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Volume 8 Supplement 1

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

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Abstracts

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.

figure a

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.

figure b

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 ovarian cancer relapse. Surgical fenestration by resection of the lymphocele wall was performed as a treatment for the upper digestive tract obstruction. A considerable number of bowel obstructions caused by compression of a lymphocele have been described in the literature: Most lympoceles affect the colon due to their location in the pelvic or lower paraaortic region. Therefore, large lymphoceles are frequently associated with clinical symptoms of lower bowel obstruction with constipation, lower abdominal pain and distension of the abdomen. In our case the large extension of the lymphocele from the left cranial renal pole up to the right diaphragm had led to a compression of the duodenum with clinical symptoms typically encountered in patients with a duodenal stenosis by e.g. pancreatic head cancer or patients with a gallstone ileus.

In patients with a precedent extended high paraaortic lymphadenectomy and post-operative clinical signs of a bowel obstruction, a symptomatic lymphocele should be considered as one potential differential diagnosis.

P.01.42

Spontaneous tubal extrauterine pregnancy into hydrosalpinx.

Klimanov A.*[1], Tugushev M.[1], Gusnyan V.[1]

[1] Medical Company Idk Samara Russian Federation

Case demonstrations of possibility a spontaneous conception and abnormal embryo implantation into tube with a surgically documented preexisting bilateral hydrosalpinges.

Ectopic pregnancy in a preexisting hydrosalpinx is the rarest localization of ectopic pregnancy, although it constitutes a high-risk situation.

Case report

A 29 year old woman, gravida 0, was admitted to our hospital with vaginal bleeding for 1 week before. Presenting complaints included vaginal bleeding and intermittent lower abdominal cramping; the patient was hemodynamically stable. The initial level of serum hCG was 35 IU/L. A transvaginal pelvic ultrasound examination revealed an empty uterus with a right adnexal mass measuring 80 × 65 mm and left adnexal mass measuring 55 × 38 mm. The patient’s past gynaecologic history included infertility for 4 years. She had no history of sexually transmitted infections or previous abdomino-pelvic surgery. She was otherwise healthy.At laparoscopy, a small amount of bleeding was noted in both the anterior and posterior cul-de-sacs. There was severe adhesions into pelvis. Right ovary had hemorrhagic cyst 40 mm in diameter. The right tube contained a mass measuring approximately 4 cm; its appearance was consistent with an ectopic pregnancy. The left tube was hydrosalpinx.Right tube was removed after adhesiolysis and right ovary was resected. Then left tube was performed stomatoplasty.Tubal pregnancy was confirmed by histology investigation.

Our observation suggests that ovulation was into hydrosalpinx because one side of hydrosalpinx was right ovary. This case demonstrations of possibility a spontaneous conception and abnormal embryo implantation into tube with a surgically documented preexisting bilateral hydrosalpinges.

P.01.43

Story of the migrating coil

Gupta A.[1], Robati S.*[1], Hammonds H.[1], Connell R.[1]

[1] Maidstone Hospital U.K United Kingdom

This is a case report of undiagnosed uterine perforation during insertion of copper IUCD. which subsequently resulted in pregnancy and coil migrating to appendix and ovary.

We Present case of a women who got pregnant with IUCD in Situ which subsequently had migration of coil to appendix and her ovary.

A 38 year old lady who had a The IUCD T-safe 380 coil insitu when she became pregnant.. She had a previous ventouse delivery at Term in where she also sustained a third degree tear. Being a traumatic experience for her, she was booked to have an elective Caesarean Section and to remove the Copper coil at that time. However, she was found to be fully dilated on the day of her surgery and had a vaginal delivery with no expulsion of coil. Following a CT abdomen and pelvis, she had a laparoscopy which revealed an appendix mass with omentum stuck to the right ovary. After careful dissection, the coil was noted through the ovary and also transfixed the appendix through both walls. She consequently had an appendicetomy

Pathology

The copper intrauterine contraceptive device protruding from the anti-mesenteric aspect and was open in the lumen of the appendix. The lumen was distended and filled with brown necrotic material. Histology showed abscess formation within the appendix lumen with acute and chronic inflammatory changes suggestive of a granulomatous inflammatory response with some evidence of fibrosis.

Uterine perforation is a serious complication associated with any IUDs and the incidence has been reported as high as 0.44 per 1000. Subsequent penetration of the appendix is rare and limited reviews in the literature. One paper reported a similar case to ours, but the patient was found to be asymptomatic.

Awareness is advised in women with IUDs particularly those who present with abdominal pain and alteration in bleeding patterns. However, uterine perforations need not be symptomatic and transmigration can occur over time.

P.01.44

Surgical management of liver and diaphragmatic endometriosis. case report illustrating the treatment challenges

Athanasias P.*[1], Rzyska E.[1], Ind T.[1]

[1] St George’S Hospital London United Kingdom

Liver and diaphragmatic endometriosis are rare pathologies that require high index of suspicion especially in patients with pelvic disease and upper abdominal symptoms.We report a case of endometriosis with liver and diaphragmatic deposits necessitating partial liver and diaphragmatic resection

Endometriosis affects primarily the pelvis.Relatively uncommon, endometriosis has been diagnosed in several remote sites including the liver and the diaphragm.Extrapelvic disease varies from asymptomatic to causing severe and disabling symptoms and faces the clinicians with diagnostic and therapeutic challenges

A 50 year old woman was referred to our unit with a 3-year history of gradually increasing pelvic pain and upper abdominal pain.She had a family history of colon and liver cancer.CT scan revealed a complex right adnexal mass,subcapsular liver deposit and right diaphragmatic nodules.Ca 125 was 150 u/ml

The clinical and radiological pictures indicated possible endometriosis but were also suspicious for malignancy thus it was felt appropriate to proceed with a laparotomy.The findings revealed pelvic endometriosis and large nodules involving the liver and the diaphragm.The liver lesion was resected using the Cavitron Ultrasonic Aspirator and the diaphragmatic disease was resected incorporating full thickness sleeve resection of the diaphragm.Histopathology confirmed endometriosis

This report highlights the significance of a thorough exploration of the abdominal cavity during laparoscopic pelvic surgery.The management of endometriosis with an atypical presentation remains controversial as it can mimic other diseases or malignancy.Non invasive medical therapy has rarely yielded successful results.Surgical treatment of hepatic and diaphragmatic endometriosis either by laparoscopy or open surgery should aim to remove the lesions,alleviate symptoms and prevent recurrence

P.01.45

Surgical technique for removing a giant ovarian cyst using an octo port combined minilaparotomy and single port laparoscopic surgery

Kim S.*[1], Lee T. S.[2], Kim K. S.[3]

[1] Severance Hospital Seoul Republic Of Korea- [2] Seoul Metropolitan Boramae Hospital Seoul Republic Of Korea- [3] Miz-Medi Hospital Seoul Republic Of Korea

This reports illustrates a case where a giant cyst of left ovary was successfully removed via novel surgical technique that combined minilaparotomy and single port laparoscopic surgery (SPLS), using an OCTO port.

An OCTO port (DalimSurgNet Corporation, Seoul, South Korea) is a product that provides up to four ports for introducing instruments via one incision. Detachable port cap of an OCTO port makes it possible to perform minilaparotomy through the single incision site.

This reports illustrates a case where a giant cyst of left ovary was successfully removed via novel surgical technique that combined minilaparotomy and single port laparoscopic surgery (SPLS), using an OCTO port.

We experienced a woman with huge mucinous cystadenoma, whose pelvic ultrasonography revealed a 22.3 × 22.8 cm multiseptated cystic mass of left ovary without solid portion inside. Surgical technique included drainage of inner contents, frozen biopsy sampling of the cystic wall, excision and suture of a large portion of the cyst via minilaparotomy through the single incision site of the umbilicus, and performing single port laparoscopic left salpingo-oophorectomy for the remained ovarian mass without intraperitoneal spillage of inner contents after comfirmation of the frozen biopsy result. The operating time was 70 min from skin incision to abdominal-wall closure. Intraoperative complications were not happened.

Novel surgical technique that combined inilaparotomy and SPLS for a giant ovarian cyst was technically feasible using an OCTO port. The advantages of it were as follows: (1) a better aesthetic outcome could be achieved; (2) we was able to confirm the frozen biopsy result during the operation and use operation time more effectively; and (3) laparoscopic removal of a giant ovarian cysts could be performed more easily without spillage of the cystic contents.

P.01.46

The case of shanghai intra uterine coil

Shankar L. R.*[3], Owien G.[1], S R.[2]

[1] Sho Obs And Gynae United Kingdom - [2] Consultant Obs And Gynae United Kingdom - [3] Spr Obs And Gynae United Kingdom

Intrauterine devices are an effective method of contraception. There are several types of IUCD’s available in the market and their choice of availability is not uniform throughout the world.

We report a case of a missing a rare type of IUCD, rarely encountered in the western world.

31 year old Chinese lady was referred to gynaecology clinic for a missing IUCD. She had one normal vaginal delivery in Shanghai. Her menstrual cycles were normal and there was no significant past medical/surgical history. As no coil thread was visible in the clinic, hysteroscopic removal was arranged.

Hysteroscopic view of the device shown in the picture.

Case note review

As a rare type of IUCD was seen in the uterine cavity. Since an appropriate retriever was not available in our setting, the IUCD was left insitu. Further internet searches and communication with medical Team in Hong Kong helped us obtain the retriever which is shown in the picture. This is a 12″ long device with a small hook.

In this day of globalisation, gynaecologist should be aware of the various types of intra uterine devices used in different part of the world. This concept will help in proper counselling and successful in retrieval of the intra uterine device.

P.01.47

The case of the shanghai coil ? reversible but/or ?permanent

Shankar L. R.*[1], Owien G.[1], Roberts R.[1], Llantrisant [1]

[1] Spr Obs And Gynae United Kingdom

31 year old Chinese woman was referred to GOPD by a GP for missing IUCD. She is para one had normal vaginal delivery in Shanghai, with normal menstrual cycle with no significant medical or surgical history.

In the out patient thread of the IUCD was not seen and she was asked to have a scan. Ultrasound revealed IUCD was in situ. Further she was booked for day surgical procedure. In the day surgery hysteroscopy revealed unfamiliar device which was difficult to remove.

Literature search helped us to find a retrieval device in China and a Gynaecologist from Hong Kong was kind enough to send the device to retrieve the IUCD.

This device used in China for last 30 years. Origin of this device is the Graefenberg ring, first being used n Graefenberg, Germany in the early 1960, and was originally made of silver and copper.

The Chinese subsequently produced a stainless-steel version of the device in the 1970s in the city of Shanghai and it was then called the ‘Shanghai ring’ AKA the ‘Chinese ring’

It is about an inch in diameter, very springy and flexible. It does not have a thread attached to it because it was not meant to be removed easily by a lay person or ‘ordinary’ practitioner. The rationale of course, was from the ‘one-child-family’ concept.

The ring is used for what is called immediate post-placental insertion (IPPI) which is common in China, referring to the application of the ring immediately (within 10 minutes) of the delivery of the placenta and even during a Caesarean section. Some IUDs are fixed to the fundus of the uterus during Caesarean section

They is a special device to remove this coil which is shown here was sent by Dr X from Hong Kong. It is x cm long and there is a hook on it. Blindly insert in to the uterus and hook the IUD and retrieve it.

Due to globalisation gynaecologist should be aware of different shape of IUDs used in different part of the world. This will help in counselling

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)

Castellacci E.*[1]

[1] Ospedale Palagi Firenze Italy

The embrioscopy represent a valid diagnostic support to confirm and complete the study of suspected morfological abnormalities diagnosticated by ultrasound imaging. a case report of a woman at 10 weeks pregnancy, with an ultrasound suspect of chromosomal abnormalities. the transcervical embrioscopy confirm the presence of embrional signs of chromosomal abnormalities suspected with ultrasound imaging and confirmed by chromosomal exam (chorionic villus sampling). This case report represents a prospective collaboration of the endoscopy unit with the prenatal diagnosis in the application of the transcervical embrioscopy to confirm the suspect of ultrasound imaging abnormalities and the direct visualization of the embrional morphological abnormalities until 12 + 6 weeks.

embrioscopy represent a valid diagnostic support to confirm and complete the study of suspected morfological abnormalities diagnosticated by ultrasound imaging.

a case report of a woman at 10 weeks pregnancy, with an ultrasound suspect of chromosomal abnormalities

the transcervical embrioscopy confirm the presence of embrional signs of chromosomal abnormalities suspected with ultrasound imaging and confirmed by chromosomal exam (chorionic villus sampling)

this case report represents a prospective collaboration of the endoscopy unit with the prenatal diagnosis in the application of the transcervical embrioscopy to confirm the suspect of ultrasound imaging abnormalities and the direct visualization of the embrional morphological abnormalities until 12 + 6 weeks.

P.01.49

The use of desogestrel 75 mcgr/day previous to tubal sterilization with essure implants

Haimovich S.*[1], Mancebo G.[1], Fernando L.[1], Serra C.[1], Carreras R.[1]

[1] Del Mar University Hospital Barcelona Spain

Visualization of the ostiums may be difficult depending on the menstrual cycle phase.For tubal sterilization with Essure implants we have to programme the patient at the right moment of the cycle or offer Combined Hormonal Contraception (CHC).We present our results of endometrial preparation with desogestrel previously.

One of the difficulties during a tubal sterilization with Essure is to manage to see the ostiums.Not always it is possible to schedule the women at the right moment of the cycle.Endometrial preparartion with a progestagene is an alternative that facilitates the insertion.

34 women scheduled for hysteroscopic sterilization with Essure microinserts between January 2010 and January 2011 and didn’t accept endometrial preparation with CHC or was contraindicated. We offered to patients Desogestrel 75 mcgr/day, according to acceptance patients were divided into the Desogestrel Group (DG) 16 women and the No Treatment Group (NTG) 18. In the DG,hysteroscopy was scheduled after 6 weeks and in the NTG, were schedule randomly according to arrival order. Procedure was performed in office,without anesthesia and always by the same professional.Endometrial biopsy was taken,time of procedure and difficulties were registered.

In the DG we found 8 cases with decidual transformation, 3 of glandular atrophy and 5 of proliferative endometrium,in the NTG, 2 women had menstruation, 9 proliferative endometrium and 7 secretor endometrium.No difficulties were found in the DG,two procedures were cancelled in the NTG due to menstruation and in 4 cases of secretor endometrium we had difficulties to visualize the ostiums due to endometrial thickness and bleeding.

The use of desogestrel 75 mcgr/day is an alternative to CHC prior to a sterilization with Essure,it facilitates the procedure and gives a solution for contraception during the 12 weeks after,till the tubal occlusion is achieved.

P.01.50

Title: chronic pelvic pain and adenomyosis in a patient with rokitansky syndrome.

Bernabeu Cifuentes A.*[1], Roig Casaban N.[1], Paredes Rios A.[1], Navarro Campoy C.[1], Gil Raga F. J.[1]

[1] Hospital De L’Horta Manises Valencia Spain

Objective:

To describe a case of leyomiomas and chronic pelvic pain in a patient with Mayer-Rokitansky-Kuster-Hauser syndrome

Description. Case report:

A forty-six year old patient with diagnosis of Rokitanski syndrome (two rudimentary hemiuterus with normal ovaries were discovered by laparoscopy at age 16 because of primary amenorrhea) is seen in our department because of chronic pelvic pain. The patient has led a normal life with normal sex intercourses. An MRI showed an image compatible with hematometra in the left vestige utero. Six months from now, the patient underwent laparoscopy for suspected GIST tumors, but multiple fibroids were found and no evidence of tumor. Given the findings, the patient was referred to our clinic. We decided to perform a new laparoscopy for resection of both uterine fibroid remains. The surgery takes place without incident, in which normal ovaries are observed and uterine fibroid vestiges are removed. There is no communication between the uterine vestiges and the vagina or in between.

A month after discharge, the patient referes that her pain has completely gone. The pathology report describes leiomyomas with focal adenomyosis.

Conclusion:

This is an unusual case of Mayer-Rokitansky-Kuster-Hauser syndrome associated with bilateral leiomyomas and adenomyosis. The excision of the tumors with the adjacent uterine remnants es indicated when they are symptomatic.

P.01.51

Total laparoscopic hysterectomy for treatment of a bicervical didelphic uterus with a myoma

Shin J.*[1]

[1] Gyeongsan National Hospital Jinju Republic Of Korea

Leiomyoma at rare localizations in the presence of uterine anomalies is a surgical challenge, but available endoscopic technology and appropriate surgery, successful results can be obtained

Leiomyomas arising from the uterine anomaly are very rare. We report the case of a laparoscopic total hysterectomy of this anomaly that was associated a large leiomyomas with menorrhagia and pelvic pain.

An 51-year-old gravida 6, para 2, woman presented for evaluation of vaginal bleeding and pelvic pain. It was suspected of uterine didelphys, and MRI was scheduled. MRI of the pelvis showed a double uterus with two separate cervices, and one vagina. Each uterus has a single myomas (Rt: 2.4 cm , Lt: 5.4 cm) at bodies. Each horn linked to the ipsilateral adnexa. And absence of right kidney were also observed. Because of bicervical anomaly, traditional colpotomizer system couldn’t be performed. So, sharp portion of rubber neonate sucker, grasped by placental forcep was inserted through vagina. Then, puff portion push up two cervices, it makes a clear distinction between cervices and vagina.

