HDHS hysteroscopy is an objective quantitative method with great potential in assisting clinical diagnosis and in guiding biopsy sampling and treatment, especially for women at high risk for endometrial malignancy.

FC.09.8

Hysteroscopic female sterilization in an outpatient setting

Fornelos G.*[1], Malafaia S.[1], Campos R.[1], Rodrigues M.[1], Rebelo C.[1], Silva P. T.[1]

[1] Hospital Pedro Hispano, Unidade Local De Saude De Matosinhos Matosinhos Portugal

The experience of Essure procedure in our department.

The Essure system claims to be a realistic alternative to laparoscopic sterilization, with about 200,000 women sterilized by this method. The evidence on efficacy and safety is mainly available from follow-up case series, which have shown 99,74% of efficacy, high patient satisfaction, low rate of adverse effects and more cost-effective.

The aim of this report is to present the experience of Essure procedure in our department.

Retrospective review of all cases of Essure hysteroscopic tubal sterilization performed between May 2005 and April 2011.

Patients submitted to Essure sterilization took a non-steroid anti-inflammatory and diazepam one hour before the procedure, which was performed under no anaesthesia (or alternatively with intravenous sedation or paracervical block), in ambulatory setting.

187 patients were selected to Essure sterilization, but only 174 of these completed the procedure. In 13 cases the procedure was cancelled due to inadequate visualization of the ostium tubares or tubal impermeabilization.

Most of the procedures (95,4%) were performed under no anaesthesia with good tolerance.

Associated procedures (polipectomy or miomectomy) were performed in 5 patients.

All patients with successful device placement had a pelvic x-ray at the third month of follow-up. Hysterosalpingogram was performed in those with inconclusive results (22 cases). Hypogastric pain was the only short-term complication of the procedure, which was reported in 3 patients. In follow up of our series we found no significant complications. We had 1 case of failure of the technique with subsequent pregnancy in one undetected case of tubal extrusion.

The Essure system is a safe, permanent, irreversible and less invasive method of contraception with high patient acceptance. The benefits of an outpatient setting with no anesthesia offset the relatively high cost of the device.

FC.09.9

Optimum intrauterine filling pressure in outpatient hysteroscopy—a double blind randomised control trial

Shahid A.*[1], Pathak M.[1], Gulumser C.[1], Parker S.[1], Palmer E.[1], Saridogan E.[1]

[1] University College London Hospital London United Kingdom

This is an adequately powered equivalence double blind rarndomised controlled trial that disproves the hypothesis that lower pressures such as 40 and 70 mmHg are as good as the pressure of 100 mmHg for performing outpatient hysteroscopy.

This study was to assess whether lower intrauterine filling pressures are as good as pressure of 100 mmHg for visualising the uterine cavity when performing outpatient hysteroscopy and to determine whether using lower pressure levels would reduce patient discomfort.

It is a double blind randomised control trial conducted at the University College London Hospital U.K. Patients were randomised into three groups comprising of three different intrauterine filling pressures—40, 70 and 100 mmHg respectively for performing diagnostic hysteroscopy from March 2007 to May 2011. Pain score was assessed using a visual analogue scale. Successful outcome was considered in terms of adequate visibility to perform hysteroscopy. Data was statistically analysed using SPSS and Graphpad Prism software.

Total of 234 patients was included in this study. There were 77 patients in group 1(40 mmHg), 78 in group 2(70 mmHg) and 79 in group 3 (100 mmHg) respectively. It was possible to perform diagnostic hysteroscopy using all three intrauterine pressures. There was adequate visibility on outpatient hysteroscopy in 87% of cases in group 1, 94.9% in group 2 and 97.5% in group 3. The correlation between different intrauterine pressures and adequate visibility was statistically significant (p = 0.01). Median pain score in each group was the same at 4.

It appears that lower intrauterine pressures i.e. <100 mmHg when used for performing outpatient hysteroscopy are associated with a significant trend of inadequate visibilty. Pain scores do not seem to differ significantly with the pressure options used.

FC.09.10

Value of hysteroscopy prior to uterine artery embolisation (UAE)

Krishnamurthy G. B.*[1], Tsimpanakos I.[1], Karamshi M.[1], Petrakis P.[1], Moustafa M.[1], Dacco M. D.[2], Magos A.[1], Davis N.[1]

[1] Royalfree Hospital London United Kingdom - [2] Universita’ di Pavia Irccs Fondazione San Matteo Pavia Italy - Royal Free Hospital London United Kingdom

We analysed the hospital record of 115 women who were scheduled to undergo UAE. Only 12 (10.7%) women were found to have type 0 or I submucous fibroids, and all but two underwent UAE. This pilot study does not show any major benefit for routine hysteroscopy prior to UAE.

This study was undertaken to evaluate the value of routine hysteroscopy prior to uterine artery embolisation (UAE) for symptomatic uterine fibroids.

We analysed the hospital record of 115 women who were scheduled to undergo UAE at the Royal Free Hospital between January 2008 and April 2011. All women had outpatient hysteroscopic assessment of uterine cavity prior the decision to carry out UAE.

The average age of the group was 44.6 (SD 4.09) years and mean uterine size on palpation was 15.4 (SD 3.5) weeks gestation equivalent. Hysteroscopy was successfully completed in 112 (97.4%), the procedure being abandoned due to pain and/or vasovagal attack in three. In the women who were hysteroscoped, 50 (44.6%) had no submucous fibroids, 50 (44.6%) had type II fibroids and 12 (10.7%) were found to have type I or 0 fibroids. Six (5.4%) women had endometrial polyps which were excised immediately.

All 12 women with type 0 or I submucous fibroids were offered hysteroscopic (n = 11) or vaginal (n = 1) myomectomy prior to UAE but only four agreed. Of these four cases, 2 cancelled their planned UAE because of symptomatic improvement. The remaining two women as well as the eight who declined surgery underwent UAE. There were no cases of infection, spontaneous expulsion of a fibroid or the need for any surgical intervention in this group.

This pilot study shows that hysteroscopy prior to UAE changes management in only a small proportion of cases. Selective hysteroscopy following MRI scanning may be a more logical protocol to identify women with intra-cavitary fibroids who may benefit from hysteroscopic or vaginal myomectomy.

FC.09.11

Success rate of the Adiana® hysteroscopic sterilization technique

Coolen A.*[1], Bongers M.[1], Thurkow A.[2], Emanuel M.[3], Timmerman E.[6], Ruhe I.[4], Veersema S.[5]

[1] Máxima Medical Centre Veldhoven Netherlands - [2] St. Lucas Andreas Hospital Amsterdam Netherlands - [3] Spaarne Hospital Hoofddorp Netherlands - [4] Flevoziekenhuis Almere Netherlands - [5] St. Antonius Hospital Nieuwegein Netherlands - [6] St. Franciscus Hospital Roosendaal Netherlands

The Adiana® sterilization is a safe, effective and well-tolerated technique. The Adiana® system provides a pregnancy prevention rate of 98%.

The aim of this study is to evaluate the results of the Adiana® hysteroscopic sterilization technique in an outpatient setting.

It was a prospective observational multicentre cohort study of consecutive 203 patients undergoing a hysteroscopic Adiana® sterilization between January 2009 and April 2011. The study was performed in 6 teaching hospitals in the Netherlands.

The Adiana® sterilization was performed in an outpatient setting by experienced hysteroscopists following the same study protocol. The sterilization was a vaginoscopic procedure without local anaesthesia. Three months after bilateral placement a hysterosalpingography (HSG) was conducted to confirm tubal occlusion. If this HSG result was judged patent or inconclusive a six month HSG was performed. An ultrasound was made to visualize the devices.

Preliminary results include data of 203 patients who were scheduled for an Adiana® sterilization. Bilateral placement was achieved in 178 patients (88%). In 10 patients the sterilization was not tried. Reasons for not trying were intra uterine adhesions, cervical stenosis and inability to visualize tubal ostia. There were 15 placement failures, in most cases due to blocked tubes. In 119 patients (90%) a successful sterilization was achieved according to the HSG. There are 40 patients pending for HSG. Ten patients are lost to follow-up. Very few complications occurred and the procedure was well-tolerated.

The pregnancy prevention rate was 98%. After HSG confirmation, 3 patients became pregnant relying on Adiana®. A 4th pregnancy occurred in a non-compliant patient.

The Adiana® sterilization is a safe, effective and well-tolerated technique. If devices are placed correctly and tubal occlusion is confirmed by HSG, Adiana® provides a pregnancy prevention rate of 98%.

Session FC.10

* Free Communications_10 *

Operative Hysteroscopy—Office & Diagnostic Hysteroscopy

FC.10.1

A comparative study of MEA and NEA in obese women

Adedipe T.*[1], Laiyemo R. O.[1], Jones S. .. E.[1]

[1] Bradford Royal Infirmary Bradford United Kingdom

This study suggests that NEA is a better ablation treatment for obese women with HMB when compared to MEA.

In the U.K., NICE (2007) recommends a second generation ablation as possible first treatment for women with HMB. Obesity in women attending for gynaecological consultation is an increasing problem. Other authors have already highlighted that EA may be less effective in obese women.

A retrospective case-note review of women having either MEA(63) or NEA(70) from Jan 2006 to Dec 2010.Data analysis was via Excel Spreadsheet. Women having MEA were mostly pre-treated with one injection of GnRH analogue or short course norethisterone and treated under GA. Women having NEA were treated under LA in a primary care setting with no pre-treatment.

6.6% of the NEA cohort were below the age of 35 years whilst in the MEA cohort this was 9.5%. Mean age and standard deviation for both groups (NEA vs MEA) were similar.(42.27 yrs +/−4.92 vs 42.67 yrs +/−4.08). 12.86% could not tolerate the procedure under LA whilst all the patients in the MEA cohort had their procedures. One case of urinary retention with an overnight stay post MEA. There was no post-operative complications in the NEA cohort. A higher percentage of women treated with NEA as compared to MEA were obese(54.09% vs 36.51%). A greater incidence of fibroids in the MEA cohort (38.1% vs 2.85%) was observed.

MEA uses electro-magnetic waves to destroy the endometrium, inherently preventing further re-epithelisation. NEA destroys endometrial tissue till resistance is achieved at the level of the myometrium by using radio frequency energy. As efficacy is non-dependent on pre-treatment endometrial thickness, it can be carried out without thinning the endometrium. In this study, NEA under LA has been shown to be effective and safe in obese women as success was achieved in 91.9% vs 60.83% as seen in the MEA arm.

FC.10.2

Comparison of tissue volume and weight following outpatient resection of fibroids and polyps under local

Bruen E.*[2], Finall A.[1], Lindsay P.[2], Patwardhen A.[2], Griffiths A.[2], Hill S.[2], Penketh R.[2]

[1] Department Of Histopathology, Cardiff And Vale University Health Board Cardiff United Kingdom - [2] Department Of Obstetrics And Gynaecology, Cardiff And Vale University Health Board Cardiff United Kingdom

Recording of weight and volume of tissue resected during outpatient resection to set standards for the future comparison of quantity of tissue removed.

Fibroids and polyps have been removed under local anaesthetic in outpatients for over a decade. There has been a perceived upper limit of tissue resectable of 2 g. (Bakour et al 21006). Using conventional Storz resectoscopes the Cardiff Shine project started resection in outpatients in May 2010 starting firstly with polyps in post menopausal women and moving on to fibroids and polyps in younger women. Quantification of tissue removed in most studies is rather vague so at the outset of the project we asked the histopathologist to both measure and weigh the tissue removed.

Tissue specimens were fixed immediately in formalin and transported to the histopathology laboratory and were assessed by a histopathologist the following day. Tissue was prepared according to Royal College of Pathologists guidelines The volume was measured by removing the tissue samples from the liquid, aggregating them, and then measured with a mm ruler in three dimensions. The specimen was then weighed in grams to one decimal place.

The weight of tissue removed was up to 10 grams and volume up to 2000 cubic mm (check latest figures). Weight broadly correlates with estimated volume, R2 Linear = 0.7.

It is recognised that tissue shrinks after fixation in formalin by varying amounts according to the fat content. Review of the literature reveals that cervical tissue shrinks approximately 2.7% (Boonstra 1983) Both weight and volume estimation are useful parameters when assessing the quantity of tissue removed at operative hysteroscopy. The correlations provided in this study will allow comparison with other publications where only one measurement is provided. In future it would be helpful if both weight and estimated volume were included

FC.10.3

Guided hysteroscopic procedures: a systematic review

El-tawab S.*[1]

[1] Shatby Maternity University Hospital Alexandria Egypt

Hysteroscopic approach with its simplicity, may still necessitate guidance in difficult situations to ensure safety and completion of the procedure.

Different techniques are used to guide a hysteroscopic procedure, but no previous review , to the author’s knowledge, collectively addressed the topic. this review is a trial to highlight the feasibility, advantages, and limitations of these procedures. Also, to broadly classify these guiding techniques & specify the indication of usage.

Different techniques are used to guide a hysteroscopic procedure, but no previous review , to the author’s knowledge, collectively addressed the topic. this review is a trial to highlight the feasibility, advantages, and limitations of these procedures. Also, to broadly classify these guiding techniques & specify the indication of usage.

Design: Pertinent studies were identified through a computer MEDLINE search. References of selected articles were hand-searched for additional citations.

Results: Different studies have been published about techniques guiding the hysteroscopists to overcome the obstacles of inability to see deep into the area of dissection or resection. These techniques could be divided into: laparoscopic-guided hysteroscopy, ultrasound-guided hysteroscopy (using TA or TV probes); ultrasound-guided endoscopic instruments (using endoluminal US probes), dye-guided hysteroscopic endometrial sampling (chromohysteroscopy) and catheter-guided hysteroscopy for cervical stenosis.

Hysteroscopic approach with its simplicity, may still necessitate guidance in difficult situations to ensure safety and completion of the procedure.

FC.10.4

Novosure endometrial ablation in women with high BMI or failed treatment with Mirena IUS

Gray T. G.*[1], Trinick S.[1], Raychaudhuri R.[1]

[1] Barnsley Hospital Nhs Foundation Trust Barnsley United Kingdom

A retrospective study to investigate the effectiveness of Novosure® endometrial ablation in patients with high BMI or failed treatment with Mirena IUS. Those who failed treatment with Mirena IUS were more likely to require a hysterectomy. Patients with high BMI were less likely to be satisfied with Novosure® endometrial ablation at four months.

To evaluate the outcome of Novosure® endometrial ablation in patients with high BMI or failed treatment with Mirena IUS.

Retrospective study of 79 patients undergoing Novosure® at Barnsley Hospital NHS Foundation Trust between April 2006 & January 2010. Outcomes were recorded using a data collection sheet filled in pre-procedure and at 4 months.

63/79 patients with BMI recorded pre-op were followed up at 4 months. 76.92% of patients with BMI 18–25 were ‘satisfied’ or ‘very satisfied’. 70% of patients with BMI 25–30 were ‘satisfied’ or ‘very satisfied’. 66.66% of patients with BMI 30+ were ‘satisfied’ or ‘very satisfied’. Of the 8 patients in the study who went on to have a hysterectomy, 5 (62.5%) were overweight or obese.

31/79 (39.24%) patients undergoing Novosure® had completed an adequate trial of Mirena IUS which had failed to prove curative. 27/31 were followed up at 4 months. 19 (70.04%) were ‘satisfied’ or ‘very satisfied’ with the treatment. 6/31(19.35%) went on to have hysterectomy compared with 2 (4.16%) of the remaining 48 who had not been treated or failed treatment with Mirena IUS.

Patients who failed treatment with the Mirena IUS were five times more likely to go on to have a hysterectomy. Patients with BMI 25+ were less likely to be satisfied with the results of Novosure® at four months. Women who were overweight or obese were two-thirds more likely to require a hysterectomy. However, Novosure® remains excellent for patients with high BMI or who fail treatment with Mirena IUS.

FC.10.5

The effect of postoperative with / without adjuvant therapy on reproductive outcome after transcervical resection of septa

Xia E.*[1]

[1] Hysteroscopic Cente,fuxing Hospital, Capital Medical University Beijing China

In order to improve the reproductive outcome IUD and / or estrogen were used for infertile women after transcervical resection of septa (TCRS). Compared with on use IUD and / or estrogen as well as compared between each r adjuvant therapy after TCRS. The result was the same.

To investigate the effect of postoperative with /without adjuvant therapy on reproductive outcome after TCRS.

216 cases who were performed TCRS were divided into three groups postoperatively: no adjuvant therapy, artificial cyclical treatment and artificial cyclical treatment combining with IUD.

195 cases were followed up. Second look of hysteroscopy were performed after 1 and 3 months postoperatively. Adhesions in fundus were occurred in 2 cases who were inserted IUD for three months. Among three groups there were no significant differences in the rates of spontaneous abortion and delivery preoperatively. The rates of spontaneous abortion and delivery postoperatively were 28.57% and 65.17% in no adjuvant therapy group, 15.15% and 72.73% in cyclical treatment group and 26.19% and 59.52% in cyclical treatment combining with IUD group, respectively. There were no significant differences among three groups in the rates of spontaneous abortion and delivery(P value >0.05).

The reproductive outcome after TCRS was clearly improved. Traditional therapy including artificial cyclical treatment and cyclical treatment combining with IUD is no difference comparing with no adjuvant therapy in improving the shape of uterine cavity and reproductive outcome. Therefore, no further adjuvant management is needed after TCRS.

FC.10.6

Success and satisfaction experienced with thermal balloon ablation

Hartmann B.*[1], Wachter M.[1]

[1] Landesklinikum Thermenregion Neunkirchen And University Of Vienna Vienna Austria

We report about our experience with thermal balloon ablation in the treatment of menorrhagia, an approved alternative to hysterectomy.

Until today hysterectomy is regarded as the definitive surgical treatment of heavy menstrual bleeding, achieving 100% success concerning cessation of menstruation. However, since hysterectomy is associated with some undesirable effects on cardiovascular and psychic functions, treatment options are especially needed.

These devices irreversibly coagulate the endometrium and underlying myometrium with the aid of heat and pressure. During 2006 and 2009 we evaluated 175 patients with focus on patient satisfaction and complications.

More recently developed thermal balloon ablation systems, reach almost equally effective improvement and normalization of bleeding patterns. Clinical studies report average success rates in the amount of 90% or even more according to our results. 89% of our considered patients represented postoperatively their menstruation bleeding as amenorrhoea, mild or moderat.

In comparison to hysterectomy thermal balloon ablation should be recommended in therapy of dysfunctional uterine bleeding because of shorter operation time, less blood loss during surgery, safety, ease of use and retention of the uterus. Due to these benefits a decrease of implemented hysterectomies and an increase of with thermal balloon ablation systems treated women in Austria has been recognizable.

Despite all that, it is eminently important to attentively furthermore monitor new occurring side effects and interactions between the treatment, medication and anatomical structures. Lately two severe complications (rupture of the uterus during operation) have been reported.

Thermal balloon ablation is deemed to be a safe alternative in the treatment of dysfunctional uterine bleeding but it can be associated with severe problems.

FC.10.7

The next generation: Novasure® endometrial ablation after uncomplicated Essure® sterilisation in the same time, a feasibility study.

Immerzeel P.*[1], Van Eyndhoven H.[1], Vleugels M.[2]

[1] Isala Klinieken Zwolle Zwoll Netherlands - [2] Ziekenhuis Rivierenland Tiel Tiel Netherlands

A prospective study to test the feasibilty and safety of Essure sterilisation directly followed by general endometrial ablation in women with menorrhagia.

In patients undergoing Novasure global endometrial ablation (GEA) directly followed by Essure sterilisation, hysterosalpingogram (HSG) as confirmation test is not reliable in 25% of the patients because of severe synechiae (Detollenaere 2011). After uncomplicated Essure procedure, ultrasound can replace HSG as confirmation test. It seems attractive to combine both procedures only when ultrasound is sufficient as confirmation test. In all other cases the endometrial ablation should be performed after the HSG. Therefore, the logical sequence of this combined procedure is to perform the essure sterilisation before the endometrial ablation.

Between September 2009 and March 2011, 15 patients were allocatetd for the combined procedure. In case the the Essure sterilisation was uncomplicated, this was directly followed by GEA under general anesthesia. After 3 month the placement of the micro-inserts was verified by ultrasound. In case HSG was needed GEA was postponed untill after the confirmation test.

Of this group, 12 patients had an uncomplicated Essure® sterilisation followed by GEA. In one of these patients one Essure microinsert was accidently pulled out with removal of the Novasure device. It was successfully replaced,and HSG after 3 months was planned. In the remaining three patients HSG was necessary because of the course of the procedure. In all patients HSG was conclusive with occlusion of both tubae and no synecchiae. In the latter three patients GEA was performed after HSG without problems.

We conclude that GEA after Essure sterilisation is feasible when ultrasound confirmation test can be applied. In case HSG is needed, GEA should be posponed until after the confirmation test.

FC.10.8

22 Fr and 26 Fr bipolar operative hysteroscopy: our experience

Mereu L.[1], Albis Florez E. D.[1], Prasciolu C.*[1], Carri G.[1], Giunta G.[1], Cofelice V.[1], Mencaglia L.[1]

[1] Centro Oncologico Fiorentino Sesto Fiorentino (Fi) Italy

To evaluate whether a bipolar resectoscope (BP) 22 Fr and 26 Fr (Karl Storz, Tuttlingen, Germany) represent a reliable improvement in operative hysteroscopy.

Bipolar electrosurgical surgery avoid electrical burns because of the proximity of active and neutral electrodes and reduce the risk of electrolyte imbalance by the use of isotonic saline

We conducted a retrospective descriptive study on a total of 140 women that referred to CFO between June 2010 and May 2011. All the patients were treated for uterine synechia, uterine septum, endometrial polyps and myomas, by the use of a bipolar resectoscope 22 Fr or 26 Fr, except for Myomas G2 and G1 >2 cm and polyps >3 cm removed only by the bipolar resectoscope 26 Fr. Mechanical dilatation of the cervix was obtained by Hegar series until N°8 for BR 22Fr and N°10 for BR 26 Fr

The patient’s mean age was 39.32 (range 23–73) and 41,5 (range 30–60) for 22 Fr and 26 Fr respectively.

We performed 65 metroplastic (55,1%), 33 polipectomy (27,9%), 7 miomectomy (5,9%), and 1 sinechiolisis (0,8%) by bipolar resectoscope 22 Fr; 5 metroplastic (22,7%), 5 polipeptomy (22,7%) and 12 miomectomy (54,5%) by bipolar resectoscope 26 Fr.

The mean surgical time was 16.4 minute (range 5 minutes—36 minutes) for 22 Fr; it was 21,40 minutes (range 8–40) for 26 Fr. The mean time of cervical dilatation by Hegar series was 54 sec for BR 22 Fr and 86 sec for 26 Fr.

We observed 1 uterine perforation, 2 post operative bleeding more than 7 days and 1 intravasation syndrome. All complications has been resolved with observation and medical therapy.

Bipolar resectoscopy reduces the risk of complications. The bipolar resectoscope 22 Fr is preferable than 26 Fr because require a lower cervical dilatation limiting possible cervical and pelvic injuries

FC.10.9

Evaluation of hysteroscopical polypodectomy and submucosal fibromyomectomy with the use of truclear morcellator in comparison with conventional resectoscopy. The Greek experience

Mathiopoulos D.*[1], Vlachos S.[1], Tsiaousi I.[1], Giatrakou M.[1]

[1] Leto Maternity Hospital Athens Greece

Since it’s recent advent the Truclear Hysteroscopical Morcellator has been gaining popularity. We evaluated the use of this device in comparison with the well established conventional resectoscopy. In this study the Truclear Morcellator reduced the operating time and was proved to be safer than the conventional resectoscopy.

The invasive hysteroscopy with the use of electric current or CO2 (resectoscopy) has been established as a method of choice for intrauterine lesions (congenital abnormalities, polyps, submucosal myomas) since 1970. However, the Truclear Hysteroscopical Morcellator has been recently gaining popularity. As it is a new modality, it needs further evaluation and comparison with the resectoscopy.

9 mm Hysteroscopic Morcellator by Smith & Nephew (Truclear) was used. Evaluation and comparison criteria were:1) operating time, 2) fluid loss, 3) visibility, 4) Normal Saline usage, 5) serious complications (perforation and bleeding), 6) learning curve.

The average operating time for the intrauterine hysteroscopic polypodectomy using Truclear was 9 min, vs 18 min of resectoscopy. The average operating time for the Truclear submucosal fibromyomectomy was 32 min vs 45 min of resectoscopy. The fluid loss related to the use of Truclear was significantly less than in resctoscopy. The serious complications rate was reduced, especially, when treating fibromyomas.

The use of Truclear Morcellator for hysteroscopical fibromyomectomy and polypodectomy is a reproducible, fast and safer technique than the conventional (uni- or bipolar) resectoscopy, particularly when treating fibromyomas.

FC.10.10

How to treat submucosal myomas with office hysteroscopy

Cammareri G.[1], Rollo D.[2], Di Francesco S.[1], Zampogna G.[1], Cirillo F.*[1], Ferrazzi E.[1]

[1] Ospedale V Buzzi Milano Italy - [2] Ieo Milano Italy

Office hysteroscopic myomectomy is a safe and well tolerated procedure, even without any anaesthetic support. With the multiple step approach we have the possibility to treat big submucosal myomas, even G2.

Histeroscopic myomectomy is a well spread procedure with a recognized safety and feasibility. At the contrary, only few groups perform office myomectomies. With this study we investigate the feasibility, safety and acceptability of office hysteroscopic myomectomy in submucosal G0, G1 and G2 myomas.

We did a retrospective analysis of 28 consecutive office hysteroscopic myomectomies from January 2009 to June 2010, operated in an outpatient’s clinic of Obstetric and Gynecology University Department.

We included 28 symptomatic women with 1 or more submucosal G0 or G1 or G2 myomas.

We performed hysteroscopic myomectomy using bipolar instruments (Versapoint, Gynecare) with slicing technique in multiple step approach. All hysteroscopies were performed without any anaesthetic support. The follow-up was made with an US control after 1 month.

We treated 34 myomas, of them: 15 were G0, 15 G1 and 4 G2. 3 patients had more then 1 myoma: one had 4 myomas, one had 3 and another 2 myomas. Every patient were subjected to 1.6 hysteroscopies on average. The mean diameter of the fibroids was 20 mm (6–42 mm). The average operating time was 11.8 ± 4.6 minutes. 5 patients (17.9%) were sent to operation room to complete the myomectomy. We observed two cases of vasovagal reaction and no major complications. The average of pain NRS was 3,4 ± 1,0 and only one patient requested a painkiller after the operation.

Office multistep approach was successful in a 83% of patients: it gave us the possibility to treat big submucosal myomas, even G2.

Office hysteroscopic myomectomy is a safe and well tolerated procedure, even without any anaesthetic support.

Session FC.11

* Free Communications_11 *

Teaching and Training—Single Access Surgery

FC.11.1

An electromagnetic motion analysis system to assess gynaecologists’ surgical skills in-vitro using straight stick (SSL) and single incision (SILS) laparoscopic surgery—construct validity and psychomotor comparisons

Kaushik S.*[1], Nama V.[1], Prietzel-meyer N.[1], Shepherd J.[2], Ind T.[1]

[1] St George’S Hospital Nhs Trust London United Kingdom - [2] The Royal Marsden Hospital London United Kingdom

We used motion analysis to assess ergonomics of Single incision laparoscopy (SILS) compared to straight stick laparoscopy (SSL). The more experienced surgeons performed the same task with fewer moves over a shorter distance.

We refined a system for analysing hand motion in-vitro. Motion analysis was used to assess and compare the manual dexterity of experienced and inexperienced surgeons when performing SSL and SILS.

An electromagnetic motion tracking system was used with software developed in-house. Sample rate was 10 sec-1. Thresholds for velocity, distance, and duration of each movement were set at as 0.1 ms-1, 0.5 cm, and 0.3 seconds respectively. Ten medical students, trainees, and consultants each performed two exercises (transferring four Hama beads across a pin board and excising a circle printed on gauze between two lines 4 mm apart) using SSL and SILS.

For both exercises and techniques, statistically significant construct validity was demonstrated between medical students, registrars, and consultants. Less experienced surgeons used more movements (median movements for beads at SSL, 2181 vs 54, P,0.0001) and travelled a greater distance (41.9 cms vs 1.2 cms, P = 0.0027). The most experienced surgeons had movements of longer duration and shorter distance.

When comparing SILS with SSL, the same exercise using SILS used more movements over a longer distance (Median diff −65 for consultants, P = 0.0371). Furthermore, each movement was of quicker velocity and of longer distance when using SILS replicating the effect more commonly seen with inexperienced surgeons.

The system demonstrates clear construct validity. Using the same analysis the ergonomics of SILS appear to be worse than SSL with inexperienced laparoscopic surgeons but not with consultants.

FC.11.2

Laparoscopic extra peritoneal aortic dissection: is single port surgery offers the same possibilities than conventional laparoscopy?

Cannone F.*[1], Lambaudie E.[1], Bannier M.[1], Michel V.[1], Buttarelli M.[1], Houvenaeghel G.[1]

[1] Paoli Calmettes Institute Marseille France

The aim of this study was to describe and to demonstrate, how single-port surgery would be a safe approach for extra peritoneal laparoscopy and aortic lymphadenectomy in patients with gynaecologic cancer.

Since the end of the 20th century, the single-port surgery (SPS), a less invasive alternative to conventional laparoscopy has emerged.

Preliminary advances of this technique applied to urologic and gastrointestinal surgery, demonstrate the feasibility of this approach. Recently, the management of benign or malignant disorders in gynaecology has been reported.

The objectives of this study is to demonstrate the feasibility of single port surgery for laparoscopic extra peritoneal aortic dissection in patients with gynaecologic cancer.

From December 2010 to April 2011, all patients referred for aortic lymph node staging underwent a laparoscopic extra peritoneal approach with a single port device.

Extra peritoneal approach was done using only one incision of 3 to 4 cm on the left side. We used the Gelpoint from Applied Medical. Concerning the material, we used a 10 mm laparoscope 0° and 5 mm standard instruments.

Thirteen patients were included: aortic dissection was complete in 11 patients and incomplete in 2 patients. Mean lymph nodes count was 16 (range, 7–40). Mean blood loss was 40,7 ml (range 0–100) and no transfusion was necessary. Mean hospital stay was 1,7 day (range 1–4) in our series.

Our results demonstrate the feasibility of single port access laparoscopy for extra peritoneal aortic lymphadenectomy. Lymph node count is similar than published experience of conventional laparoscopic extra peritoneal dissection.

In this preliminary report, SPS technique is usable in extra peritoneal aortic dissection with the possibility to realize this procedure with only one skin incision compared to 3 or 4 in conventional laparoscopy.

FC.11.3

Development and validation of a generic tool for assessment of laparoscopic skills in gynaecology using videotaped procedures

Khazali S.*[1], Carpenter T.[1], Moors A.[2], Ballard K.[3]

[1] Poole General Hospital Poole United Kingdom - [2] Southampton University Hospital Southampton United Kingdom - [3] University Of Surrey Guildford United Kingdom

This study reports on the design of Generic Laparoscopic Video Scoring system (GLVS) and tests its reliability in evaluating surgical skills using videos of gynaecological laparoscopic procedures.

Assessing surgical competence is complex. Traditional subjective evaluation methods with fuzzy criteria are no longer fit for purpose and face-to-face methods are subject to significant bias. Anonymised videotaped endoscopic procedures can be used for objective assessment of surgical skills in gynaecological endoscopy but a reliable non procedure-specific scoring system is needed.

17 unedited videos of various basic gynaecological endoscopic procedures and the edited versions of the same videos performed by senior specialty trainees and newly appointed Consultant gynaecologists were assessed by two experts, twice, using GLVS. The experts received no training in scoring.

GLVS had excellent internal consistency reliability (Cronbach’s alpha 0.92–0.97). Test-retest reliability for edited videos was excellent for scorer 1 and good for scorer 2 with intra-class correlation coefficient (ICC) of 0.88 and 0.62 respectively. Inter-rater reliability was fair to good in three of the four combinations of rounds (ICC = 0.54–0.64) and good when mean score of both rounds of scoring was used (ICC = 0.60). Test-retest reliability and inter-rater reliability was generally lower for unedited videos (ICC 0.40–0.67 and ICC −0.24–0.60 respectively). There was no significant difference between the scores of edited and unedited versions of videos.

GLVS is feasible and reliable for surgical skills assessment using edited and anonymised videos of basic gynaecological laparoscopic procedures. Further studies are needed to investigate the construct validity of GLVS and to establish its reliability for scoring unedited videos.

FC.11.4

Face and construct validity of a virtual reality simulator for hysteroscopy Essure sterilization

Janse J.*[1], Veersema S.[1], Broekmans F.[2], Schreuder H.[2]

[1] Sint Antonius Hospital Nieuwegein Netherlands - [2] University Medical Centre Utrecht Utrecht Netherlands

The face and construct validity of a new virtual reality simulator for the hysteroscopy Essure sterilization method is established by determining the extent of realism of the simulation to the actual task and by analysis of the performance of participants with varying hysteroscopy experience.

The aim of this study is to determine face and construct validity of the EssureSim™, a new virtual reality simulator for the Essure sterilization method.

Residents and gynecologists (N = 63) were recruited for voluntary participation. Three groups were made based on hysteroscopy experience: novices (N = 10), intermediates (N = 43) and experts (N = 10). Participants completed three exercises. The second and third exercises were used for analysis. Parameters ‘time’, ‘path length’, ‘patient comfort’, ‘successful placement’, ‘cavum contacts’ and ‘distension medium’ were compared between groups to determine construct validity. Afterwards, participants filled out a questionnaire addressing hysteroscopy experience and the simulator. By analysis of the questionnaire face validity was determined.

The experts performed both exercises significantly faster than the novice group (p < .05). The novices had a longer path length in the first exercise in comparison to the intermediate and expert group (p < .05). Analysis of the other parameters did not show any significant results between groups. In the questionnaire realism and training capacity of the EssureSim™ were both scored with a median of 4 points on a 5-point Likert scale. Of all participants, 96.8% indicated the EssureSim™ as a useful preparation for real-time Essure placement.

Face and construct validity was established of the EssureSim™ and this simulator is considered to be a useful training method for different levels of expertise. Virtual reality simulation could offer a significant contribution to the training of hysteroscopy skills.

FC.11.5

Grading surgical skills curricula and training facilities for minimally invasive surgery

Hiemstra E.*[1], Schreuder H.[2], Stiggelbout A.[1], Jansen F. W.[1]

[1] Leiden University Medical Center Leiden Netherlands - [2] University Medical Center Utrecht Utrecht Netherlands

Exploding numbers of skills laboratories are being set, in absence of concrete guideline how to do this. Therefore, a set of quality criteria was develop using the knowledge of 23 well recognized experts. The resulting consensus list can be used when setting up a skills laboratory and for verifying the quality of an existing laboratory.