Pathologic evaluation of the surgical specimen showed a didelphic uterus with submucosal and intramural myoma, proliferative endometrium and adenomyosis.

When we operate total laparoscopic hysterectomy, we couldn’t adapt the traditional colpotomizer system because of bicervical anomaly. To accomplish these difficulties, we used a neonate sucker instead of traditional colpotomizer designed for single cervical uterus. The neonate rubber sucker make us to be done successfully laparoscopic colpotomy. The entire procedure was done laparoscopically and the uterus was removed vaginally. From our own experience, laparoscopic hysterectomy with rubber neonate sucker to facilitate anatomic delineation of vagina fornix is a worthwhile measure.

P.01.52

Treatment of pelvic organ prolapse by laparoscopic lateral suspension using mesh: a continuous series of 293 patients

Dubuisson J.* [1], Dubuisson J. [1], Eperon I. [1]

[1] Head Department Of Obstetrics And Gynecology, University Hospitals Of Geneva - Switzerland

The study objective is to evaluate the efficacy of laparoscopic lateral suspension using mesh in patients with pelvic organ prolapse (POP).

Patients with previous hysterectomy were excluded from the study. All 293 patients were assessed before and after surgery.

From January 2004 through March 2010, 293 patients with POP underwent laparoscopic lateral suspension using mesh. Assessment included a description of their functional symptoms and the degree of their POP, according to the Baden-Walker classification system.

Patients were followed up postoperatively for a median of 15.76 (range 1–69) months.

Patients’ median age was 56.72 (range 34–81) years. Median parity was 2.16 (range 0–8).

In all, 139 (67.4%) patients were postmenopausal, of whom 31 (10.6%) were on hormone replacement therapy. Median body mass index (kg/m2) was 26.24 (range 18–39).

A total of 143 (48.8%) patients were sexually active.

We observed a recurrence of prolapse in thirty patients (9.6%). A repeated operation was performed in 14 patients (4.8%). All operations were performed laparoscopically. Mesh erosion was noted in 9 patients (3.1%), of which seven were treated by vaginal excision of the mesh (2.4%).

Laparoscopic lateral suspension using mesh effectively treats POP with low morbidity.

P.01.53

Ultrasound guided hysteroscopic treatment of asherman syndrome report of three cases

Ait Benkaddour Y.*[1], Abderrahim A.[1], Karima F.[1], Bouchra F.[1], Hamid A.[1], Abderraouf S.[1]

[1] Department Of Obstetrics And Gynecology, University Hospital Of Marrakesh Marrakesh Morocco

Asherman syndrome is defined as complete obliteration of uterine cavity.We report three cases of Asherman syndrome secondary to infection. The patients had ultrasound guided hysteroscopic synechiolysis with excellent anatomical result and regular withdrawal bleeding but all of them failed to get pregnancy. Ultrasound assistance seems to improve effectiveness and safety of hysteroscopic synechiolysis with good anatomical results.

Asherman syndrome is defined as complete obliteration of uterine cavity. It’s caused by trauma in 90% of cases and infections in other cases. Hysteroscopy is the gold standard for the treatment of Asherman syndrome. Uterine perforation is the most frequent complication of this surgery.

We report three cases of Asherman syndrome secondary to infection.

Tow patients had history of unsuccessful hysteroscopic treatment. The three patients had ultrasound guided hysteroscopic synechiolysis with excellent anatomical result and regular withdrawal bleeding but all of them failed to get pregnancy.

Treatment of Asherman syndrome is one of the most difficult hysteroscopic procedures with a high rate of complications. Ultrasound assistance seems to improve effectiveness and safety of this procedure with good anatomical results. However reproductive outcome is still poor and needs further research to be improved.

P.01.54

URINOTHORAX AFTER LAPAROSCOPIC HYSTERECTOMY; A RARE COMPLICATION

Vankan E.*[1], Smeets N.[1]

[1] Atrium Medical Center Heerlen Netherlands

Urinothorax is a rare cause of pleural effusion. In case of respiratory symptoms and rapidly increasing pleural effusion, urinothorax should be included in the differential diagnosis, especially when there is suspicion of urinary tract injury.

Urinothorax is a rare condition defined as the presence of urine in the pleural space. It is associated with obstructive uropathy after which urine may reach the pleural space by different mechanisms. We describe a case of urinothorax after laparoscopic hysterectomy with conversion to laparotomy.

A 47-year-old woman underwent a laparoscopic hysterectomy which was converted to laparotomy because of difficult haemostasis. One month after the procedure she reported progressive shortness of breath. Evaluation of an amount of pleural fluid showed an elevated creatinine and the macroscopic aspect of urine. Ultrasonography of the kidneys showed hydronephrosis. Therefore an urinothorax was diagnosed. After thoracocentesis and a nefrostomy the urinothorax resolved. Finally an ureter re-implantation was performed and the patient recovered completely.

An urinothorax often presents with modest symptoms. The condition can be diagnosed by performing thoracocentesis. Evaluation of the pleural fluid shows features of transudate and elevated creatinine. Imaging to visualize a defect in the urinary tract can confirm the diagnosis. In the different methods of hysterectomy, the risk of ureteral injuries seems highest in laparoscopic hysterectomy. This can be explained by the technique of the procedure, where the bladder is completely dissected from the uterus and the use of electro-coagulation may cause complete tissue coagulation, resulting in defects of the ureter.

In case of respiratory symptoms and rapidly increasing pleural effusion, urinothorax should be included in the differential diagnosis, especially when there is the possibility of an urinary tract injury.

P.01.55

Uters duplex with vagina atretica followed by consecutive unilateral hematocolpos—hysteroscopic appreoach to the diagnosis

Petronijevic M.*[1], Vrzic-petronijevic S.[1], Dokic M.[1], Bratic D.[1], Maricic Z.[1]

[1] Clinic Of Gynecology And Obstetrics, Clinical Centre Of Serbia Belgrade Serbia

Disorders due to incomplete fusion of Mullerian canals can be mild—uterus arquatus and complex as uterus duplex with vagina duplex.

In some cases one uterus is connected with atretic vagina causing formation of haematometra in puberty. Diagnosis can be established by clinical and ultrasound exaimination, hysteroslpingography and laparoscopy.

Patient aged 28 expirienced first problems with menarcha at the age of 13 and she was treated as hymen imperforatus with incision. Later problems were lower abdominal pain during menstrual cycle, prolonged bleeding ending with dark, odorous blood. Examination under specula apeared normal: one vagina with one cervix. Examination during menstrual bleeding showed whole right vaginal wall altered in long, elastic, tight and tender tumour draining blood through small oriffice at distal part of tumour. Ultrasound showed two uteruses with two completely separated cavities and two cervixes. Hysterosalpingography was performed with introducing contrast through left cervix into the left uterus, and through oriffice on the right vaginal wall via catether into the right side, with visualisation of right vagina, uterus and Fallopian tube. Radiological examination showed agenesia of the right kidney. We concluded that second vagina is blindly closed, and the right vaginal wall of left vagina was in fact the septum between two vaginas.

Introducing the hysteroscope through the oriffice on the right vaginal wall of left vagina, we were able to visualise at the proximal end of cavity cervix smaller than contralateral and decided to cut the septum and liberate blood flow from the right uterus. After removal of septum two cervixis were visible at the proximal part of unified vagina.

Although rare, such conditions should be investigated thoroughly in order to establish correct diagnosis and conduct proper treatment.

figure c

P.01.56

Vaginal expulsion of submucosal fibroids post embolization: a cure or a complication?

Kolhe S.*[1], Powell M.[2]

[1] Presenting Author From Queen’S Medical Centre Nottingham United Kingdom - [2] Co-Author Nottingham United Kingdom

Intramural and submucosal fibroids are accepted indications for uterine artery embolization (UAE). We report a case series of UAE for fibroid uterus, predominantly submucosal, leading to complete restoration of uterine cavity following vaginal expulsion of fibroid/s.

Submucosal fibroids are more likely to migrate into the endometrial cavity after UAE. We report our experience with UAE as a cure for women with submucosal fibroids restoring uterine cavity.

Since 2002, UAE is performed at Queen’s Medical Centre in Nottingham. This is a case series of 10 selective cases that underwent successful UAE for large submucosal fibroids, thereby resulting in spontaneous expulsion of fibroid over a period of several months.

All reported cases in our series had spontaneous expulsion of the predominant submucosal fibroid either partially or completely over a period of 5 months post UAE.None of these women had frank sepsis requiring hysterectomy. Repeat MRI or outpatient hysteroscopy revealed complete restoration of uterine cavity.

Spontaneous expulsion of infracted fibroid is a recognized complication post UAE and is generally described as a cause for prolonged vaginal discharge with potential risk of sepsis. Our experience with women in reproductive age group, particularly interested in restoring fertility, and who had predominantly large submucosal fibroid showed that UAE can result in potential cure- eventually restoring the uterine cavity. Our patients were appropriately counselled pre-embolization regarding high possibility of vaginal expulsion of the fibroid after the procedure. Although most delivered the fibroid spontaneously, some required aid with hysteroscopic retrieval of the necrotic fibroid tissue or resection of residual fibroid to achieve complete symptomatic cure. We see fibroid expulsion post-embolizaton as just another way to attain cure.

Session P.02

* Complications *

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?

Tselos E.*[1], Whitlow B.[2]

[1] Evangelos Tselos Colchester United Kingdom - [2] Barry Whitlow Colchester United Kingdom

In the Endometriosis Center of a district general hospital, 24 cases of deeply infiltrated pelvic endometriosis analyzed. The short term outcomes were compared with those published by a big endometriosis centre of excellence.

Laparoscopic treatment for deeply infiltrated pelvic endometriosis requires advanced surgical skills and multidisciplinary teams for best result. This lead to the development of Endometriosis Centers which are overlooked by BSGE and for accreditation is needed a minimum of 12 major endometriosis operations per year.

We collected retrospective data from 24 patients’ laparoscopic surgical treatment for deeply infiltrating pelvic endometriosis and analyzed the results. The data we looked into were similar to the data that have been published by a big endometriosis centre of for easier comparison.

A total of 24 cases analyzed who underwent complex operation. From these, 23 (96%) cases had bowel involvement. From the 24 cases, 16(67%) had rectal shave, 2(8.3%) disc resection, 3(12.5%) segmental bowel resection, 3(12.5%) rectovaginal dissection, 5(21%) ureterolysis and 1(4%) full thickness bladder resection. Total number of patients with complications were 2(8.7%). Women spent a median of 2 days in hospital (range 1–6). Al the operations performed as joined procedure with a laparoscopic colorectal surgeon.

Although the sample is small and fails to reach statistical significance, the total number of complications was 8.7%. This compares favorably with the total complication rate of 10.2% of the bigger center. However the 2 complications were both severe and are significantly higher compared with the 3.4% severe complication rate from the bigger center. We are continuing our data collection to present the results of more cases for a more accurate comparison.

P.02.2

Feasibility of advanced laparoscopic gynaecologic surgery in obese women

Syed Hashim S.*[1], Lotfallah H.[1]

[1] Rotherham District General Hospital Rotherham United Kingdom

This study evaluates the complication rates of advanced laparoscopic gynaecologic surgery in obese women. Our findings suggests that obesity is not associated with increased complication rates.

The latest Health Survey for England data shows that in 2009, 32.8% of adult women in England were overweight, 23.9% obese and 3.5% morbidly obese. Obesity has been considered by some as a relative contraindication to laparoscopic surgery. Our aim is to assess the feasibility of advanced laparoscopic surgery in obese women.

We identified 172 cases from Jan 2009 to Dec 2010. We excluded 51 patients who had non-operative laparoscopy and 1 with BMI of 17. The 120 cases who underwent various laparoscopic procedures were divided according to their BMI as per WHO criteria (normal 18.5–24.9, pre-obese 25–29.9, obese >30). The obese group is subdivided into class 1 (BMI 30–34.9), class 2 (BMI 35–39.9) and class 3 (BMI > 40). The outcomes were analysed in terms of conversion to laparotomy, intra-operative and post-operative complications.

Overall 120 operative laparoscopic cases were analysed (normal weight n = 59, pre-obese n = 27, obese 1 n = 34, obese 2 n = 6 and obese 3 n = 8). There were 2 conversions to laparotomy. The rate of conversion to laparotomy in obese women was not significantly higher than in normal BMI women (2.91% vs. 1.69% p = 0.69). The intra-operative complication rate in obese women is not significantly higher than in normal BMI women (3.3% vs. 5.9% p = 0.568). The post-operative complication rate in obese women (n = 2) is higher than women who are overweight (n = 1) and those with normal BMI (n = 3) but it is not statistically significant. (5.88% vs. 3.7% vs. 5.08% respectively p = 0.927).

Our experience seems to suggest that the risks of laparoscopic surgery in pre-obese and obese women are similar to normal weight women in terms of laparotomy conversion rate, intra-operative and post-operative complications.

P.02.3

Major vascular injuries in a clinical hospital of latinoamérica

Puga M.*[1], Miranda-mendoza I.[1], Carvajal A.[1], Meier R. M.[1], Hidalgo G.[1], Cerda S.[1], Miranda C.[1]

[1] Hospital Clinico Universidad De Chile Santiago Chile

Major vascular Injuries in laparoscopy are rare but potentially lethal complications, most of them are during the setting up phase. The retrospective analysis of cases allows us to learn about important details useful in the prevention and management of this injuries. We report 6 patients with MVI that occur at Clinical Hospital of University of Chile. Characteristics of patients, related factors associated, management and possible manners of prevention are discussed.

Major vascular Injuries (MVI) are infrequent but potentially lethal complications of the laparoscopical surgery. Almost 50% of them occur during the setting up phase. Prevention is the key to avoid this complication, but when MVI happens the rapid recognition and immediate repair of the damage by a vascular trained surgeon can save the patients life.

Patients were obtained from the Review of the Hospital database between 1994–2010.

6 patients with 7 MVI and 1case of minimal stable retroperitoneal hematoma were identified between 5404 laparoscopies. All the injuries occurred during the laparoscopy setting up phase. 5 of 6 cases were secondary to umbilical trocar. The first patient of the study was the only one who needs reoperation, because of an undiagnosed lesion in the posterior wall of the aorta. In two subsequent cases the posterior wall injury was diagnosed an immediately repaired. No dead occur. Characteristics of patients, surgeon experience, related factors associated, management and possible manners of prevention are discussed

MVI as a group are the most life-threatening complications in laparoscopy. Prevention by strict safety rules in the setting of the surgery is the key factor. The analysis of the cases revealed important details that might be associated to the injury and give us information that might be usefull to avoid future complications.

P.02.4

Pubic osteomyelitis following laparoscopic retropubic surgery

Rosen D.*[1]

[1] Sydney Women’S Endosurgery Centre Sydney Australia Australia

A case of retropubic osteolmyelitis following laparoscopic sacrohysteropexy and paravaginal repair see below

This is the first report of retropubic osteomyelitis following laparoscopic paravaginal repair. A 71 year old woman with a history of previous right hip replacement underwent Laparoscopic Mesh sacrohysteropexy and anterior paravaginal repair for Stage 3 pelvic prolapse. 2 weeks postop she experienced a left sided pain commencing on the left side of the hemi-pelvis extending down the left thigh causing difficulty on ambulation. No sensory defect was noted however a mild muscular weakness left compared to right was noted. Neourological examination excluded obturator neuropathy and the pain was somewhat relieved by anti-inflammatories however continued to progress. Initial orthopaedic review diagnosed a ‘stress’ reaction based on the marrow oedoma seen at MRI scan however with ongoing symptoms, a diagnosis of osteitis pubis was made. CT scan of the pelvis showed mild inflammatory changes consistent with osteitis pubis and a steroid injection into the symphysis relieved pain immediately for 3 days. Thereafter pain recurred and the classical waddling gait was noted.

Referral was then made to the orthopaedic surgeon who performed the original hip replacement agreed with the diagnosis of osteitis pubis, however a raised CRP/WCC, Pseudomonas aeruginosa on BC’s and MSU and hot spots in the symphysis on Nuclear Imaging changed the diagnosis to one of Pubic osteomyelitis. Admission for antibiotic treatment failed as the CRP continued to rise (max 327) and the patient returned to theatre for removal of the paravaginal sutures on the left and curettage of the symphysis pubis. Pseudomonas grew from the abscess however the suture material showed no growth. Tthe patient made a slow but steady recovery. Recommendations regarding warning signs and management strategies will be discussed.

P.02.5

The definition for conversion in mis: is there consensus?

Blikkendaal M.*[1], Twijnstra A.[1], Jansen F. W.[1]

[1] Leiden University Medical Centre Leiden Netherlands

A literature search showed that 70% of studies on gynaecological laparoscopy do not include a definition for conversion to laparotomy. In order to obtain a valid quality assessment tool, consensus on a definition is necessary.

Conversion to laparotomy is associated with worse postoperative outcomes, especially if conversion is performed because of intra-operative complications (reactive conversion). Next to complications, a conversion has to be recorded, because it is a quality assessment tool towards MIS. However, according to MIS in general surgery, a wide variety in definitions is reported in gynaecology as well. Aim of this study is to achieve consensus on the definition for conversion.

To identify the spectrum of definitions currently in use, a literature search on PubMed was performed. Observational studies concerning laparoscopic gynaecological procedures, published in English, after the year 2000 and with an abstract were analysed. Additionally, a survey was conducted under all gynaecologists in the Netherlands, performing level 3 laparoscopic procedures.

Fifty relevant studies were found. In 70% a definition for conversion was not included. Ten studies considered switching to laparotomy due to either reactive reasons or surgical difficulties (i.e. strategic) a conversion, whereas two studies only took reactive conversions into account. Three studies considered an abdominal incision >7 cm a conversion. Results of the national survey will be announced.

A wide variety in definitions is currently in use. Although clinically relevant a definition is not always mentioned and conversion for strategic reasons is often not considered to be a conversion. This partly explains the wide range of conversion rates reported. In order to obtain a valid quality assessment tool allowing adequate comparison of procedures at risk, consensus on a distinct definition for conversion has to be implemented.

P.02.6

The obstetrical complications of laparoscopic surgery for adnexal masses during pregnancy

Takashi K.*[1], Yuko T.[2], Kazuo M.[1], Satomi S.[1], Nagako S.[1], Nobuya T.[1]

[1] Palmore Hospital Kobe Japan - [2] Department Of Dermatology, University Of Alabama At Birmingham Alabama United States

The retrospective study has shown relatively higher rate of obstetrical complications after laparoscopy for adnexal masses in pregnancy than that of laparotomy.

Laparoscopy for adnexal masses in pregnancy has become increasingly more common in the last decade. To date, the benefits of laparoscopy include shorter hospital stay and earlier return to normal activity. However, there is little evidence guiding the risks for post-operative obstetrical complications of laparoscopy. The purpose of our study is to evaluate the safety and efficacy of laparoscopy over laparotomy for adnexal masses in pregnancy, with a particular attention to the pregnancy outcome.

We conducted a retrospective review of 7 cases of laparoscopy for adnexal masses in pregnancy and 12 cases of laparotomy for them in our institution from 2001–2010.

All operations were performed at 14 ± 1.1 weeks’ gestation. As expected, the mean operation time was longer in laparoscopy group compared to laparotomy group (96.2 ± 32.3 vs. 46.7 ± 11.4 min, p < 0.01). The benefits of laparoscopy group showed significant reduction in blood loss at operation (10.8 ± 9.0 vs. 41.3 ± 24.2 ml, p < 0.05) and shorter hospital stay (4.8 ± 2.3 vs. 9.0 ± 3.1 day, p < 0.05). Remarkably, 2 major obstetrical complications occurred in laparoscopy group (28.6%): 1 fetal loss at 17 weeks’ gestation and 1 preterm labor at 36 weeks’ gestation. Contrary, 1 preterm labor at 35 weeks’ gestation was the only incidence in laparotomy group (8.3%). All cases were identified as benign tumors. There was no significant difference in tumor size between two groups (7.7 ± 1.8 vs. 7.8 ± 2.2 cm).

The increased obstetrical complications after laparoscopy for adnexal masses during pregnancy are not negligible despite short-term advantages of it as a minimal invasive method. It is necessary to accumulate further experiences before we may conclude safety and efficacy of laparoscopy during pregnancy.

P.02.7

Thermal leasions after uncomplicated novasure endometrial ablation

Spath M.[1], Geense W.[1], Aufenacker T.[1], Dijkhuizen P.*[1]

[1] Rijnstate Hospital Arnhem Netherlands

Case report of a NovaSure bipolar endometrial ablation without perforation of the uterus but with thermal damage of the uterus and intestines.

Endometrial ablation is a commonly used uterus-saving treatment for menorrhagia. Although the NovaSure bipolar thermal endometrial ablation is accepted as safe and effective, in women with dysfunctional uterine bleeding, we report a case of uterine thermal injury after an uncomplicated NovaSure procedure that resulted in an intestinal perforation.

A 35-year-old, multiparous woman was suffering from menorrhagia. Medical treatment did not solve the problem. Pre-operative assessment showed a normal uterus and no intracavitairy abnormalities on Saline Infusion Sonograhy (SIS). PAP smear and Pipelle aspiration of the endometrium were both normal.

She underwent an uncomplicated NovaSure ablation. The procedure was successful in the first attempt and lasted 90 seconds. Following the ablation, a laparoscopic sterilization was performed. Laparoscopy revealed two thermal leasions of the uterine serosa and another thermal leasion on the small intestine facing the uterus. There were no signs of uterine perforation. Even though the thermal leasion on the intestine was sutured, seven days after the NovaSure ablation the patient returned with a perforation of the intestine 10 cm distal to the previously sutured thermal leasion.

Although the NovaSure bipolar ablation method is regarded as a safe ablation technique, we report a case that without perforation of the uterus but by thermal damage to the uterus can lead to intestinal perforation.

P.02.8

Uterine perforation during hysteroscopy—serbian experience

Tavcar J.*[1], Dokic M.[1], Djakonovic Maravic M.[1], Ljubic A.[1], Vidakovic S.[1]

[1] Clinic For Gynecology And Obstetrics, Clinical Center Of Serbia Belgrade Serbia

Our retrospective study analyses uterine perforation during hysteroscopy in The Clinic for Gynaecology and Obstetrics during 3 previous years.Uterine perforation during hysteroscopy occurred in 3 patients during observed period of time (0.21%). Diagnostic hysteroscopy was complicated with perforation in one case (0.19%) and two cases of perforation occurred during operative procedures (0.22%).

Our retrospective study analyses uterine perforation during hysteroscopy, and our goal was to compare our results with other studies from developed countries

We evaluated all hysteroscopic procedure done in Clinic for Gynaecology and Obstetrics during previous 3 years (2008, 2009, 2010). We analysed number of hysteroscopies per year, number of diagnostic and operative hysteroscopies, number of uterine perforations during hysteroscopy, treatment of perforation and its short term outcome.

We had 1424 hysteroscopic procedures—514 diagnostic and 910 operative. Uterine perforation during hysteroscopy occurred in 3 patients (0.21%). Diagnostic hysteroscopy was complicated with perforation in 1 case (0.19%) and 2 cases of perforation occurred during operative procedures (0.22%). Two hysteroscopies were followed by laparoscopy and one was followed by laparotomy for suturing perforation site. No perforation caused serious intraabdominal or ex utero bleeding and in no case was transfusion required. No other complications were noticed in hospital follow up.

Uterine perforation is rare but the most common complication of hysteroscopy. In most studies, hysteroscopy is complicated by confirmed uterine perforation in 0.8 to 1.6 percent of operative procedures [1–5]. Hysteroscopy is still young discipline in our Clinic, and Serbia as a country, and having in mind very low economic standard and challenges of our transitional health care system, our results are rather encouraging.

Session P.03

* Endometriosis: Diagnosis *

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

Vassilieff M.*[1], Roman H.[1], Savoye-collet C.[1], Suaud O.[1], Da Costa C.[1], Bridoux V.[1], Tuech J.[1], Marpeau L.[1]

[1] University Hospital Rouen France

Pre- and postoperative CTC allow an objective assessment of the effects of conservative rectal surgery on the digestive tract diameter and provide objective arguments supporting the choice of conservative rectal surgery in a majority of women managed for symptomatic rectal endometriosis.

We studied the relationship between the improvement of digestive symptoms and the relief of digestive tract stenosis using the assessment by computed tomography-based virtual colonoscopy (CTC).

In patients managed for a symptomatic colorectal endometriosis, pereoperative and 6 months postoperative evaluation by CTC has systematically been proposed.

Among 19 patients benefiting for both pre- and postoperative CTC, 12 women were managed by rectal shaving, 2 patients by combined laparoscopic and transanal disc excision, 3 women by colorectal resection and 2 patients by sigmoid colon resection.

Among 10 women undergoing rectal shaving and presenting with preoperative stenosis, 7 women reached regular and uniform digestive tract, while 3 patients still presented a digestive stenosis measured at 8, 7 and 12 mm. Preoperative constipation still present postoperatively was found in latter 2 patients, but none of them feel the symptom as unpleasant as to justify further explorations. In women undergoing disc resection of the nodule, the stenosis and digestive symptoms were completely relieved. Among the 5 women managed by segmental resection and colorectal anastomosis, symptomatic anastomotic stenosis was recorded in one case, requiring secondary endoscopic dilatation of the anastomosis.

Pre- and postoperative CTC allow an objective assessment of the effects of conservative rectal surgery on the digestive tract diameter by revealing the cure of preoperative stenosis in 75% of cases.

figure d

P.03.2

Continuous low-dose estro-progestin combination in the treatment of colorectal endometriosis as evaluated by rectal endoscopic ultrasonography

Ferrari S.*[1], Persico P.[1], Di Puppo F.[1], Viganò P.[1], Tandoi I.[1], Garavaglia E.[1], Mezzi G.[1], Candiani M.[1]

[1] Irccs Ospedale San Raffaele Milano Italy

This study evaluated the efficacy of low-dose estro-progestin combination in the treatment of patients with colorectal endometriotic nodules. The therapy determined a significant improvement in symptoms and a reduction in nodules.

This study was aimed to determine the efficacy of a 12-month continuous low-dose estro-progestin combination in treating women with colorectal endometriotic nodules. The nodule volume was monitored by rectal endoscopic ultrasonography (EUS).

Fertile women (26) who had a diagnosis of colorectal endometriosis as diagnosed by rectal EUS, received a continuous low-dose oral estrogen-progestogen combination containing 15 mcg ethinylstradiol and 25 mcg gestodene for 12 months. Subjective symptoms were prospectively evaluated and the nodule volume was monitored by a new EUS

The therapy determined a significant improvement in the intensity of dysmenorrhea, nonmenstrual pelvic pain, deep dyspareunia, and dyschezia as determined by visual analog scale (VAS). Before the treatment, EUS technique revealed that 14 of the endometriotic lesions (54%) were allocated between 5 and 10 cm from the anal margin, 8 at a distance greater than 10 cm (31%; 2 lesions were at 20 cm) and only 4 lesions were found at a distance less than 5 cm (15%). A substantial reduction in diameter (26%) and in volume (63%) was observed after the proposed medical treatment.

Continuous low-dose oral estrogen-progestogen combination is effective and safe in the treatment of symptoms related to the presence of rectovaginal endometriosis. In addition, this therapy was shown to induce a significant volumetric reduction of rectovaginal plaques as evaluated by EUS. Importantly EUS was able to diagnose even nodules found at a distance of more than 10 cm from the anal rime, potentially misrecognised by vaginal ultrasound.

P.03.3

Dare south african women have endometriosis?

De Bruin A.*[1]

[1] Abri De Bruin University Of Pretoria, South Africa South Africa

South Africa is a large country with limited access to private healthcare due to costs and poverty. Limited resources in state healthcare places a burden on the optimal management of this severe disease

At the current time, endometriosis is not managed optimally and strategies should be made to improve the management of this disease throughout the country

In South Africa, only a small percentage of people have access to private healthcare. The state provides free healthcare to all patients that do not have private medical insurance. Due to the high incidence of cervix cancer, fibroid uteri and infective conditions with it’s associated complications, most of the theatre time in gynaecology is taken up by these cases in the government hospitals. The other issue is that not all the university hospitals have the necessary skills or optimal equipment to operate on the patients with severe endometriosis. In private healthcare, there are more skills to operate these patients as well as better equipment. However, as this only helps a small part of the population, it is clear that there are many women with severe endometriosis that will not be able to receive optimal treatment. Renumeration for surgery is poor as there has been no update on the codes medical insurers accept for endometriosis since the days the codes were decided upon many years ago. The difficulty of the surgery for severe endometriosis as well as the possible complications together with the poor renumeration, makes this an unpopular operation to perform even in private healthcare. Medical treatment is very expensive and also not available in government hospitals and also only help for the time that it is given? With all this in mind, can women in South Africa afford to have endometriosis?

P.03.4

Digestive symptoms in women presenting with pelvic endometriosis and their relationship with the localisation of the lesions

Ness J.*[1], Roman H.[1], Vassilieff M.[1], Gourcerol G.[1], Savoye G.[1], Bridoux V.[1], Tuech J.[1], Marpeau L.[1]

[1] University Hospital Rouen France

In women presenting with pelvic endometriosis, the mechanism of the digestive symptoms could rather be the consequence of the irritation of the digestive tract by local inflammatory phenomena than that of an actual infiltration by the disease.

The aim of the study was to compare the frequency of digestive symptoms in patients with different localizations of pelvic endometriosis.

Among women recorded in CIRENDO database, we identified the patients presenting respectively with superficial stage 1 (AFSr < = 5) endometriosis of the Douglas’ pouch (group 1), with deep nodules of the rectovaginal septum (group 2) and with deep endometriosis involving either the rectum or the sigmoid colon.

One hundred women were included in our study: 25 women with stage 1 disease (group 1), 34 women with rectovaginal nodules (group2) and 41 patients with colorectal endometriosis (group 3). The AFSr score was respectively 3.3 ± 2, 43.4 ± 39.5 and 74.2 ± 36. The preoperative GIQLI score was more impaired in women with peritoneal endometriosis (82.7 ± 20.4) than in those included in the group 2 (95.3 ± 20.2) and 3 (94.6 ± 18.8) (P = 0.047). The values of the KESS score were comparable between the groups (12 ± 6.3, 11.7 ± 6.1 and 11.2 ± 6.9, P = 0.82). Cyclic troubles of digestive transit were respectively found in 78.3, 87.1 and 76.5% of the women (P = 0.55), particularly an increase of daily number of stools, with a tendency towards liquid stools (39.1, 35.6 and 41.2%), or alternating pattern of diarrhoea and constipation (30.4, 22.6 and 17.7%). Cyclic defecation pain was more frequent in women with colorectal endometriosis (61.8%), but this symptom was also described by respectively 23.8% and 32.3% of women of groups 1 and 2 (P = 0.05).

The mechanism of the digestive symptoms appears to be the consequence of the irritation of the digestive tract by local inflammatory phenomena.

P.03.5

Does laparoscopy change the management of chronic pelvic pan?

Al-omari I.*[1], Hapuarachi S.[1], Atalla R.[1]

[1] Qe2 Hospital Wlwyn Garden City United Kingdom

Retrospective study of 100 patiet who had diagnostic laparoscopy for chronic pelvic pain.51% of patients there was no evident cause for the pain at laparoscopy.28% of cases the cause of pelvic pain was endometriosis and there was 19% of patients with pelvic adhesions as the cause of pain.2% of patients had small ovarian cysts or fibroids.

The management was not affected by the laparoscopy findings ,However ,there was reduction in the admission to the hospital following the procedure.

There is an increased use of laparoscopy as a diagnostic tool for chronic pelvic pain, keeping in mind that in more than 50% of the cases no cause can be found, as agreed by most studies.

The aim of this study was to analyze the benefit of diagnostic laparoscopies for chronic pelvic pain and whether they affect the long term management.

A retrospective study done at Queen Elizabeth II Hospital,

Data collected from 1st April 2008 to 31st March 2009 where 100 laparocopic procedures were performed for chronic pelvic pain. We compared the management plan before and after the laparoscopy procedures, with and without the presence of positive findings.

Age of patients range from 19–66 years. Among 100 patients who underwent laparoscopy, 51 had no abnormalities detected , 49 patients had positive findings which were mainly endometriosis and adhesions

Out of the 100 cases of chronic pelvic pain, 28 cases were endometriosis and 19 cases were adhesions.

The rule of laparoscopy in the management of chronic pelvic pain is mainly to diagnose or exclude Endometriosis ,There was no change in the management following laparoscopy in more than half of cases,However ,there was reduction in the admission to the hospital following the procedure.

P.03.6

Effective treatment for dysfunctional uterine bleeding within an out-patient setting

Holvey N.*[1], Vellacott I.[1], Dighe V.[1], Armitage R.[1]

[1] Lincoln County Hospital Nhs Trust England United Kingdom

Analysis through audit using endometrial ablation technique

Assessment through audit for Thermachioce Balloon Ablation of the endometrium, carried out within the out patient setting

Assessment of patients using guidelines and protocols for women with dysfunctional uterine bleeding.

Audit carried out to access satisfaction rates 6 months post treatment. Safety and effectiveness of pain protocol guidelines.

High satisfaction rates of 98% with guidelines showing an effective care pathway.

Analysis of a previous audit in 2008 using Cavaterm ablation treatment, gave us an effective assessment tool for further development of ablative treatments of the endometrium

This treatment is safe and effective achieving high satisfaction rates

With the simplicity and safety of this equipment, could nurse hysteroscopists and junior doctors be trained to carry out this technique?

P.03.7

Endometriosis in oman: experience in a tertiary hospital

Al Khaduri M.*[1], Al Farsi Y.[1], Ouhtit A.[1]

[1] Sultan Qaboos University Muscat Oman

We conducted a retrospective charts review over a 5 years to assess the clinical and socio-demographic profile of known endometriosis cases at a tertiary care hospital (SQUH). A total of 102 cases of endometriosis were enumerated. Endometriosis in Oman affects women at younger age when compared to international data.Younger cases of endometriosis tended to be from rural areas (p-value 0.002).

Despite the fact that endometriosis is one of the most common diseases that affect women in reproductive age, the extent of it in Oman is still unknown. Early observations of the number of patients attending Sultan Qaboos University Hospital (SQUH), suggest that endometriosis is a common disease. The purpose of this study is to provide preliminary estimates of the number of known cases for further investigation of etiology and the genetics of endometriosis in Oman.