In teaching hospitals all over the world, skills laboratories have been set up in order to train and assess minimally invasive (e.g. laparoscopic) surgical skills outside the operating room. However, no guideline exists on how to design and use a MIS skills laboratory. This study is aimed at developing consensus based quality criteria for a skills laboratory, including aspects of the curriculum.

Three quality domains for skills laboratory were defined; Personnel and Resources, Trainee motivation and training Curriculum. A list of consensus-based criteria, 9 items per domain, was made. Additionally, well recognized experts in MIS were asked to rate each item on a 0 to 3 scale in level of importance.

All 23 selected experts agreed participation. No one added an item to this list. In the domain Personnel and Resources, the presence of a box trainer, a laparoscopic expert and the availability of financial resources were considered the most important. In the domain Trainee motivation, mandatory training supervised by laparoscopic experts were considered the most important. In the domain Curriculum, the presence of a structured skills curriculum, dedicated time for skills training, and a yearly evaluation of the progress and maintenance of laparoscopic skills of the resident were considered the most important factors.

The consensus list can be used when setting up a skills laboratory, but also for verifying the quality of an existing laboratory. From there, the focus for new developments can be chosen.

FC.11.6

Implementing the total laparoscopic route for hysterectomy in a private maternity hospital setting

Erdemir R.[1], Ozyurek E.*[1]

[1] Erpa Denizli Ozel Saglik Hospital Denizli Turkey

Since 2009, we performed 157 total laparascopic hysterectomies in a private maternity hosptal.

As a development project, we started performing our hysterectomy operations through the total laparascopic route starting in 2009.

The ergonomic principles and the energy sources, energy modalities used for dissection coagulation and incision; the uterine manipulator system; the camera and vision systems were revised. One surgeon took 3 courses at IRCAD

157 total laparascopic hysterectomies were performed. The mean operative time 122 (+/−) 35 minutes. 3 cases were converted to laparotomy due to an initial trocar bowel injury, bladder injury (within the first 10 cases), and to control peroperative general bleeding status. Complications included; 1 primary trocar bowel injury, 3 unintended bladder injuries (1 was repaired with laparotomy and 2 were repaired laparascopically). The mean blood loss was −1(+/−)0.2 mg/dl hemoglobin. The mean postoperative hospitalization interval was 1.2 days.

Within the first year: 1 excessive vaginal bleeding due to early sexual intercourse; 1, required a cuff hematoma drainage. The most common minor postoperative complaint was constipation. We had one postoperative cuff prolapse for which we performed a later sacrospinous colpopexy.

Laparascopic inoperability criteria, severe adhesions, uterine sizes, BMI’s, can be overcome provided that the learning curve is completed. The cuff closure (including a vaginal cuff support , considering the vitality of the vaginal cuff tissue); performing ureteral dissection and exposure of the uterine arteries; cytoscopic checking, when suspected; uterine manipulation with screws; uterine manipulators, suspensions; alternative trocar positioning; angled optics; using the palmers’ point are especially required.

FC.11.7

Is open surgical training necessary for laparoscopic competency

Nama V.*[1], Afors K.[1], Athanasia P.[1], Kaushik S.[1], Ind T. E.[1]

[1] St. George’S University Of London London United Kingdom

Open surgical experience is considered as essential to perform laparoscopic surgery. This study compared laparoscopic skills in open surgery trained registrars to novices. We found no difference between the groups. It is plausible that open surgical training and laparoscopic training should be two different routes of training.

Open surgical experience is considered as essential to perform laparoscopic surgery. There has no been no study in the literature to see if open surgery trained individuals can transfer these skills to the laparoscopic setting. Our objective was to determine if training in open surgery improved performance in laparoscopic surgery. Open surgical experience is considered as essential to perform laparoscopic surgery.

15 medical students who had never performed any surgery were compared to 10 registrars who were confident of performing caesarean sections independently. Bseline dexterity skills were assessed in both the groups. A series of tasks were given to be performed on a laparoscopic simulator (i-Sim, I Surgicals, UK).Validated scoring system (Mistels score, McGill University, Canada) was calculated for each individual. Comparison between the groups for mental rotation ability, manual dexterity, Mistels score for each tasks and combination of tasks were made. Both groups were compared using non-parametric tests.Data is presented as median and range.

The manual dexterity test and the metal rotation ability were not significantly different between the two groups. There was no statistically significant difference in Mistle scores between the two groups for transfer of washers, cutting circles, endo-loop placement or suturing. The average Mistels score for MS was 310.79 (121.14-379.49) Vs 305 (233.48-465), p value 0.65.

The performance of medical students in laparoscopic simulator tasks was equal to speciality trainees who were trained in performing caesarean sections.

FC.11.8

Proving construct validity of virtual reality hysteroscopy

Bajka M.*[1]

[1] Clinic Of Gynecology, University Hospital Of Zürich Zurich Switzerland

Virtual Reality (VR) Simulation is a new training opportunity for diagnostic as well as therapeutic hysteroscopy. Its significance is now under systematic validation with promising results. The main advantages using simulation are no risk for patients, no limits for training access, no need for a teacher, systematic instead of random case supply, and objective, validated performance feedback.

Since a century, the traditional training in operative disciplines has been learning by doing as part of the apprenticeship model. But more and more ethical concerns are rising next to a number of well known disadvantages of the procedure. But so far, also substitutes come along with lots of draw backs, e.g. animal protections concerns, lack of realism, need for intense support during training, restricted number of training cases, and still no opportunity for objective performance feedback. VR Simulation allow for overcoming many restrictions hampering effective operative training.

Construct validity of the simulator training on HystSim was investigated by comparing novices and experienced hysteroscopists assessed by a new Multi Metric Scoring System (MMSS) consisting of 15 performance metrics grouped by four modules.

The ergonomics and fluid handling modules resulted in construct validity, while the visualization module did not, and for the safety module the experienced group even scored significantly lower than novices in two exercises. The overall score showed only construct validity when the safety module was excluded. Concerning learning curves, all subjects improved significantly during the training on HystSim.

Construct validity for HystSim has been established for different modules of VR metrics on a new MMSS developed for diagnostic hysteroscopy. Careful refinement and further testing of metrics and scores is required before using them as assessment tools for operative skills.

FC.11.9

Psychomotor skills in laparoscopy

Afors K.*[1], Nama V.[1], Kaushik S.[1], Athanasias P.[1], Ind T.[1]

[1] St George’S Hospital Nhs Trust London United Kingdom

Minimal access surgery requires the use of a unique set of psychomotor skills. Objective assessment of these skills lacks evidence. 33 subjects were invited to complete specific manual dexterity tasks. Mental rotation tests were found to be a useful predictor in assessing trainees potential to learn laparoscopic skills.

Operative competence at the end of training is crucial to safe patient care. Psychomotor skills are important predictors of surgical skill. There are three main psychomotor skills necessary for minimal access surgery. These are manipulative, visual-spatial and eye-hand co-ordination. There is lack of evidence as to which skills plays the most important role. Our objective was to test if one or all the psychomotor components play an important role in Minimal Access Surgery.

23 students and 10 registrars confident in performing Caesarean sections were recruited. The novices in laparoscopic surgery were tested using the Purdue Peg Board test and mental rotation test. A series of tasks with increasing complexity were given to each candidate to perform on a laparoscopic simulator. Validated Mistels scoring system were calculated for each individual. Linear regression analysis was performed with mental rotation tests and the Purdue Pegboard Test as predictor variables in both groups.

The registrar group was signifcantly older than the novices group (Median 24 yrs vs median 35 yrs in the registrar group, p = 0.003). Neither the mental rotation test nor the Purdue Pegboard Tests correlated to the Mistels score in the novices group (R = 0.04). In the registrar group the mental rotation test showed a correlation to the Mistels score (R = 0.7) but the Purdue Peg Board did not show any correlation.

Mental Rotation test of visual-spatial orientation may be useful in assessing the ability to learn laparoscopic skills in older trainees. Age should be taken into consideration when assessing psychomotor ability.

FC.11.10

Specialized course to teach intracorporeal laparoscopic suturing

Mereu L.[1], Cofelice V.*[1], Carri G.[1], Albis Florez E. D.[1], Prasciolu C.[1], Giunta G.[1], Pontis A.[1], Mencaglia L.[1]

[1] Centro Oncologico Fiorentino Sesto Fiorentino, Firenze Italy

A specialized training course of laparoscopic suturing technique of five days to evaluate if “the gladiator rule” is an usefull, applicable and riproducibile method to teach intracorporeal suturing.

Laparoscopic surgery requires a set of skills different from open surgery, and learning in the operating room may increase surgical time, and even may be harmful to patients.

We designed a specialized training course for laparoscopic suturing skills of five days. Two coursists in each working station and 1 tutor every two pelvic trainer were present. Gladiator rule method was used to teach intracorporeal suturing. The coursist has been trained in intracoporeal knotting, stiches with right and left hand from lateral and sovrapubic access. Coursist’s features were collected. Data on ergonomy, coordination, sense of depth, precision and familiarity at the beginning and at the end of the course were detected. Follow up on subsequent live laparoscopic application of intracorporeal suturing was obtained.

We enrolled 44 consecutive doctors; mean age was 36.95 (range 25–55): 16 were doctors in formation, 14 surgeon assistant and 14 first surgeon. 28 of them have previously attended at least one laparoscopic course on suturing technique.8/44 were left hand. In all doctors we found a significant statistical improvement during the course in coordination (p = 0.001), dexterity (p = 0,000), traction power (p = 0.002) and posture (p = 0.003). Males have been better than females in coordination (p = 0,002), dexterity (p = 0,000) and traction power (p = 0,014). No significant statistical difference in suturing skill was found in relation to age, gender, previous courses, surgical rule and dominant hand.

Suturing skill is one of the most difficult laparoscopic procedure to learn. We demostrate that “the gladiator rule” is an usefull, applicable and riproducibile method to teach intracorporeal suturing.

FC.11.11

The impact of the learning curve upon adhesion formation in a laparoscopic mouse model

Corona R.*[1], Verguts J.[1], Binda M. M.[1], Casorelli A.[2], Koninckx P. R.[1]

[1] Kuleuven Leuven Belgium - [2] Uneversità La Sapienza, Dipartimento Ginecologia e Ostetricia Roma Italy

Laparoscopic skills improve with training with a decreasing in duration of surgery and adhesion formation. Therefore completion of a standardized learning curve should be mandatory when initiating adhesion formation studies.

During laparoscopic surgery bowel manipulation was demonstrated to enhance postoperative adhesion formation. Therefore, the present study was designed to evaluate the impact of the surgeon training on adhesion formation in a laparoscopic mouse model.

The study was performed in an academic research centre as a prospective randomized trial in 200 Balb/c and 200 Swiss female mice. Adhesions were induced by opposing bipolar lesions and 60 minutes of pneumoperitoneum. Each surgeon operated 80 mice (40 Swiss and 40 Balb/c) the only variable thus being his increasing experience. Endpoints were the duration of surgery while performing the lesions and the adhesion formation scored after 7 days quantitatively (proportion) and qualitatively (extent, type, and tenacity). Some surgeons were already experienced gynaecologists, others were starting their training.

With training, duration of surgery and adhesion formation decreased exponentially for all surgeons (P < 0.0001, t test), whether experienced (P = 0.0001) or not (P = 0.0001). Experienced surgeons had initially a shorter duration of surgery (P = 0.0095, t test), less adhesion formation (P < 0.0001, Proc GLM) and less de novo adhesions (P = 0.003, Proc GLM) than non-experienced surgeons.

These data suggest that laparoscopic skills improve with training, leading to a decrease in the duration of surgery and formation of adhesions. Therefore completion of a standardized learning curve should be mandatory when initiating adhesion formation studies both in laboratory or clinical setting.

FC.11.12

Trainee perceptions of ultrasound training—a UK study

Treharne A.*[1]

[1] University Hospital Wales Cardiff United Kingdom

A survey of trainee perceptions in ultrasound training was conducted.

A reduction in working hours and increased trainees have increased training pressures. Training has had to develop in order to keep up with these demands.

An e-survey of training was distributed to all trainees in Obstetrics and Gynaecology. The survey consisted of ten questions. Trainees were contacted via the National Trainees Committee (NTC). The survey was open from January 1st 2011 to April 1st 2011.

311 responses were received from 13 responding deaneries (25% ST1-2, 62% ST3-7, 4 sub-specialty and 9% other grade). While awareness of the formal training programme was good (72%), 77% of respondents were concerned about the level of training exposure they received. Only 49% believe they will complete the 2 basic ultrasound modules, and only 20% consider it possible to complete 1 module in the current training climate.

Training in ultrasound has problems to overcome to ensure uniform competency. Only 57% and 60% of respondents felt confident to confirm location and viability while 50% and 84% felt they were able to confidently asses placental location and fetal presentation.

Examination of ultrasound skills and dedicated simulation suites were felt by trainees to be the most useful learning support modalities (61% and 63% respectively). Direct supervision on a virtual simulator with a trainer or with virtual feedback was thought to be equally useful (51% of respondents each). Locally organised training in ultrasound is vital and provided respondents with basic theoretical (66%) and practical (42%) knowledge.

Training in ultrasound does not have to be patient based and a wide variety of multi media and non-patient based learning aids are available to facilitate learning.

Session FC.12

* Free Communications_12 *

Operative Risk Management—Robotics—Infertility and Reproductive Medicine

FC.12.1

How can articulated instruments help in endoscopic surgery?

Mettler L.*[1], Schollmeyer T.[1], Alkatout I.[1]

[1] Dept Of Ob/gyn, University Hospitals Schleswig-Holstein

Over the last 30 years, laparoscopic surgery has gone through wonderful developments of techniques and instrumentations as a result of good cooperation between doctors, technical engineers and industrial companies.

Endoscopic surgery arrived at HDTV cameras, the Cameleon optical system with 120 degrees peripheral vision, new haemostatic and cutting instruments, good suturing and finally robotics—at present best with the DaVinci. Do we still need other technologies??

Yes. Let us have a look at the “Precision-Drive-Articulating Instrument System” from TERUMO. It consists of 3 components, a console, a handle and individual instruments. The console and handle are captial equipment with long use life. The instruments include a needle driver, monopolar L-hook cautery, monopolar scissors, Maryland dissector /grasper and are reusable with limited-usage. They serve for all surgical tasks and can be used in combination with conventional instruments.

The exploration of the new “Art 2 Drive gives a certain precision at your fingertips.”

Features and Benefits: As the instrument tip articulation is computer assisted, it allows the surgeon to control the movements through individual manipulations with yaw and roll controls on the handle’s interface. The articulating instrument allows 2 more degrees of liberty to the conventional instruments with 4 degrees of liberty. Through articulation of the instrument tip, the system allows the surgeon to position the angles to the desired tissue planes easier. Fine dissection and cauterization is possible. The opening and closing of the jaws or blades are manually controlled through a trigger on the handle allowing the surgeon to have tactile feedback.

First surgical experience has been gained in the LASTT training boxes and with animal material and working on cadavers in the institute of anatomy. With this articulation and the resulting flexibility of the tip, after an initial learning curve, an easier dissection and suturing is possible

Compared to the present robotic systems these instruments are portable, will not cost very much and can be used in conjunction with conventional laparoscopic instruments. They facilitate easy and precise surgery.

The variations with the “art 2 Drive” system allows a complete 360 degree rotation and inclination of the tip.

FC.12.2

Documentation in laparoscopic surgery

Pandravada A.*[1], Acharya S.[1], Rae D.[1]

[1] Cross House Hospital, Glasgow Glasgow United Kingdom

Procedure documentation is crucial.

Systematic documentation of surgical procedures is essential for research and medico legal purposes. This survey is to explore the clinician’s way of documenting and their opinion about the necessity of uniform documentation and a nationwide database

Questionnaire consisting of 10 questions was sent out to the gynaecologists in Scotland, and also to some senior trainees and consultants in England.

Out of 108 responses, 54% were consultants.44% of them have special interest in minimal access surgery.93% of them said they would document the type of the entry technique, 94% of them about port sites and sizes. Only 47% of them were documenting the pressure on entry and only 36% of them about the intraoperative pressure. About operative findings at laparoscopy 93% are documenting by written notes, 75% by written notes and image documentation. Regarding Endometriosis, only 34% are using rAFS classification. 72% felt the necessity for a uniform approach to the documentation, 43% felt that a nationwide data base is necessary in laparoscopic surgery.

This survey shows us that there is good documentation in many aspects and increasing usage of image documentation. Most of them also felt that uniform documentation and nationwide data base are essential. About 250,000 women undergo laparoscopic surgery in UK each year and serious complications occur in about one in 1000 cases. Most of the injuries are entry related. It is very important to document the intra abdominal pressures during entry and also during the insertion of the secondary ports.As there is great variation in the surgical techniques used, adequate documentation of counselling, procedure and complications is crucial. Uniform documentation aid to set up a nationwide database, which this will provide more evidence, improve the patient care, and decrease the risk of litigation.

FC.12.3

Multidisciplinary guideline development in mis: a challenge for all?

La Chapelle C.*[1], Jansen F. W.[1]

[1] Leiden Universitary Medical Centre Leiden Netherlands

To enhance patient care and safety in MIS we developed a MULTIDISCIPLINARY Evidence-Based Guideline (EBG).

In 2007, the Dutch Health Care Inspectorate drew largely negative conclusions about the assurance of patient safety in minimally invasive surgery (MIS). Although different specialties perform laparoscopic surgery, there is a enormous variety in training, policy, quality assurance and instrument safety. We therefore aimed to develop a multidisciplinary EBG on MIS.

The guideline development group consisted of gynaecologists, general surgeons, an anaesthesist and urologist authorised by their scientific association. Two advisors in EBG development supported the group. The guideline was developed using the ‘Appraisal of Guidelines for Research and Evaluation” instrument. Steps for designing the guideline were: problem analysis and identification of important topics, formulation of key questions, literature search, selection and assessment of its quality, formulation of summary statements of evidence, further considerations and finally recommendations.

The multidisciplinary EBG on MIS took one year to be completed. Important topics were: laparoscopic entry techniques, specific trocar use, electrosurgical techniques, prevention of trocar site herniation, patient positioning, anaesthesiology, perioperative care, training, patient information, multidisciplinary user consultation, complication registration and introduction of new techniques/technology. Consensus was reached on all controversial subjects and recommen¬dations were formulated.

To our knowledge we developed the first multidisciplinary EBG on MIS. The assessment of knowledge, techniques, skills and other aspects required for safe MIS procedures should be performed multidisciplinary to transcend the boundaries of individual disciplines. Multidisciplinary EBG development could facilitate the implementation in practice and enhance patient safety.

FC.12.4

Surgical risk perception with laparoscopic and abdominal hysterectomy

Roy S. N.*[1], Yeoh L. S.[1], Nalawade A.[1], Ballard K.[2]

[1] University Hospital Of Hartlepool Hartlepool United Kingdom - [2] University Of Surrey Guildford United Kingdom

This prospective randomised questionnaire based study evaluated if women’s perception of surgical risk was influenced by the type of surgical approach and addressed this question in relation to laparoscopic hysterectomy (LH) and abdominal hysterectomy (LH). Results show that women perceive the risks associated with laparoscopic hysterectomy are less compared to that of abdominal hysterectomy. Women also underestimate the true frequency of occurrence of complications with laparoscopic hysterectomy.

Laparoscopic surgery is associated with higher risk of litigation. It is possible that this stems from inadequate understanding or appreciation of the risks of laparoscopic surgery by the patients.

This study was carried out in the University Hospital of Hartlepool. Three elective hysterectomy scenarios were devised describing a woman having hysterectomy through: a 10 cm abdominal bikini line cut, 3–4 small abdominal incisions or keyhole surgery. A standardised description of risk using common vocabulary paired with a colour visual chart (divided into 6 risk categories from negligible to high) was used for measuring risk perception. The questionnaires were randomly distributed. Following power calculation, 135 participants were recruited in to the study. 45 participants were allocated to each 3 groups via randomisation. SPSS was used for data analysis.

Women perceived the risk of minor complications and life threatening complications to be significantly less with LH compared to AH. They appeared to also underestimate the true frequency of occurrence of complications with LH.

Women perceive laparoscopic hysterectomy is safer than abdominal hysterectomy and seem to presume that the laparoscopic hysterectomy is safer than actually it is. They expect a shorter hospital stay with laparoscopic hysterectomy.

FC.12.5

High aorto-cava limphadenectomy by transperitoneal robotic approach with double docking and less than 7 ports. Report of 14 initial cases

Sabrià E.*[1], Ponce J.[1], Martí L.[1], Pla M. J.[1], Barahona M. A.[1], Giné L.[1]

[1] Hopsìtal Universitari De Bellvitge Hospitalet De Llobregat Spain

Aorto-cava robotic lymphadenectomy by double docking approach is feasible with good results

Robotic system not allows do high and low abdominal approach in one time. We describe our initial experience in double docking in order to perform a complete aorto-cava limphadenectomy between common iliac and renal vessels.

To demonstrate the feasibility of this robotic approach in endometrial or ovarian cancer. Patient characteristics, histological results, surgical time and complications were reported. Fourteen 14 patients since November 2010 were included. Three of them with only high abdominal approach and 11 by double docking of Da Vinci System with 180° twist of patient in order to change abdominal or pelvic approach. We add a video that shows technical approach, port sites and twist of patient. Usually we need les than 7 ports.

Median of age: 63.15 years (SD 15.00). Median BMI: 25.45 (SD 3.51). Four patients had previous laparotomic surgery. Nine patients had endometrial cancer type 2 (high histological grade) and 5 initial ovarian cancer staging.

We spend a median of 78.76 minutes (SD 24.20) in complete aorto-cava dissection and 20.55 minutes (SD 12.39) in double docking with 180° twist of patient.

Median of nodes extracted was 9.31 (SD 5.11) and length of hospital stay 2.27 days (SD 0.7 SD). Complications were one late lymphocele that no needed any treatment and one vena cava bleeding that requires a 5/0 Prolene suture. We show complete procedure in a video including cava suture.

Aorto-cava robotic lymphadenectomy by double docking approach is feasible and raises standard number of nodes in order to stage endometrial or ovarian cancer. We need some additional cases in order to analyze learning curves and improve surgical time.

FC.12.6

Audit of complications of laparoscopy

Sastry A. J.*[1], Jamieson R.[1]

[1] Rcog Glasgow United Kingdom

We looked at all laparoscopies done in our city by gynaecologists in a 6 month period using the existing computer databases.This was complemented by manually looking through the paper records held by operating theatres.It was noted that there were several unreported complications and collecting the data was not straight forward. There is an urgent need to set up appropriate data collection and reporting mechanism prior to establishing a laparoscopy dashboard-a lesson well learnt by obstetric colleagues.

Assess incidence of complications of laparoscopy and reporting mechanisms.

This was a Retrospective audit which involved.

Review of cases on Datix (voluantary reporting) and lists of cases obtained from theatre database.

Theatre log books were also reviewed.

Clinical portal was used to look through all subsequent visits of the patient to the hospitals in Greater Glasgow and Clyde area during the period of review-1st Jan 2010 to 30th June 2010.
  1. 1)

    7 unreported complications in one unit-eg; port site hernia treated by surgical colleagues,unexpected drop in Hb treated by blood transfusion

     
  2. 2)

    improper coding in one unit-no cases of laparoscopy in the whole list maintained as “ laparoscopy” on the theatre data base

     
  3. 3)

    no coding at all in the other 2 units

     

We are not aware of any specific databases for general laparoscopy. There is the national BSGE endometriosis database which does have a complication section when dealing with major Endo cases. A robust reporting mechanism helps in accurate data collection,audits,peer review and is the back bone of continuing professional development of the individual surgeon as well as the unit. All maternity services in UK have a robust reporting system. This is lacking in the gynaecology services. A “GYNAECOLGY DASHBOARD” is essential for the new and improved NHS and laparoscopic surgery should lead the way.

FC.12.7

Robotic surgical reconstruction for complete lateral and central anterior plus posterior pelvic floor defect using a modified “Y” shape mesh

Monod P.[2], Muet F.[2], Evelyne M.[2], Vlastos A.*[1]

[1] Geneva University Hospital Geneva Switzerland - [2] Clinique Belledonne Grenoble France

A new Robotic surgical procedure allowing the reconstruction of large lateral and central anterior wall prolapse as well as large posterior wall defect using a modified “Y” shape mesh handshaped according to patient anatomy. The mesh fixation starts at the Cooper ligaments goes through the cervix and the muscles elevator ani to be finally attached to the sacrospinous ligament.

Procedures for complete pelvic floor defect are performed robotically in our team including both Urologist and Gynecologist. The aim of this study is to demonstrate the feasibility and safety of our technique.

From 2007 to 2010, 68 patients were referred for complete pelvic floor defect classified minimum stage 3 (Villet classification). Robotic reconstruction by sacrospinous ligament fixation was performed using a modified handmade Y soft polypropylene mesh inserted after subtotal hysterectomy with bilateral oophorectomy in 54 (81%) patients or without oophorectomy in 6 (9%) patients. In 7 patients (10%) hysterectomy had already been performed for benign condition. Mean age was 64 years and body mass index 23. Only 3(5%) patients had a previous surgery for a genital prolapse.

Median follow-up is 12 months (1 to 48). Mean operating time blood loss and hospital-stay are respectively: 120 minutes (range 90 to 180), 150 ml (60 to 400 ml) and 3½ days. No per-operative complication, probably because of our laparoscopic learning curve for this technique. Post-operative complications included nausea and asthenia. One patient suffered from ovarian torsion and needed a surgery.No recurrence at 12 months, however, 8 patients (11,9%) presented with urinary incontinence. Anatomical overall objective cure rate was observed in 65 patients (96%).

This procedure requires a significant level of skill and training, but has, however, a very high success rate.

FC.12.8

Laparoscopic management of ectopic pregnancy: 10 years experience in A

Olowu O.*[1], Deo N.[2], Shahid A.[3], Odejinmi F.[4]

[1] Oladimeji Olowu London United Kingdom - [2] Nandita Deo London United Kingdom - [3] Anupama Shahid London United Kingdom - [4] Odejinmi Funlayo London United Kingdom

Operative laparoscopy is now regarded as the standard for the surgical management of ectopic pregnancy in both haemodynamically stable and unstable women with increasing technologic advances, and operative skill and expertise.

Ectopic pregnancy (EP) occurs in 1–2% of reported pregnancies. Laparoscopic approach to the surgical management of ectopic pregnancy is preferable to an open approach. Management has also shifted from radical to conservative methods, aimed at preserving fertility and minimising morbidity.

This was a retrospective and prospective cohort data analysis of all women with ectopic pregnancies managed surgically. A total of 116 women had surgical management from January 2000 to December 2002 and 562 women who had surgery for ectopic pregnancy between January 2003 and December 2010 took part in the study. Patient characteristics were extracted from our database in early pregnancy unit, such as socio-demography, symptomatology (stable and unstable), pre-operative ultrasound diagnosis, operative findings and specific procedure. The x2-test was used to determine if there was any statistically significant difference between the two proportions. A difference was deemed statistically significant if p- value <0.05. This difference was statistically significant (p-value <0.001).

The main outcome measure was the proportion of women requiring surgery who had operative laparoscopy in the two study periods. There has been a consistent rise in the proportion over 98% of ectopic pregnancies managed laparoscopically since January 2003 while 34% of women were managed laparoscopically during the preceding two years (2000–2002). Overall laparoscopy rate for haemodynamically stable and unstable patients were 95% and 85% respectively.

Our study demonstrates that it is possible to sustain a high rate of laparoscopic surgery for women with stable and unstable ectopic requiring surgery.

Session FC.13

* Free Communications_13 *

Technical Tricks and New Instrumentation—Operative Hysteroscopy

FC.13.1

Alternative cheap retrieval method of fibroids in laparoscopic myomectomy

Yap J.[1], Gaber M.*[1], De Lange M.[1], Afifi Y.[1]

[1] Birmingham Women’S Nhs Foundation Trust Birmingham United Kingdom

We present our case series of using the Alexis Wound Protector/Retractor® for retrieval of fibroids during laparoscopic myomectomy, providing an easy,safe and cheap alternative to morcellation.

Uterine myomectomy is the preferred treatment for symptomatic patients who are requesting preservation of fertility. A meta-analysis of randomised controlled trials of laparoscopicmyomectomy (LM) vs. open myomectomy showed that LM performed by suitably specialized surgeons in selected patients is a better choice than open surgery. We describe a new method for retrieval of fibroids during LM using the AR.

After enucleation, the fibroid is transfixed with a suture, which is brought out through the suprapubic trocar and held in an artery forceps. The trocar is then removed and the port site extended to 2–3 cm. The suture is passed through the AR, which is inserted through the extended port site into the peritoneal cavity following manufacturers’ instructions, providing atraumatic wound retraction. The fibroid is fished out through the AR with the stay suture. Fibroids are removed piecemeal. Twisting the wound sheath of the retractor will enable quick re-establishment of the pneumoperitoneum.

We used the AR in 22 cases. A total of 40 fibroids were removed (size 5–14 cm). Time used for retrieval was 8–25 min depending on the number and size of fibroids.There were no intra- or post-operative complications; hospital stay was less then 24 hours for all but 1 patient.

Extraction of fibroids during LM can be done through posterior colpotomy, morcellation or mini-laparotomy. Morcellation requires an expensive instrument and there have been concerns about safety as earlier systematic review of morcellator-related injuries across all specialities found 14 non-trivial visceral injuries and 3 patient deaths. For 1/12 of the price per patient compared to the morcellator, the AR is a safe and cost-effective alternative.

FC.13.2

Pulsed ultrasound for improved haemostasis

Frappell J.*[1], Morris E.[2], Young S.[1]

[1] Derriford Hospital Plymouth United Kingdom - [2] Norfolk And Norwich Hospital Norwich United Kingdom

LOTUS(Laparoscopic Operating by Torsional Ultrasound) is an established technology for cutting with haemostasis i n both laparoscopic and open surgery.Experimentation has shown that pulsed ultrasound combined with a change in design of the active blade results in significantly improved haemostatic performance.This is the first description of pulsed ultrasound for this indication.We present the results of animal studies on haemostasis and burst pressures after vessel sealing with LOTUS pulsed ultrasound compared with a bipolar energy device.

This study was designed to test the performance of the pulsed ultrasound LOTUS shears in a lifelike scenario, on live anaesthetised pigs.Vessels were sealed,then resected and subjected to burst pressure testing.

Pulsed ultrasound LOTUS shears

Anaesthetised pigs

Resection of sealed iliac arteries and aorta

Successful sealing of vessels up to 8 mm diameter with the LOTUS pulsed ultrasonic shears presented both graphically and with video footage confirming authenticity.

Comparison with burst pressures of a bipolar device(Enseal) on the same vessels,and with published data on other ultrasonic devices

FC.13.3

Techniques for laparoscopic re-entry for post-operative bleeding

Keedwell R.*[1], Byrne D.[1]

[1] Royal Cornwall Hospital Truro United Kingdom

Two cases of serious post-operative bleeding are shown in this video presentation. Techniques for rapid identification and cessation of bleeding points are shown. The rationale for various strategies are discussed with reference to current accepted techniques.

Post-operative bleeding following laparoscopic procedures can be a life-threatening event, and requires early diagnosis and rapid management. The current literature suggest the incidence of post-operative bleeding requiring surgical intervention following gynaecological laparoscopy is between 0.82 and 1.8%. Laparoscopic intervention for such cases, even with haemodynamic instability, has been suggested as an efficient means of achieving haemostasis due to the magnification, close inspection and suction-irrigation available during laparoscopic surgery. This approach also conveys the advantages of laparoscopy over laparotomy, such as shorter hospital stay, decreased post-operative pain and improved wound care.

In this video presentation we report two cases in which serious post-operative bleeding was dealt with quickly and effectively using direct re-entry laparoscopy. Both cases are where clinical deterioration was detected following routine laparoscopic procedures (excision of endometriosis and TLH). Herein, we discuss and demonstrate methods for rapid laparoscopic assessment and treatment to address post-laparoscopic bleeding.

Optimal clearance of intra-peritoneal blood clots is demonstrated via 5 mm suction probe, and rationale discussed. Failure of bipolar diathermy to control large bleeding vessels is shown, with application of looped suture to achieve haemostasis.

We propose that with blunt direct re-entry and effective intra-operative techniques, laparoscopy for serious post-operative bleeding is an effective and advantageous alternative to emergency laparotomy.

FC.13.4

The “Easy Load” universal knot pusher

Petrakis P.*[1], Dacco’ M. D.[2], Moustafa M.[1], Krishnamurthy G.[1], Tsimpanakos I.[1], Magos A.[1]

[1] Royal Free Hospital London United Kingdom - [2] Universita’ di Pavia Irccs Fondazione San Matteo Pavia Italy - Royal Free Hospital London United Kingdom -

The new “Easy Load”Universal Knot Pusher is suitable for all types of extra-corporeal suturing techniques.Unlike traditional devices,it can be threaded by touch rather than vision & it is suitable to tie both sliding knots and multi-throw flat knots.

Extra-corporeal laparoscopic suturing requires the use of a knot pusher.The“Easy Load”Universal Knot Pusher has been designed to make this process easier by overcoming the limitations of existing instruments:
  1. 1.

    Currently available knot pushers are designed to secure either sliding(e.g.Roeder knot)or flat knots(e.g.Surgeon’s knot)but not both.

     
  2. 2.

    Closed ended knot pushers can be difficult to load with the suture particularly if this involves having to threading through a small eye in a darkened endoscopy theatre.

     
  3. 3.

    Open ended knot pushers can drop the suture before the knot has been tied.

     

The “Easy Load” is reusable and made from high quality surgical stainless steel. It can be used through a 5 mm port.Loading the suture into the knot pusher is done by touch rather than vision by sliding the shaft of the pusher over the suture. Once caught in the tip, the suture is held securely.The pusher can then be used to tighten all types of extra-corporeal knots.The new knot pusher can also be used to apply a loop ligatures prepared from a tie.This is considerably cheaper than using pre-tied sutures, and more versatile as even relatively large pedicles can be ligated.Although designed for laparoscopy,the knot pusher might be of interest to other specialities,may prove helpful at conventional surgery when access is difficult,such as when operating deep in the pelvis.

The “Easy Load” has proved to be easier to use than conventional knot pushers.The ability to load the knot pusher by touch in a darkened operating theatre was perceived as a major advantage.

Our experience in over 50 procedures has confirmed the benefits of this new knot pusher, and this is now the only knot pusher we use at surgery.