Clinical data from patients attending the gynecology clinic at SQUH since 2006 were examined for correlation studies to determine the incidence and the factors associated with the disease.

Overall, a total of 102 cases of endometriosis were enumerated from 2006 to 2010. The mean age was 32.7 ± 8.1, and it ranged from 18 to 42 years. Of total, 38 (37.3%) women were considered young (<30 years). The most common type was unspecified endometriosis (48; 47.1%) followed by ovarian (40, 39.2%) and uterine (9; 8.8%). Compared to women of older age, younger cases of endometriosis tended to be from rural areas (81.6% vs. 42.2%, p-value 0.002). Young and old women were comparable in terms of distribution of type of endometriosis.

Our findings show that compared to international standards, endometriosis in Oman seems to affect women at a relatively younger age. This finding may be due to the young population in the country or that these women present to our hospital to seek treatment for infertility.

P.03.8

Laparoscopic treatment of endometrial cancer versus open abdominal surgery: 15-years experience at the jena university hospital

Runnebaum I.*[1], Koehler A.[1], Ludwig B.[1], Diebolder H.[1], Radosa M.[1], Michels W.[1], Camara O.[1]

[1] Jena University Hospital, Jena, Germany

To evaluate laparoscopic management of primary endometrial cancer (EMC) in comparison with the abdominal route regarding safety, disease-free and overall survival.

Patients aged from 38 to 94 with primary endometrial cancer treated with at least either a laparoscopically assisted vaginal hysterectomy (LAVH) +/− laparoscopic lymph node dissection (LND) or an abdominal hysterectomy +/− LND at the Jena University Hospital between January 1st, 1995 and December 31st, 2009 were included.

The hysterectomy exclusion criteria were concurrent ovarian cancer, metastatic disease, no adequate documentation of follow-up, reduced radicality due to comorbidity, or R1 resection. Low-and high-risk stratification of endometrial cancer was according to accepted risk factors.

Totally, 337 patients were eligible with a complete data set fulfilling the criteria of this study. By laparoscopy, 238 were treated, 78% of the pts. with low risk EMC and 62% with high-risk EMC. DFS of the low risk group had 95.8% vs 95.1% and 77.5% vs 75.9% of laparoscopic vs open surgery, respectively. Overall survival was again similar for all risk and age groups.

Laparoscopic management was safe in early endometrial cancer in this large retrospective long-term study.

P.03.9

Minimal perisigmoidal adhesions in cases with normally appearing peritoneum is a sure sign of endometriosis.

Said T. H.*[1], El Kassar Y.[1]

[1] Alexandria University- Department Of Obstetrics And Gynecology Alexandria Egypt

To test for the presence of perisigmoidal adhesions in cases with suspected endometriosis.

Design: Prospective cohort controlled study.

Setting: University hospital—Centers of Excellence

Peritoneal cavity is sometimes missed for endometriosis during laparoscopic procedures. The relation between the endometriosis and perisigmoidal adhesions is studied.

Seventy four women with no clinical or ultrasonic evidence of ovarian cysts or endometriosis. All cases were admitted to have laparoscopy done for different indications.

All cases had laparoscopy for different indications by two experienced laparoscopists. In all cases thorough inspection of pelvic peritoneum was done. Then these patients were divided into two groups. The first group had visible endometrotic lesions (typical or atypical) and the second group had no visibly endometriosis and the peritoneum appeared normal. In both groups, bipolar cauterization of small parts of uterosacral ligaments, ovarian beds, sides of Douglas pouch were done. Documentation of black spots and/ or positive biopsy at pathology are evidences of endometriosis.

All patients (27 cases) with visible endometriosis had perisigmoidal adhesions. Patients with normal appearing peritoneum with perisigmoidal adhesions (32 cases), had positive electrocoagulation test in all cases in one or more pre-selected parts of the pelvic peritoneum. Patients with normally appearing peritoneum (15 cases) without perisigmoidal adhesions had negative electrocoagulation test (bipolar cauterization turned white).

It could be concluded that presence of perisigmoidal adhesions causing tenting of the sigmoid segment could be a strong evidence of presence of at least minimal or subtle endometriosis and should warrant careful inspection of the peritoneum cavity before exclusion of endometriosis.

P.03.10

Nurse-led self-referral service for women with endometriosis and pelvic pain:

Bruen L.*[1], Shacaluga A.[1], Penketh R.[1]

[1] Cardiff And Vale University Health Board Trust Cardiff United Kingdom

A service for patients with endometriosis and pelvic pain was developed to provide assessment of pain, patient experience and to provide support for this patient group. General Practitioner (GP) adjusted management. This resulted in increased patient satisfaction and a reduction in acute admissions and clinic appointments.

In 2009, a nurse-led self-referral service for endometriosis and pelvic pain was developed at a tertiary referral unit to provide an alternative management approach for women with problematic symptoms. The patient’s GP was then contacted to adjust management strategies to help improve outcome.

Each patient seen completed a comprehensive pain assessment covering pain levels, impact on quality of life (QOL), cyclical pain distribution and body mapping.

Each woman also had the opportunity to relay her experience and understanding of her symptoms to the nurse. A personalised plan was then developed with the patient regarding hormonal treatment, analgesia and possible further intervention. All managemernt adjustments were then discussed with a Consultant prior to contacting GP to instigate changes.

Over a 2-year period from 2009–2011, 200 women have attended this clinic. The majority have only required 1 appointment only some have required more. Patient satisfaction scores on the service reflect the benefits of this clinic especially in symptom control and psychological well being.

The service has now developed into a valuable resource providing women with a forum to assess their level of pain, proactive management of their symptoms and an opportunity to discuss how it impacts on their life. There was a correlation of reduced hospital intervention and increased patient satisfaction.

P.03.11

The destruction of tie2macrophages in human endometriosis reduces lesion’s growth in a mouse model

Ferrari S.*[1], Di Puppo F.[1], Capobianco A.[1], Rovere-querini P.[1], Garavaglia E.[1], Persico P.[1], Giardina P.[1], Tandoi I.[1], Candiani M.[1]

[1] Hospital San Raffaele Milan Italy

We set up a mouse model with targeted Tie2+ macrophages (TEMs) and transplanted in wild type recipients bone marrow cells with a suicide gene (Herpes simplex virus type 1 thymidine kinase). The depletion of TEMs infiltrating endometriotic lesions by ganciclovir arrested the growth of established lesions.

Endometriosis originates when shed endometrium initiates an inflammatory circuit that leads to angiogenesis. Tumor infiltrating cells derived from TEMs represent a fraction of Tumor-associated macrophages (TAMs) with high angiogenic activity.

HSV1tk bone marrow cells were transplanted in a Balb/c irradiated mice. On day 7 endometrial tissue was isolated and intraperitoneally injected to a mice pair. 12 days after lesions were excised. The transplanted mice were treated with gangiclovir GCV 100 mg/gr or PBS daily from day 4 to 12. TEMs were quantified by expression of the Tie2 and CD163.

TEMs were found in the perivascular areas of newly formed vessels of endometriotic lesions. Upon hematopoietic reconstitution, Tie2-expressing cells can be depleted by administration of GCV. At sacrifice the number of implanted endometriotic lesions did not differ in GCV- and PBSinjected Tie2-HSV-tk/BM mice nor in GCV- and PBSinjected WT/BM mice. In TEM-depleted mice, the dry weight of the lesions was strikingly lower and their architecture was disrupted. By contrast, endometriotic lesions developed normally in control PBS-injected Tie2-HSV-tk/BM mice and in WT/BM mice treated with GCV or PBS

Data demonstrate involvement of macrophages that infiltrate tumors in the angiogenic process of endometriosis. If TEMs are specifically depleted, endothelial cells fail to organize in neovessels and undergo apoptosis. The preferential localization of TEM in perivascular areas may provide growth signals to endothelial cells. Their selective ablation jeopardizes growth and spreading of the lesions.

Session P.04

* Endometriosis: Surgery *

P.04.1

Endometriosis in adolescence: endomans study

Shams M.*[1], Badwey A.[1], Badwey A.[1]

[1] Maher Shams Mansoura Egypt Egypt

Endometriosis still unresolved enigma. there is a scanty studies regarding adolescent endometriosis regarding the diagnosis and the intervention Complete laparoscopic excision of endometriosis in adolescence including areas of typical and atypical endometriosis has the potential to eradicate disease. These results do not depend on postoperative hormonal suppression.

Adolescents are more likely to experience pain during their periods and at other times in the cycle,..Treatment option include surgery, expectant management ,analgesia and hormonal therapy as combined oral contraceptive pills cyclic or continuous, gonadotropin releasing hormone agonis screening for endometriosis in mansoura city among 654 adolescent female with age ranging from 12 up to 18 year in three different schools 40adolescence with symptoms suspicious for endometriosis were included in the study ultrasonography and MRI for all suspected cases. All patients underwent diagnostic laparoscopy and complete excision of all areas of abnormal peritoneum with typical and atypical endometriosis. 34 patients had endometriosis confirmed by histology at initial surgery. Follow-up was up to 66 months (average 23.1 months). Patients were not specifically advised to take postoperative hormonal suppression

There was a statistically significant improvement in most pain symptoms, including bowel-related symptoms, during this time period. The rate of repeat surgery was 16 of34 patients (47.1%), but the rate of endometriosis (diagnosed visually or histologically) found at surgery was zero. Only one-third of patients took postoperative hormonal suppression for any length of time.

Combined treatment involves a course of hormonal treatment before or after surgery to enhance the effects of surgery. Laparoscopic surgery remains the “gold standard” for tretment of endometriosis. In looking for endometriosis in adolescents at the time of surgery,..

P.04.2

Combined treatment of patients with genital endometriosis.

Drampyan A.*[1], Khachaturyan M.[2], Manukyan Z.[3], Drampyan A.[4]

[1] Ara Drampyan Yerevan Armenia - [2] Marina Khachaturyan Armenia Armenia - [3] Manukyan Zara Yerevan Armenia - [4] Drampyan Ashot Yerevan Armenia

Although laparoscopic surgery is known to be the only definitive way to diagnose and treat endometriosis, however, it cannot completely guarantee the recurrence of the disease. That’s why the problem of the optimal combined treatment is very important today.

The aim of our study was to evaluate the feasibility of the combined treatment of endometriosis, including laparoscopic excision of endometrioid implants.

120 women with genital endometriosis, who underwent combined treatment(including laparoscopic surgical treatment- removal or destruction of endometrial implants, removal of ovarian cysts, removal of adhesions and further hormonal therapy- GnRH analogues -zoladex 3,6 mg 3–6 month)were examined.

Before beginning and after one year later after the treatment we assessed; pain syndrome(dysmenorrhea , dyspareunia dischezia and pelvic pain) long duration of menstrual cycle; infertility and severity of disorders related organs(bowel and urinary tract),quality of life and frequency of endometriosis recurrence. After one year of combined treatment we received the following results-frequency of pain syndrome decreased by 92%; 42% of women, with infertility got pregnant, disorders of related organs decreased by 60%; assessment of quality of life increased by 2,5 fold.

In conclusion,our combined treatment of endometriosis, including laparoscopic excision of endometrioid implants with further hormonal therapy, allowed to reach optimal results in treating patients with genital endometriosis.

P.04.3

Digestive functional outcomes of the surgical management of deep endometriosis infiltrating the rectum: radical versus symptom guided approach

Roman H.*[1], Vassilieff M.[1], Tuech J.[1], Marpeau L.[1]

[1] University Hospital Rouen France

Conservative approach could provide better functional outcomes than the radical management and warrants to be considered in young women presenting with rectal endometriosis.

To treat rectal endometriosis, the radical approach (based on colorectal resection) had been performed by our team until 2007, and then the conservative approach (based on shaving and nodules full thickness excision) has become a rule. The aim of the study was to assess whether or not digestive functional outcomes depend on the surgical approach.

Among patients managed for DIER (up to 15 cm of the anus) we selected those whose postoperative followup was longer than 1 year. All women answered a self-administered questionnaire of symptoms, including the scores KESS, FIQLI, GIQLI and BRISTOL.

74 women were included, respectively 23 and 51 in each group. No significant differences between the two periods of time were revealed regarding women characteristics, disease stage, nodules localizations and additional surgical procedures.The rates of colorectal resections, disc excisions and shaving were respectively 65.2, 4.4 and 30.4% during the period with radical approach and 19.6, 5.9 and 74.5% iduring that of conservative approach. The post-operative follow-up was respectively of 52 ± 10 months (28 to 69) and 21 ± 10 months (12 to 34).

The overall KESS score was higher in women managed during the period of radical approach (14.2 ± 7.4 vs 10.1 ± 6.4, P = 0.022) corresponding to a higher degree of constipation. FIQL score values were better in women managed during the period of conservative approach.

The adoption of the conservative approach allowed to divide by 3 the rate of colorectal resections, without impairement on postoperative pain and recurrence, but with significant improvement in constipation scores and quality of life related to fecal incontinence.

P.04.4

Gynecological bowel resection for deep endometriosis

Wattiez A. [1], Leroy J. [1], Maia S.* [1], Vazquez A. [1]

[1] Department Of Gynecology, Hôpitaux Universitaires De Strasbourg/ Ircad/eits, Strasbourg - France

The rectosigmoid is affected in 3% of the patients with endometriosis.

For deep infiltrative or obstructive lesions of this region the treatment is a rectosigmoid resection that usually requires an abdominal incision to retrieve the specimen and perform some steps of the surgery.

The objective is to describe a totally laparoscopic technique used in segmental rectosigmoid resection for the treatment of bowel endometriosis.

Surgical technique: (1) Exposure by adhesiolysis of the sigmoid and transparietal suspension of the ovaries; (2) Dissection of pararectal fossa, rectovaginal space and endometriotic nodule; (3) Retrorectal dissection; (4) Division of the rectum; (5) Colpotomy with transvaginal exteriorization of the colon; (6) Anvil insertion; (7) Proximal division of the colon and transvaginal specimen extraction; (8) Anvil extraction; (9) Laparoscopic closure of colpotomy; (10) Intracorporeal colorectal anastomosis.

In this surgical technique all necessary steps for mechanical bowel anastomosis are performed laparoscopically and transvaginal access allows specimen extraction obviating the need to create an abdominal incision.

Another advantage is a shorter division of the mesentery enabling to a better vascularization of the bowel.

P.04.5

Laparoscopic approach to ureteral endometriosis. analysis of a surgical serie.

Dessole M.* [1], Arena I. [1], Pirarba S. [1], Stochino Loi E. [1], Maricosu G. [1], Melis M. [1], Melis G. [1], Angioni S. [1]

[1] Division Of Gynecology, Obstetrics And Pathophysiology Of Human Reproduction, University Of Cagliari

Endometriosis has been estimated to affect 4%–15% of all women with child-bearing potential, and is the most frequent pelvic gynaecologic disorder.

The pelvic region is the most common location particularly, the ovaries and the broad ligament. Urinary tract involvement is uncommon, with a variable incidence reported. Deep infiltrating endometriosis may involve the ureters in some cases. Most of them have an extrinsic compression that can be solved with careful excision of the disease. The symptoms of ureteral compression are non-specific at clinical presentation and preoperative diagnosis is very important.

We report twenty case of endometriosis infiltrating the urinary tract treated with ureterolysis and two cases of ureterectomy and ureterocystoneostomy using the laparoscopic approach. The patients presented chronic pelvic pain and signs of ureteral involvement.

Complete resolution of symptoms was achieved by complete excision of deep endometriosis. Following histological examination, all the two patients with ureterocystoneostomy revealed an intrinsic involvement of the ureters. No ureteral endometriosis relapses occurred within the follow-up. Urinary function and renal ultrasound at regularly intervals revealed a normal follow up in all cases.

Ureteral endometriosis is marked by non-specific symptoms, making preoperative diagnosis sometime difficult. Therefore, an ultrasound or urographic examination of the urinary tract in case of pelvic deep endometriosis is mandatory. Laparoscopic terminal ureterectomy with ureterocystoneostomy and ureterolysis have provided long-term favourable results. In expert hands they are feasible and present the well known advantages of the mini-invasive approach.

P.04.6

Laparoscopic bowel resection for colorectal endometriosis: the hungarian experience

Bokor A.*[1], Lukovich P.[1], Berkes E.[1], Nyirady P.[1], Rigo J. J.[1]

[1] Semmelweis University Budapest Hungary

With the present study we aimed to evaluate the outcome of the first consecutive series of radical laparoscopic resection of bowel endometriosis in Hungary.

The surgical treatment of the colorectal endometriosis requires complete excision of all implants, but the modality of bowel resection is still debated. We describe the results of our experience in complete laser laparoscopic management of deeply infiltrating endometriosis (DIE) with bowel involvement.

Between 10/07/2009 and 20/04/2011 at the 1st Dept.of OB/GYN, Semmelweis University, Budapest a series of 17 multidisciplinary CO2-laser laparoscopic bowel resection was performed for colorectal DIE. The indication for surgery was a stenosis = 50% and /or transluminal infiltration. During our procedures special care was taken to preserve the inferior hypogastric nerves and the inferior hypogastric plexus. A prospective database was established for all elective patients undergoing laparoscopic colorectal surgery by the same surgical team. The main outcome measures assessed were operative duration, conversion rate, incidence of early complications, length of hospital stay, morbidity and mortality.

Surgical details: operative time (min., median, range) 330(180–580), non-colorectal DIE (number, %)* 4(23.53), laparoconversion (number, %) 3 (17.65), hospital stay (days, median, range) 7 (3–17).

Early postoperative complications (number, %): anastomotic insuffitienty 0 (0), reoperation 0 (0), blood transfusion 4 (23.53), transient obstipation 1 (5.88), ureter perforation 1 (5.88), transient urinary retention 3 (17.65).

All occured complications were laparoscopically managed.

*DIE of the ureter and/or bladder besides bowel involvement

Multidisciplinary nerve sparing laparoscopic colorectal resection for endometriosis is feasible and can be advised for selected patients who are informed of the potential risks of complications.

P.04.7

Laparoscopic neurolisys for deep endometriosis infiltrating pelvic wall and somatic nerves: a retrospective study

Ceccaroni M.[1], Clarizia R.*[1], Roviglione G.[1], Bruni F.[1], Ruffo G.[2], Minelli L.[3], De Placido G.[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] Sacred Heart Hospital, Department Of Gynecology And Obstetrics Negrar (Verona) Italy - [4] Department Of Obsetrical And Gynecological Sciences, Urology And Reproductive Medicine, University Of Naples “federico Ii” Naples Italy

Objective of the present study is to review efficacy and feasibility of laparoscopic neurolysis for cases of endometriosis involving sacral plexus and/or somatic nerves causing ano-genital and pelvic pain.

Deep infiltrating endometriosis is able, not unfrequently, to give parametrial invasion towards pelvic wall and somatic neural structures (sacral plexus, sciatic nerve, pudendal nerve) such causing neurologic symptoms like sciatalgia and Alcock’s canal syndrome.

Retrospective experience and anatomo-surgical consideration regarding the laparoscopic neurolysis of sacral roots and somatic nerves.

The median follow up was 19,3 months.

Two different laparoscopic transperitoneal approaches are feasible to get access to the lateral pelvic wall in case of:

  1. (A)

    deep pelvic endometriosis with rectal and/or parametrial involvement extending to pelvic wall and somatic nerve;

  2. (B)

    isolated endometriosis of pelvic wall and somatic nerves.

In 17 patients (53.1%) a bowel resection was performed to obtain a radical therapy on nodules involving the ileum, sigma or rectum.

In all of the 32 patients a laparoscopic evidence of nervous compression of somatic structures was shown, whereas in 7 patients (21.9%) the same structures were deeply infiltrated, towards the assonal and peri-nevral planes.

In all of the patients a surgical whole decompression of nervous structures was performed, where in 6 (18.75%) cases a complete neurolysis was required.

Complete relief from neurologic symptoms was achieved at 1 month after surgery, where relapse of endometriosis was encountered in 3 patients.

Laparoscopic transperitoneal retroperitoneal nerve-sparing approach to the pelvic wall (the Possover Operation) proved to be a feasible and useful procedure even if limited to referred laparoscopic centers and anatomically experienced and skilled surgeons.

P.04.8

Laparoscopic surgical therapy of endometrimas before IVF protocols

Esposito A.*[1], Rota G.[1], Marino G.[1]

[1] P.O.S.Giovanni di Dio Napoli Italy

Laparoscopic surgery for endometriomas before IVF protocols improves outcome.

About 12% of women of childbearing age are affected by endometriosis and of this population, 20–50% has ovarian endometriosis associated with infertility.

The aim of our work is to provide arguments for a laparoscopic therapy in all cases of infertility associated with endometriomas before protocol of IVF.

Medical therapy involves only a temporary reduction in volume of the lesions allowing the continuation of endometrial tissue and feeding the recurrence (4

38 patients studied were all related to our Fertility Center.

All the patients had already made previous cycles of PMA. in all cases had already been diagnosed endometriosis without a staging of patology. In 20 cases the patients were treated with medical therapy protocols prior to controlled ovarian hyperstimulation (OHC).

All patients were then treated from us by laparoscopy with total escission using poor bipolar coagulation.

We observed in all patients undergoing laparoscopy from us

  1. 1)

    an improvement of access to the oocyte collection under ultrasound, especially in cases of stage IV endometriosis.

  2. 2)

    an improvement of ovarian response to pharmacological stimulation

  3. 3)

    an improvement in the percentage of fertilized eggs and then a slight improvement in the quality oocyte

  4. 4)

    a slight improvement in the quality of the embryos

  5. 5)

    Reduction of recurrance in all cases

  6. 6)

    We not observed an increase in clinical pregnancy rate.

We have not achieved an improved performance as a percentage of pregnancy cycle, but certainly we found an improvement of oocyte collection with a relative improvement in the number of oocytes.

These improvements lead us to recommend the laparoscopic treatment of ovarian endometriotic lesions before stimulation protocols for IVF.

P.04.9

Ovarian endometrioma ablation using plasma energy: above all preserving the ovarian parenchyma!

Auber M.*[1], Roman H.[1], Bourdel N.[2], Mokdad C.[1], Sabourin J.[1]

[1] University Hospital Rouen France - [2] University Hospital Estaign Clermont Ferrand France

Ablation of endometriomas using plasma energy appears to be effective in destroying the endometrial epithelium with minimal effects to the underlying ovarian parenchyma. This technique could be an alternative to cystectomy in women attempting pregnancy and presenting with risk factors for postoperative ovarian failure, such as bilateral localization or ovarian endometrioma recurrence.

Our purpose was to assess the effects of the ablation of ovarian endometriomas using plasma energy on the underlying ovarian parenchyma.

A pilot study of 10 cysts operated in 8 women was used to estimate the depth of necrosis and the risk of destruction of the ovarian parenchyma induced by plasma energy ablation. Patients were initially treated by ablation, then a cystectomy was performed in order to allow for the histological analysis of the cyst wall. We performed a separate, retrospective study on 10 women presenting with a unilateral endometrioma superior to 30 mm who were treated solely by plasma energy ablation. We used 3D Ultrasound at 3–5 months after the surgery, in order to evaluate the response to treatment.

The average depth of necrosis was 145 ± 135 μm, which remained inferior to the thickness of the fibrosis undelying cyst wall, measured at 637 ± 264 μm. In 4 cases, endometrial epithelium was still present, and represented less than 10% of the total surface of the cyst. Small areas of necrosis were identified in the underlying ovarian parenchyma in 3 cases, representing less than 10% of the parenchyma excised during cystectomy. Ultrasound comparison of the operated ovaries vs. the contralateral ovaries showed a reduction in ovarian volume and in the number of antral follicles of 12% and 18% respectively.

Ablation of endometriomas using plasma energy appears to be effective in destroying the endometrial epithelium with minimal effects to the underlying ovarian parenchyma.

figure e

P.04.10

Pathophysiological approach to bowel dysfunction after segmental colorectal resection for deep endometriosis infiltrating the rectum

Roman H.*[1], Armengol-debeir L.[1], Savoye G.[1], Gourcerol G.[1], Tuech J.[1], Bridoux V.[1], Marpeau L.[1]

[1] University Hospital Rouen France

The risk of postoperative bowel dysfunction following colorectal endometriosis must be taken into account whenever this technique is proposed in young women presenting with a benign disease such as deep endometriosis.

Colorectal segmental resection is performed worldwide in a majority of women presenting with symptomatic deep endometriosis infiltrating the rectum. The aim of the present study was to investigate the pathophysiological mechanisms involved in postoperative digestive dysfunction.

We selected patients who had developed postoperative severe constipation among those managed by colorectal resection for rectal endometriosis and whose follow up was longer than 24 months. To assess the mechanisms involved in the pathogenesis of this complaint, we performed a step by step work up including: low digestive tract endoscopy, colonic transit time measurement and when appropriate anorectal manometry, electromyography and defecographic evaluation.

Five patients out of 25 (20%), whose age ranged from 27 to 41 years, were investigated for severe postoperative terminal constipation. Four different mechanisms responsible for terminal constipation were identified: tight stenosis of the colorectal anastomosis, postoperative neurological sequelae, colonic intussusception through the colorectal anastomosis, and transit constipation which developed post surgery.

Postoperative constipation is a frequent complaint in women managed by colorectal resection for rectal endometriosis. A multidisciplinary approach is mandatory, as pathophysiologic mechanisms vary and prove difficult to understand.

P.04.11

Patient level information costing systems (PLICS): could be used to get right tariffs for endometriosis cases?

Tselos E.*[1], Whitlow B.[2]

[1] Evangelos Tselos Colchester United Kingdom - [2] Barry Whitlow Colchester United Kingdom

Complex laparoscopic procedures for advanced endometriosis performed in a tertiary centre, are often underpaid when coded and paid according to the national tariffs. We now present how PLICS could be used as a tool to create realistic national tariffs for endometriosis centres.

PLICS are programs that have been developed to collect data at patient level and give the ability to measure the resources consumed by individual patients. Endometriosis treatment in a tertiary centre is a good example of how PLICS could be used to improve cost efficiency.

By using PLICS we calculated the cost for treatment of endometriosis at patient level by tracing the resources actually used by each patient and using actual costs incurred by the organisation in providing the service. We used this system to calculate the cost of surgical treatment for endometriosis in a tertiary centre for 6 months. We then compared the actual costs with the equivalent national tariffs for these operations according to their coding.

We showed that in several occasions there were significant deviations between actual cost and national tariffs. PLICS was helpful to identify specific reasons for the higher costs attributed to these procedures, such as presence of surgical and gynaecological consultant in theatre or longer theatre times. The cost for surgical treatment for endometriosis varied considerably depending on the severity of the case.

PLICS can be used as a tool to provide evidence for the real cost of treatment for endometriosis. The data collected can be used for evidence based discussions with commissioners and the development of realistic national tariffs for endometriosis treatment. Organisations need to know that their investment will be cost effective. In our opinion specialised national tariffs for advanced surgical endometriosis treatment is the way forward, and PLICS is the tool.

P.04.12

Pre and postoperative pelvic pain. The patient experience

Birch J.*[1], Birch J.[1], Zaragoza M.[1], Harvey J.[1], Hough J.[1], Zillwood R.[1]

[1] Pelvic Pain Support Network Poole United Kingdom

This anonymous online survey reports on the assessment, investigation and follow up of those undergoing surgery for pelvic pain. There are a number of concerns which have implications for the development of care pathways for those with pelvic pain.

We report from the patient perspective the extent to which: pelvic pain was assessed, clinical examination and investigations carried out prior to surgery, whether surgery relieved the pelvic pain symptoms and the extent to which pain outcomes were followed up.

The survey was carried out on the website www.pelvicpain.org.uk duringl 2010/11. The results presented are for those who had undergone surgery for pelvic pain. This applied to more than half of the 496 survey participants.

The majoriity of participants were from GB. The most common type of surgery was diagnostic laparoscopy, followed by operative laparoscopy. The majority had undergone surgery during the last 3 years and had had their pain assessed before surgery. 42% had an internal exam before their most recent pelvic surgery. Abdominal ultrasound and/or vaginal ultrasound were the most common investigations. 25% of respondents stated the pain improved for a few months,13%for one year,16% stated that the pain was worse than before surgery. 48% of respondents had their pain assessed after surgery. Over 50% of respondents continued to have pain after surgery and of these 40% received help in managing their pain. The main diagnoses were endometriosis, followed by adhesions and ovarian cysts.

We conclude that investigations and examination of pelvic pain prior to surgery vary considerably. The number of respondents not gaining any benefit from surgery or who are worse is a cause for concern as is lack of follow up. Pre-surgical assessment and examination, earlier involvement of pain specialists and post surgical follow up and referral warrant much greater attention.

P.04.13

Recurrence rate and recurrence risk factors of ovarian endometriomas

Prietzel-meyer N.*[2], Kaushik S.[1], Goss Nielsen G.[1], Krishna A.[1], Ind T.[1]

[1] St George’S Hospital London United Kingdom - [2] Frimley Park Hospital Camberley United Kingdom

This is a retrospective analysis of recurrence rate and recurrence risk factors of ovarian endometriomas after laparoscopic treatment comparing outcomes between Endometriosis Centre and Non-Centre patients.

We evaluated the long-term recurrence and the rate for repeat surgery after endometrioma treatment. Risk factors analyzed included the location of treatment (centre/non-centre), bilateral disease, co-existent stage 3 or 4 endometriosis, CA125 elevation, subsequent pregnancy, postoperative down-regulation, an attempt at stripping, endometrioma size of more than 4 cm and previous surgery for endometrioma.

153 cases of endometrioma were retrospectively reviewed at St George’s Hospital, London and The London Clinic between 2000–2011. Actuarial analysis for recurrent endometrioma was performed using the Kaplan-Maier method with univariant comparisons made using the Log-rank test. Multivariant analysis was performed using Cox multi-variant analysis looking at the specified risk factors.

At the time of submission, the median follow-up until recurrence or censorship was 328 days (IQ range 79–788 days). The overall recurrence rate was 18.30% at five years. This was 13.43% and 22.35% for centre and non-centre patients respectively. Using actuarial analysis, the mean probability of recurrence was 0.05, 0.15, 0.21, 0.29, 0.36, and 0.48 at 6 months and 1 , 2, 3, 4 & 5 years respectively. Surgery was repeated in 13.43% and 16.47% in centre and non-centre patients. The proportion of endometriomas that were stripped was 92.53% at the centre and 83.53% for the non-centre patients.

The endometrioma recurrence rate appears to be related to treatment location, favouring patients in the Endometriosis centre. The proportion of endometrioma stripping was higher at the centre. The repeat surgery rate was slightly higher for non-centre patients. Stage IV disease and previous surgery carry an unfavourable prognosis.

P.04.14

Safety of use of hemostatic sutures for hemostasis of the ovarian bed after ovarian cystectomy of endometriomas

Said T. H.*[1]

[1] Alexandria University- Department Of Obstetrics And Gynecology Alexandria Egypt

To study the safety of hemostatic sutures for achieving hemostasis of the ovarian bed after ovarian cystectomy of endometriomas.

Design: Prospective cohort controlled study.

Setting: University hospital—Centers of Excellence

The use of the hemostatic sutures minimize the damage related to the use of cautery. The main concern for the wide use of this method is the concerns about the safety of the sutures as the hemostasis seems to be incomplete when compared to cauterization.

Eighty four women with unilateral or bilateral endometriomas. Patients will be randomized to have laparoscopic ovarian cystectomy with regular use of electrocutery (bipolar or unipolar) or use of sutures for control of bleeding from ovarian bed.

All cases will undergo laparoscopy for removal of ovarian endometriomas by stripping. Hemostasis of the bleeding from the ovarian bed will be controlled by either 1—Electrocautery (bipolar or monopolar) or 2—Hemostatic sutures. Effect of use of both methods will be studied including hemoglobin level, hematocrit level, duration of surgery, number of sutures needed, use of intraperitoneal drains, hospital stay, need for blood transfusion, postoperative complications including ovarian hematomas, pelvic fluid collection, fever, need for analgesics and presence of any complication.

It was found that using hemostatic suture was effective in controlling the bleeding from the ovarian bed. The hemoglobin and the hematocrit were comparable. There was a routine use of intraperitoneal drain in all suture cases. Complications for both techniques were documented and treated conservatively.

It could be concluded that hemostatic sutures is safe procedure and tolerable for the patient.This technique has the advantage of minimizing the damage of cystectomy to the stripping only by avoiding cauterization of healthy ovarian tissues.

P.04.15

The impact of surgery on the quality of life (QOL) & fertility in patients with Stage 3 or 4 endometriosis

Singh R.*[1], Singh V. P.[2], Ravikanti L.[2]

[1] Palmerston North Hospital Palmerston North New Zealand - [2] Waikato Hospital Hamilton New Zealand

Surgical excision of endometriosis not only enhances pain relief and improves the quality of life, it also improves the odds of spontaneous conception. Patients with Stage 3 or 4 endometriosis should be offered surgery as part of their subfertility management esp if they also present with pain.

Endometriosis affects 10% of women worldwide, & 30–40% of couples with subfertility. Laparoscopy is the gold standard in its management. Excision is increasingly preferred over diathermy of lesions for lasting relief of symptoms. Its role in improving fertility remains controversial.

A retrospective study involving over 300 patients at Waikato Hospital, Hamilton, New Zealand. The effect of excision of endometriosis on patient symptom profile, quality of life and impact on fertility were studied.

Over 300 patients with Stage 3/4 endometriosis were analysed. 2/3 of patients presented with pain only, 1/3 with pain & subfertility. Most patients had their first attempt at excision of endometriosis but for 9% this was a second look, usually following recurrence of symptoms. 94% had histological confirmation of endometriosis seen at laparoscopy. 75% of those with stage 3/4 endometriosis had 70–100% pain relief. 11.5% of those with Stage 3/4 endometriosis and presenting with pain conceived during follow up, while 38.6% of those with Stage 3/4 endometriosis and presenting with pain & subfertility became pregnant. Improvement in quality of life were seen in patients of both groups.

Medical therapy gives temporary relief from symptoms. Surgical excision of endometriosis clearly reduces pain & improves QOL. 3 RCTs show some benefit in post op medical therapy. There are contradictory claims regarding its effect on fertility. Our study indicates improvement in symptoms, quality of life & fertility following surgical excision of lesions in patients of stage 3 & 4 endometriosis.

P.04.16

The importance of strategy in deep endometriosis surgery

Wattiez A.[1], Vazquez A.*[1], Maia S.[1], Alcocer J.[1]

[1] Ircad Strasbourg France

A correct strategy during endometriosis surgery allows us to perform this difficult procedure safely.