FC.13.5

The TLH stripped

Rhemrev J.*[1], Smeets M.[1], Blikkendaal M.[2], Gahler M.[3], Van De Berg N.[3], Jansen F. W.[2]

[1] Bronovo Hospital The Hague Netherlands - [2] Lumc Leiden Netherlands - [3] Technical University Delft Netherlands

The Total Laparoscopic Hysterectomy (TLH) seems to be a complex procedure. In order to make the laparoscopic approach applicable for most hysterectomies, its complexity needs to be reduced. Therefore we introduced a new technique to simplify the most difficult step in the procedure.

The TLH procedure should be preferred above an Abdominal hysterectomy if possible. However in contrast with the known advantages its introduction in the gynaecological practise is delayed by the complexity of the procedure. In order to improve this process subsequent steps of the TLH were evaluated.

A questionnaire was answered by 20 expert laparoscopic gynaecologists. Subsequently a prospective time measurement study was performed to determine the most time consuming steps of the TLH (N = 36). Moreover a new technique to close the vaginal cuff was compared to the existing techniques (N = 320).

Finally in collaboration with the technical university of Delft we developed a method to simplify the colpotomy (the amputation of the uterus from the vaginal wall).

The questionnaire showed a total TLH procedure time of 118 min (75–158) among the experts (N = 20) and 155 min (100–190) in the novice group. The colpotomy time / total operation time was 17%. The prospective time measurement study showed a total TLH operation time of 117 (35–240) min. Whereas the colpotomy/ total operation time was 18%. The new method of colpotomy enabled a reduction of 80–90% of amputation time of the TLH measured in vitro. A prototype will be shown.

The TLH procedure evaluated by a questionnaire has been adequately objectivised by a prospective time measurement procedure. Both experts and novices use approximately 18% of their operating time on the colpotomy. A new approach resulted in a prototype that reduces the colpotomy time by 80–90% in vitro. Furthermore this technique could be superior in simplicity and safety compared to existing techniques.

FC.13.6

Trans-umbilical glove port: a simple and cost effective method for single port laparoscopic surgery for benign adnexal disease. Case report and video demonstration

Craig E.*[1], Moohan J.[1], Lawther R.[1], Semple C.[1]

[1] Altnagelvin Hospital Derry United Kingdom

We describe with pictorial and video demonstrations a novel and cheap approach to single lumen surgery. This improvised technique where a simple surgical glove is used as the port is significantly more economical than current commercially available products.

Single access techniques are a rapidly evolving field of minimal access surgery. However innovations in technology cannot easily be uncoupled from expensive patented technologies. The overall cost of single access surgery may prevent uptake of the technique. This technique has been described to perform Appendicetomies previously. We have successfully used this to address adnexal disease. This method has the advantages of being cheap, easy to set up and operator friendly, but also allows for good operative dexterity.

The natural orifice of the umbilicus is utilized. An open Hassan entry is performed through an omega shaped incision. A medium sized Alexis ® Wound retractor is inserted into the abdominal cavity. A size five glove is prepared. The tips of three fingers are removed and the reusable trocars are inserted and secured using elastic bands fashioned from the remaining glove. The cuff of the glove is then stretched over the exterior ring of the Alexis retractor. The operator uses the 2 other fingers to introduce the instrument.

A patient with suspected benign adnexal disease successfully underwent single lumen glove laparoscopy. The operation was uncomplicated and significant adhesiolysis was performed without incident. The significant economic advantages are obvious: the reusable trocars have a one off cost of £100 (€113) and the Alexis retractor costs £40 (€44) for each use compared to £250–300 for a once only single port.

We have fluidly demonstrated this and extremely cost effective transumbilical glove technique.

FC.13.7

Using filemaker Pro to document gynaecological surgery

Moustafa M.*[1], Krishnamurthy G.[1], Petrakis P.[1], Tsimpanakos I.[1], Dacco M. D.[2], Magos A.[1]

[1] Royal Free Hospital London United Kingdom - [2] Universita’ di Pavia Irccs Fondazione San Matteo Pavia Italy - Royal Free Hospital London United Kingdom

We describe the use of FileMaker Pro (FileMaker, Inc., Santa Clara, CA), a widely available relational database available for PCs and Apple computers, for documenting surgical procedures and out-patient hysteroscopies. The software is also used to generate typed reports which are given to all our patients and their GPs, and for analysis.

Although commercial medical databases for recording surgery and clinic data are available, they tend to be cumbersome and difficult to customise once installed. We describe the application of FileMaker Pro which is relatively easy to use, and most importantly, is easily configured to individual’s practice.

Although commercial medical databases for recording surgery and clinic data are available, they tend to be cumbersome and difficult to customise once installed. We describe the application of FileMaker Pro which is relatively easy to use, and most importantly, is easily configured to individual’s practice.

We have been using these two databases since 2004, and all our patients undergoing surgery or hysteroscopy are now routinely provided with a Report (along with any photographs and video recordings), a copy being sent to their GP. Our impression is that patients greatly appreciate the Reports they are given. The only limitation of FileMaker Pro is that data analysis involves writing scripts rather than being built in to the programme, but this is easily circumvented by exporting the data to other programmes (e.g. Excel).

Electronic recording of patient information is becoming the norm in modern clinical practice. FileMaker Pro is easily adapted for this type of clinical use and has several advantages over alternative software, in particular the facility for editing the drop down lists. We commend the programme to our colleagues and are happy to provide the templates for Surgery Report and Hysteroscopy Report.

FC.13.8

Reported pregnancies after Essure® hysteroscopic sterilization: a retrospective analysis of pregnancy reports worldwide during commercial distribution: 2001–2010

Levy B.[1], Veersema S.[2], Munro M.[3], Vleugels M.*[4]

[1] Franciscan Health System Tacoma United States - [2] St. Antonius Hospital Netherlands Netherlands - [3] David Geffen School Of Medicine Ucla Los Angeles United States - [4] Riverland Hospital Tiel Netherlands

We report and analyze worldwide pregnancies after Essure sterilization through 2010. Hysteroscopic sterilization using the Essure system is the most effective form of permanent sterilization available worldwide.

The CREST study disclosed that the performance of sterilization methods in commercial settings was far below that in clinical trials. We analyze and discuss pregnancies reported to the manufacturer of the Essure system worldwide through 2010 to assess the performance of this system during widespread use.

Conceptus has received worldwide reports of 748 pregnancies between commercial launc in 2001 and December 31, 2010. A total of 497,305 Essure kits were distributed worldwide. Orders were small and frequent which suggests rapid use of low inventory. Although the number of procedures performed is unknown, quantity of product distributed appears a reasonable surrogate.

The 748 pregnancies reported out of 497,305 kits dispensed results in an estimated 0.15% pregnancy rate. 660 (88%) were reported in the United States (US), and 88 (12%) outside the US (OUS). Most were due to patient or physician non-compliance (N = 263) or misinterpreted confirmation tests (N = 211). An additional 32 patients had luteal phase pregnancies or were pregnant at the procedure time. Despite repeated follow-up attempts, insufficient information was provided for the remaining 239 reported pregnancies.

Essure has been successfully used for >10 years (1998–2010). Of the 748 pregnancies reported, most were likely avoidable since they resulted from patient and physician noncompliance (N = 263) and misinterpreted confirmation tests (N = 239). The commercial data are similar to previous findings and demonstrate that the evaluable performance of Essure is consistent with the labeled age-adjusted effectiveness of 99.74% at 5 years.

Session FC.14

* Free Communications_14 *

Urogynaecology

FC.14.1

Laparoscopic Sacrocolpopexy (LSCP) vs Transvaginal mesh (TVM) repair: comparison of anatomical and functional results in the medium term. Bi-center retrospective study about 122 cases

Bader G.*[1], Ben Brahim F.[1], Huchon C.[1], Pigne A.[2], Fauconnier A.[1]

[1] Poissy University Hospital Poissy France - [2] Rothschild University Hospital Paris France

Objective: to compare the medium term anatomical and functional results of Laparoscopic Sarcocolpopexy (LSCP) and Transvaginal mesh (TVM, prosthesis Apogee ®) for POP repair.

LSCP is considered to be the reference technique for POP repair. Transvaginal mesh repair (TVM) techniques offer satisfactory anatomical results but seem to be associated with higher postoperative risk of complications and reoperation.

Bi-centric retrospective study comparing two groups of 61 patients operated for POP, respectively by abdominal and vaginal routes: LSCP vs TVM repair. The perioperative data as well as anatomical and functional results were compared.

The mean age and the population characteristics were comparable in both groups. The mean operating time of LSCP was significantly longer than TVM (p = 0.001). The rate of intraoperative complications was higher in the TVM group (p = 0.36 NS). The hospital stay was shorter in the LSCP group (p = 0.08). The anatomical result was equivalent in both groups. At 18 months of surgery, de novo dyspareunia was significantly higher in the TVM group (p = 0.015). The rate of postoperative constipation was significantly higher in the LSCP group (p = 0.02). The rate of reoperation was higher in the TVM group (p = 0.27 NS). The rate of surgery for recurrent POP was identical in both groups (p = 1).

LSCP offers a better quality of life and a greater degree of patient satisfaction with less postoperative morbidity and less reoperation rate compared with TVM techniques. These data should be confirmed by randomized trials comparing laparoscopic to vaginal route.

FC.14.2

Our experience in treatment of recurrent stress urinary incontinence

Shaparnev A.*[1], Vardanyan S.[1], Tsivyan B.[1]

[1] State City Hospital # 40 Sestroretsk, Saint-Petersburg Russian Federation

37 patients operated for SUI by TOT. 4 (10,8%) had SUI recurrence. All were treated by TVT procedure. In 18 months follow up no recurrence was mentioned.

Surgical treatment of stress urinary incontinence (SUI) by midurethral sling operations is now considered to be “gold standard” for that disease. TOT , TVT-O and TVT procedures are widely spread. But in some cases there is low or no effect.

37 patients from 51 to 65 years were operated for SUI by TOT. 4 (10,8%) patients, operated for SUI by TOT, had recurrence.

In 3 cases TOT was performed, in 1 case TOT, vaginal hysterectomy and vaginal wall reconstruction were performed simultaneously.

TOT was not effective in 2 cases, in 1 case SUI returned in 3 months (case of simultaneous operation) and in 1 case in 2 years after surgery (due to removal of part of the tape during the surgical treatment of inflammatory fistula in the place of tape introduction.).

In all cases TVT procedure was performed without the removal of the tape. It was held from 3 days to 2 years after surgery.

TVT was effective in all cases at 18 months follow up.

TVT procedure can be the operation of choice for correction of recurrence of SUI. It can be done without tape removal and is effective at any time after surgery.

FC.14.3

Pre-pubic tendon / trans obturatory arcus tendineus insertion—ischial spine mesh anchoring for simultaneous pop-repair and urinary incontinence therapy using only one vaginal mesh. Nazca TC: one mesh therapy for two pathologies?

Sawalhe P. S.*[1]

[1] Centre For Minimally Invasive Gynaecological Surgery , Female Incontinence And Pelvic Floor Surgery. Department For Obs. / Gyn., Kreisklinikum Dingolfing, Teisbacherstr. 1—Germany

Pelvic organ prolapse (POP) is very common and may affect up to 50% of porous women (1), (2), (3), (4).

Prolapse recurrence after traditional repair surgery varies from 30% up to 58% within three years after the operation) (5), (6). This rate is presumably higher if the number of women treated conservatively or those who refiuse further surgery is considered. This number is often not included in the statistics. Demographic changes associated with long life expectation of the female population will accentuate problems related to POP and urinary incontinence and force physicians to adopt new, more effective and durable repair techniques.

The present study, designed to assess the safety, efficacy, efficiency, vaginal function and anatomic results as well as urinary incontinence cure rate after Nazca TC implantation. This tension-free, monofilament, macro porous type I vaginal mesh used for the treatment of advanced cystocele, uterus and vaginal prolapse repair, with or without concomitant urinary incontinence. The rational of this procedure is to create a new robust barrier mechanism by utilizing the maximum distance between the ischial spine and the pubic bone in order to stabilize the anterior pelvic floor and support the urinary bladder including the vaginal apex, the paracolpium and the bladder neck using one mesh only.

Longitudinal clinical study from April 2008 to April 2011 of 50 patients treated with Nazca TC according to a standardized surgical procedure. Post-operative evaluation including interview and physical—gynaecological—examination using the Baden Walker halfway system for POP quantification, pelvic ultrasound and sexual function questionnaire was undertaken for sexually active women. Urodynamic assessment and questionnaire according to Ingelmann -Sundberg were applied for classification of stress urinary incontinence as per ICS criteria.

The median colpotomy incision is carried out in the anterior vaginal wall starting 2 centimetres from the external urethral meatus and extending to the uterine cervix or to the vaginal apex in women who have had a hysterectomy. The urinary bladder is dissected all the way to the ischial spine. Two small skin incisions are made; one on each side of the linea alba one centimetre cranially and one centimetre laterally from the upper edge of the pubic bone. Additional two small skin-incisions are made in the posterior area of the obturator foramen;one on each side. The anterior/ pre- pubic needle is introduced laterally to the urethra behind the tendons of the bulbospongiosus and ischio-cavenosus muscles to the pubic bone (between the periosteum and tendon) and guided pre pubically along the major labia to the previously made suprapubic incisions. The anterior arms of the mesh are connected bilaterally to the tip of the needle and pulled to the suprapubic incisions. The posterior arms of the mesh are brought around the arcus tendineus of the levator ani muscles close to the ischial spine and connected to the transobtoratory introduced helix tip. The helix is gently pulled Backwards. It is most important to make sure that the sub-urethral segment of the mesh remains tension free, while the anterior mesh arms are fixed to the pre-pubic tendon. The posterior arms are brought around the arcus tendineus of the levator ani muscles. To reinforce the vaginal apex and the paracolpium, the posterior segment of the mesh is fixed bilaterally to the sacro-uterine ligaments with permanent stitches. The vaginal wall is closed using overlapping sutures. A vaginal pack is inserted for 48 hours.A total of 50 women with symptomatic, advanced POP and SUI were assessed. Their Mean age was 65,3 years (36–84 years). The Follow up period was 24,9 months. Examination schedule: All women were examined one week, 6 weeks, 8 months and 24 months and later after surgery. Nine women (18%) had recurrence from previous treatments, seven of whom (14%) after traditional prolapse operation and 2 (4%) after biomesh implantation. Forty one women(82%) were treated with Nazca TC primarily. Thirty women (60%) suffered urinary stress incontinence, twenty nine (58%) were sexually active. Sixteen women (32%) had stage IV cystocele whereas 21(42%) had stage III cystocele and 13 (26%) had stage II cystocele. Seven patients out of fifty (14%) had uterus prolapse stage IV , 18 women (36%) stage III. , 12 (24%) stage II, and 13 (26%) had no uterine prolapse.

POP

Anatomic success, defined as prolapse stage 0 , was detected in 47 women (94%) , two (4%) had asymptomatic cystocele stage I. , and one patient (2%) had recurrence cystocele stage III. solved by colpo -mesh- / sacral fixation.

Continence: 25 women (84%) became absolutely continent, 2 (6%) had incontinence stage I. and 3 (10%) had incontinence stage II. None had incontinence stage III. The number of women with improved incontinence has not been considered, to avoid mixture of totally healed and only improved cases.

Objective satisfaction: 48 women (96%) were very satisfied with the result of surgery indicating significant improvement of their quality of life, 1 (2%) is indifferent and 1 (2%) is unsatisfied.

Sexual satisfaction: 25 women (93%) were very satisfied , 2 (7%) felt mild vaginal tension and mild dyspareonia 1 patient improved after partial resection of the mesh 3 months after the primary surgery.

Complications: No complications occurred in 47 cases (93%), two hematomas (4%) and 1 wound revision was required because of negligence: (vaginal wound dehiscence caused by vaginal pack removal at day 4 after surgery).

Erosion / exposition: 3 cases (6%) had mesh exposition in the vaginal mucosa. One of them is asymptomatic, desire to maintain status quo, the other 2 cases were solved by excision of the eroded part of the mesh in local anaesthesia without impact to the result. No bladder, urethra or intestine erosion occurred.

Excessive bleeding / blood transfusion, bladder, intestine vessel injury and abscess did not occurred.

The pre- pubic tendon anchoring method of the vaginal mesh Nazca TC is effective in POP repair and efficient in USI therapy as well. The pre-pubic tendon technique is a safe procedure, with good anatomical an functional results especially for the treatment of patients with advanced cysto—colpo and hysterocele and concomitant urinary stress incontinence.

It offers good anatomical and functional results. Prolapsed organs are relocated back to their original position respecting the morphologic anatomy of the female pelvis. Compared with other techniques (7), this method is associated with low complications ,high prolapse and incontinence cure rate. This may justify its use in primary prolapse repair in rationally indicated and accurately selected cases with or without urinary incontinence.

FC.14.4

The surgical anatomy of the rectovaginal septum

Garbin O.*[1], Frigo S.[1], Wolfram R.[2]

[1] Cmco - Pôle De Gynécologie Obstétrique Des Hôpitaux Universitaires Strasbourg France - [2] Anatomie Normale - Hôpitaux Universitaires Strasbourg France

To precise the anatomy of recto-vaginal septum in women, we study pelvises of female foetal specimens. Posterior anatomy of the pelvic floor supports is different to anterior one. The recto-vaginal septum does not really exist as a fascia. The recto-vaginal fascia, especially at the level II, is lateral and can be defined as the recto-vaginal meso.

The anatomy of the posterior supports are not so well defined and the reality of the recto-vaginal septum is discussed in women.

Pelvises of female fetal specimens embedded in paraffin, were sectioned, stained and histologically investigated with a Zeiss microscope.

At the upper side (level I), the recto-vaginal septum is a dense bind web in continuity with the paracervix, the torus uterinum and the utero-sacral ligaments. In the middle (level II), there is not a rectovaginal septum but a free-space, between the rectal and the vaginal serosas. At the underside (level III), there is no more plane of dissection and it exists a mix between the external anus sphincter and the perineal body. The space between vagina and rectum is laterally limited by a triangular strong connective structure. It contains some vessels and some nerves for the vagina and the rectum. Contrary to what we can observe on the anterior compartment, there is no exchange of conjunctive fibbers between the right and the left sides.

Some authors describe in women a dense bind web between vagina and rectum, identical to the Denonvillier’s fascia in men. In fact, this “fascia” is a surgical artefact. At the level II, histological studies describe a free space between vagina and rectum layers and the lateral triangular structure. This one, often called the mesorectum, is in fact the recto-vaginal fascia. It contains vascularization and innervation for the rectum and the vagina, joins them and fixes both to the lateral pelvic side wall.

FC.14.5

Vaginal Burch

Çapar M.*[1]

[1] Selcuk University, Meram Faculty Of Medicine Konya Turkey

Here we described a new suspension operation for the management of stress urinary incontinence in women, which we have called the transvaginal Burch operation (Capar procedure).

Stress urinary incontinence is not a life-threatening disease but can lead to discomfort caused by wetness and irritation, which can also limit the social and sexual activities of women. Several techniques have been developed for the management of stress urinary incontinence.

We previously described a new suspension operation for the management of stress urinary incontinence in women, which we have called the transvaginal Burch operation (Capar procedure).

Operative technique

The anterior vaginal wall was cut longitudinally in the midline. The anterior vaginal mucosa was opened. The urethra and the bladder were dissected away from the vaginal mucosa. The Retzius space was entered from the inferior of the symphsis pubis, and Cooper’s (iliopectineal) ligament was found indirectly with the help of the mirror of the Capar valve. An absorbable polyglactin suture (Vicryl; Ethicon Inc., Somerville, NJ, USA) was passed through the Cooper’s ligament bilaterally with the guidance of the valve. The same suture was passed from the bladder neck and the vaginal mucosa on the same side and tied appropriately. A single suture was placed on each side. After the bladder neck had been elevated suf?ciently, the vaginal mucosa was sutured.

385 women had been operated on for stress incontinence using this technique and completed 5 years of follow up. We observed complete remission during the follow-up period in most of women (90%). No major complication related to the procedure was reported.

With this technique, we have been able to achieve resolution of stress urinary incontinence using a transvaginal approach without the need for an abdominal incision.

Session V.01

* Video Session_1 *

Case reports

V.01.1

A rare case of undescended left uterine horn

Mittal A.*[1], English J.[2]

[1] Arvind Mittal London United Kingdom - [2] James English Brighton United Kingdom

A 21-year-old woman with a seven-year history of left iliac fossa pain (LIF) and dysmenorrhea was found to have a completely undescended left uterine horn; removal resulted in symptomatic cure.

The uterus develops from the Mullerian ducts from 6 to 22 weeks gestation. Disruption in this development gives rise to a variety of abnormalities ranging from uterine septation to agenesis. Renal and axial skeletal abnormalities may be associated.

A 21-year-old nulliparous woman was referred by her general practitioner with a 7-year history of worsening cyclical LIF pain associated with nausea and vomiting. She menstruated regularly. Although the pain initially responded to tricyclic pills, it later changed to a constant dull ache with severe exacerbation during withdrawal bleeds. Transvaginal scanning (TVS) showed a left pelvic kidney, a normal uterus and right ovary. The left ovary was not seen. Laparoscopy revealed a right uterine horn communicating with the cervix and vagina. There was a 4 cms non-communicating left uterine horn adherent to the abdominal wall in the LIF, connected to the vagina by a fibrous band. The left adnexa lay in proximity to the uterine horn; the latter was readily removed at laparoscopy with morcellation.

Excision of the uterine horn cured the pain.

The development of a haematometra in the left uterine horn caused LIF pain and dysmenorrhea.

Diagnosis of uterine abnormalities may be delayed and consideration should be given to diagnostic laparoscopy in symptomatic girls. Renal tract and mullerian abnormalities may be associated and the former need to be excluded. This case is unusual in that the left uterine horn was high in the LIF and not seen on TVS. Laparoscopic excision resulted in symptomatic cure.

V.01.2

Conservative laparoscopic approach of a perforated pyomyoma after uterine fibroid embolization

Pinto E.*[1], Amaral J.[1], Oliveira P.[1], Trovão A.[1], Pina C.[1], Costa A. R.[2], Morgado P.[2], Leitão S.[1], Mak F. K.[1], Lanhoso A.[1]

[1] Centro Hospitalar Entre Douro e Vouga Santa Maria Da Feira Portugal - [2] Hospital São João Porto Portugal

This video shows a successful conservative laparoscopic approach of a perforated pyomyoma with purulent peritonitis after uterine fibroid embolization.

Uterine fibroid embolization (UFE) is an optional nonsurgical treatment for premenopausal women with fibroid-related symptoms. It is currently performed at increasing rates, in patients who wish to retain their uterus and avoid surgery. Infection is one of the most serious complications, occurring in 1–2% of patients. Endometritis has been frequently reported, but pyomyoma has fewer than one hundred cases described in the literature.

A 36-year-old woman was admitted to the emergency, eight weeks after undergoing UFE. She complained of mild abdominal pain in the previous weeks, which progressed to painful cramps. Physical examination revealed fever, tachycardia, hypotension, diffuse abdominal pain with rebound tenderness and a very painful bimanual examination. Ultrasonography showed a fundal leiomyoma measuring 68 × 56 × 55 mm, that became subserosal, and moderate amount of fluid in the abdominal cavity. Due to a worsening general condition, she underwent a diagnostic laparoscopy.

In this video it is presented a laparoscopic approach for drainage and lavage of a perforated pyomyoma. The patient had an uneventful recovery and remained well at follow-up visits.

Pyomyoma is a rare condition with high morbidity and mortality. Treatment with surgery is the primary approach, however, hysterectomy leads to irreversible sterility and myomectomy can be very difficult to perform. Therefore, the need for a less invasive but curative intervention exists for women who seek conservative therapy. Recently, treatment using computed tomography-guided drainage was successfully performed in two cases of pyomyoma in the postpartum period. For the first time in the literature, the authors present a conservative laparoscopic approach for pyomyoma.

V.01.3

Extensive laparoscopic adhesiolysis and salpingo-oophorectomy in an obese patient with six previous laparotomies.

Wipplinger P.*[1], Panayotidis C.[1], Byrne D.[1]

[1] Royal Cornwall Hospital Trust Truro United Kingdom

Extensive abdomino-pelvic adhesions influence diagnostic choices and complicate definitive surgery. We present a patient with unremitting pain from a retained endometriotic ovary, who had previously had six laparotomies. Her obesity and the complex detailed dissection needed to retrieve the retained ovary favoured a laparoscopic approach.

Gynaecologists are often faced with patients who have had multiple previous operations, and who are consequently at an increased risk of adhesion formation.

Although adhesiolysis is generally not recommended as a treatment for chronic pelvic pain, it is often required to reach the operative area.

Our video demonstrates an elective laparoscopic procedure involving the freeing of extensive abdominopelvic adhesions containing small and large bowel along with ureterolysis to accomplish a right salpingo-oopherectomy in a patient who had six previous laparotomies (including TAH and adnexectomy) and six previous laparoscopies.

The procedure was carried out jointly with a gynaecologist and a colorectal surgeon and was completed without complication. The result was removal of the endometriotic ovary and complete resolution of the patient’s pain at three and sixth month follow-up.

Laparoscopic surgery is ideal for careful and delicate dissection of abdominal adhesions. It provides a detailed magnified view which allows the surgeon to work carefully to release adhesions without organ damage and to seal blood vessels as they are encountered. It also offers the considerable advantage of faster patient recovery and reduced wound related morbidity, especially in Obese patients. However severe adhesions such as this case requires careful planning, and experienced surgeons from different disciplines eg. colorectal surgeons, urologists and gynaecologists.

V.01.4

Laparoscopic myomectomy of cystic fibroid with abnormal tract to uterine cavity

De Lange M.*[1], Singh R.[1], Afifi Y.[1]

[1] Birmingham Women’S Hospital Foundation Trust Birmingham United Kingdom

We present a laparoscopic myomectomy of a 9 cm posterior wall fibroid with an abnormal tract to the uterine cavity. A cystic degenerated fibroid was identified and 200 ml of purulent fluid was aspirated. Enucleation of the fibroid was followed by multilayer uterine reconstruction and histopathology confirmed an infarcted fibroid.

A 35-year-old nulliparous woman presented with menorrhagia and recurrent miscarriage. Ultrasound scan showed a degenerated 9 cm posterior wall fibroid. Hysterosalpingography suggested a didelphic uterus. Hysteroscopy revealed a single cavity without abnormalities. MRI excluded uterine anomaly and showed a 9 cm posterior wall degenerated fibroid with an abnormal tract between a cavity in the fibroid and the endometrial cavity. Patient was consented for laparoscopic myomectomy and received three GnRH analogue injections pre-operatively. Procedure was done using 4-port laparoscopy. Vasopressin was used prior to incision. Upon incision a cystic, degenerated fibroid was found and 200 ml purulent fluid was aspirated. Enucleation of the fibroid was associated with breaching of the cavity. Closure of cavity was followed by 2 layer closure of myometrium. Surgery lasted 70 minutes. Patient was discharged within 24 hours without complications. Histopathology reported a completely infarcted fibroid, with degenerative inflammatory cells mixed with bacterial colonies in some fragments.

Fibroid degeneration can occur spontaneously, in pregnancy or after treatment such as uterine artery embolization or GnRH analogue injections. It is unusual to find degenerated fibroid of a cystic nature with purulent fluid present. The impression of a didelphic uterus on HSG can be explained by the presence of the tract connecting the fibroid with the endometrial cavity as suspected by MRI. Purulent fluid may have been present in the endometrial cavity, possibly having an embryotoxic effect.

V.01.5

Laparoscopic partial cystectomy for bladder endometriosis: report of three cases that have desire for childbearing.

Arima H.*[1], Asada H.[1], Ito K.[1], Tsuji-nishiyama H.[1], Furuya M.[1], Kishi I.[2], Kobiki K.[3], Yoshimura Y.[1]

[1] Keio University School Of Medicine Tokyo Japan - [2] Saiseikai Central Hospital, Department Of Gynecology Tokyo Japan - [3] Kobiki Women’s Clinic Kawasaki Japan

Laparoscopic partial cystectomy for bladder endometriosis seems effective for women who were difficult to be medicated with hormonal therapy.

Endometriosis is the proliferation of endometrial tissue outside the normal confines of the myometrium or uterine cavity. Endometriosis involving the urinary tract occurs in approximately 1% to 2% of cases. Urinary bladder endometriosis may be treated surgically or medically with hormone-suppressive therapy. We report our experience in three patients with vesical endometriosis who were managed successfully with laparoscopic partial cystectomy and got pregnant.

Three women (33, 34 and 35-years-old) who had desire for childbearing had dysmenorrhea and severe urinary frequency during menses. All patients were diagnosed by existence of bladder nodule with transvaginal ultrasound and small foci of increased high signal intensity with T2-WI of magnetic resonance imaging. Intraoperative cystoscopy was performed on all patients. Cystoscopic guidance was used for the initial cystotomy. And ureteral stents were placed if lesion area of endometriosis that was distant from the ureteral orifices to allow a resection margin of 1-2 cm. Laparoscopic partial cystectomy was performed after complete dissection of the uterovesical space with separation of the bladder from the uterus. All cases had adenomyotic focus lying under the vesical lesion, so we removed a 0.5- to 1-cm-deep myometrium. Patients had extravasation on cystogram 1 week postoperatively, without evidence of leakage into the peritoneum.

After laparoscopic surgery, the symptoms totally regressed in all patients. Two cases got pregnant naturally and one was obtained using in-vitro fertilization techniques (IVF).

Laparoscopic partial cystectomy for bladder endometriosis seems effective for women who were difficult to be medicated with hormonal therapy.

V.01.6

Laparoscopic repair of a uterine wall defect on a caesarean scar

Dimitriou E.*[1], Mpalinakos P.[1], Bardis N.[1], Pistofidis G.[1]

[1] Leukos Stauros Athens Athens Greece

To present an edited video of an interesting and unusual case

M.K. 33 had a caesarean section in 2009 at term of her 1st pregnancy for failure to progress in 1st stage of labour. In 2010, had a second pregnancy who miscarried at 19 weeks following rupture of the membranes. The fetus was delivered vaginally and labor was induced by prostaglandins. 2 months later in a routine follow up with ultrasound, a cystic structure was seen anteriorly to the uterus in direct communication with the uterine cavity at the level of the caesarean scar. This was thought to be a fenestration of the uterine wall and a laparoscopic excision and repair was planned.

Under general anaesthetic, a main port was inserted at the umbilicus with the Hasson technique. Three auxiliary trocars 5 mm each were also inserted under direct view. The bladder was then mobilized from the cystic structure and the uterovescical area, where very dense adhesions were noted. The cyst was then detached from the anterior surface of the isthmus of the uterus when it was ruptured as well. The communicating canal was seen and was noted to be covered by endometrium as it was the inner side of the cystic wall. The defect was closed primarily after rejuvenation of the edges. The bladder was then further mobilised and a defect on the detrusor was closed with separate sutures.

The outcome was good and an ultrasound scan 3 weeks later showed normal anatomy.

This was an unusual case of a ceasarean scar dehiscence, probably caused by the induction of labour for the late miscarriage.

V.01.7

Laparoscopic repair of uterine scar after c section

Istre O.*[1], Springborg H.[1]

[1] Division Of Minimal Invasive Gynecology Private Hospital Hamlet, Copenhagen Denmark

It’s of importance to be aware of this condition in patient with change in menstrual pattern and pain after CS. This condition can be repaired both with hysteroscopy or laparoscopy. The different clinical pictures as well as their treatment is discussed.

After a caesarean section (CS) 60–70% of all patients have a defect in the uterine scar. It is defined as a triangular anechogenic space at the presumed site of the CS scar. It is associated with post menstrual spotting and it is seen in 34% of these women. Spotting due to a niche is not responding to hormonal therapy and is associated with cyclic pain and reduced quality of life.

A video shows the diagnostic evaluation in these patients. Preoperative ultrasound, hysteroscopy and laparoscopic repair is presented in this video

This video shows a patient with above symptoms and a complete defect in the uterine scar as well as very dense adhesion from the anterior part of the uterus to the abdominal wall, this is repaired with excision and suture of the defect and interceed to prevent postoperative adhesion formation

It’s of importance to be aware of this condition in patient with change in menstrual pattern and pain after CS.

V.01.8

Laparoscopic sacrohysteropexy on a unicornuate uterus

Wipplinger P.*[1], Panayotidis C.[1], Byrne D.[1]

[1] Royal Cornwall Hospital Nhs Truro , Cornwall United Kingdom

We demonstrate a laparoscopic the first laparoscopic mesh sacrohysteropexy on a unicornuate uterus as treatment for primary uterine prolapse.

Our literature search has not revealed any other such reports. We describe the first laparoscopic sacrohysteropexy performed on a unicornuate uterus as treatment for primary uterine prolapse. The finding of a unicornuate uterus was unexpected pre-operatively but the procedure was still successfully completed. The anatomical distortion altered the technique as one side of the broad ligament was almost completely absent.

Laparoscopic sacrohysteropexy was performed through four ports using a hand shaped polypropylene knitted non-asborbable mesh (Prolene™), sutured around the cervix and then fixed to the sacral promontary with a ProTack™ fixation divice. Our standard technique was altered to accomadate the anatomical changes found at surgery.

The outcome was successful treatment of primary uterine prolapse. Pre and post operative Pelvic Organ Prolapse measurements (POP-Q) were taken to demonstrate the anatomical improvement as well as record of symptomatic improvement from patient consultation. There was no surgical or post-operative complications.

We discuss the adaptation of the sacrohysteropexy technique that was required to overcome the challenges faced by the congenital abnormality. We demonstrate this technique in our video presentation. This publication will allow other surgeons to be confindent that the procedure can be performed in cases of unicornuate uterus. We make reference to the literature relating to surgery on congitally abnormal uteri.

V.01.9

Laparoscopic staging and debulking of a uterine malignant mixed mullerian tumor.

Wattiez A.[1], Alcocer J.*[1], Vazquez A.[1]

[1] Ircad Strasbourg France

We present the surgery of a 61-year-old woman with a pelvic mass of an utero-adnexial origin diagnosed by ultrasound. The patient complained of transvaginal bleeding, light pelvic pain, and dyschezia. At bimanual examination, we found the Pouch of Douglas occupied and a fixed uterus. A contrasted CT scan revealed no apparent signs of metastasis.