While endometriosis is by far the most frequent cause of pelvic pain in women of reproductive age (Vercellini, 1997), deep infiltrating endometriosis (DIE) is associated with severe pain, nerves involvement and decrease of fertility. As we deal with a benign disease in young patients the objetives of deep endometriosis surgery should be the improvement of women’s quality of life by reducing pain and recurrences and trying to preserve fertility and function. To get these goals we must be radical towards the disease but conservative towards the function to taylor the surgery according to the needs and risks for the patient.

The fibrosis, the disruption of the anatomy and the difficulty to find the cleavage plane make deep endometriosis surgery the most challenging surgery for a gynecologic surgeon. We believe that the role of the strategy during the surgery is cruzial to minimize the risks for the patient and to achieve our objetives. We differentiate between general and specific strategy. The general strategy includes: Inspection of abdominal cavity, restoring of anatomy, exposure, ureters identification, pararectal fossa dissection if necessary, and reevaluation of lessions. The specific strategy is related to the organ affected by the disease: Vagina and uterosacral ligaments, bladder, ureters and bowel. It is also important to remember that correlation between organ and function is not always strictly parallel.

P.04.17

The place of laparoscopic gynaecology in the United Kingdom—survey of UK consultants

Rajesh S.*[1], Porter S.[1]

[1] Bsge, Uk Leeds United Kingdom

Operative laparoscopy is employed widely in the UK for management of ectopic pregnancies, ovarian cysts and minor endometriosis. The more difficult procedures like total laparoscopic hysterectomies or advanced endometriosis surgeries were performed by relatively fewer gynaecologists.

We devised this survey to determine current gynaecological laparoscopic practice in the UK.

Survey questionnaire was e-mailed to all consultants in Yorkshire deanery and responses collected using the SurveyMonkey website.Survey is on-going(mailed to all the Consultants in the UK) and results will be available to be presented at the conference.

The initial response rate was 29.1%,a reminder is planned to increase responses. There were 56.9% generalists,31.4% gynaecologists and 13.7% obstetricians. 34.7% were members of BSGE/AALG. Most(91.5%) saw an increasing role for laparoscopic surgery in gynaecology. About 90% managed stable ectopic pregnancies and 46.5% managed benign ovarian cysts laparoscopically. Advanced endometriosis surgeries were performed by 23.8%. 80.5% performed hysterectomies vaginally vs 12.2% performed laparoscopic hysterectomies routinely.Out of 33 surgeons who performed laparoscopic hysterectomies,only 38.9% performed TLH.4% thought laparoscopic surgery was inherently more dangerous than laparotomy but 62.2% related safety to surgical expertise.

This survey the first of its kind in UK,provides us with some insight into current attitudes towards operative laparoscopic amongst UK gynaecologists.Majority of Consultants agreed that role of laparoscopy was increasing. Although operative laparoscopy was essentially pioneered in gynecology,it’s use amongst gynecologists appears to be much less than their general surgical counter-parts. We wonder if lack of surgical expertise could be a reason.Introduction of advanced laparoscopy ATSM training programme by RCOG might change current trends.

P.04.18

When surgery is inappropriate or inadequate for endometriosis-associated pain: back to the future!

Vilos G.*[1], Vilos A.[2], Abu-rafea B.[3], Marks J.[2], Garcia-erdeljan M.[2], Casper R.[4]

[1] St. Joseph’S Health Care London Canada - [2] The University Of Western Ontario London Canada - [3] King Saud University Riyadh Saudi Arabia - [4] The University Of Toronto Toronto Canada

Endometriosis-pain treated effectively with GnRH-a/add-back therapy.

We studied the efficacy of long-term GnRH-a/add-back with chronic endometriosis associated pain.

1) leuprolide acetate 3.75 mg-monthly;2) micronized17b-estradiol 1 mg- daily;3)pulsed norethinedrone 0.35 mg, 2- days-on-2-off;4)letrozole 2.5 mg-first −5- days.

ROS:30y/o, BMI-51 kg/m2, CPP/dyspareunia had 12 laparoscopies/LAVH.

33y/o, LQP/ residual left adnexal/rectosigmoid endometriosis following LAVH + RSO.

ORS:50y/o, multiple surgeries/TAH + BSO, history of a stroke presented with RLQP/hydronephrosis. MRI-right (4.5 × 3.4 cm-cyst). Treated with GnRH-a/ureteral-stent. Cyst/pain/hydro-uretero-nephrosis resolved after 12 months.

45y/o, multiple surgeries/TAH + BSO, LLQP. Ultrasound-left cyst& hydronephrosis. Cyst/pain/hydronephrosis resolved after 3 months.

Mullerian Anomaly/Endometriosis:15y/o, BMI-21 kg/m2, presented to ER with severe pelvic pain. Menarche-14y, irregular/non-painful periods. U/S-absent right kidney, uterus didelphys, right(9.8 × 6.8 cm) mutiloculated cyst. MR-uterus didelphys, right hematometra communicating with 6 × 6 cm cyst, second retro-uterine cyst(6 cm). CA-125 = 83 IU/mL.

Patient/Iliostomy: 38y/o, nulliparous, BMI 38 kg/m2, multiple surgeries, had ureteral and bowel injury requiring iliostomy. For 3y completely pain free on GnRH-a + tibolone

Pulmonary/Endometriosis: 29y/o, infertility /CPP, developed catamenial hemoptysis. Imaging/ bronchoscopy/ biopsy confirmed lung-endometriosis. Asymptomatic at 7-yr treatment.

Diaphragmatic/Endometriosis: 3-patients with catamenial shoulder-tip-pain/confirmed diaphragmatic endometriosis are asymptomatic.

Cerebral/Endometriosis: 41y/o, catamenial epilepsy, successfully treated with GnRH-a + add-back and subsequent oophorectomy.

GnRH-a with add-back is effective long-term therapy in endometriosis-pain when surgery is ineffective, contraindicated, refused or difficult.

P.04.19

Serum anti-Mullerian hormone (AMH) and antral follicle count (AFC) as predictors of ovarian reserve after laparoscopic management of endometriotic cysts

Pados G.*[1], Tsolakidis D.[1], Billi H.[1], Athanatos D.[1], Tarlatzis B.[1]

[1] 1st Dept. Of Obgyn, “papageorgiou” Hospital, Aristotle University Of Thessaloniki, Greece Thessaloniki Greece

In this prospective randomized trial, it was demonstrated that serum AMH levels and AFC measurement provide valuable prognostic information regarding ovarian reserve after laparoscopic intervention for ovarian endometriomas.

The aim of this study was to determine the AMH variations and AFC values in patients undergoing laparoscopic management of ovarian endometriomas.

In this prospective randomized study, 20 patients of reproductive age with endometriotic cyst were randomly assigned to undergo either laparoscopic cystectomy (Group I) or the three-stage procedure (Donnez et al., 1996).

Mean serum AMH was reduced significantly in both groups (Group I: from 3.9 to 2.9 ng/ml; Group II from 4.5 to 3.9 ng/ml; p = 0.026). No significant difference was observed in the concentration of FSH, LH, E2 and inhibin-b between the two groups. AFC was increased significantly in the operated overy in Group II compared with Group I (p = 0.002)

: Serum AMH levels provide valuable prognostic information regarding ovarian reserve. Also, AFC measurement comprises a precise alternative , which is cost effective but operator depende

Session P.05

* Hysterectomy *

P.05.1

Advantages of laparoscopic hysterectomy standardization

Gorostiaga A.* [1], Villegas I.[2], Quílez J. C.[2], Rui-wamba M. J.[2], Arriba T.[2]

[1] Centro De Ginecología Y Medicina Fetal. Cegymf. Bilbao, Spain - University Of The Pays Basque - [2] Centro De Ginecología Y Medicina Fetal. Cegymf. Bilbao, Spain

Laparoscopy has become the gold standard surgical technique to perform a hysterectomy, due to the minimally invasive access, the growing experience of the surgeons and the improvement in the materials employed. The standardization of the technique acquired after the personal experience, allow a more adequate management and creates a routine that minimizes the problem caused by an incorrect planification.

Retrospective analysis of 37 laparoscopic hysterectomies performed at our institution between September 08–March 11. All the surgical procedures were planned and performed after the standardization of the technique using 4 trocars (umbilical, suprailiac and infraumbilical), V-Care movilization, bipolar haemostasia and scissors (except from oncologic procedures in which armonic scalpel (Ultracision) was also employed) and vaginal closure with endoscopic Vicryl stitches. The median age of the patients was 48 (36–47) and in 18 cases the indication of hysterectomy was oncologic (17 endometrial carcinoma and one microinvasive epidermoid carcinoma).

The median time required to complete the procedure was 87 min. Patients were discharged in a median time of 2,1 days (1–5), without major intraoperatory complications and only two postsurgical complications (internal bleeding that required laparotomy and an incisional infraumbilical hernia in an obese patient). In one case, due to the size of the uterus, we needed to place a right 10 mm subcostal access for the optic and, in another, a 5 mm subcostal access.

After the experience adquired for years, the standardization of the laparoscopic hysterectomy reduces the surgical time, offers the surgeon an easier access what creates an increased security for the patient. Neither expensive materials nor a special surgical ability are needed and allow a quicker and more efficient help to the surgeon as the procedure is turned into a mimetic act and repeated in all cases.

P.05.2

Audit of introduction of laparoscopic total and subtotal hysterectomies in a DGH

Khalil A.*[1], Louden K.[1], Behrens R.[1]

[1] Royal Hampshire County Hospital Winchester United Kingdom

Laparoscopic hysterectomy is recently introduced in Royal Hampshire County Hospital, Winchester.

The aim of this audit is to compare our practice against the published data and good practice. The results will help us improve our own practice and patients will be given more choice for hysterectomy routes.

Traditionally, hysterectomy is carried out through the abdominal incisions or through vagina. Laparoscopic hysterectomy involves removing the uterus, and sometimes the tubes and ovaries through smaller abdominal incisions.

The potential advantages are less pain, shorter recovery time and more patient acceptability. (NICE: 2002).

Standards set and proforma designed, retrospective case note review undertaken.

Patient Questionnaire sent.

Excel spreadsheet designed and results for presentation.

50 patients identified.

Questionnaire received back from 31 patients out of 50. Response rate 62%.

Age range 31–65 years.

BMI range 21–47.

Presenting Symptoms: Mainly bleeding and pain

Duration of Symptoms: Minimum 1–2 yrs, Maximum 15 yrs.

All patients tried some treatment before going for hysterectomy.

Duration for TLH: 70–245 min, Average time per case 97 min

Duration for LSTH: 60–175 min, Average time per case 103 min

72% of the patients stayed only one night in the hospital.

Estimated Blood loss ‘minimal’—400 mls, average blood loss—112 mls.

Return to theatres or ITU admission—nil

Pain Relief Use: 70% of patients required Paracetamol, NSAID and/or morphine.

71% of patients took less than 40 days to resume daily activities.

90% of patients would recommend the service. 10% were not sure.

Results show reduced hospital stay, less post-op pain killers use and quicker recovery.

This data will help us give first hand information to our patients based on our own audit figures.

No major complications seen in this series..

P.05.3

Can all hysterectomies be laparoscopic? A four-year prospective study of hysterectomy in an unselected hospital population

Ghosh D.*[1], Byrne D.[1]

[1] Royal Cornwall Hospital Truro United Kingdom

The outcome of one surgeon’s experience of all hysterectomy cases is reported and show that the incidence of laparoscopic hysterectomy increased each year to 100% by year four, and the complexity of procedure increased with time.

Despite the advantages, Total laparoscopic hysterectomy (TLH) has not been widely adopted into general gynaecological practice. We investigated if it is possible to perform TLH in most cases in an unselected hospital population.

We collected data on all hysterectomies over a 4-year period, irrespective of route, performed by one surgeon who offered TLH as the default method.

144 hysterectomies were performed; 18 TAH (12%), 17 VH (12%) and 109 TLH (76%). All the authors’ TAH were performed for very large uterine size, or multiple previous caesarean section. TLH rates increased from 51% in year one to 100% in year four. There were 8 surgical complications; VH 0 (0%), TAH 1 (6%) and TLH 7 (6%). In the TLH group the complication rate fell each consecutive year to 3% in year 4 despite the mean uterine weight increasing each year (119–262 g). 71% of complications occurred within the first 50 procedures. There were 3 conversions to laparotomy (3%).

These data confirm that in benign gynaecology TLH can replace traditional abdominal hysterectomy in an unselected hospital population. Complication rates fall with experience defining the surgeon’s learning curve for unselected patients as 50 procedures.

The use of a laparoscopic morcellator and the introduction of laparoscopic sacrohysteropexy corresponds with a further fall in TAH, and in VH respectively.

Increasing surgical experience, better equipment and newer surgical techniques enable more hysterectomies to be performed laparoscopically, with fewer complications, despite selection of more complex cases.

 

TAH

VH

TLH

Total Hysterectomies

Year

1

9 (27.3%)

7 (21.2%)

17 (51.5%)

33

2

9 (23.1%)

8 (20.5%)

22 (56.4%)

39

3

0

2 (6.1%)

31 (93.9%)

33

4

0

0

39 (100%)

39

Total

18 (12.5%)

17 (11.8%)

109 (75.7%)

144

P.05.4

Characteristics indicating adenomyosis at the time of hysterectomy: a retrospective study of 291 patients

Florin Andrei T.*[1], Ralf R.[2], Katharina R.[1], Sara B.[1], Markus W.[3]

[1] Dept. Ob/gyn University Tuebingen Tuebingen Germany - [2] Dept. Ob/gyn University Heidelberg Heidelberg Germany - [3] Dept. Ob/gyn University Heidelberg Heidelberg Germany

The objective of this study was to elucidate the clinical profile of adenomyosis by comparison with uterine leiomyomas.

We conducted a retrospective study of women undergoing hysterectomy for benign disease with a histologic diagnosis of adenomyosis, a diagnosis of both adenomyosis and leiomyomas and women with uterine leiomyomas but no adenomyosis.

A retrospective medical record review was performed to ascertain sociodemographic and anthropometric variables, as well as to confirm intraoperative and pathologic findings.

Our study sample comprised 291 patients, 38 women with adenomyosis, 56 women with adenomyosis and leiomyomas and 197 women with only leiomyomas. In multinomial logistic regression analyses, women with adenomyosis were associated with older age [odds ratio (OR) 0,9; 95% confidence interval (CI) 0,8–1,0], a history of smoking (OR 3,72; 95% CI 1,2–11,3), were more likely to be parous (OR 7,5; 95% CI 2,4–23,6) when compared with women with adenomyosis and leiomyomas. Women with leiomyomas were associated with older age (OR 0,9; 95% CI 0,9–1,0) when compared with women with adenomyosis and leiomyomas. Finally, women with adenomyosis had a lower uterine weight (OR 1,0; 95% CI 0,9–1,0), were more likely to have more pelvic pain (OR 4,8; 95% CI 1,5–15,2), were more likely to have a history of smoking (OR 2,6; 95% CI 1,1–6,5) and were more likely to be parous (OR 4,3; 95% CI 1,5–12,3) when compared with women with leiomyomas.

Women undergoing hysterectomy with adenomyosis and with both adenomyosis and leiomyomas have a number of different features compared with women with only leiomyomas at the time of hysterectomy. Better understanding of this disease is required to improve diagnosis and management.

P.05.5

Clinical efficacy of two minimally invasive hysterectomy techniques for benign pathology: TLH vs. VH

Cho H.*[1]

[1] Seoul National University Hospital, Bundang Seongnam Republic Of Korea

This study is designed to compare the clinical outcomes of two minimally invasive hysterectomy techniques; Total laparoscopic hysterectomy (TLH) and vaginal hysterectomy (VH). TLH might offer some benefits in clinical outcomes and quality of life, compared with VH for benign disease.

Traditionally, abdominal hysterectomy have been occupied about 70–80% of cases. However, as the minimal invasive approach has been preferred recently, TLH and VH has been revaluated of its value. We therefore compared the clinical outcomes including quality of life in these two procedures.

A retrospective chart review of 385 women who underwent TLH or VH between November 2008 and October 2009 was accomplished. Clinical outcomes including operation time, hemoglobin change, rate of complications, febrile morbidity, consumption of analgesics, and hospital stay were estimated. Sexual activity and resumption to work of these patients were evaluated according to outpatient medical records and additional questionnaire.

One hundred and ninety eight women underwent VH, and 187 women underwent TLH. There were no differences in outcomes between two groups other than the mean weight of uterus (P = 0.019) and operating time (P < 0.001). TLH was also associated with shorter hospital stay (P < 0.001) and less consumption of analgesics. The sexual activity after the operation was not different but resumption to work was definitely earlier in TLH group. (P < 0.001).

Though there are some benefits in VH, TLH could offer more clinical benefits such as less postoperative pain, reduced hospital stay, and early recovery. Therefore, we could prefer TLH as a primary choice for treatment of benign uterine pathology, in some selective circumstances.

P.05.6

Effects of perioperative strategies to reduce postoperative pain in patients undergoing laparoscopic hysterectomy

Radosa J.*[1], Baum S.[1], Radosa M.[2], Guzmann D.[1], Solomayer E.[1]

[1] Universitätsfrauenklinik Homburg Homburg Germany - [2] Universitätsfrauenklinik Jena Jena Germany

Influence of two perioperative strategies in 300 patients undergoing laparoscopic hysterectomy were evaluated. Both techniques seem to be effective tools in decreasing early postoperative pain.

We conducted a prospective clinical trial to evaluate the influence of peri-incisional application of lidocaine and reduction of residual intraperitoneal gas on early and late postoperative pain after laparoscopic hysterectomies.

Women undergoing laparoscopic surgery for TLH or LASH were randomized into 3 groups. Group A (100 patients) received no special treatment, Group B received peri-incisional injections with 0.4% lidocaine (10 ml) after closure of laparoscopic incisions, Group C (100 patients) received lidocaine injection and reduction of residual intraperitoneal gas volume by maintenance of the umbilical trocar for five additional minutes after removal of the other trocars. Postoperative pain was evaluated by using a patients questionnaire at 1, 2 and 4 hours. Postoperative analgetic requirements and hospital stay were assessed as well.

Group B and C had a statistically significant decrease in pain scores compared to group A at 1 hour postoperatively. Mean pain scores in group B and C after 2 and 4 hours were decreased as well but not statistically significant. Compared to group B, pain score after one hour was significantly lower in Group C. Similarly, the cumulative analgetic requirements at 1, 2 and 4 hours postoperatively were significantly lower in Group B and C compared to group A.

This study demonstrates that peri-incisional infiltration of lidocaine and reduction of residual intraperitoneal gas volume seem to be effective strategies to reduce early postoperative pain.

P.05.7

High prevalence of adenomyosis in hysterectomy after novasure endometrial ablation

Mengerink B.*[1], Van Der Wurff A.[2], Ter Haar J.[1], Pijnenborg J.[1]

[1] Tweesteden Hospital Tilburg Netherlands - [2] Elisabeth Hospital Tilburg Netherlands

After NovaSure endometrial ablation hysterectomy is done in 8–10% cases due to therapy failure. The prevalence of adenomyosis is reported in 20–30% of patients after hysterectomy, however in our study adenomyosis was found in 43,5% of all hysterectomies done after the ablation technique. It is unsure if adenomyosis is the cause or consequence of NovaSure.

The aim of current study was to evaluate the incidence of adenomyosis in hysterectomies after NovaSure endometrial ablation. NovaSure is an effective, simple and safe treatment for menorrhagia and dysmenorrhea. Treatment failure resulting in hysterectomy is reported in 8–10% of all cases. There might be a correlation with adenomyosis but still little is known, especially in NovaSure.

In an observational study all woman planned for NovaSure endometrial ablation between November 2007 until January 2011 in our hospital were evaluated. Hysterectomies done after a conducted NovaSure were defined as being a primary therapy failure. Histology was done in all cases.

Endometrial ablation was performed in 98,2% (217/221) of the scheduled procedures. Hysterectomy was performed in 23 patients (10,6%) after NovaSure with a median time interval of 12 months (range 2–21). Histological investigation showed adenomyosis in 10 out of 23 uteri (43,5%). In 21 cases hysterectomy was done due to persistent menorrhagia or dysmenorrhea and in two cases for prolapse, one out of these two adenomyosis was found.

Adenomyosis is reported to be present in 20–30% of all women undergoing hysterectomy. In our study this prevalence is much higher. It is unknown whether endometrial ablation might be the cause of adenomyosis or the consequence of failure of therapy. If adenomyosis is a predictive value of failure, further diagnostics like MRI might be cost effective and patient friendly in choosing the right therapy.

P.05.8

Intra and post operative outcome after laparoscopic intra-fascial hysterectomy (LHI) in women with BMI over 35

Marinakis G.*[1], Waters N.[1], Gallagher B.[1], Kent A.[1]

[1] Royal Surrey County Hospital Guildford United Kingdom

This study showes that there are not any significant differences in intra, post-operative complications in women having LHi with severe obesiry compared with those with normal BMI.

The obesity rate in the UK has tripled over the last 20 years and is on a constant rise. Although operative laparoscopy has gained field over the open surgery in gynaecology—because of less postoperative pain, shorter hospital stay and recovery- women with high BMI remain a challenging group of patients for operative laparoscopy.

We prospectively collected data pertaining to 305 consecutive laparoscopic intra-fascial hysterectomies and compared the results of the normal BMI group with the severe obese group (BMI > 35).

Out of 305 cases 92 women had BMI 20–25 (Group I) and 28 had BMI over 35 (Group II). The mean age of the first groups was 45 years and in group II was 47 years. We did not identify any significant differences in terms of parity, previous abdominal or pelvic surgery and degree of adhesions between the 2 groups.

The average uterus weight in group I was 218 grams and 212 grams in group II (p = 0.8). The mean intra-operative time in Group I was 68 minutes (SD 29) and in Group II was 82 minutes (SD 40) (p = 0.04). The mean drop in haemoglobin was 0.9 g/dl in Group I and 1.1 g/dl in Group II (p = 0.5).

2 women required to return to theatres and 4 had blood transfusions in Group I, and 1 returned to theatre and no one had blood transfusion in group II. None of the procedures was converted to open laparotomy and none was complicated with bowel or urinary tract injury. 87% of women discharged within 23 hours in Group I versus 92% in Group II.

Although there was a mean difference of 14 minutes in intra-operative time we did not identify any significant differences between the normal BMI and severe obese group in terms of intra, post-operative complications and hospital stay.

P.05.9

Laparoscopic assisted vaginal hysterectomy experience of the department of gynecology, university hospital of Marrakesh

Yassir A. B.*[1], Abderrahim A.[1], Sawsane E. H.[1], Karima F.[1], Bouchra F.[1], Hamid A.[1], Abderraouf S.[1]

[1] Department Of Obstetrics And Gynecology, University Hospital Of Marrakesh Marrakesh Morocco

Hysterectomy is one of the most performed surgical procedures in gynecology. we report the results of our early experience of LAVH.

There were 29 LAVH procedures performed in the period of study. The mean age of patients was 48 ans. The most frequent indications were myomas and abnormal uterine bleeding. There were 4 complications and conversion to laparotomy was needed in 3 cases.

Hysterectomy is one of the most performed surgical procedures in gynecology. There are three possible routes to perform hysterectomy: abdominal, vaginal and laparoscopy. Use of the later route seems to be increasingly implemented worldwide.

We began to use this approach since two years and we report in this study the results of our early experience.

Methods: we conducted a retrospective study of laparoscopic assisted vaginal hysterectomy (LAVH) performed during the last two years in the department of gynecology, university hospital of Marrakesh, Morocco. We analyzed patient’s characteristics, evolution of indications of hysterectomy, and complications.

Results: there were 29 LAVH procedures performed in the period of study. In this period 111 hysterectomies were performed. The procedure was performed abdominally in 34%, vaginally in 40% and laparoscopically in 26% of cases. The mean age of patients was 48 ans. The most frequent indications were myomas and abnormal uterine bleeding. Type 4 LAVH was performed in 17 cases, type 3 in 12 cases and type 5 in one case. There were 4 complications and conversion to laparotomy was needed in 3 cases.

Laparoscopic assistance is actually incorporated in the arsenal of the gynecologist for hysterectomy procedure. It has its specific indications and permits to reduce the need for abdominal route. Even if our team is novice in this approach, moving to this technique has been safe.

P.05.10

Laparoscopic assisted vaginal hysterectomy versus vaginal hysterectomy

Condeco R.*[1], Barreto S.[1], Leitão C.[1], Silva M. C.[1], Mira R.[1]

[1] Hospital Dona Estefania - Chlc Lisboa Portugal

The purpose of this study is to compare the surgical and immediate post-operative outcomes of Laparoscopic Assisted Vaginal Hysterectomy (LAVH) with those of Vaginal Hysterectomy (VH).

Hysterectomy is the commonest gynecologic operation, performed for malignant and benign conditions. Studies comparing the different techniques of hysterectomy showed that vaginal hysterectomy has benefits in terms of reducing hospital stay, recovery and operating time.

Retrospective study, comparing two groups of women who underwent LAVH or VH in our department, from January 2009 to December 2010. The two groups were compared regarding age, vaginal deliveries, previous abdominal surgery, uterine and adnexal pathology, intra-operative and post-operative complications, uterus weight, blood loss and days until discharge.

In our study 42 LAVH and 99 VH were included, with a patient mean age of 47 and 59, respectively. The most frequent indication for hysterectomy was fibroids (80%) for LAVH and POP (58.6%) for HV. The medium operative time was 167 minutes for LAVH vs 99 minutes for HV. The intra-operative complications were one case (2%) of accidental incision of rectum in LAVH, and one bladder incision in the VH (1%). There were 3 conversions to laparotomy (7%) in LAVH group. There were no significant post-operative complications for LAVH. In VH group there were 2 cases of haemoperitoneum (2%) and 1 case requiring blood transfusion (1%). The mean time for discharge was 4.23 days for LAVH and 4.46 days for VH.

In our study, the main advantage for VH was the reduced operative time. There was no difference in time to discharge between the 2 groups. The main intra-operative complication of LAVH was conversion to laparotomy, but post-operatively this procedure had fewer complications than VH. In conclusion, LAVH is a safe option for women requiring hysterectomy in cases where VH is anticipated to be technically difficult.

P.05.11

Laparoscopic hysterectomy for big uterus. Tips and tricks

Visotsky M.*[1]

[1] Mgmsu, Gyn Surgery Moscow Russian Federation

Laparoscopic hysterectomy in patients with big uterus is safe and feasible operation with good results and high level of patient satisfaction. Surgical maneuvers are very simple and reproducible. The main problem is uterine extraction in reasonable time.

Introduction: Hysterectomy is one of the most frequently performed gynecological operation and most frequent from the radical ones. Laparoscopic hysterectomy (LH) is considered as a less invasive alternative to abdominal route. However the implementation of LH develops at a very slow pace due to a lot of reasons: long learning curve, expensive and sophisticated equipment etc. One of the widely discussed problem is the technique of LH in patients with uterus sized more than 12 wks of pregnancy.

The aim of the investigation: to estimate and standardize the technical maneuvers for LH in pts with big uterus.

Methods: A thousand and fifty two total hysterectomies were performed by laparoscopic approach in 2000–2010 yrs. From which we randomly analyzed the video records of 50 performed by one surgeon in 2009: 25 hysterectomies were performed for myoma less than 12 wks of pregnancy and 25 operations on myoma of size more than 12 wks.

Results: The wide dissection of parametrium allows rapid and safe approach to uterine vessels. All the other steps should be temporarily abandoned. Maneuvers on uterine vessels were significantly longer in big uterus (10.4 ± 3.79 min vs 13.36 ± 4.11; p = 0.004) but the most time consuming step was morcellation. With manual assistance it was significantly shorter than with mechanical morcellation (31.26 ± 4.01 vs 41.04 ± 4.67). The mean operating time was 54.8 ± 8.23 vs104.2 ± 18.7 min. (p = 0.0001).

Discussion: Manual maneuvers for extraction of uterus are less time consuming and more efficient in pts with big uterus. This data allow us to standardize surgical technique of LH in patients with big uterus.

P.05.12

Laparoscopic hysterectomy for the large uterus and associated costs

Legit C.*[1], Farooq H.[1], Seed P.[1], Kunde K.[1]

[1] Guy’S And St Thomas’ Hospital London United Kingdom

Costs of laparoscopic hysterectomy for the large uterus compared with abdominal hysterectomy.

Increasing evidence to date has shown that for the experienced laparoscopic surgeon there should only be few indications to perform a hysterectomy abdominally (TAH). And yet 70% of the hysterectomies performed worldwide are still conducted abdominally.

Laparoscopic hysterectomy (LH) is a safe procedure and is associated with fewer complications, reduced hospital stay and a quicker recovery.

We conducted a retrospective analysis of 34 cases undergoing LH (mean uterine size 14 weeks, range 8–18) compared with 42 women undergoing TAH (mean uterine size 16 weeks, range 8–24) between 2008 and 2009. Indications for surgery included menorrhagia associated with leiomyoma, dysmenorroea and pelvic pain.

Mean post operative hospital stay in the laparoscopic group was reduced by 36 hours (CI −45.88 to −26.92). There were less perioperative complications in the laparoscopic group. Four patients required blood transfusion in both groups. In the TAH group there was 1 case of sepsis, 1 case of pelvic abscess, 1 vault haematoma, 1 vault infection, 1 wound infection and 1 case of pneumonia. Not surprisingly operating time was 15 min longer in the LH group. Interestingly uterine size does not seem to have an implication on operating time or hospital stay. Considering costs of instruments and bed costs per 24 hours, reduced hospital stay resulted in average cost savings of £314 per procedure. This calculation does not include indirect costs.

Our findings confirm that LH even in the larger uterus is a safe and more cost effective procedure than a TAH. Higher surgical training for Specialist Trainees should include training in advanced Laparoscopic procedures.

P.05.13

Vaginal hysterecomy under regional anaesthesia with intrathecal morphine

Mccarthy L.*[1], Rogerson L.[1], Dresner M.[1]

[1] Leeds Teaching Hopsital Trust Leeds United Kingdom

Vaginal hysterectomy under spinal anaesthesia with intrathecal diamorphine achieved lower pain scores & postop opiate requirements than plain spinal or GA.

In an audit of patients undergoing vaginal hysterectomy, the administration ofintrathecal diamorphine with spinal anaesthesia resulted in significant reduction in postop pain, PONV and a faster recovery compared to plain spinal or general anaesthesia.

The audit reviewed 73 women undergoing vaginal hysterectomy with four variants of anaesthesia: Plain Spinal Anaesthesia (S), Plain Spinal + 300 μg intrathecal diamorphine (SD), Plain Spinal + 300 μg diamorphine + enhanced antiemetic prophylaxis with Cyclizine 50 mg IM and Dexamethasone 8 mg IV (SDX). The most appropriate form of anaesthetic was selected depending upon patient factors and the availability of intrathecal diamorphine. Patients declining regional anaesthesia underwent general anaesthesia (GA). Surgical technique also included administration of 20 ml Xylocaine & 1:200000 Adrenaline.

The table displays the mean pain scores over the immediate postop 24 hr period, the requirement of further post operative analgesia and incidence of PONV.

GA (n = 9) S (n = 22) SD (n = 21) SDX (n = 21)

Mean initial pain score 0–10 4.6 0.3 0 0

Analgesia in recovery 67% 14% 0% 0%

SIckness in recovery 43% 0% 5% 0%

Antiemetic in recovery 43% 0% 0% 0%

Mean worst pain in 24 hrs 6.3 5.3 3.0 2.2

Morphine given in 1st 24 hrs 56% 27% 9.5% 0%

Sickness in 1st 24 hrs 33% 50% 43% 0%

Antiemetic in 1st 24 hrs 22% 41% 33% 0%

The audit suggests an enhanced surgical and anaesthetic combination for vaginal hysterectomy, providing both excellent analgesia and minimal PONV. There was very high patient satisfaction with the technique suggesting this could be a more utilised anaesthetic method. A formal trial monitoring the postop pain scores over the entire hospital stay, follow up and incidence of chronic pain is recommended.

P.05.14

Laparoscopic hysterectomy in a district general hospital—a learning curve

Bavananthan T.*[1], Facey L.[1], Sinha D.[1]

[1] Alexandra Hospital, Redditch Birmingham United Kingdom

Laparoscopic hysterectomy was introduced to this district general hospital in May 2008 and this audit was done to find out the effectiveness of this procedure and also to analyse complications.

Aim: To evaluate outcome measures at intra operative, immediate post operative and follow up visits and to analyse case selection and the laparoscopic procedure for this newly introduced procedure.

Standards: NICE, RCOG—Laparoscopy-Green top—2009.

Retrospective case notes analysis was done from May 2008 to April 2010. 32 cases were identified and 27 case notes were retrieved. A pre designed proforma was used for data collection.

The BMI of study population ranges from 19–42. More than 30% of them were BMI of over 30. Majority of them were multiparous and 11% was nulliparous. 59% of the cases have had a previous laparoscopic surgery and 37% of them had some form of abdominal surgery including Caesarean Sections. Primary indications for the laparoscopic hysterectomy were heavy periods (43%) and abdominal pain (36%). 78% of the procedures were total laparoscopic hysterectomies, 19% were subtotal and the rest were laparoscopy assisted vaginal hysterectomies. One or more additional procedures were carried out in majority of cases (88%) including BSO, adhesiolysis & TVT. Mean time taken for a procedure was 2 hours and 9 min. Procedure was completed as per plan in 85%of the cases and the rest had open procedure or finished vaginally. Mean stay was 2–3 days. Intra and post operative complications were minimal. Late complication of vaginal spotting was reported in 2 cases and managed conservatively in one and cauterization to vault granulation tissue in other.

Laparoscopic hysterectomy is a technically demanding procedure, but permits the transformation of many abdominal hysterectomies into less invasive procedures. It should be offered to all suitable women.

P.05.15

Laparoscopic hysterectomy: our experience and criteria for choice of route

Al-amoosh H.*[1], Kayani S.[1]

[1] Benenden Hospital Trust Kent United Kingdom

The American Association of Gynaecologic Laparoscopists published guidelines to indicate and justify the route of hysterectomy for benign disease in October 2010. Analysis of our prospective data collection found us to be consistent with the AAGL recommendations. We suggest ESGE to take the lead and develop guidelines for Europe.