In this high definition video we show, step by step, the procedure of a peritoneal washing, adhesiolysis for restoration of normal anatomy, bilateral adnexectomy, radical hysterectomy, pelvic lymphadenectomy, and pelvic debulking. In this case, it was necessary to do a rectal mucosa shaving, with posterior wall reinforcement. During the surgery, we sent the both ovaries for transoperatory study, which revealed malignity and necrosis. The definitive histological report was of a “malignant mixed mullerian tumor” with a heterologous rhabdomyosarcoma, serous adenocarcinoma components, and parametrial infiltration. Therefore it was staged as a T3bN0M0, FIGO 2009 Stage IIIB. There were no complications during or after the surgery. The patient is in general good conditions to receive multiple agent chemotherapy, although with a bad survival prognosis.

V.01.10

Preserving fertility on cervical cancer—case report

Amaral J.*[1], Arteiro D.[1], Pinto E.[1], Oliveira C.[1], Leitão S.[1], Ferreira S.[1], Alves A.[1], Lanhoso A.[1]

[1] Entre-O-Douro-E Vouga Hospital Center, Santa Maria Da Feira, Portugal

Cervical cancer is the second most common cancer in women with an incidence of 13-14/100000 in Portugal. An increasing number of women with invasive disease are submitted to radical hysterectomy (RH) losing their reproductive ability even before family plannig. Radical trachelectomy (RT) comes as an option to preserve fertility without compromising oncological prognosis.

On this video the authors show the first vaginal RT with pelvic lymphadenectomy (PL) performed by laparoscopy in their institution.

31-year-old healthy women, G0P0, sent to our hospital with a high-grade squamous intraepithelial lesion (HG-SIL) diagnosed by routine cytology. Colposcopy showed acetowhiteness and mosaic involving half of the right side of the cervix, suggesting high-grade lesion. Biopsy showed severe dysplasia (CIN III). Conization with loop electrosurgical excision procedure reveals squamous cell carcinoma with 6 mm extension, 4 mm corion invasion, without evidence of lymph-vascular or perineural structures invasion, 1 mm distant from surgical plan (stage IA2). Considering the diagnosis and the pacient’s wishes in mantaining fertility, she was selected for vaginal RT with PL by laparoscopy. Lymph nodes were negative and vaginal RT was performed. Definitive hystological evaluation of the cervix showed no evidence of malignancy and confirmed the absense of nodal metastases. Four mouths after surgery no changes were found on cytology and colposcopy. One year after the patient is still free of disease.

Few years ago, treating cervical cancer with safety ment losing reproductive function. With the development of vaginal RT with PL by laparoscopy and careful selection of patients it is possible to select a group of women that can benefit from this conservative procedure with the same or less perioperative morbidity than with RH and with comparable oncological prognosis.

A strict surveillance of the patient with cervical cytology and colposcopy is essential.

V.01.11

Sils for ovarian malignancy cases

Andou M.*[1], Ohta Y.[1], Hada T.[1]

[1] Kurashiki Medical Center Kurashiki Japan

In carefully selected cases, single port surgery (SILS) can play a therapeutic role in the treatment of ovarian malignancies. We will present two unique cases.

Recent trends to reduce the number of laparoscopic ports prompted us to introduce SILS port into malignant ovarian tumor cases.

We will present two cases with ovarian malignancy who underwent single incision laparoscopic surgery (SILS). Case one presented with 11 kg suspected borderline tumor. The young patient’s parents strongly requested minimally invasive surgery despite the risks of tumor content spillage which also existed in open surgery due to tumor size. She underwent a SILS port adnexectomy as the skin incision is larger than traditional laparoscopy. To minimalize tumor content spillage we made a purse-string suture on the tumor wall and aspirated the content. After removal, the peritoneal cavity was irrigated with saline. Pathology revealed mutinous borderline malignancy so we performed a SILS port laparoscopic intraperitoneal restaging procedure consisting of ascetic fluid sapling, multiple peritoneal biopsy, appendectomy, omentectomy. The second case suffered from epithelial ovarian cancer and underwent a SILS port transperitoneal lymphdenectomy and extraperitoneal para-aortic dissection.

Patients were able to take advantage of the fast recovery time to begin adjuvant therapy earlier. As one patient was young, the cosmetic advantage was an important result.

SILS makes it possible to access retroperitoneal space and offers good cosmesis and fast recovery even for patients with gynecologic magnancies.

V.01.12

Symptomatic subserous multicystic uterus: case presentation.

Pados G.[1], Makedos A.*[1], Diamanti K.[2], Ntinou Z.[2], Misiaka D.[2], Tarlatzis B.[1]

[1] 1st Department Of Obstetrics And Gynecology, Aristotle University Of Thessaloniki, “papageorgiou” G.H. Thessaloniki Greece - [2] Centre For Endoscopic Surgery “diavalkaniko” Hospital Thessaloniki Greece

Video presentation of the laparoscopic management of multiple subserous uterine cysts, in a 34 year old female patient presented with urinary urgency.

Case presentation of a female patient with multiple uterine cysts, a rare entity of unknown etiology.

A 39 years old patient presented in our gynecological outpatient clinic with symptom of urgency for urination. From the radiological investigation with trans-vaginal ultrasound scan and MRI, the presence of multiple subserous cysts were diagnosed around the uterus with diameters of 0.5–3.9 cm, with the greatest of these situated on the anterior uterine wall at the level of the isthmus, applying pressure to the urinary bladder. Due to the inconclusive diagnosis and the absence of relevant literature, a diagnostic laparoscopy was performed. During the procedure multiple cysts were seen around the uterine body, fully covering it. Tubes and ovaries were checked anatomically normal. Cystic tissue was primarily sent for acute pathology, which came up as cystadenomas with endometrial type epithelium, but without atypia. With the use of CO2 laser the greater cysts were excited and the smaller in size were vaporized. The final histopathological report was “multiple small endometrioid cystadenomas with extended tubal metaplasia of the endothelium in field of adenomyosis”.

Patient’s symptoms resolved just after the operation.

Subserous uterine cysts are widely unknown and present with inconclusive symptomatology. Laparoscopic surgery can be a safe and accurate diagnostic and operative approach.

V.01.13

Unusual causes of fallopian tube enlargement

Lord J.*[1], Malhotra A.[1], Justin W.[1]

[1] Southend University Hospital Southend-On-Sea United Kingdom

Fallopian tube enlargement is common and mostly a result of pelvic infection. We present a case of fallopian tube hemangioma and one of intraluminal endometriosis of the tube

Most cases of pathological tubal enlargement are because of pelvic inflammatory disease. However, occasionally other causes may be found at histological examination. We present two such cases of benign tubal enlargement.

Retrospective analysis of case notes, histology reports and operative videos

Case 1–42 year old presenting with dysmenorrhea , menorrhagia and midcycle pelvic pain. Transvaginal scan did not show any suspicious findings. On laparoscopy a dilated left tube was found. Laparoscopic partial salpingectomy was performed. Histology showed hemangioma of the fallopian tube.

Case 2–41 year old lady who presented with subfertility, pelvic pain and deep dyspareunia. Ultrasound demonstrated bilateral dilated tubes. Laparoscopic salpingectomy was performed prior to IVF treatment. Histology showed endometriosis of the fallopian tube.

Only 8 cases of hemangioma of the fallopian tube have been reported in the literature so far. Most reported cases have presented acutely with severe abdominal pain and hemoperitoneum. Our case is different as the presentation was more chronic, perhaps because the hemangioma was not very large.

Endometriosis is a common condition and can occasionally affect the serosal surface of the fallopian tube. Intraluminal fallopian tube endometriosis is less common and can lead to distension of the fallopian tube with blood which can be identified on ultrasound. It is important to know that all tubal enlargements are not because of PID and other aetiologies need to be ruled out.

V.01.14

Video presentation: laparoscopic right partial oophorectomy to treat ruptured ovarian ectopic pregnancy

Afifi Y.[1], Lokman M.*[1]

[1] Birmingham Women’S Nhs Foundation Trust Birmingham United Kingdom

Ovarian ectopic pregnancies are rare events. Recently, a ruptured ovarian pregnancy was managed by laparoscopic right partial oophorectomy in the Birmingham Women’s Hospital. This operation has been recorded as a video presentation.

This case involves a 20 year old woman (Ms K) with severe right abdominal pain and a positive pregnancy test. On assessment, Ms K’s observations were normal other than slight tachycardia. However, patient had collapsed 5 times at home. Scan findings showed a right adnexal mass consistent with a 7/40 ectopic pregnancy and free fluid in the pelvis. The patient was prepared for laparoscopy, salpingectomy +/− proceed.

The surgical procedure has been recorded as a video presentation on CD-ROM.

Literature search was performed on the topic of ovarian pregnancy.

Systematic examination at laparoscopy revealed a ruptured right ovarian pregnancy. Both the Fallopian tubes and uterus appeared normal. We proceeded with right partial oophorectomy and products of conception were sent for histology. Ms K made a good recovery and was discharged the next day. The histological report showed disrupted ovarian cortical tissue and adherent blood clot within which immature chorionic villi from an early pregnancy are seen, as well as disrupted placental membranes. Appearances confirm clinical diagnosis of an ovarian ectopic pregnancy.

Current literature report the rate of ovarian pregnancies is between 0.5 to 3% of all ectopic pregnancies. Risk factors are similar to all types of ectopic pregnancies. It has been hypothesised that an ovarian pregnancy is a result of secondary implantation of the embryo or of failure of follicular extrusion. Diagnosis can be made by ultrasound appearance of a wide echogenic ring on the ovary with a yolk sac or fetal parts but more frequently through diagnostic laparoscopy. This is then confirmed by histological findings.

Session V.02

* Video Session_2 *

Complications—Endometriosis: Surgery—Hysterectomy

V.02.1

Intestinal repair using single port laparoscopic surgery

Çapar M.*[1]

[1] Selcuk University, Meram Faculty Of Medicine Konya Turkey

We present a case of intestinal injury during laparascopic surgery which was repaired by laparoscopic intervention. Benefits of minimally invasive surgery can be safely and efficaciously extended to select patients with small bowel perforation.

Laparoscopic surgery has gained clinical acceptance in recent years for the treatment of patients with a variety of gastrointestinal diseases. operative wound sepsis and its resultant morbidity in patients with small bowel perforations has been a major limitation for this type of surgery. We intended to extend the benefits of minimally invasive surgery to traumatic l bowel perforations, in terms of assessing its feasibility and limiting wound sepsis.

Case: 31 Years old patient presented with chronic pelvic pain for one year duration. Laparoscopy was planned because endometriosis was suspected. Under general anaesthesia Optic trochar was introduced directly (closed entry). Small intestine was seen perforated with about 1.5 cm. Multiple adhesions were seen between abdominal organs. A 5 mm trochar was introduced from adhesion free area. The injury in the intestinal wall was repaired using 3.0 no. vicryl suture, 2 sutures were applied. The adhesions were removed using sharp discection.

Abdominal cavity was washed and the operation ended.

The patient was discharged on 3rd postoperative day and called for control after 1 week, she was very well and she had no more pelvic pain.

we conclude that laparoscopic intervention in small bowel perforation is technically feasible and that it yields favorable outcomes. Benefits of minimally invasive surgery can be safely and efficaciously extended to select patients with small bowel perforation in terms of limiting sepsis-related wound complications.

V.02.2

Laparoscopic repair of uterine scar dehiscence following caesarean section

Garbin O.*[1], Vautravers A.[1], Wattiez A.[1]

[1] Cmco - Hôpitaux Universitaires Strasbourg France

This video shows the laparoscopic repair of a uterine scar dehiscence following caesarean section.

Caesarean section is very common. Scar dehiscence may occur, be symptomatic and compromise subsequent pregnancy.

A 30 years old patient was referred for a symptomatic pelvic mass. She had a praevious caesarean section. Ultrasound scan showed a haematic mass in continuity with the isthmus. Hysterography revealed a fistula between the caesarean scar and the subperitoneal space. Laparoscopic procedure was performed.

After the incision of the bladder peritoneum and the dissection of the uterovesical fold, scar tissues were excised and the hysterotomy was closed in two layers. Postoperative course was uncomplicated and controls (ultrasound and hysterography) were satisfying.

Scar uterine dehiscence following caesarean section are not uncommon. They can be responsible to bleeding, pain and uterine rupture. They are recognised by ultrasound scan. There are no guidelines for their management. Some authors reports vaginal or vaginal and laparoscopic combined repairs. Laparoscopic reparation alone is feasible.

V.02.3

Pearls of laparoscopic surgery, part ii—a fine selection of intra-operative complications

Mohr S.*[1], Buss J.[2], Dubuisson J.[3], Eberhard M.[4], Fehr P. M.[4], Günthert A.[1], Hohl M. K.[5], Stucki D.[2], Wenger J.[3], Mueller M. D.[1]

[1] University Women’S Hospital Inselspital Bern Switzerland - [2] Hopital Cantonal De Fribourg Fribourg Switzerland - [3] Hopitaux Universitaires De Geneve Geneve Switzerland - [4] Kantonsspital Schaffhausen Schaffhausen Switzerland - [5] Kantonsspital Baden Baden Switzerland

A selection of intraoperative complications will be provided in short video sequences for educational purposes.

After having shown Part I of our Pearls of laparoscopic surgery with special intra-operative findings last year, this year’s video focuses on intra-operative laparoscopic complications. We would like to comment and present take-outs from laparoscopic recordings of such special situations from different swiss hospitals.

Laparoscopic surgery recordings were processed and merged in short didactic sequences. Thereby intraoperative complications like bowel and vessel lesions and other challenging situations are shown.

With sequences ranging from simple faulty devices to the technical handling of special situations the film is a versatile and educational mixture of short films

Due to consistent recording of all endoscopic operations it is possible to retain exceptional laparoscopic findings, unexpected intraoperative situations and prospects of laparoscopic management. Recordings allow circulation of this information. This advantage of endoscopic surgery should more extensively be used in university studies, CME and training.

V.02.4

Title: Laparoscopic removal of mccall suture following ureteric injury

Boggs E.*[1], Mcdermott C.[1], Lefebvre G.[1]

[1] St. Michael’S Hospital Toronto Canada

To review a case complicated by ureteric ligation injury following vaginal hysterectomy and McCall culdoplasty for prolapse. To describe the sequential management of this injury that utilized a laparoscopic approach for ureterolyisis and release of McCall suture.

A video of the surgery is presented to demonstrate this technique.

The role of prophylactic vault suspension following vaginal hysterectomy has been proven to reduce vault prolapse recurrence. Ureteric injury complicates vault suspension techniques in up to 7% of cases. Once a ureteric ligation injury has been identified the traditional step-wise approach to management involves removing the vault suspension and anterior colporrhapy sutures. We employed a different approach by laparoscopically identifying the ligation suture and rermoving.

Case review and video presentation demonstrating the step-wise approach to diagnosis and management. A 3.30 min video of the laparoscopic technique for ureterolysis and suture removal.

In this case, a ureteric injury was diagnosed on post-operative CT urogram. The McCall suture was then cut vaginally without release. Retrograde and antegrade stenting was attempted but unsuccessful leading to placement of a nephostomy tube on the affected side.

Options for release of ureteric ligation include approaches via vaginal, abdominal laparotomy or abdominal laparoscopy. In conjunction with urology, the decision was made for laparoscopic ureterolysis.

The operative video demonstrates the ureterolysis extending distally from the common iliac to the vaginal vault. The internal McCall suture is clearly seen ligating the ureter. Laparoscopic cutting of the suture results in the immediate release of the ureter.

Intraoperative fluoroscopy and retrograde stenting completes the procedure.

This case demonstrates a minimally invasive correction technique for ureteric ligation injury following McCall culdoplasty.

V.02.5

Uterine incarceration of a fallopian tube

Garbin O.*[1], Chauvet-degot M.[1], Wattiez A.[1]

[1] Cmco - Hôpitaux Universitaires Strasbourg France

This video shows the hysterocopic discovery and the laparoscopic management of uterine incarceration of a fallopian tube.

Suction curettage for abortion, or of afterbirth can be responsible to various complications. Incarceration of the tube is an uncommon one.

A 28 years old patient delivered 2 months ago. She presented heavy bleeding 3 weeks later. Two D and C were performed the same day. Bleeding remained and the patient was referred for a placental polyp.

Diagnostic hysteroscopy revealed synechias, placental rests and discovered a fimbria inside the uterine cavity. A laparoscopy revealed 4 uterine perforations scars and a right fallopian tube incarceration through the posterior uterine wall. The tube was extracted and the dehiscence of the uterine wall was closed. In the postoperative course, an Ashermann’s syndrome was treated 5 week’s later.

Incarceration of the tube is an uncommon complication of a uterine perforation. It can be responsible to bleeding, vaginal discharge and pelvic pain. The diagnosis is rarely done before the diagnostic hysteroscopy. Desincarceration of the tube and uterine repair can be realized by laparoscopy.

V.02.6

Vaginal dehiscence and small bowel procidence after laparoscopic radical hysterectomy

Rossetti A.*[1], Sizzi O.[1], Ruggiero A.[1]

[1] Nuova Villa Claudia Hospital Rome Italy

A RARE CASE OF VAGINAL DEHISCENCE AND SMALL BOWEL PROCIDENCE AFTER LRH

This video presents a rare case of surgical complication.The patient had been previously operated on in another hospital of laparoscopic radical hysterectomy for early cervical cancer. Probably because of an injury of the hypogastric nerve, postoperatively the patient lamented difficulties in completely voiding the bladder with completely lack of voiding stimulus. On post-operative day 15, while the patient was straining to void the bladder, the bowel protruded through the suture of the vaginal vault.

The patient presented at the emergency room of our institute with several loops of the small bowel protruding through the vagina and a severe pelvic pain.

The bowel loops appeared to be cyanotic and edematous. It was impossible to reduce the procidence through the vagina.An emergency laparoscopy was planned, but again it was impossible to reduce the prolapse of the bowel loops by gentle pulling on the small bowel. The bowel was contracting thus further moving out and too edematous.The vagina was reopened, cutting the suturing stitches. At this point it was feasible to pulling back into the abdomen the prolapsed bowel loops.

The vaginal suture was completed both vaginally and laparoscopically, to strengthen it as much as possible. The procedure was concluded with a thorough check of the integrity of the bowel and its vascular supply.The patient had an uneventful postoperative period with bowel canalization restored 12 hours after the surgical procedure.

Only a very timely intervention is able to avoid the need to perform a bowel resection due to ischemic necrosis of the small bowel loops.After this case and given the many cases of dehiscence or bleeding of the vaginal vault after laparoscopic hysterectomy, to avoid this common complications we strongly recommend to suture the vagina in a double layer fashion.

V.02.7

Laparoscopic boari flap- psoas hitch method for extensive ureteral endometriosis

Andou M.*[1], Ohta Y.[1], Hada T.[1]

[1] Kurashiki Medical Center Kurashiki Japan

Extensive urinary tract defect is compensated for by Boari flap and Psoas hitch techniques performed totally laparoscopically in cases suffering from urinary tract stenosis due to endometriosis.

Ureteral endometriosis is a rare yet important entity that can lead to even silent renal failure. Sometimes extensive resection and complex reconstruction of the urinary tract is required to compensate for large ureteral defects.

To make this intrinsically invasive procedure more patient friendly we have introduced a laparoscopic Boari flap with psoas hitch method. This method is an effective option for bridging large lower ureteral defects when tension would still exist after anastomosis. We present both extravesical and transvesical methods. To enhance extension of the bladder, the Boari flap duct is hitched to the psoas tendon. Finally the ureteral stump is anastomosed to the bladder duct created by this flap. In case 1 we performed an extravesical Boari’s flap technique with a psoas hitch to extend the bladder to deal with the shortness of the ureter. In the Case 2 procedure we performed our transvesical technique. The difference is the creation of a submucosal tunnel to prevent regurgitation.

The recovery time was quick and no case has suffered from urinary regurgitation or stenosis. The extravesical technique may be more feasible in cases with more extensive defects. In this situation it also offers easier connect-ability but has the disadvantage of possible urine backflow. The transvesical technique has the advantage of creating an anti-reflux valve and offering a more stable result.

Laparoscopic reconstruction of the urinary tract using Boari flap with psoas hitch is safe and feasible with the patient friendly advantage of being minimally invasive. As this procedure is technically demanding, training and improvement of suturing skills is important.

V.02.8

Total laparoscopic removal of huge uterus using the ligasure™ device, classical bipolar and barbed v-loc™ suture

Wattiez A.[1], Vazquez A.*[1], Maia S.[1], Alcocer J.[1]

[1] Ircad Strasbourg France

We present the case of a 54-year-old woman with pelvic pain. Ultrasound shows a huge uterus with multiple fibroids. Abdominal exploration manifests an uterus size equivalent to 24 weeks gestation. In this video, we demonstrate that with different technology like LigaSure™, barbed suture and Clermont-Ferrand uterine manipulator, and with an adequate knowledge of the anatomy and surgical technique a total laparoscopic hysterectomy can be performed without too much difficulty despite the uterine size.

V.02.9

Laparoscopic excision of endometriosis & left ureteric re-implantation

Misra G.*[1], Golash A.[1]

[1] Gourab Misra Stoke-On-Trent United Kingdom

Laparoscopic excision of 8 cm left endometrioma involving the left ureter and re-implantation of left ureter.

A 39 yrs old patient presented with pelvic pain and secondary subfertility. An USS , MRI and CT urogram was done to evaluate the extent of disease. Imaging confirmed left endometrioma with ureteric involvement and partial obstruction and diminished kidney function (38%).

Case report and video presentation

Laparcopic excision of disease and left ureteric re-implantation was perfored by a team of consultant gynaecologist and consultant urologist. The patient made a very good recovery and follow up CT urogram confirmed a patent ureter and no signs of leakage.

An example of multidesciplinary approach in the surgical management of endometriosis involving the left ureter.

V.02.10

Laparoscopic excision of severe endometriosis

Einarsson J. I.*[1]

[1] Brigham And Women’S Hospital/harvard Medical School Boston United States

We present a case of a 31 year old G0 with left sided pelvic pain and intermittent left sided hydronephrosis. On examination her pelvis is essentially frozen, with very limited mobility. This case was extensively discussed on the AAGL ListServ site and various treatment options were recommended, including Lupron, in vitro fertilization and surgery. We opted to proceed with surgery first given the significant amount of induration on examination and the history of intermittent hydronephrosis. The video demonstrates our routine for performing these challenging cases.

We present a case of a 31 year old G0 with left sided pelvic pain and intermittent left sided hydronephrosis.

On examination her pelvis is essentially frozen, with very limited mobility. This case was extensively discussed on the AAGL ListServ site and various treatment options were recommended, including Lupron, in vitro fertilization and surgery.

We opted to proceed with surgery first given the significant amount of induration on examination and the history of intermittent hydronephrosis. The surgical technique and findings are shown.

Laparoscopic excision can be challenging. Knowledge of anatomy and adequate exposure are essential tools for a successful procedure.

V.02.11

Rectal disc excision in cases of deep infiltrating endometriosis

Kostov P.*[1], Neukomm C.[1], Mueller M.[1]

[1] University Hospital Bern Switzerland

A laparoscopic disc excision with a curved intraluminal stapler in cases of deep infiltrating endometriosis is a valid technique if only a single nodule infiltrates less than 3 cm of the rectum wall

In cases of deep infiltrating endometriosis many authors suggest a colorectal resection removing the rectal segment affected by the disease, while others the nodule excision either without opening the rectum (shaving) or by removing the nodule along with the surrounding rectal wall (full thickness or disc excision). The main argumentation for the more conservative procedure is the lower complication rate. Both surgical techniques may be performed minimally invasive by a laparoscopic approach

In this video we present our technique for disc excision. The indication is single nodule with area infiltrating the rectum wall smaller than 3 cm. The nodule is first isolated from the ureters and the vagina after colpectomy and dissection of the rectovaginal septum. Then follows a subtotal resection of the nodule leaving the rectum wall intact. The remaining infiltrated rectum wall is excised with a Curved Intraluminal Stapler (EthiconEndo-Sugery, USA)

The nodules were removed completely with endometriosis free resection boards. No intra- or postoperative complications occurred. In a follow up of 12 months all patients were free of endometriosis-related bowel symptoms

This technique allows the complete laparoscopic excision of single nodule when the infiltrating area is smaller than 3 cm. The intraluminal bowel resection and specimen extraction is performed without intraabdominal opening of the rectum wall with minimal anatomic alteration and less risk for complications. Therefore the indication remains limited because of frequent presence of satellite nodules which requires a segment resection

V.02.12

Best video selection of the ibs □ (integrated bigatti shaver) in action

Bigatti G.*[1], Ferrario C.[1], Rosales M.[2], Baglioni A.[1], Bianchi S.[3]

[1] U.O. di Ostetricia e Ginecologia, Ospedale Classificato San Giuseppe Via San Vittore, 12–20123 Milano - Italia - [2] U.O. di Ostetricia e Ginecologia, Ospedale Classificato San Giuseppe Via San Vittore, 12–20123 Milano - Italia - [3] ° Università degli Studi di Milano, Direttore Dell’unità Opertiva di Ostetricia e Ginecologia Ospedale Classificato San Giuseppe Via San Vittore, 12–20123 Milano - Italia

Conventional bipolar resectoscopy is widely recognized as first choice procedure for major hysteroscopic operations

We have recently proposed an alternative approach to operative hysteroscopy called IBS® Integrated Bigatti Shaver that improving the visualization during the procedure reduces several problems of conventional resectoscopy such as, fluid overload, water intoxication uterine perforation and long learning curve.

In cooperation with Karl Storz GmbH & Co. we have created a new shaving system that, introduced through a straight operative channel of a panoramic 90° optic, allows performing all kinds of major hysteroscopic operations.

At present we have performed more than 150 cases including all kinds of operative hysteroscopic procedures such as polyps and submucosal myomas resection, septum resection and endometrial ablation according to ESGE classification. We present this video selection with the most interesting cases performed with the IBS□ in comparison with conventional bipolar technique.

We confirm the several advantages offered by the IBS□ that with a better visualization during the procedure as tissue chips are removed at the same time of resection, makes operative hysteroscopy safer, easier and faster.

V.02.13

Single port access subtotal hysterectomy: a first case with a new device (x-cone)

Pontis A.*[1], Maricosu G.[1], Dessole M.[1], Mereu L.[2], Mencaglia L.[2], Melis G.[1], Angioni S.[1]

[1] Division Of Gynecology, Obstetrics And Pathophysiology Of Human Reproduction, University Of Cagliari, Italy - [2] Gynecological Division, Florence Oncological Centre (Cfo), Italy

We present a case of subtotal hysterectomy by single port access laparoscopy (SPAL)

A 42-years-old women, with a history of two births via vaginal delivery and with a previous surgery for endometriosis. The patient had middle cycle pain (VAS 10) and dysmennorrea (VAS 10). She had a regular menstrual cycle and a normal hormonal profile indicating an ovulatory cycle. Gynecological examination revealed an antiverted uterus, markedly tender, normal ovaries. Ultrasound evaluation was suspicious for adenomyosis with no signs of pelvic endometriosis.

A. single port access laparoscopy was performed. We used a reusable single site trocar with 5 integrated access port (S-Portal X-Cone; Karl Storz, Tuttlingen, Germany). A 2 cm intraumbilical vertical skin incision and a 2,5 cm rectus fasciotomy were perfomed to enter the peritoneal cavity. A rigid single curved forceps or scissor (S-Portal; Karl Storz), monopolar hook, a standard straight bipolar forceps and a multifunction device for grasping, coagulating, and sealing (En Seal Trio, Ethicon Endo-Surgery, USA) were used.

Removal of the uterus was obtained by morcellation (PKS™ PlasmaSORD™ Bipolar Morcellator, Olympus) through the umbilical trocar under direct vision after entering optic in the cervical canal.

Surgery was performed with no intra-operative and postoperative complications. Patient was discharged after 2 days of hospitalization with a complete satisfaction in term of pain and cosmetic outcome. The postoperative control after one month revealed a complete restoration of the umbilical scar and the 6 months follow up evidenced a complete resolution of pelvic pain.

V.02.14

Single-port access laparoscopic hysterectomy using storz excone port

Amini L.*[1]

[1] Jam General Hospital Tehran Islamic Republic Of Iran

Laparoscopic hysterectomies first began by being laparoscopic assisted vaginal hysterectomies, then total laparoscopic hysterectomies and with introduction of mechanical morcellation mostly supra cervical laparoscopic hysterectomies using three, four or five ports (or trocars).

Innovative technologies with new instrumentation are now offering single port access in order to reduce patients’ morbidity in gynecological surgery.

We have performed 101 cases of laparoscopic total and subtotal hysterectomies with 3 trocars.

In single port systems also there can be used only three instruments.

The Excone port (Storz single port) system offers the possibility of performing LSH and TLH with a single 12 mm transumbilical incision.

TLH and LSH are both feasible and safe by this technique.

There’s a need to use curved instruments because of their orientation along the same axis and it seems to make the procedure more difficult in case of big uterus or endometriosis with limited uterine mobilization.

This is most probably one of the options to be considered in minimally invasive gynecological surgery in the future.

V.02.15

Laparoscopic excision of bladder nodule in a patient with multiple previous open surgeries

Nassif J.*[1], Al Chami A.[1], Abu Mussa A.[1], Al Hassan J.[2], Ghulmiyyah L.[1]

[1] American University Of Beirut Medical Center Beirut Lebanon - [2] Clemenceau Medical Center Beirut Lebanon

We present the video of a laparoscopic excision of bladder nodule in a patient with multiple previous open surgeries.

Endometriosis of the urinary bladder is a rare entity affecting approximately 1% of women with endometriosis.

We present the video of a 37 years old female patient, Gravida 1 Para 1, who presented with dysmenorrhea with a pain score of 4/10, dyspareunia 8/10 and chronic pelvic pain of 5/10. She has catamenial dysuria and no gastrointestinal symptoms. She has a history of open appendectomy, open right cystectomy for dermoid cyst and cesarean section. On physical exam she has a soft non tender abdomen. On pelvic exam she had normal uterosacral ligaments with no recto vaginal nodule identified. On MRI, a nodule of about 2.5 cm was found on the right lateral aspect of the urinary bladder that is suggestive of endometriosis. A JJ ureteral stent was inserted intraoperatively to the right ureter by cystoscopy. A laparoscopy with adhesions lysis and excision of the bladder nodule was performed.

The pain scores for dysmenorhhea, dyspareunia and chronic pelvic pain at 1 month and 6 months postoperatively are 3/10, 5/10, 2/10 and 2/10, 0/10 and 1/10 respectively.

Laparoscopic excision of bladder endometriosis is feasible. Complete excision of the disease is associated with resolution of bladder symptoms.

Session V.03

* Video Session_3 *

Technical Tricks and New Instrumentation—Operative Risk Management

V.03.1

Laparoscopic suturing—tips, tricks and techniques

Kondrup J.*[1]

[1] Lourdes Hospital Binghamton, New York United States

This video describes suture intro and tying techniques including straight stick and robotic. The techniques include basic simple intra corporeal tying, cuff closure with single suture and Quill. Also shown is myomectomy closure with V-loc, Quill and LapraTy.

Beginning laparoscopic surgeons are often frustrated with tying their “first” sutures. They struggle with introducing the suture as well as having the suture too short or too long. Sometimes the tissue tears or the knot loosens while passing the second knot. Also, myomectomy closure can be a challenge since time can be important when bleeding is occurring. To get minimal adhesions we have to approximate the myometrial edges without tension. Finally some surgeons continue to have trouble tying knots and we will illustrate the use of Quill, V-loc and LapraTy that do not require knots.

Storz video, 1 and 0 vicryl suture (Ethicon Suture), Koh curved needle driver (Storz), LapraTy (Ethicon Endo), Quill (Angiotech) and V-loc (Covidien)

Excellent suturing techniques achieved with excellent tissue closure.

By following simple tips and tricks and basics almost all surgeons can master these techniques. Suturing starts in the pelvic trainer or simulator, moves on to the animal lab then finally to the actual surgery.

V.03.2

Intraoperative endoscopic and sonographic investigation of the lower urinary tract: personal experience

Tzitzimikas S.*[1], Karavida A.[1], Mikos T.[1], Avgoustinakis E.[1], Andreou A.[1]

[1] Bioclinic Thessaloniki Greece

The use of urethrocystoscopy and Doppler ultrasound in the intraoperative investigation and the detection of complications from the lower urinary tract (LUT) during advanced laparoscopic gynecological procedures are presented. The use of Bettochi’s, 30o hysteroscope is suggested for intraoperative urethrocystoscopy.

The universal application of MIS in Gynecology had as a result the increase of the complications from the LUT. The latest ACOG Committee Opinion Nr. 372 July 2007 suggests that intraoperative use of urethrocystoscopy has an improved cost benefit ratio and it leads to the early recognition of undetected complications

Intraoperative urethrocystoscopy is performed with the aids of (a) a 0o, 20o, 30o, 70o and 120o optic scope, (b) a sheath, (c) a cold light cable, (d) a distention medium, and (e) a camera. Intraoperative Doppler ultrasound is applied to enable the imaging of the peristalsis of the intradetrusor part of the ureters (uretereric jet).

In an initial educational video the set up is presented. The following videos include the presentations of: (1)normal cystoscopic findings, (2) papillomatous urothelial appearance, (3) angulations of the internal urethral orifice after proximal placement of a midurethral tape, (4) attempt to insert an ureteric double-J catheter in a case of complete ureteric obstruction, (5) insertion of fluoresced ureteric stents, (7) cervical carcinoma infiltrating the bladder wall and causing oedema of the ureters, 8) bladder candidiasis, 9) cervical fibroma protruding to bladder wall,10) bladder mucosa wall biopsies.

The use of Bettochi’s, 30o hysteroscope is suggested for intraoperative urethrocystoscopy, during advanced gynecologic procedures. The 30o scope enables the adequate inspection of the urethra, of the trigone and the ureteral orifices, as well as the bladder epithelium.

V.03.3

Ablation of ovarian, peritoneal and diaphragmatic endometriosis using plasma energy

Roman H.*[1], Auber M.[1]

[1] University Hospital Rouen France

Plasma energy has recently been introduced in gynecologic laparoscopic surgery, and allows safe ablation of endometriotic implants arrising on the inner surface of ovarian endometriomas, the peritoneum and the diaphragm.

In the movie, we present several procedures suitable for various localisations of endometriotic implants, and we thoroughly describe the technique of laparoscopic ablation of ovarian endometriomas using plasma energy, which is routinely performed in our department in women seeking to get pregnant.

The ablation of inner wall of ovarian endometriomas is performed through a small area of original invagination of the cyst, free of ovarian tissue. Once the cyst is free from adhesions, the surgeon attempts to turn it completely inside out via the site of its original invagination, of diameter averaging 1 to 2 cm. Ablation of the inner surface of the cyst is then performed using plasma energy in coagulation mode set at 10, at a distance averaging 5 mm from the tip of the handpiece, and with an exposure time limited to 1 to 2 seconds on each site. Care should be taken not to leave any untreated sites and to ablate around the edges of the invagination site and the corresponding peritoneal implants on the adjacent broad ligament.

N/A

We have started to use plasma energy ablation of endometriosis lesions since January 2009, and we believe that the results are comparable to those of laser CO2 vaporisation. We believe that ovarian endometrioma ablation using plasma energy may be a valuable alternative to cystectomy, specifically for those women with a high risk of postoperative irreversible ovarian reserve impairment, as we have already reported that this procedure allows for a satisfactory ablation of the endometrial epithelium and stroma and spared more than 90% of the underlying ovarian parenchyma that is usually removed during cystectomy.

V.03.4

Herlyn-werner-wunderlich syndrome—a case report

Kondrup J.*[1]

[1] Lourdes Hospital Binghamton, Ny United States

Mullerian anomalies range from 6.7% in the general population to 16%. This patient had a form of Herlyn-Werner-Wunderlich Syndrome (HWW); Uterus Didelphys, sagittal vaginal septum and ipsilateral renal agenesis. She presented with pain & was found to have more transverse septum

The exact presentation of Mullerian anomalies is variable & the initial task involves putting the pieces together to formulate a surgical plan. Invariably an MRI plays a role in evaluating the pelvis.Ultrasound gives an overview of the pelvic structures but advanced MRI gives the specifics.The GYN surgeon needs to view the MRI personally to get a 3-D picture in their mind before surgery. Goals should be set with the patient and her parents since the first surgery may not be definitive but palliative. Major concerns include fertility,function preservation & anatomic challenges such as working on children in a narrow vagina

This 14 yo girl was found to have Didelphys with a septum obstructing the right cervix. Hymenal ring was intact making vaginal manipulation challenging. We demonstrate the use of vaginoscopy to perform minor surgey. Storz 3 mm 0 deg hysteroscope was introduced over a pediatric speculum. Outer sheath was attached for suctioning smoke and rrigation.The assistant held the scope while small instruments and cautery were introduced adjacent to the scope by the surgeon. Constant abdominal ultrasound guidance via a distended bladder was utilized to prevent wandering into the bladder or rectum. The septum was opened in a cruciate fashion & a pediatric foley catheter introduced up into the right uterus & left in place for 14 days to prevent reclosure

Patient discharged home same day with minimal pain & hymenal ring was preserved

Working in the vagina using a hysteroscope can be very useful in the young or elderly when the vagina is narrow. In the elderly the scope is used to see the cervix, grasp it then dilate it for hysteroscopy and D&C

V.03.5

Effective control of blood loss by misoprostol administration prior to laparoscopic management of cornual pregnancy

Çapar M.*[1], Karatayli R.[1], Balci O.[1], Mahmoud A.[1]

[1] Selcuk University, Meram Faculty Of Medicine Konya Turkey

We present the video of an unruptured cornual pregnancy and its management laparoscopically with a minimal blood loss achieved by preoperative administration of misoprostol.

Cornual (interstitial) ectopic pregnancy is an uncommon variant of ectopic pregnancy with a significant risk of rupturing and bleeding. We present an unruptured cornual pregnancy and its management laparoscopically with a minimal blood loss achieved by preoperative administration of misoprostol.

Case: 26 year old patient was referred to our clinic with suspicion of cornual pregnancy. At admission vital signs were stable. Both pelvic and transvaginal ultrasonography revealed a gestational sac and live fetus with a CRL of 9 weeks of gestation located on the right corneal region adjacent to tubal orifice. Laparoscopy was planned. 2 hours prior to operation vaginal misoprostol was administered in a dose of 400 mcg. During laparoscopy, pelvic inspection showed a high-volume hypervascularized mobile uterus, with a 3 cm subserosal fundal congested and soft right mass. We performed an incision over the right corneal mass with a monopolar dissector and removed gestational material by grasping forceps. After washing and accurately checking the incision site the myometrium was sutured using single intracorporeal “X” stitche, of 0 absorbable monofilament poliglecaprone.

The total blood loss during operation was recorded as 100 cc.

Preoperative medication of misoprostol significantly reduced blood loss in laparoscopic management of cornual pregnancy.

V.03.6

Original technique of combined laparoscopic and transanal excision of deep endometriosis nodules infiltrating the low and middle rectum

Roman H.*[1], Bridoux V.[1], Michot F.[1], Marpeau L.[1], Tuech J.[1]

[1] University Hospital Rouen France

We report an original surgical procedure usually performed by our team in the conservative management of middle and low rectal endometriosis (up to 10 cm above the anus). It starts by performing a rectal shaving, which separates the main part of the nodule from the rectum. Deep endometriosis nodule is then removed along with the adjacent infiltrated vaginal fornix and uterosacral ligaments, and vagina is sutured. The limits of the rectal wall involved by endometriosis are identified by transanal route and two stitches are placed on each side, allowing its intrarectal invagination. The Contour 30 transtar stapler (Ethicon Endo-Surgery, Cincinnati) safely allows both excision and suture of the rectal wall surrounding the nodule site. The specimen may be as high as 50 × 60 mm. Bowel functional outcomes are excellent. This technique may interest those surgeons who do not intend systematically performing colorectal resection in deep infiltrating middle and low rectal endometriosis.

V.03.7

Technical tricks in laparoscopic sacrocolpopexy

Rombaut S.*[1], Barri-soldevila P.[1], Cusidó M.[1], Rodriguez N.[1], Ubeda A.[1]

[1] Instituto Universitario Dexeus Barcelona Spain

Laparoscopic colposacropexy provides the outcomes of the abdominal approach while offering the benefits of minimally invasive surgery. We have analyzed our results and present some technical and suturing tricks in order to facilitate the surgical procedure.

Laparoscopic sacrocolpopexy (LSC) was first described almost 20 years ago. This technique aims to provide the outcomes of the gold standard abdominal approach while offering the benefits of minimally invasive surgery. However, the diffusion of LSC is hampered by its presumed length and technical difficulties. It is resulting in a long learning curve and long operation times. Furthermore, we have adopted several technical tricks in order to help the surgeon in decreasing the length of intervention and facilitate it.

We have performed 17 LSC in the last 14 months. (13 subtotal hysterectomy, 2 conserving the uterus, and 2 vaginal vault prolapses). Mean age of 51. The exposure of the surgical field is one of the main points before surgery. The setting of sigma and the cervix to the abdominal wall facilitates promontory and rectovaginal dissection. The draft of the mesh can be avoided by using ALYTE Y-mesh graft. Compared to conventional ones its not to be shaped intraoperatively. It consists of two single knit vaginal flaps and one dual knit sacral flap. The peritoneal closure above the mesh remains an essential step of the procedure. We have chosen a barbed suture (V-Loc) to facilitate it. This suture is characterized by self-anchoring, achieved with barbs on a conventional monofilament suture. The benefits of the self-retaining sutures for tissue approximation relate to the ease, speed and economy of suture placement.

Mean operation time is 227 minutes. Mean hospital stay 2.1 days. Two complications have been reported (one bladder and one rectal injury)

Our results encourage us to progress the learning curve and keep looking for further tools to improve the outcomes.

V.03.8

The used of new minilaparoscopic instrumental in minor vascular yatrogenic damage, in pelvic vessels, during gynecologic laparoscopic surgery

González Ramos P.*[1], Pastor Oliver C.[1], Lou Mercadé A. C.[1], González Pastor C.[1], Carranza Martínez J. M.[1], Gómez - Arrue Azpiazu J.[1], González Alastuey P.[1]

[1] Gómez Laguna 5 50009 Zaragoza Spain

To show the used of mini-laparoscopic istruments in the solution of mayor laparoscopic vascular complications.

To show the used of mini-laparoscopic istruments in the solution of mayor vascular complications that may occur during a gynecologic laparoscopic procedure, as trainning in animal model.

MATERIAL
  • 10 female pigs, variety Large White (L.W.)

  • Laparoscopic and mini-laparoscopic instruments (Figure 1)

METHODS
  • We used one animal to study the vascular abdominal and pelvic map with a vascular surgeon and a intervencionist radiologist.

  • In 4 animals we did deliberately a puncture in the external left iliac artery with the Verres needle.

  • In 2 animals we did deliberately a puncture in the aorta artery with the Verres needle. (Figure 2)

  • In 3 animals we performed a longitudinal cut on the aorta artery, of about 3 mm long with the mini-laparoscopic scissors.

RESULTS
  • Unlike humans, in the pig the iliac vessels born separately from the aorta, there is not a common vessel. (Figure 3)

  • When a big vessel, as external iliac or aorta artery, is punctured with the Verres neddle, if the punctured is a clean one, local pressure or local haemostatic product may be sufficient to solve the problem , as we did in 6 animals

In number 7 pig, the movement of the neddle tore the vessel, and it was required an inmediate conversion into laparotomy. (Figure 4)
  • When a longitudinal cut of about 5 mm was made with mini-laparoscopic scissors, we performed a laparoscopic vascular suture and also haemostatic products were used. We performed the suture with mini-laparoscopic material. (Figure 5). We managed to solved the injure with laparoscopy in 2 of the animals.

COMMENTS AND CONCLUSIONS

The new mini-laparoscopic surgical intruments may help us for the solution of vascular complications.

V.03.9

Using enseal® for large-sized hysterectomy: a new technology for gynecological surgery

Sommella C.[1], Sollazzi S.[1], Bruni L.[1], Lelli F.*[1]

[1] Ospedale Santa Maria Alla Gruccia, A.U.S.L 8 Arezzo, Zona Valdarno Montevarchi (Ar) Italy

New technologies play increasingly important in gynecologic endoscopic surgery. The proper use of equipment currently on the market offers to perform complex surgeries with greater safety

The aim of our study was to demonstrate the usefulness of the new technology of advanced bipolar surgery in difficult situations.

We used an advanced bipolar instrument with a thermal dispersion control system (PTC) and controlled closure of the branches (I-BladeTM) during a total laparoscopic hysterectomy for uterine fibroids in a patient of 53 years with a BMI of 23.2 and a uterus with increased volume reaching the transverse umbilical line.

The operative time was 210 minutes, blood loss was calculated at 150 ml and hospital stay was only two days. There were no postoperative complications. The surgical instrument has proved very useful and ergonomic in difficult situations due to the large size of the uterus that involved the use of bipolar energy near noble structures as the ureter and iliac veins.

The operative time was 150 minutes, blood loss was calculated at 150 ml and hospital stay was only two days. There were no postoperative complications. The surgical instrument has proved very useful and ergonomic in difficult situations due to the large size of the uterus that involved the use of bipolar energy near noble structures as the ureter and iliac veins.

Session V.04

* Video Session_4 *

Oncology—Operative Hysteroscopy

V.04.1

Intraperitoneal laparoscopic aortic limphadenectomy. tips and tricks

Fuster Rojas S. I.[1], Soler Ferrero I.*[1], Rodríguez Tárrega E.[1], Vega Omen O.[1], Domingo Del Pozo S.[1], Boldó Rodá A.[1], Pellicer Martínez A.[1]

[1] Valencia Valencia Spain

Surgery with laparoscopic aortic lymph node disection greatly reduced morbidity compared to laparotomy…

We describe in 3 videos, the intraperitoneal laparoscopic technique used in our institution to perform an aorto-cava lymph node disection.

The first video will be an standard lymphadenectomy for staging, outpointing the main technique aspects. The other two videos we will see a lymph node disection of an adhenopaty of five centimeters in a case of endometrial carcinoma relapse treated previously with chemotherapy. Finally an staging limphadenectomy in a obese woman will be shown. In all of them the main thecnical steps, tips and tricks will be discussed: disecction of ureters , ovarian veins toward the renal hilium and sealing devices employed.

The dissection of the ureters and ovarian vessels is basic for aortic lymphadenectomy safely. We exhibited all the tips and tricks used in the standardization of the technique at our institution

Using a standardized technique facilitates dissection of aortic lymph nodes up to the renal vessels in both the normal situation as in obese patients or in cases with lymph node metastases.

V.04.2

Laparoscopic en bloc anterior exenteration for recurrent vulval cancer

Pandey S.*[1], Pathiraja P.[2], Garruto Campanile R.[2], Giannice R.[2], Charnock M.[2], Tozzi R.[2]

[1] John Radcliffe Hospital Oxford United Kingdom - [2] Churchill Hospital Oxford United Kingdom

We report a laparoscopic en bloc anterior exenteration performed along with a loop colostomy, ileal conduit and plastic reconstruction of the vulvo-perineal defect for a radiotherapy treated recurrent vulval cancer presenting as a large, ulcerated and necrotic wound.

Pelvic exenteration, the treatment for locally advanced recurrent vuval cancer, is one of the most complex gynaecological surgeries which has a 25% morbidity rate. Laparoscopic surgery may play a very important role in decreasing the morbidity of pelvic exenteration.

A 5 port laparoscopy was performed. After ruling out intra abdominal disease, bilateral exposure of lateral pelvic side wall was performed. The uterine, vaginal, superior and inferior vescial arteries were sealed. Ureters were dissected. Infundibulo-pelvic pedicles were secured. Dissection of bladder was performed from the cave of Retzius in a retrograde fashion. Once the laparoscopic resectability was established, concomitant laparoscopic and perineal dissection was started by 2 teams. Recto-vaginal space was developed and laparoscopic dissection carried out up to the pelvic diaphragm until the vulva was reached. En-bloc resection of bladder, uterus, ovaries, tubes, along with the entire vagina & vulva containing the necrotic tumour was performed and the specimen was removed from the perineum. Ileal conduit and loop colostomy were performed by extending the laparoscopic umbilical port site. Perineal defect was reconstructed using a Vastus lateralis and Rectus femoris flap.

The laparoscopic segment of exenteration procedure was completed in 3 hours with a blood loss during of less than 100 mls without any complications. The patient made good recovery and was discharged in 10 days.

The successful anterior exenteration performed for this patient highlights the feasibility of pelvic exenteration laparoscopically without compromising oncologic outcome.

V.04.3

Laparoscopic extraperitoneal total lymphadenectomy

Çapar M.*[1]

[1] Selcuk University, Meram Faculty Of Medicine Konya Turkey

Laparoscopic extraperitoneal total lymphadenectomy is safe; feasible which should be considered where there is isolated involvement of retroperitoneal lymph nodes. Here we present the video of this surgery.

To evaluate the safety and feasibility of laparoscopic extraperitoneal total lymphadenectomy

22 cases of endometrium and cervix cancer were operated on. A 2 cm incision was made medially at the renal level. A 10 mm trochar was introduced through the incision. The retroperitoneal space was made visible using finger dialatation.

The optic was introduced from that incision; a second incision was made near the umbilicus using the light guide of the optic. Then the optic was directed to the symphysis pubis were a 3rd incison was made at the suprapubic area after seeing the light reflex.

After adequate insufflations, lyph nodes around external and internal iliac arteries, paraaortic lymph nodes and lymph nodes on inferior vena cava were collected.

The average number of collected lymph nodes was 30–56

We think that laparoscopic extraperitoneal total lymphadenectomy is safe; feasible which should be considered where there is isolated involvement of retroperitoneal lymph nodes. This procedure is a minimally invasive technique that allows an excellent approach to the paraaortic lymph nodes. We did not encounter any complication.

V.04.4

Pelvic lymphadenectomy: standard technique and tips and tricks

Akladios C. Y.*[1], Wattiez A.[1]

[1] Strasbourg Univesity Hospital Strasbourg France

Pelvic lymphadenectomy is a master piece in the management of gynecological malignancies for either staging or therapeutic purposes. Laparoscopy provides an excellent exposure, a precise dissection, a perfect haemostasis and an equal number of lymph-nodes. Vascular and nervous complications are possible. They might be serious but fortunately, always avoidable. This needs a very strict surgical technique and awareness of trappy steps. In this video we present the standard technique of pelvic lymphadenectomy, and most relevant tips and tricks that allow any gynaecological surgeon to safely reproduce it.

V.04.5

Single site surgery for malignancy

Andou M.*[1], Yoshiaki O.[1], Hada T.[1]

[1] Kurashiki Medical Center Kurashiki Japan

We have introduced single site multi-trocar techniques into oncologic surgery to reduce the invasiveness and to prevent the delay of post operative adjuvant therapy.

We have introduced single site laparoscopic surgery into gynecologic malignancy to reduce the impact of surgery for both cosmesis and invasiveness.

For this technique we don’t need special platforms and require only standard laparoscopic instruments. We make a 2.5 cm incision in the umbilicus. After exposure of rectus fascia, a 150 mm length, 5 mm camera trocar is inserted through the natural defect in the rectus fascia. Shorter trocars (100 mm and 75 mm) are also placed for manipulation. Our technique development came in three steps. In step1 we began with pelvic lymphadenectomy. In step 2 we expanded to para-aortic dissection using a transvaginal telescope for observation of the para-aortic zone. In step 3 we combined steps 1 and 2 to facilitate a total retroperitoneal dissection covering both the para-aortic and pelvic regions. We also performed a modified radical hysterectomy. The operative field is maintained by peritoneal suspension to the abdominal wall to create a natural retraction effect.

Operative duration is longer than standard laparoscopy with the quality of dissection being the same. The level of recorded pain is much less and the cosmetic result is also much better than standard laparoscopy.

As the length of the peritoneal and fascial incision is minimal for oncologic surgery, postoperative recovery for this procedure was very quick with minimal pain.

V.04.6

Transvaginal retroperitoneal lymphadenectomy

Çapar M.*[1]

[1] Selcuk University, Meram Faculty Of Medicine Konya Turkey

We tried to assess the feasibility of extraperitoneal lymphadenectomy using the vaginal route Vaginal surgery offers several advantages for the treatment of endometrial and cervical cancer. Here we present the video of this surge

Vaginal surgery offers several advantages for the treatment of endometrial and cervical cancer in comparison to the correspondent abdominal procedures, while giving equivalent long-term results. Such advantages, namely the shorter operative time, the reduced surgical trauma and the possible use of regional anesthesia, are of value in any case, but are especially relevant in the management of obese or medically compromised patients. On the other hand, the vaginal approach has always been criticized because it omitted lymph node removal. We tried to assess the feasibility of extraperitoneal lymphadenectomy using the vaginal route.

Case: A patient with diagnosis of endometrial cancer of endometriod type was operated on for complementary surgery.

Under general anaesthesia, the patient was put in lithotomy position. We entered from right and left lateral fornices each in time using 10 mm trochar.

After adequate insufflations, the optic was introduced to the retroperitoneal space through the trochar so it became more visible.

Then directing the optic to the lateral abdominal wall, an incision was made using the light guide of the optic. A 5 mm trochar was introduced from the incision area.

The lymph nodes that could be seen from the optic angle of 30–40 degrees were excised one by one. The same procedure was carried out on the other side.

The operation lasted for 58 minutes. The patient was discharged on 4th postoperative day with no complication.

The histopathology report revealed 22 reactive lymph nodes.

This case demonstrated the technical feasibility and safety of extraperitoneal lymphadenectomy using Natural Orifices.

V.04.7

Combined laparoscopic/ hysteroscopic management of large hematocolpos from complete uterine septum

Kondrup J.*[1]

[1] Lourdes Hospital Binghamton, New York United States

This video demonstrates an unusual case of a young girl with a large right hematocolpos from a complete uterine septum. She had menorrhagia, was anemic and required blood transfusions. Hematologic work up was normal. Her right fallopian tube was occluded from a previous appendicitis.

The actual incidence of uterine fusion anomalies is unknown but estimates range from 0.1%–2.5%. Symptoms in young women occur sometime after menses and usual occur from a “non-communicating” type defect. Some remain asymptomatic (complete didelphys without obstruction) and some can have severe symptoms (non-communicating horn). Recognition & proper management are essential. Fertility needs to be preserved and proper referrals made to a pediatric specialist surgeon if indicated.

Patient received a pre-op mechanical bowel prep, placed in lithotomy position initially to evaluate the uterus hysteroscopically. A 5 mm 0 deg Storz laparoscope placed at umbilicus and a 5 mm trocar (Excel, Ethicon Endo) placed in the right & left lower abdomen lateral to the inf epigastric arteries. Patient was placed in steep head down the right pelvic adhesions lysed with Enseal Trio (Ethicon Endo). The Versapoint (Ethicon Women’s Health) bipolar resectoscope utilized with saline to lyse septum under laparoscopic surveillance. Patient discharged home two hours later.

The patient did well postoperatively & return to normal menses. Follow up MRI still shows enlargement of the right side compared to the left. The patient remains asymptomatic. The anemia has resolved.

This case had a successful outcome utilizing minimally invasive procedures. The use of MRI is essential in formulating a surgical plan. We used two separate video towers to facilitate smooth operating surveillance. The patient will be evaluated in the future prior to conceiving with hysterosalingography and perhaps hysteroscopy if indicated.

V.04.8

Hysteroscopy and rescetion of submucous fibroids with an intramural component

Al Khaduri M.*[1], Shawki O.[2]

[1] Sultan Qaboos University Muscat Oman - [2] Cairo University Cairo Egypt

The objective of this video is to demonstrate the technique of hysteroscopic resection of submucous fibroids with an intramural component using a monopolar loop.

We present the case of a 29 yr old nulliparous woman married for 7 months and trying to conceive. She was complaining of irregular menses but no history of menorrhagia or dysmenorrhea. An ultrasound showed multiple 3–5 cm fibroids distorting the uterine cavity so a saline infusion sonography was performed and demonstrated an irregular cavity with submucous fibroids.

We performed a hysteroscopy and diagnosed submucous fibroids and were able to successfully resect the submucous fibroids and restore a normal uterine cavity using a monopolar loop.

Successful resection of submucous fibroids with restoration of uterine cavity.

The technique of hysteroscopic submucous fibroid resection is demonstrated for junior doctors.

Session V.05

* Video Session_5 *

Innovation in Surgery

V.05.1

Laparoscopic suspension for uterovaginal prolapse using new tools

Dubuisson J.* [1]

[1] Head Department Of Obstetrics And Gynecology, University Hospitals Of Geneva -Switzerland

This presentation describes new tools, instruments and procedures that may be used today during operative laparoscopy

The video shows laparoscopic treatment of uterine prolapse, coupled with subtotal hysterectomy

During the operation, which is a lateral suspension using mesh, new tools are used: new HD video camera, new cutting bipolar forceps, new sutures which do not need any knot, new meshes made of titanium, polypropylene and absorbable tackers.

The objectives of the new tools are to improve the efficacy of the techniques, to prevent complications, and to win time.

V.05.2

Endoscopic vaginal oophorectomy: a video presentation of a new surgical technique

Jones R.*[1], Beynon G.[2]

[1] Ashford & St Peter’S Nhs Fundation Trust Chertsey United Kingdom - [2] Frimley Park Nhs Foundation Trust Frimley United Kingdom

We present a video of total endoscopic vaginal oophorectomy, performed in the absence of vaginal hysterectomy.

Bilateral oophorectomy (BO) can be part of planned treatment for hormone sensitive breast cancer and prophylactic BO can be undertaken in patients with certain gene mutations. We have developed a total endoscopic technique using NOTES principals via the transvaginal route, resulting in improved cosmetic outcome and reduced recovery time making prophylactic BO more acceptable and allowing for more rapid follow-up treatment.

The technique developed from the traditional 3 port technique through stages including a 2 port technique with the ovaries removed via posterior colpotomy and a single port technique with excision and removal carried out via a posterior colpotomy. Our first case was performed with a blunt 8 mm trocar introduced into the posterior fornix after displacing the colon with a sigmoidoscope and a pneumoperitoneum created. A secondary 5 mm blunt trocar was inserted under direct vision. A flexible endoscope was introduced via the 8 mm port with dissection undertaken with a 5 mm harmonic scalpel. The ovaries were removed via the 5 mm port site. The port sites were left to act as natural drains. A single dose of IV antibiotics were given intra-operatively.

The technique has continued to evolve: we now use 15 cm long ports and a rigid laparoscope. We have performed 6 successful total endoscopic vaginal oophorectomies from 8 attempts.

We believe our experience has demonstrated the feasibility of total vaginal oophorectomy and that bacterial contamination is not a clinically significant problem. With further experience and likely developments in available equipment the transvaginal approach has the potential to supersede the currently popular laparoscopic approach both for its rapid recovery and its cosmetic benefits.

V.05.3

Focusing on transvaginal laparoscopy- hybrid notes

Andou M.*[1], Ohta Y.[1], Hada T.[1]

[1] Kurashiki Medical Center Kurashiki Japan

To reduce the size and number of ports we developed a minimal abdominal access technique using transvaginal laparoscopy using either up to two vaginal ports and one or two abdominal ports.

Endoluminal surgery such as “NOTES” has become the new wave in minimally invasive surgery. Technical difficulty in manipulation and immaturity of instrumental development prompted other practical approaches like Hybrid NOTES, which is combination of transluminal endoscopy and a few abdominal wall ports. Our answer to this is ultra-minimally invasive transvaginal laparoscopy.

For myomectomy and hysterectomy, only 2 small ports (5 mm umbilical trocar and 3 mm trocar- left lower quadrant) are placed. The procedure is performed the same as traditional laparoscopy. Only one 5 mm port is required for our adnexectomy as another manipulation port is placed in the vagina to reduce abdominal trauma even more. In these procedures a 5 or 10 mm distal chip flexible videoendoscope is introduced into the vaginal port and flexed 180 degrees. A similar image to umbilical laparoscopy is obtained with an image converter.

All procedures were completed with this approach without conversion to open laparotomy or a standard laparoscopic approach. The cosmetic result was excellent as the incision for the hysterectomy and myomectomy requires only a 3 mm incision and an incision in the umbilicus. While the adnexectomy is almost scarless. Post-operative discomfort is reduced due to minimal abdominal wall incisions.

Transvaginal lapaproscopy shows the potential of introducing novel approaches and instrumentation.

V.05.4

Hybrid-notes adnexectomy—transvaginal laparoscopy

Hada T.*[1], Andou M.[1], Ota Y.[1]

[1] Kurashiki Medical Center Okayama Japan

We performed 12 adnexectomy cases via one 5 mm umbilical port and two 5 mm vaginal ports. Culdoscopy, a procedure where we use a flexible, high-quality camera from the vaginal port, enabling us to create a Hybrid-NOTES (Natural Orifice Transluminal Endoscopic Surgery) procedure. Using culdoscopy in laparoscopic surgery is a new minimally invasive approach.

Fewer and smaller wounds, less invasive and more cosmetic are our missions. NOTES is an example of our ideal procedure in laparoscopic surgery, but it is too technically difficult and limited now. Hybrid-NOTES is a combination of NOTES and conventional laparoscopic surgery and can be more applicable for a large number of patients. We performed 12 adnexectomy cases as Hybrid-NOTES procedures by using 1 umbilical port and 2 vaginal ports.

To recognize the intra-pelvic conditions safely, we started using a 5 mm umbilical port in the same fashion as usual laparoscopic surgery. Under direct vision including visual comprehension of the tumor, adhesions, and Douglas’ Pouch, we inserted two 5 mm ports from both sides of posterior vaginal fornix safely. Proper distance between the two vaginal ports is necessary to make using forceps easier. From the vaginal port, our flexible 5 mm camera could see the uterus and adnexa by bending it 180 degrees. The adnexectomy was performed via the umbilical port and a vaginal port using flexible forceps. After placing the resected tumor into the bag, we performed a culdotomy and extracted the tumor from the vagina.

We could perform an adnexectomy without any complications. The skin wound was only 5 mm at the navel and could not be seen 1 month after of the operation. Tumor sizes were between 33 and 95 mm and operative time was between 34 and 62 min.

Hybrid-NOTES using culdoscopy and an umbilical port offers a more feasible and more cosmetic laparoscopic operation. This procedure is a window to next generation minimal invasive surgery.

V.05.5

Laparoscopic hysterectomy using cinematographic 3d

Kent A.*[1], Smith R.[1], Rockall T.[1], Jourdan I.[1]

1] Minimal Access Therapy Training Unit Guildford United Kingdom

We present the first laparoscopic hysterectomy carried out in the UK using a new 3D passive polarising stereoscopic vision system. This video requires a 3D projection system and glasses similar to that used in cinemas.

Over the last decade laparoscopic surgery has embraced the explosion in technology that has brought high definition flat screens to the operating room. 3D has been tried but the headsets were bulky and not ergonomically practical for everyday use. They also suffered from the problems encountered with 3D systems utilised by da Vinci in that the image is only available to the surgeon.

Passive polarising stereoscopic vision allows the entire OR and audience to experience 3D, the only accessory being polarising glasses similar to those used in cinemas.

A video demonstrating the technique of laparoscopic hysterectomy in 3D will be shown. The main benefits demonstrated include dramatically enhanced depth perception allowing greater use of panoramic views and less movement of the camera, simplifying complex tasks such as suturing and pelvic side wall dissection.

Cinematographic 3D is likely to be the next major step forward in imaging technology in the operating room.

V.05.6

Laparoscopic interventions during pregnancy

Craina M.*[1], Nitu R.[1], Bernad E.[1], Anastasiu D.[1]

[1] Univeristy Clinic Of Ob/gyn “bega” Timisoara Romania

Since 1995 in our clinic were performed 8000 laparoscopic interventions out of which 53 were performed during the first trimester of pregnancy.

There were clear indications for surgery. There were no complications.

Since 1995, there were performed over 7000 laparoscopic and hysteroscopic interventions in The University Clinic of Ob/Gyn “Bega” Timisoara, Romania.

53 cases represented interventions during the first trimester of pregnancy out of which, 31 cases of cystectomy, 20 cases with partial ovary resection and 2 cases of hyper stimulation syndrome.

The indications were: the volume and structure of the cyst, symptomatology and the response of the cyst under treatment.

The particularities were represented by the difficulty of manipulating the uterus without injuring it, conservation of the corpus luteum and anesthesia.

There were no complications intra or post operatory, the average time spent in hospital was 48 to 96 hours.

Laparoscopic surgery represents the ideal surgical treatment during pregnancy.

Laparoscopic surgery represents the ideal surgical treatment during pregnancy

V.05.7

Laparoscopic pectopexy

Noe G.*[1], Banerjee C.[2]

[1] Esge Cologne Germany - [2] Agub Cologne Germany

Major difficulties of sacral colpopexy are ileus and defecation difficulties. The ileo- pectineal ligament has been used over a long period for Burch operation and the pectopexy does this either. The lateral positioning of the mesh beneath the round ligament has enabled a sufficient fixation without restriction of the bowel. The study shows the good outcome of the technique.

Our cure rate of 92,1% and our experience of more than 600 sacral colpopexies led our view to some weak points of the technique and encouraged us in developing a new technique we first described in 10/2010. The sigmoid colon is often enlarged by fatty tissue ore by diverticolosis. In this case there is less space for the placement of a mesh between the vagina and the sacrum. Consecutively pain or defecation problems can result.The pectopexy uses the iliopectineal ligament on both sides for the mesh fixation so there is no restriction caused by mesh.

A prospective, randomized trial was started to compare the standard laparoscopic sacral colpopexy to the pectopexy. We documented the operation time, the blood loss, body measurements and different complications for the postoperative outcome.

The first 61 patients were evaluated and showed no difference in complication rate or hospital stay (4–5 days). No major complication (bowel injury, ileus; mesh infection) were seen in both groups. We saw 1 urinary infection in the pectopexy group. No defecation problems or denovo incontinence was found. The mean operation time was 44,5 min for the pectopexy and 52,7 min for the sacral colpopexy. Blood loss was documented with 4.8 to 14,7 ml.

The first data show that the new technique carries no new risks and can be performed as well as the classic “gold standard”, the sacral colpopexy. Due to the surgical design there are less problems caused by narrowing the pelvis to be expected in the long term coming out.

V.05.8

Die: egt (endogynaeteam) surgical steps

Fiaccavento A.*[1], Zaccoletti R.[1], Barbieri F.[2], Landi S.[3]

[1] Casa di Cura Pederzoli Peschiera Del Garda Italy - [2] Ospedale Orlandi Bussolengo Italy - [3] Ospedale Sondrio Sondrio Italy

In this video the Endogynaeteam, after a long experience in the surgical treatment of DIE, proposes to standardize a surgical method with the aim of obtaining two main purposes: the complete excision of the disease while minimizing neurological damage.

The endogynaeteam after years dedicated to laparoscopic surgery for D.I.E. developed an innovative surgical technique with the aim of making it efficient and reliable, reproducible

The surgical technique requires four main steps divided into subcategories

approach starting from anterior uterine

approach starting from the right iliac region of the medial external iliac vessels:

approach starting from the left iliac region of the medial external iliac vessels.

retro-uterine space approach.

The two main objectives, the radical surgery and prevention of neurological damage are demonstrated by histological confirmation of the disease in more than 90% of histological sections and the low incidence of neurological complications (1%)

Currently, although there are differences between ablation and excision of endometriosis there are several surgical techniques and has not yet been described any technique to follow precise steps of surgical time.

The main objective of the video is to illustrate a surgical technique for excision dell’endometrios, became the standard of quality for the group EGT

V.05.9

New technique: laparoscopic modified moschcowitz mccall (mmm) for vaginal vault suspension and enterocoele closure

Boggs E.*[1], Satkunaratnam A.[1]

[1] St. Michael’S Hospital Toronto Canada

Laparoscopic McCalls, Moschcowitz and uterosrcal plication have been described for vaginal vault suspension. Drawing on these established procedures a new laparoscopic technique has been developed, the Modified Moschowitz McCalls Culdoplasty, MMM.

Prophylactic vault suspension following vaginal hysterctomy has been shown to reduce recurrent vault prolapse. To potentially achieve better outcomes laparoscopic suspension techniques could be considered.

Following LH the MMM suture is commenced high on the left uterosacral ligament medial to the ureter. A minimum of 2 plication sutures are placed along its length to reach the pubocervical fascia of the posterior vault. Several bites of the anterior peritoneum are taken and the suture passed posteriorly through the right posterior vaginal vault. A minimum of 2 plication sutures are placed in the right uterosacral ligament medial to the right ureter, bringing the stitch to the level of the rectosigmoid. The rectosigmoid is plicated right to left, avoiding the epiploeica and staying superficial on the bowel serosa. The purse string component can now be clearly visualised, and the MMM is tied and completed.

The anterior and rectosigmoid peritoneum are incorporated obliterating the enterocoele sac. The uterosacral ligaments are shortened and opposed thus suspending the vault,

This case report clearly demonstates a new vault suspension technique. The proposed advantages of this safe and feasible procedure include minimal additional operating time, effective vault suspension and reperitonealisation of the vaginal stump.

V.05.10

Our experience of laparoscopic myomectomy with temporary occlusion of internal iliac arteries

Puchkov K.*[1], Andreeva J.[1], Serebryanskiy O.[1], Dobychina A.[1]

[1] Center For Clinical And Experimental Surgery Moscow Russian Federation

Laparoscopic Surgical treatment for complicated myomas In cases of « complicated » myomas our clinic developed a technique of laparoscopic myomectomy with temporary occlusion of internal iliac arteries.

We have successfully been applying this technique since 2008.

The parietal peritoneum is opened above the iliac arteries. Smooth vascular clamps “De Bakey” are introduced into the abdominal cavity by “Endoclinch” forceps. The clamps are applied on the dissected arteries from both sides. The incision of the uterus wall above the myoma node is performed by ultrasonic scissors (Auto Sonix Covidien)or using monopolar coagulation. The myoma node is extracted from the surrounding tissue by two 10 mm forceps. We have never found wound bleeding, so we have excellent opportunity to visualize the border of node. We separate the node with minimal electrosurgical damage of myometrium, without the risk of uterine cavity opening. While the node is being pulled out, we introduce intravenous oxitocin; more contracting uterus “pushes” the node helping it to get out, the wound surface is decreasing. We suture the wound in several layers safe and careful under the conditions of good visualization. We use synthetic absorbable suture material for closing the wound. Convenient exposition is created by means of uterus manipulator. Myoma nodes are removed by morcellation. The uterus body is covered with antiadhesion barrier. At the end of the operation the soft clamps are taken off.

204 patients (average 22–48y.o.) have been treated by the above described method. 140(68%) patients have had multiple “difficult” myomas. Average duration—40–90 min., average time of stay at hospital—3 days, average recovery period—14 days. Complications—2, conversions—0.

Based on the results of our experience we can recommend this method for complicated myomas treatment

V.05.11

The benefits of cinematographic 3d in laparoscopic suturing

Kent A.*[1], Smith R.[1], Rockall T.[1], Jourdan I.[1]

[1] Minimal Access Therapy Training Unit Guildford United Kingdom

We demonstrate the benefits in using a new 3D passive polarising stereoscopic vision system in the art of laparoscopic suturing. This video requires a 3D projection system and glasses similar to that used in cinemas.

Over the last decade laparoscopic surgery has embraced the explosion in technology that has brought high definition flat screens to the operating room. 3D has been tried but the headsets were bulky and not ergonomically practical for everyday use. They also suffered from the problems encountered with 3D systems utilised by da Vinci in that the image is only available to the surgeon.

Passive polarising stereoscopic vision allows the entire OR and audience to experience 3D, the only accessory being polarising glasses similar to those used in cinemas.

A video demonstrating various techniques of laparoscopic suturing in 3D will be shown. The main benefits demonstrated include dramatically enhanced depth perception allowing greater use of panoramic views and less movement of the camera. This is particularly beneficial for the various key steps of laparoscopic suturing such as needle mounting and intra-corporeal knot tying

Cinematographic 3D is likely to be the next major step forward in imaging technology in the operating room.

V.05.12

Orifice assisted small incision surgery (oasis)

Einarsson J. I.*[1]

[1] Brigham And Women’S Hospital/harvard Medical School Boston United States

Orifice-assisted small-incision surgery (OASIS) is a novel technique that attempts to incorporate the benefits of single-incision and natural-orifice surgery while minimizing issues such as instrument crowding at the umbilicus. In this method, optical access is gained via the posterior cul-de-sac by placing a flexible sigmoidoscope through a vaginally placed trocar. The decoupling of the optical access from the operative ports faciliates the progress of the surgical procedure.

Orifice-assisted small-incision surgery (OASIS) is a novel technique that attempts to incorporate the benefits of single-incision and natural-orifice surgery while minimizing issues such as instrument crowding at the umbilicus.

In this method, optical access is gained via the posterior cul-de-sac by placing a flexible sigmoidoscope through a vaginally placed trocar.

The decoupling of the optical access from the operative ports faciliates the progress of the surgical procedure. This in turn allows for performance of advanced laparoscopic procedures without need for specialized single-port access devices or instruments. OASIS also allows for a minimized traumatic and cosmetic footprint on the abdominal wall.

Based on preliminary case series experience, OASIS appears to be a safe and feasible addition to the advanced minimally invasive surgeons’ armamentarium.

Session V.06

* Video Session_6 *

Single Access Surgery—Robotics—Urogynaecology

V.06.1

Robotic hysterectomy for obese patient- a possible advantage to conventional laparoscopy?

Sarlos D.*[1], Meier G.[1], Schär G.[1]

[1] Kantonsspital Aarau Aarau Switzerland

For certain patients especially for obese patients a benefit of robotic surgery compared to conventional procedures is often cited. This video shows a robotic laparoscopic hysterectomy of a 46 year old patient with menometrorrhagia and anemia and a BMI of 36. For obese patients robot-assisted laparoscopic hysterectomy can be performed safely and may be favorable to conventional laparoscopic hysterectomy

The first robot- assisted laparoscopic hysterectomy was preformed 2006 in the USA. Many studies have investigate and demonstrated safety and feasibility of this method. Cost for a robotic hysterectomy are significantly higher than for conventional laparoscopic procedure. The question remains if there is a difference in clinical outcome between both methods. It is also open to discussion if this method is of advantage for the experienced surgeon or if the learning curve is better for the novice surgeon. For certain patients especially for obese patients a benefit of the robotic method compared to conventional procedures can be considered

In this video a 46 year old pre-menopausal patient with menometrorrhagie and anemia due to uterus myomatosus is presented. The patient weighing 99 kg at 165 cm is severely obese with an BMI of 36. As this patient is a nullipara a vaginal hysterectomy is not suitable.

First we show preparation for surgery, positioning of the patient and then installation of the robot. Following this the most important steps of the procedure are shown in chronologic order. Feasibility of the robot-assisted method can be well documented in our video.

Robot-assisted laparoscopic hysterectomy is an appropriate procedure for obese patients with a BMI > 30. It can be performed safely and may be favorable to conventional laparoscopic hysterectomy

V.06.2

Robotic myomectomy of a difficult degenerated myoma

Chatzirafail V.*[1], Mitsis T.[1]

[1] Euroclinic Hospital Athens Greece

This is a video presenting a case of a robotic myomectomy of a completed degenerated myoma of 6 cm at the level of the isthmus, in a woman with persistent pelvic pain, full of adhesions due to two previous CS by vertical subumbilical incisions

The optimal surgical treatment for myomas remains debatable because of the limitations of minimally invasive techniques and the disadvantages of laparotomy. Robot-assisted myomectomy is a recently introduced technique. This video shows this technique for the excision of a 6 cm degenerated myoma in a 48 years old woman, presented with persistent pelvic pain who had 2 CS, by vertical subumbilical incision.

Ultrasonographic examination revealed a 6 × 4 cm degenerated fibroid located to the left lateral, at the level of the cervical isthmus.

Entering in the abdomen we saw the uterus attached to the anterior abdominal wall. Laparoscopicaly, using simultaneously 2 cameras one from the umbilicus and an other 5 mm camera from the left side port, we separated the uterus from the anterior abdominal wall and from the bladder.

Then robotically, using robotic tenaculum and hook we have excised from the left lateral of the uterus a 6 × 4 cm completed degenerated fibroid.

A big gap had occurred at the uterus and using 2 large robotic needles drivers, we sutured the uterus in two layers using monocryl No 0.

RESULTS. The combination of laparoscopy and robotic surgery gave the best results for this woman. The 3D view from the robotic console permitted us to indentify the limits of the degenerated fibroid in the myometrium, remove it, and suture easier the uterus in 2 layers.

CONCLUSIONS. Robotic assistance provides good access, stereoscopic view and precise maneuvers that facilitate excision of fibroids in difficult positions, as suggested by our experience that we present elsewhere.Still to discuss the cost and prove the necesity of the robotic procedures

V.06.3

Robotic surgical reconstruction for complete lateral and central anterior plus posterior pelvic floor defect using a modified “y” shape mesh

Monod P.[1], Muet F.[1], Evelyne M.[1], Vlastos A.*[2]

[1] Clinique Belledonne Grenoble France - [2] Geneva University Hospital Geneva Switzerland

A new Robotic surgical procedure allowing the reconstruction of large lateral and central anterior wall prolapse as well as large posterior wall defect using a modified “Y” shape mesh handshaped according to patient anatomy. The mesh fixation starts at the Cooper ligaments goes through the cervix and the muscles elevator ani to be finally attached to the sacrospinous ligament.

The robotic approach to sacrocolpopexy theoretically combines the advantages of the laparoscopic and abdominal approaches with acceptable rates of intraoperative and postoperative complications.

The particularity of the presented technique is the simultaneous reconstruction of lateral and central anterior defect.

After the dissection of the sacral promontory, the vesicovaginal space is developped. Depending on the patient history and especially caesarean section, little bleeding can occur. When the bladder trigone is reached, the vaginal blade is rotated in order to separate the bladder from the ureter and the dissection proceeds to the paravesical space till the pelvic fascia. The Retzus space is then opened. Once the Cooper ligament is reached, the little bleeding from the paravesical space should direct the dissection posterior in order to connect the Retzus space to the paravesical space. The supracervical hysterectomy is then completed and the cervix is fixed to the abdominal wall using a retracting suture brought out through the skin in order to facilitate the posterior dissection. From this point, the procedure is similar to the classical sacrocolpopexy, except for the muscles elevator ani dissection.

In this technique the anterior part of the mesh creates a hammock able to sustain the bladder not only on the centre part but also laterally, however this is not a urinary incontinence procedure.

V.06.4

What is the place of laparoscopic richter spinofixation to treat genital prolapse?

Dubuisson J.* [1]

[1] Head Department Of Obstetrics And Gynecology, University Hospitals Of Geneva - Switzerland

At present, laparoscopic procedures using mesh treat genital prolapse efficiently and are comparable with vaginal procedures.

Laparoscopic sacral fixation using mash is considered today to be the gold standard technique in treating genital prolapse in young women.

Richter sacrospinous fixation performed by laparoscopy has shown good results. Accessing the sacrospinous ligament by laparoscopy is quite easy, usually by entering Retzius space. Visualization of the Arcus tendineus fascia pelvi offers access to the spine and the sacrospinous ligament. The second possibility is to dissect the pararectal space posterior to the middle rectal vessels.

The two accesses are quick and easy to perform with low risk of complications.

We need now to compare the results of laparoscopic sacrospinous fixation with sacral fixation using a mesh.

V.06.5

No more controindications in less surgery: a complex case of thl with bso in an obese patient, previously subjected to an hysteropexy

Surico D.[1], Leo L.[1], Galli L.*[1], Nupieri I.[1], Vigone A.[1], Surico N.[1], Surico N.[1]

[1] Advanced Gynaecological Oncology Centre, Department Of Obstetrics And Gynaecology, University Of Eastern Piedmont Novara Italy

This case report describes the first case of Single port hysterectomy with bilateral adnexiectomy in an obese patient, previously subjected to a longitudinal laparotomy for hysteropexy sec. Pestalozza.

LESS Surgery increases the benefits of traditional laparoscopy. Until now, one of the limitation is the difficulty to performe LESS surgery with a massive complex adhesions due to previous abdominal surgery.

A 61 year-old woman reported pelvic fullness, localised especially on the left side. Her past surgical history was positive for a previous laparotomy hysteropexy for a symptomatic uterine retroversion and enucleation of left ovarian cyst. Her body mass index was 31.5 kg/m3. On transvaginal ultrasound examination the right ovary was enlarged by the presence of a pluri-locular cyst of 50 mm of diameter, without atypical vascularity. The patient was candidate for an elective single port (Quad-port, Olympus) hysterectomy with bilateral adnexiectomy.

Laparoscopy confirmed the presence of a massive complex adhesions between the omentum and peritoneum and the bladder tenaciously adherent to the fundus of uterus, as result of previous surgery. Adhesions and the detachment of the bladder were release with a 5 mm flexible grasper. Hysterectomy with bilateral adnexiectomy was performed. The operative time was 188 minutes and estimated blood loss was 30 ml, without intra-operative complications. Time of hospitalization was 24 hours. Cosmetic result was excellent.

This case report shows the possibility to perform LESS surgery in obese women undergoing to previous laparotomic surgery, also in presence of massive adhesions, without intra-operative or post-operative complications. The operative time, intra-operative blood loss and hospital time are in agreement with the literature.

V.06.6

Single access laparoscopic supracervical hysterectomy for very large uterus

Roman H.*[1]

[1] University Hospital Rouen France

The aim of the movie is to describe the single access laparoscopic supracervical hysterectomy technique in very large benign uterus using primary uterine devascularization. The keys to a successful procedure are: the complete devascularization of the uterus before any other surgical procedure is performed on the uterus, the use of a monopolar current supraloop to safely cut the isthmus and uterine transcervical fragmentation. To these could be added the previous free-residue diet that further guarantees safety and peroperative convenience and the strong mobilization of the uterus by use of a uterine manipulator. The first stage, performed at the onset of the surgical procedure, is complete uterus devascularization, by coagulating both uterine arteries at the artery origin and infundibulo-pelvic ligaments or utero-ovarian vessels. This step can be done using the single access but requires strong lateral mobilisation of the uterus by the third operator placed between the patient’s leggs. The second stage involves the section of the isthmus using a monopolar current supraloop which allows doing it rapidly and safely. Then uterine morcellation can be easly performed by introducing the morcellator transcervically. This procedure avoids unexpected peroperative hemorrhage requiring conversion to the abdominal route and provides optimal protection for the ureter.

V.06.7

A novel approach to sacrohysteropexy

Einarsson J. I.*[1]

[1] Brigham And Women’S Hospital/harvard Medical School Boston United States

In this video, we present a novel method for passing mesh arms medial to the uterine vessels using 5 mm Mersilene tape with straightened blunt tip needle. The potential advantage of this approach is simplification of the passing of mesh as there is no dissection required. The procedure time for the case presented here was approximately 85 minutes. Estimated blood loss was less than 30 cc, and there were no intra-operative or post-operative complications.

When performing a sacrohysteropexy, mesh arms are frequently passed through the broad ligament to connect the anterior and posterior pieces of mesh. Passing the mesh arms medial to the uterine vessels may have a theoretical advantage in an ensuing pregnancy as this may reduce constriction on the uterine vasculature as the uterus expands.

In this video, we present a novel method for passing mesh arms medial to the uterine vessels using 5 mm Mersilene tape with straightened blunt tip needle. The potential advantage of this approach is simplification of the passing of mesh as there is no dissection required.

The procedure time for the case presented here was approximately 85 minutes. Estimated blood loss was less than 30 cc, and there were no intra-operative or post-operative complications.

Sacrohysteropexy can be performed safely laparoscopically.

V.06.8

Da vinci assisted laparoscopic sacrocolpopexy

Stevanovic N.*[1], Sarlos D.[1], Schär G.[1]

[1] Kantonsspital Aarau Aarau Switzerland

Abdominal sacrocolpopexy is regarded as gold standard for surgery of an isolated or combined apical defect. This video shows a sacrocolpopexy assisted by a daVinci robot. Laparoscopy is superior in terms of morbidity and recovery but it is technically demanding. The daVinci robot may offer another approach to perform sacrocolpopexy minimally invasive.

A Cochrane review in 2004 confirmed abdominal sacrocolpopexy as gold standard for surgery of an isolated or combined apical defect. Compared to laparotomy the laparoscopic technique is superior in terms of morbidity and recovery but it is also technically demanding with a extended learning curve. The daVinci robot supposedly facilitates learning and accomplishing of minimal invasive techniques. For some time we are evaluating this technique regarding its application, value and its comparison to regular laparoscopy. In the beginning we were investigating hysterectomies by comparing laparoscopy and robot assisted techniques. Now we evaluate sacrocolpopexy.

Our video shows an endoscopic sacrocolpopexy with a daVinci robot. The polypropylene mesh (Gynemesh) is inserted in a 57 year old female with an apical prolapse stage III, a rectocele stage I and no descent of the anterior vaginal wall.

The video shows in detailed steps the dissection (peritoneum, promontory, dorsal and ventral vaginal wall), mesh fixation to the anterior and posterior vagina and the promontory and then the peritoneum closure. Videos for installation of and working with the robot as well as such for robot assisted hysterectomies have been presented at earlier opportunities and might be ordered from the speaker

With the help of a DaVinci robot even less experienced pelvic floor surgeons have an instrument in their hands enabling them to perform sacrocolpopexy minimally invasive.

V.06.9

Laparoscopic sacrocervicopexy—tips and tricks

Einarsson J. I.*[1]

[1] Brigham And Women’S Hospital/harvard Medical School Boston United States

We present several tips and tricks for facilitating the performance of a laparoscopic sacrocervicopexy. We prefer to conserve the cervix at the time of hysterectomy since preliminary data seems to support decreased risk of mesh erosion as compared to a total laparoscopic hysterectomy. We will demonstrate how to obtain adequate exposure to the promontory, tips for performing the rectovaginal and vesicovaginal dissection, suturing tips as well as suggestions for easier peritoneal closure.

We present several tips and tricks for facilitating the performance of a laparoscopic sacrocervicopexy.

We prefer to conserve the cervix at the time of hysterectomy since preliminary data seems to support decreased risk of mesh erosion as compared to a total laparoscopic hysterectomy. We will demonstrate how to obtain adequate exposure to the promontory, tips for performing the rectovaginal and vesicovaginal dissection, suturing tips as well as suggestions for easier peritoneal closure.

Laparoscopic sacrocervicopexy can be performed safely and effectively using regular laparoscopy. Average operating time in our hands for LSH and sacrocervicopexy is 90 minutes.

Laparoscopic sacrocervicopexy is a safe and effective treatment for apical pelvic organ prolapse.

V.06.10

Laparoscopig cervico vesical fistula repair

Patel P.*[1], Banker M.[1], Munshi S.[1]

[1] Gujarat Ahmedabad India

Laparoscopy offers the opportunity to efficiently perform a vesico-cervical fistula repair through a minimally-invasive technique that is similar to the open procedure in addition offering all the advantages minimally invasive surgery.

Second para patient who had history of C-section followed by vaginal delivery after three years and had symptoms of cyclical hematuria and intermittent involuntary leakage of urine. On IVP cystogram and pelvic MRI small fistulous communicating tract between anterior cervix and bladder dome was identified.

After cystoscpopic and hysteroscopic confirmation Laparoscopic excision of the fistula tract, wide mobilization of the bladder base from the anterior vaginal wall and bladder dome from the anterior abdominal wall, closure of the cervix, and closure of the bladder. Omentopexy was preformed.

Two months follow up post surgery shows no evidence of recurrence.

Literature from across the world suggest Laparoscopy and Robot Assisted Laparoscopic surgery as a equally efficient method in dealing with these fistulas.

V.06.11

Nerve sparing laparoscopic sacrocolpopexy—surgical technique

Sarlos D.*[1], Kots L. A.[1], Schär G.[1]

[1] Kantonsspital Aarau Aarau Switzerland

Prospective studies show that laparoscopic sacrocolpopexy has excellent anatomical outcomes but often a de novo stool-outlet problem is reported. Nerve sparing dissection as shown in this video, may avoid injury of autonomic nerve fibers of the plexus hypogastricus superior

Several prospective studies demonstrate that laparoscopic sacrocolpopexy results in excellent anatomical outcomes at least in short term follow-up. Rates of mesh erosions and dypareunia are low compared to insertion of vaginal meshs. An often cited complication is a de novo stool-outlet problem quoted in the literature with frequencies between 10–30%.The exact cause remains uncertain, a possible neurogenic factor could be an injury of autonomic nerve fibers of the plexus hypogastricus superior and therefore an injury of the sympathetic innervation of pelvic organs. Through nerve sparing dissection, which is often facilitated by the better laparoscopic visual field, this lesion can be avoided

This video shows the nerve-sparing laparoscopic sacrocolpopexy of a 47 year old patient presenting with symptomatic descensus uteri grade III0 , cystocele grade II0 and rectocele grade II0.

We show how the fibers of the plexus hypogastricus superior are prepared and spared during dissection of the presacral plane. Furthermore this video illustrates nerve sparing preparation of the plexus hypogastricus inferior during parasigmoidal opening of the retroperitoneum. Additionally the video presents the tension free fixation of the ventral and dorsal polypropylene mesh to the ligamentum longitidinale with sparing of the autonomic nerves.

Laparoscopic sectioning of the superior and inferior hypogastric plexus fibers during sacrocolpopexy procedure is feasible and can be easily done by experienced surgeons without prolonging surgery time. Fist results show that as a consequence of this approach de novo stool outlet complications may be reduced

V.06.12

Extending the scope of single site surgery- myomectomy to retroperitoneal lymphadenectomy

Andou M.*[1], Ohta Y.[1], Hada T.[1]

[1] Kurashiki Medical Center Kurashiki Japan

We have introduced a single site, multi-trocar approach for various cases such as myomectomy, hysterectomy and malignancy surgery including retroperitoneal lymphadenectomy.

The desire for minimal scar surgery promoted the advent of new approaches such as single port laparoscopy. We introduced our single incision multi-trocar approach and have been expanding the applications. We will present 3 minimally invasive surgeries that use the same approach; myomectomy, hysterectomy and malignancy surgery including retroperitoneal lymphadenectomy.

For this method we don’t use special platforms and only standard laparoscopic instruments are required. We create a 2.5 cm incision at the umbilical base and through this we expose the rectus fascia and place 3 different length 5 mm trocars in the fascia. After becoming accustomed to this approach with myomectomy and hysterectomy, we started using the same approach for pelvic lymphadenectomy then expanded to the para-aortic area with the aid of a vaginal telescope.

As the peritoneal incision was small in all cases except for myomectomy is quite small, patient recovery was quick. The skin incision on healing was almost invisible. As for the lymphadenectomy, we could cover both the para-aortic and pelvic lymph nodes with just one 2.5 cm incision

This surgery offers the least invasive and most cosmetically appealing result desired by patients. Single incision laparoscopic surgery has the possibility of greater future potential.

Session V.07

* Video Session_7 *

Teaching and Training—Myomectomy

V.07.1

Bladder leiomyoma

Rossetti A.*[1], Sizzi O.[1], Ruggiero A.[1]

[1] Nuova Villa Claudia Hospital Rome Italy

Unusual case of bladder leiomyoma treated with laparoscopic excision.

The video presents the case of a patient with a palpable mass arising from the dome of the bladder, densely adherents to the pubic symphysis and extremely painful.

While the CT scan examination resulted in an involvement also of the posterior aspect of the bladder, US examination correctly diagnosed the extension and localization of the disease. First a diagnostic cistoscopy was performed. The lesion impinged the left lateral anterior aspect of the bladder that showed no signs of infiltration. The bladder was then filled with 300 cc of saline and 2 cc of methylene blue.

Through laparoscopy an incision of the peritoneum anteriorly to the bladder between the two opposite obliterated arteries was performed. A blunt dissection of the retroperitoneal areolar tissue was carried out up to the abdominal wall at the level of the pubic symphysis. This manoeuvre was consistenly more complex next to the lesion where the adhesions were extremely denser. At this level a sharp dissection following a preventive bipolar coagulation was used. After a thorough adhesiolysis of the mass, a superficial incision of the bladder around the lesion was carried out managing at the end to remove the tumor using a mix of blunt dissection, bipolar coagulation and cold scissor techniques being successful in avoiding opening the bladder. The bladder muscular layers were sutured with interrupted stitches using Vycril 2–0 suture swaged to a 26 mm needle. The suture was applied with the right hand through the midline ancillary trocar, intracorporeally tied. In post-operative day 1 the patient was asymptomatic. Histological finding resulted in a bladder leiomyoma.

the video has shown that this uncommon pathology can be easily approached in a retroperitoneal fashion especially when involving the anterior aspect of the bladder dome.

V.07.2

Endometriotic nodule resection, multiple myomectomy using barbed v-loc™ suture, right ovarian cystectomy and sprayshield™

Wattiez A.[1], Vazquez A.*[1], Maia S.[1], Alcocer J.[1], Redondo C.[1]

[1] Ircad Strasbourg France

We present the interesting case of a 39-year-old woman with primary infertility, pelvic pain and menorrhagia. MRI shows an endometriotic nodule at the level of the left uterosacral ligament, two intramural fibroids and a right ovarian endometrioma. Abdominal exploration manifests an enlarged uterus and pain at the level of left uterosacral ligament.

In this video, we try to show the importance of surgical strategy to perform this surgery safely and quickly. We start with the exposure that consists of trendelenburg, the suspension of the ovaries to the abdominal wall and the adhesiolysis releasing lateral adhesions of the left sigmoid colon. Then, the resection of the endometriotic nodule is carried out. To facilitate this part of the procedure the dissection of the left ureter and the left pararectal fossa is mandatory. The myomectomy is begun with transitory clipping of uterine arteries and infundibulopelvic (IP) ligaments to avoid massive bleeding. Once the myomectomy has been performed, the uterine serosa is closed using the V-Loc™ barbed suture. Before proceeding to the myoma’s morcellation, clips are gently removed. The surgery continues with the right ovarian cystectomy. Then, the SprayShield™ is used to prevent postoperative adhesion formation, and once the myoma has been morcellated, the procedure is completed with adequate hemostasis and profuse lavage of the abdominal cavity.

V.07.3

Direct entry and trocars placement: the way to do it safely, ergonomically, and esthetically

Wattiez A.[1], Vazquez A.*[1], Maia S.[1], Alcocer J.[1]

[1] Ircad Strasbourg France

Direct entry for laparoscopy is a safe and fast method under experienced hands.

A recent Cochrane review (Ahmad G et al, 2008) concluded that there is no scientific evidence regarding the benefit in terms of security among the different laparoscopic entry techniques. However, the technique of direct trocar entry is faster and cheaper (Zakherah MS, 2010) compared to the entry with a Veress needle, which is probably the most widespread. In this video we try to show some tricks to do the direct entry safely and also esthetic. We also consider that is very important the adequate placement of the accessory trocars to gain ergonomy. The way we do is also shown on this short video.

V.07.4

Geometric laparoscopic suturing

Hudgens J.[1], Pasic R.*[1]

[1] University Of Louisville Louisville United States

The objective of this video is to present the geometric principles used for effecient laparoscopic suturing.

This video will present the geometric principles and visualiztion principles that allow for efficient laparoscopic suturing. We will describe the visual cues that allow for adequate depth perception. We will also discuss the importance ofunderstanding the geometric relationships that are created by different port placements in relation to anatomy.

V.07.5

Steep and deep—the challenge of steep head down (trendelenburg) during surgery

Kondrup J.*[1]

[1] Lourdes Hospital Binghamton, N Y United States

Hospitals just beginning or have not fully instituted a MIS program may have challenges with steep “head down” or Trendelenburg position. This is especially evident where Gyn or Urological robotic programs have been instituted. We share our successful tips in over 10,000 steep Trendelenburg or head down cases

As I travel throughout the U.S. & other countries I am often approached by GYN surgeons concerned over the reluctance of the anesthesia team to provide them steep head down position. This concern is valid since intra-operative anesthesia risks may increase eg: pneumothorax, C02 retention & heart rate & BP changes. This becomes more critical when the patient is morbidly obese or has pulmonary issues. We must help each other to remember that minimally invasive surgery is a “team” approach & all parts need to be strong to achieve success. Some minor intra-op changes as well as a change in mindset can make a huge difference in the anesthesia aspect.

When a steep head down position is anticipated several initial modifications are made. These include: Using a larger ET tube eg: 7.5 or 8.0 fr., mechanical bowel prep (can relieve some of the thoracic pressure) & a long acting paralytic agent is used eg: Rocuronium. Nitrous is avoided. After abdominal distention & trocar insertion we lower the intra-abdominal pressure to 15 mmHg “prior” to head down. In morbidly obese head down is achieved gradually. Anesthesia machine changes made & importance of deep paralysis cannot be understated. Peak pressures increase and the T.V. should be decreased and the rate increased to compensate. Further, the I/E ratio is changed (1:1–1:3) to deal with C02 build up. Pressure control ventilation is ideal

When instituting these methods, only rarely can we not give the surgeon steep head down

We must work as a team and listen to the vast experience of others to move into the MIS field

V.07.6

Surgical management of the asymptomatic brca positive woman

Kondrup J.*[1]

[1] Lourdes Hospital Binghamton, New York United States

The prevalence of the BRCA gene in the general population is approximately 1 in 300 and 1 in 40 in the Ashkenazi jewish population. Screening is essential & can be a life and death discovery not only for the patient but other family members. This video discusses the management of the asymptomatic BRCA positive woman & shows two cases, one discovered & one missed.

It is well known that the presence of a BRCA mutation significantly increases a woman’s risk of breast cancer as well as ovarian cancer. Lifetime risks can be as high as 60% for ovarian cancer. This is an autosomal dominant inheritance & therefore the offspring have a 50% risk of carrying this gene whether they are male or female. Screening remains inadequate. Management of the asymptomatic BRCA positive woman remains debatable but all agree the ovaries & fallopian tubes need to be removed by age 37 or when child bearing is finished.

Patients are mechanically bowel prepped pre-op. General anesthesia utilized. 5 mm Laparoscope at umbilicus and a 10/12 mm trocar in LLQ and a 5 mm trocar in the RLQ. Pelvic washings obtained. Entire abdomen explored. The retroperitoneal space opened on each side utilizing the Enseal or Harmonic Scalpel (Ethicon Endo) above the ovary and the entire ovary and tube removed. Residual ovarian tissue is unacceptable. LSH or TLH is performed if indicated. Ovaries & tubes removed via an endopouch. Patient discharged same day.

The video demonstrated proper procedure for BRCA management. Patients discharged home same day unless TLH or LSH performed (discharged next day). Referral for breast surveillance made & patient aware of rare incidence of primary peritoneal cancer. Proper referrals are made & family members tested.

Adequate education for healthcare providers as well as the general public is a must. So many women are undiagnosed and are at high risk for preventable breast and ovarian cancer. Proper management is essential.

V.07.7

Total laparoscopic hysterectomy with bilateral adnexectomy: standard technique

Wattiez A.[1], Vazquez A.*[1], Maia S.[1], Alcocer J.[1]

[1] Ircad Strasbourg France

Despite the unquestionable passion at the beginning, laparoscopic surgery did not developed as hoped. The major arguments against laparoscopic surgery are its difficulty and its length. And probably due to these reasons only around 12% of hysterectomies are perfomed by laparoscopy (Wu JM et al, 2007). Nevertheless, we believe that the stardardization of total laparoscopic hysterectomy (TLH) can simplify this surgery, make it faster and also reproducible. In this video we present the 10 keysteps of a TLH with adnexectomy that can help any gynaecological surgeon to safely reproduce the procedure.

Session P.01

* Case reports *

P.01.1

Argument against “supra-cervical hysterectomy is a trendy unproven fad”

Attilia B.[1], Woldman S.*[1], Patwardhan M.[1], Charalampos K.[1], Nivedita G.[1], Kyriajos P.[1]

[1] South London Healthcare Nhs Trust London United Kingdom

Case review of 40 laparoscopic subtotal hysterectomy performed 2009–2011.

We argue that laparoscopic supra-cervical hysterectomy is trendy: not as an unproven fad but as a safe effective alternative to total laparoscopic hysterectomy for uterine fibroids.

Review of case notes with data collection and analysis.

In our study of 40 cases of laparoscopic supra-cervical hysterectomy (LSH) between 2010–2011 performed at two District General Hospitals for 14–24 week size fibroid uterus we show that LSH has an average operating time of 90 minutes (range 55–120 minutes), with a time difference mainly due to morcellation of calcified fibroids.The primary port was supra-umbilical and only 3 ports were used in all cases. Bipolar technology was used in each case and a laparoscopic loop for excision of the cervix. Only 1 patient required a blood transfusion of 2 units. There were no cases of ureteric or bladder injury, conversion to laparotomy or return to theatre. Seventy per cent of patients were discharged within 24 hours.

We argue that laparoscopic supra-cervical hysterectomy is trendy: not as an unproven fad but as a safe effective alternative to total laparoscopic hysterectomy for uterine fibroids.

P.01.2

Bowel herniation after laparoscopic sacral mesh fixation

Trompoukis P.*[1], Nassif J.[2], Gabriel B.[3], Osorio F.[4], Wattiez A.[5]

[1] Attikon University Hospital Athens Greece - [2] American University Hospital Of Beirut Beirut Lebanon - [3] Freiburg University Hospital Freiburg Germany - [4] Hospital Da Luz Lisbon Portugal - [5] Ircad/eits Strasbourg France

We report a case of the small bowel being obstructed under a peritoneal defect covering the mesh that was sutured at the level of the sacral promontory. This type of operation seems to be very safe with a very low recurrence rate of prolapse compared with other procedures. However there is a controversy as whether the parietal peritoneum covering the mesh has to be sutured or not. We stress point together with the basic steps of this demanding procedure.

Laparoscopic sacrocolpopexy, for the treatment of genital organ prolapse is an effective procedure.We report a case of pelvic organ prolapse that was treated surgically and presented with signs and symptoms of acute abdomen indicating intestinal obstruction. The findings were small bowel loop invagination and obstruction through a defect of the peritoneum covering the mesh just posterior to it, in a small distance away of the sacral promontory.

49 years old woman treated for vault prolapse with laparoscpic sacral mesh fixation (sacrocervicopexy)

The target of this case report is first to stress the importance of having a high index of suspicion in similar cases of bowel obstruction following laparoscopic repair for organ prolapse but also to emphasize the critical points of a good surgical technique such as the peritonealization of the mesh in order to avoid any other potential complications.

Pelvic organ prolapse has a prevalence around 30.8%. This type of operation seems to be very safe with a very low recurrence rate of prolapse compared with other procedures. However there is a controversy as whether the parietal peritoneum covering the mesh has to be sutured or not.

We analyze the essential surgical steps and we review and reevaluate, based in our experience, the basic surgical steps, the results and potential complications of this highly effective technique of treating genital organ prolapse for better results and minimum complications.

P.01.3

A case of rectus sheath endometriosis infiltrating the liver parenchyma: diagnosis and surgical management

Afors K.*[1], Athanasias P.[1], Mudan S.[2], Vesely M.[1], Byrne H.[1]

[1] St George’S Hospital Nhs Trust London United Kingdom - [2] Royal Marsden Nhs Trust London United Kingdom

Hepatic endometriosis is a rare disorder. We report a unique case of liver endometriosis with extensive involvement of overlying rectus muscle managed with laparotomy and rectus muscle reconstruction using mesh.

Endometriosis involving the liver is a rare entity. We report a case of endometriosis arising from the rectus sheath, extending through the posterior aspect of the sheath with infiltration of the liver.

A 43 year old woman presented with a 6 month history of cyclical abdominal pain and a right upper quadrant mass. Liver function test and tumour markers were normal. Radiological imaging (ultrasound and magnetic resonance imaging) suggested an ill-defined mass with multiple haemorrhagic foci extending through the rectus muscle with involvement of liver. An ultrasound-guided biopsy of the mass was taken and endometriosis confirmed. Due to the severity of symptoms decision was made for operative management.

The case was performed as a joint procedure with gynaecology, plastics and hepatic surgery involvement. Laparotomy was performed with successful resection of the endometriotic mass from the anterior surface of the liver. Reconstruction of the anterior abdominal wall using a mesh extending from the costal margin was used. The patient made an excellent post-operative recovery.

The most common sites of endometriosis are within the pelvis, however, distant involvement of organs such as lungs, pleura, diaphragm and heart have been described. Hepatic endometrioma is a rare entity and its aetiology and pathogenesis remain unclear. Such cases support the coleomic metaplasia theory of endometriosis rather than the retrograde menstruation theory. Surgery remains the mainstay of treatment and in cases of extensive involvement of the anterior abdominal wall specialist reconstructive measures using mesh or graft should be undertaken.

P.01.4

A rare case of bladder endocervicosis and review of literature.

Singh R.*[1], De Lange M.[1], Afifi Y.[1]

[1] Birmingham Women’s Hospital Foundation Trust Birmingham United Kingdom

We present a case report of endocervicosis of urinary bladder, a very rare benign condition exclusively seen in women usually of reproductive age group which could mimic adenocarcinoma of urinary bladder.

A 45 year old nulliparous woman with a longstanding history of endometriosis. She had a left oophorectomy and removal of right ovarian cyst for endometriosis in the past. She presented with a 2 year history of dysuria and urgency. An MRI was arranged which showed extensive pelvic endometriosis involving the bowel and a complex right adenexal multicystic mass. There was a 2.3 × 1.7 cm soft tissue nodule at the dome of bladder suggestive of endometriosis. The tumour markers were normal. She subsequently had a cystoscopy and biopsy which confirmed the diagnosis of bladder endocervicosis. The lesion was removed cystoscopically and patient is managed conservatively.

Endocervicosis of the urinary bladder is a very rare benign condition characterized by mucinous endocervical epithelium within the muscle of the bladder. It is believed to be a lesion of Müllerian origin. The aetiology and pathogenesis of this condition remain unknown. Although it is usually an incidental histologic finding, it may cause non-specific symptoms of chronic pelvic pain and dysuria. It can be confused with an adenocarcinoma of the bladder. Unless the correct diagnosis is made these patients can undergo potentially debilitating surgery. As demonstrated in our patient even symptomatic endocervicosis can be managed conservatively.

P.01.5

A rare case of gastric injury during routine laparoscopic surgery

Abdullah Z.*[1], Nnochiri A.[1]

[1] Nhs London United Kingdom

We present the case of a woman who was undergoing laparoscopic sterilisation that resulted in gastric injury, possibly secondary to gastric hyperinflation caused by a laryngeal mask airway

Laparoscopic surgery is the primary method of choice for the management of most gynaecological conditions. Trials have shown that the risk of minor complications after surgery is 40% lower with laparoscopy compared to laparotomy, however, the risk of major complications is rising

A 38-year-old multiparous woman with three vaginal deliveries and one caesarean section was admitted for laparoscopic sterilisation. She weighed 41 kg (BMI17). General anaesthesia was induced and a laryngeal mask maintained the airway. A 5 mm intra-umbilical incision was made and a veress needle was inserted easily. Palmer’s test was satisfactory. At a pressure of 20 mmHg, a 5 mm umbilical trocar was inserted using the standard technique. After insertion of the trocar it was noticed that the initial intraperitoneal pressures were between 12-15 mmHg. The trocar was removed and a 5 mm visiport was used. The camera was introduced, and it was immediately recognised that a lumen had been entered. The gas was turned off and the camera was withdrawn but the trocar was left in place, and the general surgeons were called. The anaesthetist, at this point, replaced the laryngeal mask with an endotracheal tube and aspirated fluid from the stomach using a nasogastric tube. With the general surgeon present, the camera was reinserted into the peritoneal cavity and there appeared to be two perforations on the anterior wall of the stomach each measuring 0.5 cm in length with dense omental adhesions to the anterior abdominal wall. Laparoscopic sterilisation was performed followed by gastroscopy, which ruled out concomitant injury to the posterior wall of the stomach. The lacerations were repaired by intracorporeal suturing

P.01.6

Acquired uterine arteriovenous malformation (uavm) after uterine artery embolisation (uae) and unsuccessful pregnancy.

Klyucharov I.*[1], Safina V.[2], Yusupov K.[3], Ustinova E.[4], Samigullova A.[1]

[1] Kazan State Medical University Kazan Russian Federation - [2] Ccc Hospital N18 Kazan Russian Federation - [3] Kazan State Medical Academy Kazan Russian Federation - [4] City Polyclinic N2 Kazan Russian Federation

UAVM are very rare and potentially life-threatening. We present a case of fertility preserving treatment of the acquired UAVM.

Treatment of UAVM by hysterectomy leads to infertility. Several treatment options preserve fertility in these patients.

A 38-year-old nulliparous woman was diagnosed with UAVM after episode of severe metrorrhagia. In 2008 she underwent an UAE for uterine myoma. No data foundon presence of UAVM before. in 2010 at 8th week of pregnancy she was diagnosed with fetal death and had an evacuation procedure. She presented 2 months later with profuse vaginal bleeding that had not responded to medical treatment. 3-d Doppler US revealed an UAVM in the left and posterior wall of the uterus 33 × 35 mm and growth of the myoma. Options were discussed with the patient, and as she wanted to conserve her fertility a decision was made for resection of the hemangioma simultaneously with laparoscopic myomectomy. Both laparoscopy and hysteroscopy were undertaken and this confirmed the integrity of the uterus. A resection of the posterior wall of the uterus and laparoscopic myomectomy were performed,

The patient is now 5 months postoperative, she is well in her health with regular periods and no abnormal vaginal bleeding. Repeat ultrasound with color flow Doppler has shown remarkable decrease of the lesion 13 × 8 mm in left and posterior wall.

UAVM are commonly acquired in pregnancy. They are usually benign and resolve spontaneously following delivery. Cases have been reported of ‘iatrogenic’ formation of arteriovenous malformation after caesarean sections and abortions. The main concern about UAEis its impact on future fertility. Successful pregnancies have been reported after UAE. However, pregnancy can trigger the appearance of UAVM. Laparoscopic resection of the UAVM is one of the treatment options to preserve future fertility.

P.01.7

Audit: surgical management of ectopic pregnancy

Liew Y. E.*[1], Lucky S.[1]

[1] Aberdeen Royal Infirmary

The incidence of the ectopic pregnancy in UK remains static (11.1/1000) over the recent years.

It continues to be the leading cause of maternal death in early pregnancy. RCOG recommended surgical approach as the gold standard in the management of ectopic pregnancy for haemodynamically stable patient.

The aim of the audit was to evaluate the care of women undergoing surgical management for ectopic pregnancy. Data was collected retrospectively over the period of 10 months from August 2010 till May 2011 by reviewing case notes.36 women underwent surgical treatment but only 33 case note were available.

Out of the 33 patients, 18% were haemodynamically unstable and 58%were haemodynamically stable on admission. 34% had no documentation. The time interval from diagnosis to surgical intervention for heamodynamically unstable patient ranges from 20 mins to 3 hours, while haemodynamically stable patient ranges from 1 hour 30 mins to 27 hours. Aberdeen is a recognized centre for advanced laparoscopic surgery.94% of the patients had laparoscopic surgery; 67% of the unstable patients were successfully managed laparoscopically. 55% of the cases were done during routine working hours and 45% during out of hours. All cases have documentation in regards to the affected side of fallopian tube and status of the contra-lateral tubes. 67% of the cases have no documentation on adhesions or any upper abdomenfindings. Only 6% of the patients who underwent laparoscopic surgery required blood transfusion. 81% of the patients who were managed laparoscopically discharged after 1 day.

28 year old female, para 0 + 0 had a laparoscopic salpingectomy for left tubal pregnancy confirmed on histopathology. She was readmitted 3 weeks later with persistent abdominal pain, positive urine pregnancy test and beta HCG of 319. Transvaginal ultrasound shows large amount of free fluid in abdomen. A diagnostic laparoscopy was performed revealing a massive haemoperitoneum. The bleeding came from a lesion on the mesosalpinx of the right fallopian tube represnting a trophoblastic peritoneal implant. The histopathology of the lesion was reported as chorionic villi confirming viable products of conception. Trophoblastic peritoneal implants following salpingectomy is an extremely rare phenomenon with scarce literature.

Laparoscopic surgery remains the preferable approach for management of haemodynamically stable patients for ectopic pregnancy. Management of tubal pregnancy In the presence of haemodynamic instability should be by the most expedient method and laparoscopic approach could be considered where expertise exists.

P.01.8

Case report: laparoscopic oophorectomy: treatment for anti-nmdar encephalitis

Roberts R.*[1], Macdougall N. J. J.[1], O’brien P.[1], Aziz K.[1], Swingler R. J.[1], Christie J.[1]

[1] Ninewells Hospital Dundee United Kingdom

We describe the role that gynaecological surgery played in the management of a patient with Anti-NMDAR encephalitis.

A previously healthy 33 year old presented following a period of abdominal pain with confusion, dizziness, shaking and hyperventilation. Initially a urinary tract infection was suspected and antibiotic treatment started. The patient deteriorated requiring psychiatric and neurological input. She suffered from abnormal movements, anxiety, and states of terror, insomnia, delirium, self harm and suicidal ideation, facial dyskinesia, verbigeration, cognitive impairment, reduced responsiveness, violence and paranoia.

Two months later a diagnosis of anti-NMDAR encephailitis (N-methyl-D-aspartate receptor) was made. This potentially lethal but reversible disorder has recently been characterised and is often associated with tumours, most frequently ovarian teratomas.

Initial treatment was with high dose methylprednisolone. A CT scan revealed a 2.5 cm dermoid cyst. Early tumour removal is associated with an improved prognosis and a laparoscopic oophorectomy was performed without complication. Within 24 hours of the procedure there was marked improvement in cognitive function and appetite. Immunoglobulin was administered for 5 days post operatively.

This case introduced the Gynaecologists within the department to this potentially lethal disorder and the complex care that patients require. Presentation is typically to Neurology and Psychiatry but management is truly multidisciplinary, despite the fact that many clinicians will be as oblivious as we were to this devastating condition. The recognition and diagnosis of this condition will remain delayed unless awareness of it increases. It became apparent through discussions with colleagues and literature searches that it is highly likely that this ‘rare’ condition is not as rare as we believe.

P.01.9

Cervical ectopic pregnancy

Gennaro S.*[1], Nappi L.[1], Greco P.[1]

[1] Institute Of Obstetrics And Gynecology, Department Of Surgical Sciences, University Of Foggia Foggia Italy

We present two cases of ectopic cervical pregnancy (CP) efficiently managed with uterine artery embolization (UAE) followed by office hysteroscopic resection

CP is a rare form of ectopic pregnancy, the incidence ranges between 1/2500–12,000 pregnancies, which represent approximately 0.15% of all ectopic pregnancies.

It is a potentially life-threatening condition because of the unexpected occurrence of uncontrollable bleeding

A 36-year-old woman, gravida 3, para 1 with one previous natural childbirth and history of two uterine curettage for abortions, with a cervical pregnancy at 6.1 weeks of gestational age.

A 37-year-old woman, gravida 12, para 4 presented with amenorrhea at 8 weeks 3 days after her last menstruation, with a cervical pregnancy.

Both patients underwent UAE as first step of treatment. The following day an office hysteroscope was introduced into the cervical canal by using the vaginoscopic approach (with no anesthesia and no tenaculum) and a bipolar electroexcision near to the implantation side was performed

The CP were evacuated, and the reproductive capability of the patients was preserved

CP treatment should be more conservative and minimally invasive possible and should respect clinical outcome, such as quick regression of serum hCG level and cervical mass and a short hospital stay after the treatment.

Thanks to office hysteroscopy we were able to induce regression of the viable cervical pregnancies and consequently of the trophoblasts’ invasion of the cervix, the CP were completely removed, and satisfactory haemostasis was achieved with electrocoagulation.

Our patients were discharged three days after admission and hCG concentration, after fifteen days, was close to 0 mUI/mL.

In conclusion UAE followed by office hysteroscopic resection has potential to minimize the patient’s discomfort and recovery time, to preserve fertility, to prevent bleeding and rebleeding, and to reduce laboratory and outpatient follow-up

P.01.10

Chronic pelvic pain: the role of laparoscopic surgery and its outcomes

Datta M.*[1], Faik S.[1], Odukoya S.[1]

[1] Scunthorpe General Hospital Scunthorpe United Kingdom

A retrospective study of 105 women who had laparoscopy for chronic pelvic pain.Most women had at least one positive finding and showed marked improvement following surgery

This study reiterates the usefulness of laparoscopic surgery as a diagnostic and therapeutic tool in patients with chronic pelvic pain

105 women,ranging from 18 to 49 years of age who had laparoscopy,either diagnostic or therapeutic,for chronic pelvic pain(including dyspareunia & congestive dysmenorrhoea)of at least 6 months duration between 2006 and 2008 were identified from the surgical database for the unit.History of contraceptive use,STI or PID,previous abdominal surgeries,parity were noted. Findings at laparoscopy were correlated with bimanual or radiological findings.Improvement in symptoms at follow up was looked at as the therapeutic intent.Data was entered on to a Microsoft excel spreadsheet and analysed using SPSS

Most women had bimanual examination(92%)and non invasive tests,ie USS/MRI(69%).Bimanual examination showed positive findings in 58%.Laparoscopy revealed positive findings in 92 patients(87%)which included pelvic adhesions in 47%(no = 49),endometriosis in 38%(40 patients),and other pathologies(ovarian cysts, fibroids etc)in 41%.Laparoscopic treatment was done in 91%(no = 96)of patients,which included adhesiolysis,diathermy/excision of endometriosis,ovarian cystectomy/cystotomy,oophorectomy,salpingectomy etc

At follow up,88 (92%) patients had improvement in symptoms at least in the short term.

This study shows that a significant number of women with symptoms of chronic pelvic pain have positive findings at laparoscopy, which are not usually found at bimanual examination or radiological investigations.Laparoscopic surgery for benign diseases like endometriosis,adhesions,etc can provide significant improvement in symptoms of pain in young women

P.01.11

Correction of utero tubal junction area damages induced by polyps as single causes of women subfertility detected during fertiloscopic examination

Mgaloblishvili I.*[1], Mgaloblishvili M. B.[1], Tabutsadze K.[1]

[1] Centre For Reproductive Medicine And Infertility, Tbilisi, Georgia

Transvaginal hydrolaparoscopy (THL) allows to look at reproductive system at optimal angle and in real conditions.

It makes possible to evaluate accurately tube-ovarian system and surrounding space of pelvic cavity. Therefore detection of single disturbance in infertile women in hard-to -reach area of utero—tubal junction and their successful correction allowed us to think about significant role of these changes in development of subfertility.

We present retrospective randomized study of 29 women (aged 19 to 39 years) with primary (21) and secondary (7) infertility of undefined etiology of various durations (from 1 to 9 years). All women underwent fertiloscopic investigation in sequence: microhysteroscopy, sonohysterosalpingography and THL. Transvaginal hydrolaparosocpy, microhysteroscopy and removal of polyps was perfomed using fertiloscope (Karl Storz, Tottingen, Germany)

In all 29 patients we found multiple polyps in uterino-tubal junction area. Size of polyps varied from 2 to 5 mm. In all cases we observed weblike or superficial sinechiae in uterino-tubal junction area that were linked with polyps.

During microhysteroscopy we performed removal of polyps, and then sonohysterosalpingographicaly both tubes were easily patent. During THL pathologies in pelvic cavity was not revealed. Condition of fimbirae and ampular lumen of tubes corresponded to class I according Puttemans and Heylen classification. Subsequently in all women monitoring of ovulation (up to 8 ovulatory cycles) was performed.

Out of 29 observed women, 21 conceived (72,4%)during the year. Three women conceived spontaneously the next year after fertility investigation. Thus total rate of pregnancy was 82.8%.

We conclude that subfertility of women of reproductive age is associated with polypoid changes of utero-tubal junction revealed by fertiloscopy. Polyps cause deformation of tubal orifice and changes in its forms and sizes. Microhysteroscopy in most of the cases allows to perform correction of utero—tubal junction area by removing polyps.

P.01.12

De-novo vaginal vault endometriosis following prolonged use of oestrogen only hormone replacement therapy (hrt).

Laiyemo R.*[1]

[1] Marika Nemcova, Stephen Porter, Kathleen Graham Bradford And Keighley, West Yorkshire United Kingdom

SUMMARY Prolonged use of oestrogen only HRT can lead to the development of de-novo endometriosis. Due to the morbidity associated with endometriosis , this information should be included in the counselling process when prescribing oestrogen only HRT to women post abdominal hysterectomy and bilateral salpingoophorectomy (TAH& BSO).

INTRODUCTION Endometriosis is an oestrogen dependent condition and residual deposits can be re-activated by HRT. However, de-novo endometriosis following HRT use is a rare occurrence when histology of pelvic organs removed at TAH&BSO have not shown any evidence of endometriosis.

We present a case of 39 yr old woman who presented with one year history of pelvic pain and dyspareunia and 3 months history of continuous per vagina spotting with occasional superimposed heavy and bright red pv bleeding. She had TAH 12 years earlier followed by BSO 2 years later for pelvic pain. Histology of organs removed on both occasions showed no evidence of endometriosis. She was commenced on oestrogen only HRT which she remained on until presentation (ie on HRT for 10 years before presntation).

CT scan with contrast was done to exclude any vascular malformation at the vault. EUA was done as patient unable to tolerate vaginal examination and it revealed a 2 × 3 cm firm hyperaemic structure at the vault and vault biopsy confirmed endometriosis. This was excised laparoscopically and patient made an uneventful post operative recovery.

The prolonged use of oestrogen only HRT is likely to have contributed to the development of endometriosis in the vaginal vault of this woman post TAH&BSO with no previous history of endometriosis. Consideration of the association between Oestrogen only HRT and possible development of de-novo endometriosis should always be considered when prescribing oestrogen only HRT to women post TAH&BSO

P.01.13

Effectiveness of laparoscopic surgery in two cases of ruptured ovarian cysts with highly elevated serum ca19-9 and ca125 level

Fukuoka K.*[1], Nakazawa A.[1], Yanai Y.[1], Tanaka S.[1], Okamura T.[1]

[1] Jr Tokyo General Hospital Tokyo Japan

We experienced two cases of spontaneous rupture of ovarian cyst with extremely elevated serum CA19-9 and CA125 level, wherein CA19-9 level was much higher.

Elevated serum level of CA19-9 and CA125 is a common condition in ovarian cysts. However we have to consider malignancy when serum CA19-9 and CA125 level is elevated extremely.

Case1:A 30-year-old woman was admitted with acute abdominal pain.CT showed peritoneal fluid and a left ovarian cyst enlarged to 10 cm. The values of CA19-9 and CA125 were 1781 IU/ml and 375 IU/ml, respectively. Suspecting ruptured ovarian endometrioma, we performed laparoscopic surgery. We confirmed the diagnosis as above and did the left adnexectomy. Case2:A 28-year-old woman came to the hospital with acute abdominal pain. CT and MRI showed an ovarian cyst and peritoneal fluid. The values of serum CA19-9 and CA125 were more than 10,000 IU/ml and 94.5 IU/ml, respectively. Suspecting ruptured ovarian cyst mixed with endometrioma and teratoma, we performed laparoscopic surgery. We confirmed that the cyst was ruptured and performed left ovarian cystectomy.

In both cases, the level of serum CA19-9 and CA125 decreased rapidly after surgery.

There are 5 cases reporting ruptured ovarian endometrioma with elevated level of serum CA19-9 and CA125. Laparoscopic surgery is effective for diagnosis in such cases with extremely high CA125 and CA19-9, in which we must consider the probability of malignancy. In these two cases, by diagnosing and treating the ruptured ovarian cysts under laparoscopic surgery, the patients were released from strong pain in a short time. We think laparoscopic surgery is the first choice of diagnosis in cases with benign ovarian cyst ruptures, even when serum CA19-9 and CA125 level is extremely elevated, as long as the patient’s general condition is well.

P.01.14

Endometrial tuberculosis—accidental finding in hysteroscopy

Cubal A.*[1], Carvalho J.[1], Rasteiro C.[1], Figueiredo O.[1], Meireles I.[1], Nunes C.[1], Oliveira C.[1]

[1] Centro Hospitalar Tamega e Sousa Epe Penafiel Portugal

Genital tuberculosis is rare and often silent. This is a case of endometrial tuberculosis accidentally found in follow-up hysteroscopy for simple hyperplasia.

In Portugal the incidence of tuberculosis is higher incidence than in other Western Europe countries.

It primarily affects the lungs, but about 1/3 of the patients have extrapulmonary disease.

Genital tuberculosis is rare; endometrium is involved in 50% of the cases. It can be explained by reactivation of Mycobacterium from systemic distribution during primary infection, but there are reports of direct transmission between sexual partners or spread from other intraperitoneal foci.

The disease may not be symptomatic until some years after the initial seeding. Major presenting symptoms are infertility, pelvic pain, poor general health and menstrual disturbances.

Review of clinical records.

A 36 years old female, G2P2, was referred for metrorrhagia. She had no previous relevant history. Ultrasound was suspicious for endometrial polyp. The patient underwent hysteroscopy with polipectomy. Histology showed a polyp with simple hyperplasia without atypia; endometrium was normal. It was inserted a levonorgestrel-releasing system for treatment.

Follow-up hysteroscopy was performed in 6 months. Uterine cavity had no intracavitary images apart for the levonorgestrel device. Endometrial sample was obtained and surprisingly the pathological result was endometrial tuberculosis. The presence of Mycobacterium was confirmed by Ziehl-Nielson method. The patient started treatment with antituberculosis agents for 9–12 months.

Genital tuberculosis is often silent and diagnosed accidentally during the histology work-up and is a very unexpected finding in Western countries.

Early detection and treatment is crucial to avoid major complications and the need for surgical treatment and usually allows patients to achieve cure.

P.01.15

Genetic predisposition to endometriosis: the results of pilot studies in ukraine

Yevdokymova V.*[1]

[1] Clinical Military Medicine Center Of The Southern Region, Odessa, Ukraine

External genital endometriosis is the pathological process characterizing with ectopic foci of stromal and glandular endometrial tissues. The prevalence of endometriosis in the population is varied from 5 to 50% amongst females of fertile age. In 30–60% cases endometriosis is complicated with infertility.

This circumstance determines the significant pertinence of the scientific and practical problem of the optimization of diagnosis and prognosis of the course of endometriosis.

The study was aimed to assess the frequency of single nucleotide polymorphism of GSTT1 gene among endometriosis.

There were examined 50 patients with the endometriosis. The samples of DNA were processed by Sambrook et al. (1989). For SNP analysis was used PCR method with specific oligoprimers. Statistical processing was conducted by the method of alternative variation assessment.

There is known that more than 35% of European population has GSTT1 deletion genotype. However the frequency of this genotype among the patients with external genital endometriosis was 62%. There were not found such allelic variants as s2266635 (Ala21Thr), rs11550606 (Leu30Pro), rs17856199 (Phe45Cys), rs11550605 (Thr104Pro), rs2266633 (Asp141Asn) and rs2234953 (Glu173Lys) in any cases. Thus the assessment of SNPs by GSTT1 for prognosis of endometriosis could be considered to be only an additional method with restricted informativeness

P.01.16

Hyperreactio lutealis in spontaneous twin pregnancy: a management dilemma

Oji V. C.*[1], Disu S.[1], Awala A.[1]

[1] Watford General Hospital Watford, Hertfordshire United Kingdom

A rare case of Hyperreactio Luteinalis in a spontaneous twin pregnancy. The incidence in twin pregnancy is unknown. 60% of the cases unassociated with trophoblastic disease occur with normal singleton pregnancy. Other bilateral multilocular cysts can mimic ovarian neoplasms. A wedge biopsy and frozen section may prevent unnecessary surgical excision though symptomatology may define the management course.

HRL is a rare condition affecting pregnancy characterized by enlarged ovaries containing multiple theca lutein cysts. Aetiology is unknown but has been related to excessive amounts of human chorionic gonadotrophin (hcg), Gestational Trophoblastic Disease and Hyperplacentosis.

A 24 year old primip with spontaneous DCDA pregnancy presented with incidental finding of bilateral multicystic ovarian enlargement at 21 weeks anomoly scan. Ovarian hyperstimulation and neoplasm were the initial differential diagnoses. Biochemical profiling revealed raised AFP and HCG. Surveillance scans showed increasing cystic volume. Following admission with threatened pre-term labiour, spontaenous vaginal delivery of 2 live infants occured at 29 weeks.

With a large cystic mass seen at CT scan post-partum and persistant elevations in serum AFP, HCG and testosterone, oophorectomy and ovarian cystectomy was recommended. Histological analysis confirmed bilateral luteinised follicular cysts, consistent with Hyperreactio luteinalis.

Moderate to marked enlargement of both ovaries by multiple benign theca lutein cysts is characteristic of HRL. The clinical presentation can mimic Ovarian Hyperstimulation Syndrome. Cystic enlargement of the ovaries may present during any trimester as an abdominal mass or acute abdomen. MRI in combination with serum tumour markers will aid the MDT approach in arriving at a diagnosis and management plan. In anticipation of a spontaneous remission after delivery, conservative management is advised.

P.01.17

Hysteroscopic female sterilization—essure® in vivo: an image description

Correia L.*[1], Marujo A.[1], Machado A. I.[1], Sereno P.[1], Biscaia I.[1], Marques C.[1]

[1] Maternidade Dr. Alfredo Da Costa Lisbon Portugal

Authors present a case report of a women with Essure® system as contraceptive method who had an hysterectomy bacause of an endometrial adenocarcinoma. Macroscopic and microscopic imaging of hysterectomy piece with micro-implants Essure® in situ was taken.

Female sterilization is one of the most required contraceptive methods worldwide. Hysteroscopic sterilization, by insertion of Essure® system in the interstitial portion of the tubes represents a safe, permanent, irreversible and non incision method. The device is 40 mm in length and consists of a stainless steel inner coil, nickel titanium elastic and polyethylene fibers outer coil. In a three months period the polyethylene fibers elicit a benign localized tissue growth in and around the devices, which culminates with the fallopian tubes lumen occlusion, resulting in permanent blockage.

Present an image description of in vivo Essure® micro-inserts, from its insertion to its removal included in a hysterectomy piece.

Forty-six years-old caucasian woman, obese, gravida: 1; para: 1, with Essure® placed as a contraceptive method in November 2005. Three months after the procedure an abdominal X-Ray and ultrasound confirmed the correct position of the implants. In January 2010, because of irregular vaginal bleeding and an ultrasound endometrial thickening, an endometrial biopsy was performed and an endometrial adenocarcinoma was diagnosed. Hysterectomy and bilateral adnexectomy were performed. It was a stage IA endometrial cancer (FIGO 2009). Macroscopic and microscopic imaging of hysterectomy piece with micro-implants Essure® in situ was taken.

Essure® was approved for female sterilization in 2001. Since then, despite extensive literature search in Pubmed, this seems to be the first description of Essure® in vivo reported in Portugal.

P.01.18

In vitro fertilization-embryo transfer and pregnancy outcomes after essure® bilateral placement for the treatment of hidrosalpinx and endometriosis: a case report

Velasco Sánchez E.*[1], Arjona Berral J. E.[1], Lorente González J.[1], Povedano Cañizares B.[1], De Andrés Cara M.[1]

[1] Hospital Universitario Reina Sofía Córdoba Spain

The correct surgical treatment for hidrosalpinx and infertility remains unclear.

Essure® microinserts are being used in selected cases for the treatment of hidrosalpinx prior to in vitro fertilization. Several studies have demonstrated its safety but its application in the treatment of hydrosalpinges has yet to be determined.

A 29 years old patient first consulted in 2008 because a 2 years subfertility. After the first approach she was diagnosed of unilateral hidrosalpinx and endometriosis was also suspected. It was performed a diagnostic laparoscopy in 2009. During surgery a grade IV endometriosis with Douglas obliteration was observed and an extensive adherence syndrome. Taking into account the risk and the benefits of the salpingectomy, a bilateral placement of Essure® device was performed.

The IVF cycle was started in 2010. Transvaginal ultrasound showed a mass of 55 mm, in the right ovary and a 46 mm mass in the left ovary and a three months treatment with triptorelin 3,75 mg was prescribed prior to stimulation. The day prior to the stimulation 3 endometriomas of 30 and 17 mm in the right ovary and one of 21 mm in the left ovary were observed. Stimulation was conducted. Three follicules were aspired and one embryo was transfered becoming pregnant. No incidences have been reported during pregnancy and in January 2011 a C-section was performed because of a breech presentation at 39 weeks of gestation, and a newborn of 3040 gr and apgar score 9/10 was obtained.

There is not enough literature to recommend the Essure® for hidrosalpinges but it can be the best option for selected cases in patients with high risk for surgery. In addition, patients that are likely to respond poorly to IVF should be given a less invasive option.

P.01.19

Intraoperative use of ultrasound for assisting the diagnosis and management of localised uterine adenomyoma

Mohan M.*[1], Sharma S.[1]

[1] The Queen Elizabeth Hospital Kings Lynn United Kingdom

Use of ultrasoung imaging could be used as adjuvent to laparoscopy in suspected adenomyosis. This case report highlights the importance of USS imaging in dealing with adenomyosis.

Abstract: This is a case report of a young adolescent girl of age 17 years with intractable dysmenorrhoea. She attained menarche at age 12 and her symptoms commenced by age 15. She was treated with analgesics and hormonal ovulation suppression treatments. None of these treatments made any difference in her quality of life.

She had an initial pelvic ultrasound which suggested hypoechoiecic area of 4 × 3 × 2 cms close to right posterior lateral body of the uterus and suspected as a possible fibroid/ rudimentary horn of the uterus. However her initial laparoscopy showed normal appearance of the uterus with no noticeable findings as represented by the initial pelvic ultrasound.

As her clinical symptoms were not controlled by medical methods of treatment, she was planned for repeat laparoscopy, hysteroscopy and exploration of uterus guided by ultrasound. Intra-operative findings suggested a possible bulge in the posterior wall of the uterus. Ultrasound was used along with laparoscopy and the site of the bulge explored. This opened up a localised area of chocolate filled space suggestive of localised adenomyoma/endometrioma.

This shows that intractable dysmenorrhoea with localised adenomyoma is a challenge to diagnose. However with the use of modern day Ultrasound machines which can be easily moved into theatres is an additional benefit and extremely useful in exploring the planes within the uterus for laparoscopic dissection.

P.01.20

Is an incidental finding of a thickened endometrial lining in post menopausal women of any consequence?

Brierley G.*[1], Karnad R.[1], Dada T.[1]

[1] O & G Department, Stoke Mandeville Hospital, Uk

The role of TVS in the assessment and management of postmenopausal women with bleeding is well established.The chance finding of a thickened endometrium in asymptomatic postmenopausal women and its further consequence has not been thoroughly investigated despite increased overall imaging. Our study concerns the hysteroscopic and histopathological sequelae of this group of patients.

We analysed the data from our outpatient hysteroscopy (OPH) database for the 5 years—Jan 2005 till August 2009 inclusive. 3237 women underwent OPH, 1365 (42%) were postmenopausal and 113 (3.5%) had a thickened endometrial lining in an asymptomatic postmenopasal woman.

Hysteroscopy was completed and tissue was obtained for histology from all women. 50 (44%) had benign polyps and 41(36%) had a normal hysteroscopic examination revealing an atrophic endometrium. Overall, nine (8%) showed abnormal histology, including atypical hyperplasia and other cellular atypia (from necrotic tissue to focal disordered proliferation). Four women went on to have a hysterectomy as a direct result of the investigations.

Outpatient hysteroscopy is a well recognised, safe investigation. Our study shows that even in asymptomatic postmenopausal women with a thickened endometrium on sonography, a significant amount of pathology may be found. Whilst about half of this will be benign, we found 4% to be of a more sinister nature requiring further surgical intervention. We hope that our results will stimulate larger studies

P.01.21

Laparoscopic approach for deep endometriosis

Martinho M.[1], Arteiro D.*[1], Malheiro L.[1], Cunha A. L.[1], Magalhães J.[1]

[1] Hospital S.João Porto Portugal

Laparoscopy performed by a multidisciplinary team is now considered the best surgical treatment for deep endometriosis.

Deep endometriosis is a challenging pathology associated to deep dyspareunia, dysmnorreia and chronic pelvic pain. Laparoscopy is the best surgical approach and success depends on a thorough diagnostic evaluation and on a radical surgical excision of the lesions.

This paper presents 2 cases of laparoscopic treatment of DIE.

Case 1:39 years old woman referred for chronic pelvic pain and dyspareunia although medicated with GnRh analogs and oral contraceptive. Previous ovarian cystectomy and left salpingectomy. Pelvic examination:painful nodule at posterior vaginal pouch. Transvaginal/transrectal ultrasound (TVU):endometriomas at both ovaries. Nodule? at recto-vaginal septum. Colonoscopy: no significant findings; Pelvic magnetic resonance imaging (MRI): endometriomas of both ovaries at wright with apparent adhesion to sigmoid. Laparoscopy with extensive pelvic adhesiolisis, bilateral ovarian cystectomy and wright salpingectomy, shaving of endometriotic lesions at sigmoid and excision of deep endometriosis at left uterosacral ligament/ureter at 20/4/10.

Case 2:27-years old woman referred for dyspareunia, severe dysmenorrhea, chronic pelvic pain and recurrent rectal bleeding for 8 months. Pelvic examination: painful and irregular posterior vaginal pouch. TVU: left ovary endometrioma, nodule located on the pouch of Douglas/colon sigmoid “attached” to the left ovary. Pelvic MRI: left ovarian endometriomas; colonoscopy: external compression of rectum and difficult transposition of sigma (adhesions?), no mucosal lesions. Laparoscopy with extensive pelvic adhesiolisis, left ovarian cystectomy and segmental bowel resection with recto-sigmoid anastomosis and prophylactic ileostomy at 14/12/10.

Both cases had a favorable evolution and significant pain relieve.

Laparoscopy for DIE is feasible but a demanding approach.

P.01.22

Laparoscopic gonadectomy for androgen insensitivity syndrome—case report

Grigore M.*[1], Lupascu I.[1], Ungureanu C.[1], Gorduza V.[1], Scripcaru D.[1], Lazar R.[1]

[1] University Of Medicine And Pharmacy Iasi Romania

We present a case of laparoscopic gonadectomy for a case with androgen insensivity syndrome (Morris syndrome).

Androgen insensitivity syndrome (AIS, Morris syndrome), formerly known as testicular feminization, is an X-linked recessive condition resulting in a failure of normal masculinization of the external genitalia in chromosomally male individuals.

We present a case of a 23-year-old girl diagnosed because of primary amenorrhea. Her cytogenetic analysis revealed the kariotype of 46, XY and clinical examinations showed features of complete AIS. Testosterone value met the norm for a male individual in reproductive age (9,4 ng/ml). Family anamnesis revealed two sisters which have probably the same syndrome and are now under current investigation. Computer tomography revealed the topography of the gonades in the pelvis, near the iliac vessels. Due to the risk of neoplasia, the diagnosis was an indication for surgical gonads removal, which was performed laparoscopically because of the abdominal position of the gonads. Histopathological examination showed tubular adenoma with immature seminiferous tubules without spermatogenesis and confirmed the diagnosis of Morris syndrome.

The postoperative course was good and the patient is receiving estrogen replacement therapy.

CONCLUSION: Laparoscopy is an effective method in AIS.

P.01.23

Laparoscopic ligation of major blood supply to the uterus; a life saving procedure in a case of endometrial cancer

Tsakos E.*[1], Bimpa K.[1], Tolikas A.[1], Katsanikos S.[1], Sioutas A.[2]

[1] St Luke’S Hospital Thessaloniki Greece - [2] Karolinska Hospital Stocholm Sweden

A 27 year old, virgin, Jehova’s witness presented with severe bleeding per vaginum and profuse iron deficiency anaemia (Hct: 13 gr%). An examination under anesthesia revealed the presence of a cancerous mass protruding through the cervix into the vagina and an MRI showed the presence of a 4.5 cm mass in the endocervix. An emergency laparoscopic ligation of infundibulopelvic ligaments, round ligaments and uterine arteries was performed with immediate effect on haemostasis.

Uterine artery ligation is a well established technique in controlling uterine bleeding and can be life saving in post-partum hemorrhage and also facilitates control of bleeding in cases of uterine myomas.

In this case report we present a novel use of uterine artery ligation.

Case reposrt. retrospective reporting.

Excellent life-saving haemostasis was achieved and hence, a hysterectomy was performed safely 10 days after the procedure.

In a young lady who refused blood transfusion and at extreme life threat this novel application of an established technique prove life saving. Laparoscopic uterine ligation is a safe, quick and effective method of controlling uterine bleeding.

P.01.24

Laparoscopic management of adnexal masses—our experience

Sousa R.* [1], Reis P. [1], Fan Y. [1], Ferreira H. [1], Lourenço C. [1], Cubal R. [1]

[1] Centro Hospitalar Do Porto, Porto, Portugal

Adnexal laparoscopic surgery is one of the most common laparoscopic procedures carried out at our centre.

The aim of our study was to analyze type of operative procedures, adnexal mass size, surgical complications and histiopathological diagnosis of all adnexal laparoscopic procedures carried out at our centre.

122 female patients were submitted to laparoscopic management of adnexal masses at Centro Hospitalar do Porto in the last couple of years.

The mean age of the operated women was 38,5 years. Laparoscopic unilateral salpingo-oophorectomy was the most frequent procedure (50%), followed by laparoscopic unilateral cystectomy, unilateral oophorectomy, unilateral salpingectomy and finally bilateral cystectomy. The mean size for the adnexal masses was 5,7 cm, with a maximum of 15 cm. No immediate operative major complications were registered, and there was need for laparotomic conversion in only one procedure (for suspected malignancy). The most common histiopathological diagnosis was the simple serous cystoadenomas (33%), followed by the dermoid cysts, endometriomas, mucinous cystadenomas and other findings such as inclusion cysts. There was one case of a serous papillary borderline tumor.

Laparoscopic management of adnexal masses is a safe procedure carried out at our centre, with a low complication risk, a shorter hospitalization time, with good overall results and should therefore be the recommended procedure.

P.01.25

Laparoscopic management of large adnexal masses

Menéndez J. M.*[1], Nieto A.[1], Solano J. A.[1], Marta G.[1], Gonzalez J.[1], Delgado J. J.[1], Zapico A.[1]

[1] Hospital Universitario Principe De Asturias Madrid Spain

We present a review of 125 patients with giant ovarian tumors treated by laparoscopy. In most cases the treatment was completed endoscopically. Four unsuspected malignant tumors were first managed by laparoscopy. These patients underwent a staging laparotomy. Follow up of these patients has been normal

The finding of a large tumor is considered a sign of suspicion of malignancy. And It ussually indicates late diagnosis has been made.

We also have the difficulty of the extraction of the specimen.

The objective of this review is to assess the feasability and outcome of laparoscopy surgery for the management of large adnexal masses.

From 1992 to May 2011, 125 patients with ovarian masses larger than 10 cm and low probability for malignancy were managed laparoscopically in the Hospital Universitario Príncipe de Asturias in Spain.

To make easier the management and avoid the accidental rupture and spillage, a controlled punction and aspiration of the fluid content is performed. The patients underwent cystectomy or adnexectomy, depending on each patient’s age. The specimen was removed by a special removal bag through the 10-mm trocar incision or by a small extension of the suprapubic incision.

The laparoscopic procedure was converted to laparotomy in 11 patients (8,8%). One case due to severe intra-abdominal adhesions, 3 cases due to technical difficulties related to the tumor size. On case due to complications and 4 cases due to malignancy suspect: 2 cancers were detected by frozen section. 4 unsuspected malignant tumors (3,2%) were first managed by laparoscopy: 3 borderline tumors and 1 mucynous carcinoma. Staging laparotomy were performed. All cases were FIGO stage Ia. Follow up of these patients has been normal.

Our experience demonstrates that laparoscopy can be applied in the management of patients with large ovarian cysts. Always with a carefully standardized surgery and removing the mass through endo bags.

P.01.26

Laparoscopic management of tubo-ovarian abscesses

Shevchenko O.*[1]

[1] Odessa National Medical University, Odessa, Ukraine Odessa Ukraine

In this study laparoscopic management of tubo-ovarian abscesses was evaluated. Laparoscopic surgery has significant advantage in terms of preserving hormonal and reproductive function.

Tubo-ovarian abscess and complex is acute complication of PID which also can result in pyosalpinx and peritonitis. Findings indicate that TOA develops in up to 32% of women hospitalized for PID. The approach to TOA is still a highly disputable issue.

There were 56 women with TOA observed. The mean age was 32 ± 7,2 years. All patients were operated using laparoscopic access. The mean time of an operation was 58 ± 12,5 min.

All patients were treated during 48 to 72 hours before operation using broad-spectrum antibiotics, infusion therapy (>2 liters per day), anti-inflammatory drugs. There was performed lysis of pelvic adhesions, drainage and irrigation of pyosalpinges and TOA with irrigation of the pelvic cavity with 2 liters of physiologic saline in all cases. Extirpation of a unilateral infectious complex and resection of ovary was done for 19 patients. We aimed to save ovarian tissue as much as possible for infertile and nulliparous women. There was not revealed any complications after using this strategy.

Laparoscopic surgery which diminishes postoperative complications should be the first choice in the managing of TOA. However, it is crucial to provide adequate preoperative treatment.

P.01.27

Laparoscopic myomectomy of a giant uterine myoma

Kavallaris A.*[1], Zygouris D.[2], Chalvatzas N.[1], Terzakis E.[2]

[1] 4Th Department Of Gynecology And Obstetrics, Aristotle Uni Thessalonikii Thessaloniki Greece - [2] 2nd Department Of Gynecology, Hellenic Anticancer Institute. Athens. Athens Greece

We present the case of an infertile woman with a giant (18 cm) uterine myoma which was laparoscopically totally enucleated and removed without disturbing the endometrial cavity and was removed using a PK (Gyrus) morcelator.

We present the case of an infertile woman with a giant myoma which was laparoscopically removed.

A 34 -year old patient was referred to our department with a large abdominal mass. The ultrasound revealed a 18 cm uterine myoma. Diagnostic laparoscopy showed a giant uterine myoma and with the help of a bent camera we started the myoma enucleation. The myoma was totally enucleated and removed without disturbing the endometrial cavity. The uterine defect was closed with an absorbable suture in 2 layers. The myoma was removed using a PK (Gyrus) morcelator, without tissue or blood spillage in the abdomen.

The operation time was 165 minutes and the myoma’s weight was 1200 gr. The patient recovered uneventfully.

Laparoscopic myomectomy can be an option even for giant myomas, with the condition of an expert surgeon and appropriate surgical instruments.

P.01.28

Laparoscopic ovariopexi at the recurrent ovarian torsion cases:case report

Güler A. E.*[1], Öztürk M.[1], Alanbay I.[1], Keskin U.[1], Çoksuer H.[1], Baser I.[1]

[1] Gulhane Military Academy Obstetrics And Gynecology Ankara Turkey

Ovarian torsion is one of the most common gynecologic emergencies.We recommend laparoscopic ovarypexy operation as a treatment in the cases of the contralateral absence of ovary,recurrent ovarian torsion.

Ovarian torsion refers to the twisting of the ovary on its ligamentous supports,often resulting in impedance of its blood supply.It is the fifth most common gynecologic emergency for all ages.

From the history of 24 year-old nulliparous patient -consulted GATA Hospital on the 28th of June 2008- it was revealed that she had been operated with endoscopic surgery due to the right ovarian distorsion one year ago and laparotomy procedure with a pre-diagnosis of acute abdomen after three days of clinical follow-up one month ago.Operation was planned in consideration of adnexal torsion after the clinical evaluation.Through the intraoperative observation of adnexes,absence of the left adnexial structure,torsioning of the right fallopian tube and ovary through 1,5 tour rotation through extented ligamentum ovary proprium were found out.The fallopian tube and the ovary were detorsioned ,so as to prevent recurrancy and protect the functions of the single ovary;ovary was fixed on the right posterior wall of uterus with a non-absorbable suture.

The mainstay of treatment is swift operative evaluation to preserve ovarian function.At the prevention of recurrence,suppression of ovarian cysts and oophoropexy methodes are useable.We recommend the use of oophoropexy in all cases of childhood torsion of normal ovaries.We also offer routine oophoropexy for women who have previously undergone an oophorectomy for prior ovarian torsion

In order to protect the torsioned ovary,the integrity of the other adnexial structure and to prevent the recurrency of the torsion;Laparoscopic ovarypexy operation is accepted as an ideal method in the cases of the recurrent adnexial torsion.

P.01.29

Laparoscopic pelvic and paraaortic lymphadenectomy in cervical cancer figo stage iv b—case report

Neis F.*[1], Rothmund R.[1], Enekwe A.[2], Jänsch K.[2], Uhl B.[2]

[1] University Of Tübingen, Department For Gynaecology And Obstetrics, Tübingen - [2] St. Vinzenz Hospital Dinslaken, Department For Gynaecology And Obstetrics, Dinslaken

Cervical cancer is the third most common cancer occurring in women worldwide

The therapy for advanced stage cervical cancer is a particular challenge. There are no evidence-based recommendations for the therapy of advanced cervical cancer FIGO stage IV in the guidelines of the German Working Group on Gynecological Oncology nor in the international literature. Large randomised and prospective studies on treatment are missing.

We present a patient with cervical cancer (FIGO stage IV B) with bulky metastatic lymph nodes in the obturator fossae and the paraaortic area. In accordance with existing studies, laparoscopic lymphadenectomy and tumour debulking with excision of the metastases was performed after clinical staging. Postoperatively, radiochemotherapy was initiated with boost in the area of the bulky lymph nodes

Laparoscopic lymphadenectomy improved the prognosis of this patient and is, according to existing studies, superior to laparotomy with regard to convalescence times, blood loss and hospital stay.

But it is absolutely necessary that the procedure is performed by an experienced surgeon who is well acquainted with the technique.

P.01.30

Laparoscopic resection of ectopic ureter ended in gartner’s cyst resulted in extensive intraabdominal infection in an infertile woman

Dokmeci F.*[1], Taskin S.[1], Kocbulut E.[1]

[1] Department Of Obstetrics And Gynecology, Ankara University School Of Medicine, Ankara, Turkey

Ureteric ectopia with Gartner’s duct cyst is caused by a failure of branching of the ureteric bud from the mesonephric duct that also leads to the persistence of Gartner’s duct, frequently with cystic dilation.

A few cases managed laparoscopically were reported.

A 34-year-old woman admitted with primary infertility for 2 years. Her past medical history was unremarkable except one situation with unknown value: the unilateral hear loss that was diagnosed at her childhood without any explained underlying reason. Speculum examination revealed a bulge through the vaginal lumen on the right side of vaginal wall at the level of lateral fornix. That bulging structure was considered as a cystic appearance -Gartner’s cyst- rather than a solid structure after digital vaginal examination. A fluid filled structure with a diameter of 2 cm that was joining with the cyst described above and subsequently elongating in superior aspect (adnexial pathology or ectopic ureter) was reported in magnetic resonance imaging. Cystoscopy revealed natural bilateral ureteral orifices and ureteral jet flow. Similarly, intravenous pyelography showed natural urinary tracts bilaterally.

A diagnostic laparoscopy showed that a hydropic ureter that was 2 cm in diameter was revealed at the area in right retroperitoneal aspect, corresponding to the normal anatomical ureteric trace. Retroperitoneal area was entered and normal ureter was identified near the hydropic ureter. Then hydropic ureter was completely liberalized trough the distal and proximal aspects. Hydropic ureter was observed in continuation with a cyst in the lateral vaginal fornix. This ureter was also observed as becoming a fibrotic band aproximately 5–6 cm away from right renal pelvis at proximal aspect. Ureter was resected after placing clips to the joining point of the both terminal sites (Figure and Video). 2–3 ml of cystic content was drained into douglas pouch while performing the resection. Gartner cyst was resected through an incision at lateral vaginal wall, via vaginal route. Consequently intra-abdominal cavity and douglas pouch was irrigated with 3 liters of saline and the procedure was ceased.

Abdominal distention and fever (38.5°C) were observed 4 days after operation. Ultrasonographic examination revealed extensive free pelvic fluid. Abdominal tomography was revealed fluid collection depending on extensive intra-abdominal infective process. The re-laparoscopy was performed. Pelvic purulent fluid, fibrinous material covering all of the peritoneal surfaces and adhesions between uterus, bladder, and intestines and also in adnexial areas, were observed. Purulent material was aspirated. Adhesions were dissected as much as possible. Intra-abdominal cavity was irrigated with 10 liters of saline and operation was ended.

The patient was observed as convalescent following the operation. No fever was observed. The patient was discharged after 14 days of intravenous antibiotic administration for MRSA that was detected in culture of the purulent material. The patient was dated up a control meeting for planning of infertility treatment.

Whether the patient is infertile or not, in the cases of ectopic ureters in association with Gartner’s cysts, leakage of cystic content in the course of the resection may lead to extensive infections. This intra-abdominal infection may affect fertility in an unfavorable manner. Therefore utmost efforts must be spent to avoid any leakage of cystic content into the intra-abdominal cavity in the course of resection.

P.01.31

Laparoscopic surgery is the best choice for managing of pregnant women who have benign ovarian tumors and tumor-like ovarian formations

Lunko T.[1], Aleksandrov O.*[1]

[1] Odessa National Medical University Odessa Ukraine

Pregnant women with benign ovarian tumors and tumor-like ovarian formations can be effectively managed using laparoscopic access. This strategy enables to avoid the majority of possible pregnancy complications.

Ovarian neoplasms affect approximately 1 in 1,000 pregnant women. The use of laparoscopic access is minimally invasive with a decreased risk of a tumorous spread and a local inflammatory reaction with low number of adhesions and absence of anterior abdominal wall trauma.

We observed 30 pregnant women who had benign ovarian tumors and tumor-like ovarian formations at the age from 21 to 32. All patients had between 12 and 16 weeks pregnancy. They all were operated using laparoscopic technique. The mean time of an operation was 31,4 ± 6,5 min. The size of removed cysts and tumors was between 5 and 12 cm.

There were diagnosed teratomas—12 women, 8—serous cystadenoma, 5—mucinous cystadenoma, 3—simple cysts, one case—endometrioma, one patient—paraovarian cyst. We provided a minimal angle of an operating table in order to avoid a failure of placental blood circulation and fetal hypoxia. There was used bipolar coagulation during all operations which prevented electric trauma of placenta and fetus. We aimed to save normal ovarian tissue as much as possible. We did not reveal any pregnancy complications after these operations. As a result 28 (93,3%) women had deliveries through the natural passages with 2 women whom caesarean section was performed (indications included severe fetal hypoxia and dystocia).

Laparoscopic surgery has to be more largely used for pregnant women who have indications for surgical treatment of benign ovarian tumors and tumor-like formations of ovaries because this pathology can result in high risk of complication during pregnancy and neonatal period.

P.01.32

Malignant mixed mullerian tumor of the uterus: laparoscopic staging, safe and feasible. case and literature review.

Alcocer J.*[1], Wattiez A.[1], Vazquez A.[1], Bonilla M.[1]

[1] Ircad Strasbourg France

61-year-old woman with a pelvic mass of an utero-adnexial origin. The patient complained of transvaginal bleeding, light pelvic pain, and dyschezia. At bimanual examination, we found the Pouch of Douglas occupied and a fixed uterus. The vaginal and hepatic ecography reported the presence of a heterogenous mass of 155 mm of length, and echogenic cavities of a possible utero-ovarian origin; liver appeared normal. Chest X-ray appeared normal. A contrasted CT scan revealed a mass of 100 × 70 × 60 mm with nodular formations, and parietal calcifications with no apparent signs of metastasis.

Uterine carcinosarcoma, also known as malignant mixed mullerian tumor, metaplastic carcinoma, or malignant mesodermal mixed tumor is a rare uterine malignancy with an incidence of fewer than 2 per 100,000 women per year. Although carcinosarcomas account for less than 5% of all uterine malignancies, they are associated with >15% of uterine cancer-associated deaths (El-Nashar, et. al. 2011).

This disease has an aggressive behavior, and a unique histology, because it includes both, malignant mesenchymal, and epithelial components. Since the first reports, many advances have appeared in the surgical and adjuvant therapies. The expected reduction in mortality has not occurred. Nowadays, there is enough information that proofs that laparoscopic staging is safe and feasible, and it has lower morbidity with the same survival rates, so it should be the preferred therapeutic approach. Unfortunately, it is necessary to be performed by surgeons with advanced laparoscopic skills, and the laparoscopy benefits could not always be reproducible (Nezhat, et. al. 2008).

P.01.33

Management of ectopic pregnancies: a retrospective observational study in a private university hospital in barcelona (spain).

Simón M.*[1], Ubeda A.[1], Cusido M.[1], Rodriguez I.[1], Perez A.[1], Pascual M. A.[1]

[1] Department Of Obstetrics, Gynecology And Reproduction Of The Instituto Universitario Dexeus

Ectopic pregnancy today remains the leading cause of maternal death during the first trimester of pregnancy, despite a decline in morbidity and mortality from this disease. This is the reason for performing a retrospective study to evaluate the management of ectopic pregnancies (EE) in our hospital and to be able to develop through this a new protocol that best meets the criteria for inclusion of patients for expectant or medical treatment, rather than surgical treatment input, given the diversity of the literature.

Patients included in the study were diagnosed and followed at our centre. They underwent an ultrasound performed by three reviewers based on previously agreed criteria, an analytical approach to assess the β-hCG before treatment and a clinical examination. Each patient followed a different treatment: either expectant management, medical treatment with methotrexate (MTX) or surgery, according to the gynecologist who performed the assessment.

In our centre there have been 199 cases of EE (2004–2008) diagnosed. In 46 of these, (23.1%) took an expectant attitude, 69 (34.7%) continued medical treatment with MTX and 83 patients (41.7%) underwent surgery. In those who took an expectant attitude, 13% failed, of those treated with MTX 21.7% failed, 20.9% of whom were given one dose of MTX, 29.4% received two doses and 12,5% three doses.

For expectant management a cutoff level of β-hCG of 206, 5 IU/ L can be set, providing a sensitivity of 83% and a specificity of 70% with (p < 0.05).

Expectant and initial medical treatment are good alternatives to surgical treatment. Do not perform ultrasound examinations and measurements of β-hCG follow up of patients treated with MTX unless you have a high suspicion of a broken EE, as this generates anxiety among both patient and professional, leading to the largest number of avoidable resource surgeries.

P.01.34

Ovarian dysgerminoma mimicking an ectopic pregnancy: case report and literature review.

Olowu O.*[1], Vimplis S.[2], Odejinmi F.[3]

[1] Oladimeji Olowu London United Kingdom - [2] Sotiris Vimplis London United Kingdom - [3] Funlayo Odejinmi London United Kingdom

Diagnosis and management of women with germ cell tumours (Dysgerminoma) may present clinical challenges for clinicians as such case may be misdiagnosed and managed as pregnancy of unknown location or suspected ectopic.

Dysgerminoma is the most common malignant germ cell tumour in young women below the age of 30 and accounts for 2% of all malignant ovarian tumours. Typically, women present with abdominal pain or distension; but symptoms of pregnancy secondary to beta-human chorionic gonadotropin (bata-hCG) secretion can also occur.

We present the case of a 28 years old nulliparous woman, who presented in our early pregnancy assessment unit with an 8 weeks history of amenorrhoea and a positive pregnancy test complaining of abdominal pain and vomiting. She had an empty uterus on the transvaginal scan and the initial diagnosis of a pregnancy of unknown location was made. She was followed up with serial beta-HCG estimations which continued to rise (210–468 iU/L). Follow-up ultrasound scans continued to show an empty uterus with anechoic fluid in the pouch of Douglas and suspicious lobulated hyper-echogenic mass at the right adnexa possibly attached to the right ovary. Because of her continuing symptoms and the ultrasound scan findings she underwent a laparoscopy.

The 3 cm mass was found on the right ovary at time of laparoscopy, which was excised. Histological examination showed a pure dysgerminoma. The patient was referred to the oncology centre where she underwent a laparoscopic right salpingo-oophorectomy, followed by adjuvant chemotherapy for Stage 1C dysgerminoma of right ovary

Though women with dysgerminoma rarely present to early pregnancy assessment unit, clinicians need to keep this differential diagnosis in mind to avoid misdiagnosis of another life threatening condition.

P.01.35

Pelvic splenosis in infertile patient: an unusual finding.

Fiore E.*[1], Granata M.[1], Caggiano F.[1], Conforti A.[1], Mollo A.[1], De Placido G.[1]

[1] Federico Ii University Naples Italy

Splenosis is a benign condition, asymptomatic, occurring frequently after splenic rupture via trauma or surgery and consists of autotransplantation of splenic tissue. A 28 year old woman with history of infertility and prior splenectomy underwent diagnotic laparoscopy which showed a not well-defined red soft-tissue mass occluding the pouch of Douglas completely. Final histopathology revealed splenic tissue. This is the first report to describe infertility related to this pathology.

Splenosis is a benign condition, usually asymptomatic, occurring frequently after splenic rupture via trauma or surgery and consists of autotransplantation of splenic tissue. When it’s located in the pelvis can mimic gynecologic pathologies and the diagnosis can be arduous.

We describe the case of a 28 year old woman referred to our department with history of infertility, dysmenorrhea, deep dyspareunia and prior splenectomy due to ß-Thalassemia Maior. Diagnostic laparoscopy showed a not well-defined red soft-tissue mass occluding the pouch of Douglas completely, densely adherent to rectum, posterior uterine wall and adnexa. Several small bluish– red masses of 1–2 cm in diameter were observed on the serosal surface of the sigmoid, on the omentum and on the parietal peritoneum.Dye test revealed bilateral tubal occlusion. Peritoneal washing and multiple biopsies of the masses were sent for intraoperative evaluation which revealed non-malignant cells and tissue. Since the exact origin of the tissue couldn’t be determined laparoscopy was suspended.

Final histopathology revealed splenic tissue, and diagnosis of splenosis was determined.

This is the first report to describe infertility related to this pathology. A direct correlation cannot be determined because a fimbrial biopsy wasn’t performed. Nevertheless it is very likely that the inflammatory reaction due to the ectopic implants represented at least a concurrent cause of infertility.

P.01.36

Port site metastases in stage 1b, g1, endometrial cancer: a case report

O’donovan J.*[1], O’donovan O.[2]

[1] Newcastle University Newcastle United Kingdom - [2] Peninsula College Of Medicine & Dentistry Plymouth United Kingdom

A case report of port site metastases in Stage 1B, G1, endometrial cancer, in a 67 year old, nulliparous lady. Only two such cases have been recorded in the literature prior to this.

Adenocarinoma of the endometrium is the most common gynaecological cancer in women (1). In recent years endometrial cancer has been increasingly treated by laparoscopic surgery (2). Here we present a case of port site metastases following laparoscopic surgery for an originally low risk case.

Case note review and interview with patient

This case regards a sixty-seven year old nulliparous lady. In 2009 she was diagnosed with endometrial cancer and underwent a total laparoscopic hysterectomy, bilateral salpingo-oophrectomy, washings and bilateral pelvic lymphadenectomy. Histology revealed Stage 1B, G1, endometrioid cancer of the endometrium. After an MDT meeting it was decided that no further treatment was necessary and she would be followed up for five years. In 2011 the lady presented with a palpable mass over the left port site scar. A CT scan revealed a likely port-site recurrence from her laparoscopic hysterectomy. An ultrasound-guided biopsy was requested which confirmed the findings of the CT scan. Histopathologically, the tumour was similar to the original primary tumour. The patient is scheduled for a re-operation in the coming months.

We were able to find seven reported cases of port-site metastases following laparoscopic surgery for endometrial cancer in the literature. Of these, only two represented an originally low risk case (2, 3). Although laparoscopic hysterectomy is a good technique to treat patients with endometrial cancer, port-site metastasis is a possible complication and should be taken into consideration when planning a laparoscopic approach for endometrial cancer. The case discussed highlights the need for a through preoperative work up and careful monitoring post-operatively.

References

1. R.T. Greenlee, T. Murray, S. Bolden and P.A. Wingo, Cancer statistics, 2000, CA Cancer J. Clin. 50 (2000), pp. 7–33

2. J.U. Maenpa, R. Nyberg, Port-site metastasis following laparoscopic hysterectomy and bilateral salpingo-ophorectomy for endometrial carcinoma, European Journal of Obstetrics & Gynecology and Reproductive Biology 143 (2009) 61–63

3. Muntz HG, Goff BA, Madsen BL, Yon JL. Port-site recurrence after laparoscopic surgery for endometrial carcinoma. Obstet Gynecol 1999;93:807–9.

P.01.37

Recurrent ascites secondary to endometriosis: a case report

Rodrigues G.*[1], Barata S.[1], Rato I.[1], Osorio F.[1], Alho C.[1], Calhaz-jorge C.[1]

[1] Centro Hospitalar De Lisboa Norte Lisboa Portugal

32-years-old patient of black African origin, hospitalized several times since 2009 due to haemorrhagic ascites. In May 2009, she underwent diagnostic laparoscopy, which revealed severe endometriosis. Submitted in 2011 to a laparoscopy. She remains under GnRH- analogs with add-back therapy until she enters an IVF cycle.

According to most recent literature, there are 63 reported cases of ascites secondary to endometriosis. This is a rare disease whose diagnosis requires differential diagnosis with peritoneal carcinomatosis, as well as with peritoneal tuberculosis or ovarian hyperstimulation syndrome. The approach to this form of the disease involves a multidisciplinary team.

Case report.

32-years-old patient of black African origin, menarche at 12, regular cycles of 28/5 days, nulliparous, primary infertility of 6 years with disabling primary dysmenorrhea, deep dyspareunia and disquezia.

She had several hospitalizations since April 2009 due to pain and bloating associated with dyspnoea caused by haemorrhagic ascites. In May 2009, she underwent diagnostic laparoscopy with drainage of haemorrhagic ascites, and multiple biopsies were performed, which revealed severe endometriosis. She had several episodes of dyspnoea caused by hemorrhagic ascites, with the need of paracentesis and administration of GnRH-analogs and she was referred to surgical gynecological consultation. After pre-surgical evaluation she was submitted to a laparoscopy with drainage of 8500 ml of haemorrhagic ascitic fluid, extensive adhesiolysis, excision of a rectovaginal endometriotic nodule, bilateral salpingectomy, excision of the pelvic parietal peritoneum and correction of umbilical hernia. She remains under GnRH- analogs with add-back therapy until she enters an IVF cycle.

It is intended with this case report to highlight the need to consider endometriosis in a patient with ascites of unknown origin.

P.01.38

Robert’s uterus with menstrual retention in the blind cavity: a case report

Herter L.[1], Paim C.[2], Gassen D.[2], Milagre M.[2], Pessini S.*[1], Deyl R.[2]

[1] Universidade Federal De Ciencias Da Saude De Porto Alegre Porto Alegre Brazil - [2] Complexo Hospitalar Santa Casa Porto Alegre Brazil

Case report of a 13 years old patient with Robert’s uterus.

Robert’s uterus is a rare malformation characterized by two cavities, one of which blind, causes dysmenorrhea and the diagnosis is made by endoscopy.

Female 13 years old with severe dysmenorrhea since menarche. Physical examination revealed pubertal development appropriate and pain of the right lower abdomen. A pelvic ultrasound identified uterus with a normal external shape and a cystic formation in proximity to the endometrial cavity measuring 1,9 cm. The ovaries were normal. CT scan showed uterus with two hypodense formations, one on the right side with a rounded shape and one on the left, with elongated form. Magnetic resonance imaging identified uterus with elongated cavity.

The patient was given the continuous contraceptive pills to stop the menstrual bleeding, to reduce the pain and to investigate a possible hematometra. After some weeks, she started to have spotting and the pain returned. She was then submitted to a hysteroscopy with laparoscopy to exclude obstructive malformation. The hysteroscopy identified lack of the right tubal ostium, normal left tubal ostium and a bulging in the right lateral uterine wall. The laporoscopy identified a uterus of normal external appearance, with a very slight increase in the right hemiuterus. The right tube was absent, the ovaries were normal. The right hemiuterus was punched with withdrawal of dark menstrual blood confirming hematometra. We indicated the removal of accessory horn. The patient progressed well, with menstrual cycles and no dysmenorrhea.

Patients with Robert Uterus have asymmetric septate uterus with two cavities, one of which is blind. This malformation cause increased risk of endometriosis and pregnancy complications. It is important to think about obstructing uterine malformation in all cases of severe and precocious dysmenorrhea, even with an external normal uterine shape.

P.01.39

Robotic myomectomy of huge myoma cases in thin asian women

Kim N. H.*[1], Moon H.[1]

[1] Ewha Womans University School Of Medicine Seoul Republic Of Korea

In case of short and thin women, the trochars insertion positioning is very difficult and they couldn’t be operated by robot. We want to report successful robot surgery cases of thin Asian women with huge myomas who couldn’t be able to operate with conventional robotic trochars insertion.

The primary surgical techniques used in myomectomy are open surgery, laparoscopic surgery, and, recently, robot-assisted (“robotic”) surgery. The optimal surgical treatment of myomas is still a subject of debate because of the limitations of minimally invasive techniques and the disadvantages of laparotomy. Robotic technology may improve efficiency, accuracy, ease, and comfort associated with the performance of laparoscopic operations. However, in case of short and thin women, the trochars insertion positioning is very difficult and they couldn’t be operated by robot. We want to report successful robot surgery cases of thin Asian women with huge myomas who couldn’t be able to operate with conventional robotic trochars insertion.

Three patients with a huge myoma(over 10 cm) who underwent robotic myomectomy in Ewha Womans university hospital were reviewed. They were 154.6 cm tall and weighed 48 kg averagely. Also, they had at least 3 myomas and largest one is at least 11 cm in diameter.

Abdominal cavity is very small and it is impossible to insert trochars for robotic myomectomy as conventional way. We rearranged robot arm positions in a different way, the operation was performed. The average myomectomy time was 243 minutes, the average estimated blood loss is less than 100 cc. All patients recovered well and discharged in 5 days.

The method we suggested makes robotic myomectomy possible in thin Asian women who couldn’t be operated in conventional way.

P.01.40

Scoping the reality of becomming a nurse hysteroscopist in the UK

Pansini-murrell J.*[1]

[1] University Of Bradford Bradford United Kingdom

Abstract oral/presentation: Scoping the reality of becoming a nurse hysteroscopist in the UK.

Submitted by Dr Julia Pansini-Murrell, University of Bradford. J.Pansini-Murrell@bradford.ac.uk

Nurse Hysteroscopy training started in the UK 10 years ago in response to clinical visioning and governmental redirection for diversifying roles and responsibilities. A view of the current numbers of nurses in hysteroscopic practice and the therapeutic skills that have extended the services to provide context evidence will be presented from a doctoral thesis.

A case study approach was taken to investigate how nurses had adapted to their roles. From these from individual interviews with a self selected group an online survey was created to explore the issues further. This was available for all nurses registered as students or part of the alumnie who had were working independently to complete.

Statistical evidence and quotations are used to illustrate the additional skills nurses have used in developing services this includes evidence on the highs and lows for the nurses as they trained and set up the nurse led outpatient hysteroscopy services. Several are now nurse consultants; however this journey from junior grade nurses has been challenging both from a personal and perspective.

Challenges include re-negotiating working boundaries when originators of service development plans leave and the impact of poor organisational cohesiveness that delays or inhibits service development. Whilst this study is within the context of hysteroscopy the lessons learnt are transferable to units where nurses are to take a lead role in developing services or those who are planning to do so.

P.01.41

Small bowel obstruction caused by a duodenal compression of a pararaortic lymphocele: a case presentation and review of the literature

Radosa M.[1], Diebolder H.*[1], Winzer H.[1], Mothes A.[1], Camara O.[1], Runnebaum I.[1]

[1] Jena University Hospital Jena Germany

SMALL BOWEL OBSTRUCTION CAUSED BY A DUODENAL COMPRESSION OF A PARARAORTIC LYMPHOCELE: A CASE PRESENTATION AND REVIEW OF THE LITERATURE

In the gynecological field, the formation of lymphoceles is a known complication after pelvic and paraaortic lymphadenectomy. Typical symptoms caused by lymphoceles include obstructive uropathy, lower limb edema, lower abdominal pain, venous thrombosis or fever due to an infection of the cyst.

A case presentation and a systematic review of the literature using medline

We present the case of a 62-year old woman with the unusual upper abdominal manifestation of a lymphocele, causing a sub-acute duodenum obstruction 15 days after radical high paraaortic lymphadenectomy in the context of tumor debulking surgery for ovari