Hysterectomy is undertaken for benign medical conditions of the female pelvis when medical and less radical surgical interventions have been unsuccessful or unacceptable to the patient or where relief of symptoms will only be achieved with a hysterectomy. We would like to share our experience and technique of LH and suggest an algorithm for indication for a laparoscopic approach to hysterectomy.

Prospective data collection of women undergoing LH (Total and Supracervical). Data included: patient demographics, indications, uterine weight, duration of surgery, intraoperative blood loss, hospital stay, early and late complications and histology.

>65 LHs are included. Data will be provided for all variables mentioned above. An alogorithm will be suggested.

Our data supports the AAGL recommendations and we suggest the European Society for Gynaecologic Endoscopy to lead and develop similar guidelines for European Gynaecologic Laparoscopists. We offer our assistance to the ESGE in developing these guidelines.

P.05.16

Laparoscopic subtotal hysterectomy: implications and cost-effectiveness

Ratnavelu N.*[1], Basu S.[1], Devlin K.[1], Elsapagh K.[1], Mcmurray D.[1], Allam M.[1]

[1] Nhs Lanarkshire Wishaw United Kingdom

Laparoscopic subtotal hysterectomy (LASH) has been performed in our DGH since 2008 for benign gynaecological abnormalities. Of the 51 consecutive cases analysed, there was a low incidence of complications, minimal blood loss and short hospital stay.

The laparoscopic approach for subtotal hysterectomy has gained popularity and acceptance amongst surgeons and patients, with shorter recovery time, return to work and normal sexual function. These translate themselves into improved health outcomes for the patients as well providing a cost-effective surgical treatment option.

51 consecutive inpatient LASH in our DGH from August 2008 until May 2011 were observed.The surgical approach was through four laparoscopic ports as previously described by Errian et al. using disposable instruments.

The main indication for LASH was menorrhagia. 72.4% of patients had failed medical or hormonal manipulation.

The mean operating theatre time was 2 hours with mean blood loss of 99 ml. Inpatient stay was on average 1.8 nights.

There was one pelvic haematoma, two wound infections and one ureteric injury.

The average operative cost was £1348.44 with an average cost of hospital stay of £826.20, giving a total cost per procedure of £2714.20. The average cost of an abdominal hysterectomy is approximately £2213.20.

Health

The reduced blood loss, shorter hospital stay and quicker recovery work in the favour of choosing LASH.

Cost

A recent analysis comparing endometrial ablation techniques, hysterectomy and the Mirena IUS found the incremental cost effectiveness ratio for first-line hysterectomy compared to second generation endometrial ablation and IUS use is £970 and £1440 per additional QALY respectively.

The cost of laparoscopic hysterectomy has also been shown to be comparable to abdominal hysterectomy. A consideration might be given to reducing cost for LASH procedures by using reusable equipment.

P.05.17

Outcome of surgical management of dysfunctional uterine bleeding: audit of practice of a new NHS consultant gynaecologist

Oboh A.*[1]

[1] Hull Royal Infirmary Hull, Uk United Kingdom

In the UK, secondary care management of Women with DUB after failed medical treatment is either by endometrial ablation or hysterectomy.

The use of endometrial ablation continues to increase in clinical practice with satisfactory outcome for majority of patient.

This paper is an audit of patients with DUB in the first 2 years of my practice as NHS consultant gynaecologist.

An audit of the outcome of all women with DUB managed by surgery in the first 2 years as consultant gynaecologist in an NHS hospital.

This audit includes only patients with DUB managed with either by endometrial ablation or hysterectomy between the period December 2008 and December 2010. The prospective collected care records including details of telephone follow-up at 6 months before discharge are audited and presented in this paper. The main outcomes are type of surgical treatment and patient satisfaction at 6 months.

37 cases of DUB cases were managed during the period under review. 31 cases were by Novasure endometrial ablation, 5 cases were by Laparoscopic assisted vaginal hysterectomy and one case by TRCE.

Majority of women managed by endometrial ablation (30/32) were successfully discharged at 6 months after treatment, 2 women who had unsatisfactory outcome required hysterectomy within one-year of treatment. Only three women (8%) preferred hysterectomy after failed medical treatment for DUB.

Endometrial ablation is an acceptable surgical treatment for women with DUB in my practice, with more than 90% patient satisfaction at 6 months.

P.05.18

Outcome of total laparoscopic hysterectomy

Jihad D.*[1], Fritz J.[1]

[1] University Medical Center Hamburg-Eppendorf Hamburg Germany

A retrospective study was performed to analyse 400 cases of total laparoscopic hysterectomy (TLH) evaluating the indications of the procedure, mean blood loss, mean uterine weight, mean hospital stay and postoperative complications.

The aim of this study is to evaluate the clinical and surgical outcome after total laparoscopic hysterectomy (TLH) for benign gynaecological diseases of the uterus.

four hundred cases of TLH were retrospectively analysed. All the procedures were done by the same surgeon. Kohl-Uterus- Manipulator was used. The vaginal vault was closed laparoscopically.

The most common indication for TLH was symptomatic uterine leiomyomas (n = 205, 51.25%), other Indications for surgery were: Adenomyosis uteri (n = 61, 15.25%), endometrial hyperplasia (n = 53, 13.25%), Ca in situ or cervical intraepithelial neoplasia (n = 51, 12.75%) endometrial polyps (n = 30, 7.5%),

All patients were completed laparoscopically without conversion to laparotomy.

The mean age of the patients was 49 (range 33–73),

The mean blood loss was180 ml (range 30–400) Mean uterine weight 490 g (range 90–1100), mean hospital stay was 3,2 days (range 2–7), postoperative complications include vaginal vault dehiscence (n = 7, 1.75%) and injury of the ureter (n = 1, 0.25%).

TLH is a feasible and safe procedure with a very low complication rate.

P.05.19

Outcomes of laparoscopic hysterectomy- at introduction and 3 years

Mohan S.*[1], Crouch N.[1], Amin T.[1], Chilcott I.[1], Watson N.[1], Kothari A.[1]

[1] Hillingdon Hospital London United Kingdom

Laparoscopic Hysterectomy(LH) is safe and with longer term use becomes increasingly widely applicable and cost-effective.

LH was introduced at our hospital in 2005. A study was performed shortly after its introduction, and after 3 years, to assess whether greater experience had led to a change in indications for LH, complication rates and length of hospital stay.

Retrospective studies were performed by case note review.

1. Jan 06–Oct 07 n = 30

2. Aug 09–Jul 10 n = 44

A. Indications for LH:

06–07: 57% Menorrhagia, 27% endometriosis, 10% fibroids, 7% prolapse

09–10: 43% Menorrhagia, 32% endometrial ca/atypical hyperplasia, 14% endometriosis, 5% PMS, 2% prolapse, 2% Ca cervix

B. Complications:

06–07: 6.6% converted to laparotomy, 3% ureteric injury, 0% bowel injury, 3% blood transfusion, 10% re-admitted (3/30)

09–10: 0% converted, 0% ureteric/bowel injury, 2% blood transfusion, 11% re-admitted (5/44)

C. Length of Stay (nights)

06–07: 1–10%, 2–43%, 3–30%, >3–17%

09–10: 1–55%, 2–39%, 3–5%

LH is now used for a wider range of indications as compared with 2006, including women with malignant disease. This may reflect greater confidence and increasing awareness of this option amongst other consultants.

Complication rates have reduced. 2/5 women re-admitted in the recent study presented with vault breakdown. These were 2/14 patients who had undergone Total Laparoscopic Hysterectomy. The rate of TLH was not documented in the original study. It is likely that TLH is being performed more commonly now, and complication rates related to this should be investigated at a further interval.

Length of stay has reduced and the majority of patients now leave hospital after 1 night. This is related to surgical technique and enhanced recovery. Many women in this series would previously have undergone abdominal hysterectomy and therefore this is a marked improvement in efficiency and convenience.

P.05.20

Perioperative outcomes and follow-up of laparoscopic supracervical hysterectomy

Saccardi C.*[1], Borgato S.[2], Berton S.[1], Fabris A.[1], Cosmi E.[1], Litta P.[1]

[1] Department Of Gynecological Sciences And Human Reproduction Padova Italy - [2] Department Of Gynaecological Sciences And Human Reproduction Padova Italy

Study about 269 women submitted to laparoscopic supracervical hysterectomy. Perioperative and follow up data were recorded. The procedure proved to be easy and fast with very low rate of complications and excellent satisfaction of patients.

In the last years, thanks to the mass screening for cervical cancer, and with the introduction of the HPV vaccine, supracervical hysterectomy has been reconsidered. Our objective was to verify the benefits and to evaluate the perioperative outcomes of laparoscopic supracervical hysterectomy.

Observational study about 269 consecutive laparoscopic supracervical hysterectomy performed between 2000–2010. Intra-operative characteristics, complications, as well as early follow-up were recorded. A 10 days questionnaire evaluating return to normal and working activity, presence of fever, need of antibiotic or analgesic therapy and satisfaction of the procedure was submitted to all patients.

Mean length of surgery was 103 ± 47.2 min., average bleeding was 132.7 ± 197.6 ml and average uterus weight was 334.3 ± 247.5 g. In 1 case we had bladder injury in a patient with a previous laparotomic myomectomy, no other intra-operative complications were recorded. We had post-operative complications in 4 cases: 3 women with fever required antibiotics and antipyretics, and 1 patient required hemotransfusion. No ureteral injuries were recorded. Mean hospital stay was 2 ± 1 days. Mean time before return to normal activity was 4.8 ± 2.8 days, and mean time to return to work was 15 ± 6.9 days. Satisfaction of the procedure was good or excellent in 99.4% of patients.

Laparoscopic supracervical hysterectomy is a fast, simple and safe procedure and it could be suggested to the patients with benign conditions of uterine corpus. The advantages of this minimally invasive surgery are the low morbidity, rapid return to normal activity and to work and a high patients’ satisfaction.

P.05.21

RCOG special skills module graduate: audit of hysterectomy procedures in the first 30 months as new NHS consultant obstetrician and gynaecologist

Oboh A.*[1]

[1] Alexander Oboh Hull United Kingdom

This is an audit to ascertain the quality of care offered to patients by a graduate of the RCOG Modular training system using the outcome of hysterectomy surgery-duration of surgery, complications and hospital stay as comparative indicators.

To audit the outcome of all hysterectomy procedures performed by a graduate of the new RCOG Modular System of Surgical Skills training in the first 30 months of appointment as consultant gynaecologist in an NHS hospital.

Hospital theatre database and patients case records were retrospectively reviewed to collect date on all hysterectomy procedures performed between December 2008 and May 2011.The main outcome was to ascertain the duration of surgery, complications and length of hospital stay.

52 hysterectomy procedures were performed, 22 cases were for uterine fibroids, 13 cases for dysfunctional uterine bleeding after failed medical treatment or failed endometrial ablation. 16 cases for prolapse and one case for endometrial hyperplasia with atypia. 23 cases were performed by LAVH, 16 cases by VH and 13 cases by TAH.

The average duration of surgery was 89 min for LAVH, 80 min for TAH and 60 min for VH. The average duration of hospital stay was 2 days for both LAVH and VH and TAH was 3 days.

There were no major injuries. One case of post-op wound infection associated with each procedure. 7 cases after LAVH had blood loss in excess of 300 mls, as were 9 cases after TAH and 2 cases after VH. None required post-op blood transfusion.

Laparoscopic assisted vaginal hysterectomy (LAVH) was the preferred method of surgery. There no significant increase in complications, duration of surgery and length of hospital stay. The results suggest that graduates of the new RCOG SSM programme provide a high quality of care to patients.

P.05.22

Reinvention of minimal invasive hystrectomy in Denmark. Results from a private hospital

Lundorff P.*[1]

[1] Private Hospital Molholm Vejle Denmark

Summary: During a period of 30 months, total abdominal hystrectomy in the vast majority of cases has changed to laparoscopic subtotal hystrectomy by minimal investment., resulting in decreased blood loss and quicker recovery.

Introduction: Abdominal hystrectomy is still the dominating procedure for menorrhagia and fibroids in DK with more than 60% of all cases. The wish for introducing minimal access surgery besides vaginal hystrectomy has been great, but so far this has only been introduced as routine surgery in private settings.

Material and method: Since 2009 we introduced laparoscopic subtotal hystrectomy (LSH) as standard surgery in patients with non-descendent uterus. Vaginal hystrectomy (VH) was performed in patients with descended uterus. Total abdominal hystrectomy (TAH) was considered as an emergency solution i.e. extreme myomas and severe adhesions.

Results: Between Jan 2009 and June 2011, we have performed 179 hystrectomies consecutively. Of these, 90% with minimal invasive surgery (VH 35,7%, LSH 50,8%, and LAVH 3,9%). Results are presented iat the congress, including yearly change of types of surgery, blood loss, weight of the uterus and time for surgery among the different kinds of approaches.

Conclusion: The rate of vaginal hystrectomy has not changed over the years in our settings. It seems as abdominal hystrectomy has been changed to LSH in the vast majority of patients leading to minor blood loss, and quicker recovery.

P.05.23

Self-assessed patient satisfaction survey after laparoscopic hysterectomy

Chykyda H.*[1], Kayani S.[1]

[1] Benenden Hospital Trust Kent United Kingdom

To assess patient satisfaction and quality of life after laparoscopic hysterectomy.

Hysterectomy remains a justified treatment for gynaecological conditions involving the uterus. The choice of route (VH,LH,AH) depends upon indication, pathology, surgical experience and patient choice. Trained advanced laparoscopic surgeons are able to undertake laparoscopic hysterectomies which normally would have required an open procedure. Although advantages of laparoscopic surgery are well recognised, there is insufficient data for evaluation of patient satisfaction following a laparoscopic hysterectomy.

A questionnaire survey to assess the impact of LH on patient QOL was designed with patient input. Patients were sent this survey at a minimum of 6 months and maximum of 14 months following LH.

50 women have been sent the questionnaire.Surveys received so far, show a high degree of patient satisfaction in various aspects of their life. Preliminary data show that 90% of women were very satisfied and would recommend the surgery to a friend, only two (4%) had minor postoperative complications, one requiring a course of oral antibiotics. None required re-admission. The majority were discharged on day 1 after the surgery and 3 women felt that they would have been happier had they stayed in-patient for another day. The data analysis will be completed in August 2011 and presented.

Laparoscopic hysterectomy is an effective procedure with a high patient satisfaction rate. Abdominal hysterectomies were avoided. Consultant delivered service contributed to increased patient satisfaction.

P.05.24

The effect of previous abdominal surgery to total laparoscopic hysterectomy for benign gynecologic condition

Lim S.*[1], Jeon S.[1], Lee K.[1], Park C.[1], Park H.[1]

[1] Gil Medical Center Incheon Republic Of Korea

A history of abdominal surgery does not adversely affect the safety of TLH.

Our study evaluated the impact of previous abdominal surgery on the feasibility of performing, the safety and complications of total laparoscopic hysterectomy(TLH).

We reviewed medical record of consecutive TLH performed at our institute between 2008 and 2010. 879 patients who underwent total laparoscopic hysterectomy were included. We included all patients including those who had previously undergone abdominal surgery. Patients with cancer and pelvic organ prolapse were excluded.

The clinicopathological factors of each patients, such as history of previous surgery, age, parity, indication for hysterectomy, operation time, estimated blood loss, length of hospital stay, transfusion, postoperative complication and conversion to laparotomy were assessed.

Of the 879 TLH cases, 334 had undergone previous abdominal surgery. Overall, 94 patients (62 in group 1 and 32 in group 2) reported postoperative complication including trochar site dehiscence or hematoma, vaginal cuff disruption, bleeding, ileus, unknown fever, anemia needed transfusion, reoperation, perineal laceration and ureter injury. The complication rate in both group was similar (11.3 and 9.5%, respectively). There was no difference in reoperation and transfusion rate between the two groups.

Conversion to laparotomy was required in 12 (1.4%) patients (7 in group 1 and 5 in group 2). No statistical difference was found between the groups in terms of the conversion rate.

In conclusion, a history of abdominal surgery does not adversely affect the safety of TLH.

P.05.25

The future of hysterectomy

Soltan O.*[1]

[1] S Juverdeanu St Mary’s Hospital Manchester

Hysterectomy should be decided only after considering other treatment modalities.

Vaginal or laparoscopic routes are preferable due to low morbidity and reduced hospital stay.

Heavy menstrual bleeding (HMB) represents 60% of all gynaecological referrals (RCOG).

60% of women with HMB will have a hysterectomy (NICE-guideline 44, 2007).

The surgical approach taken at hysterectomy depends upon the experience and biases of the surgeon (Cochrane 2006). However, NICE recommends vaginal route as first line.

This was a retrospective audit of management of heavy menstrual bleeding in four District General Hospitals in the North West region. A total of 229 case notes were selected randomly between January 2006 and December 2007 excluding the hysterectomies having as indication malignancy, uterine prolapse or pelvic pain.

Alternative treatment to hysterectomy was not offered in 22% cases.

Route of hysterectomy: Abdominal 96% of cases.

Vaginal 2% of cases.

Laparoscopic 2% of cases.

Trainees performed only 20% of cases and the rest was undertaken by consultants.

Overall there was no documentation of why a particular route was chosen.

Vaginal hysterectomy with or without the laparoscopic aid minimizes patient’s morbidity and reduces hospital stay. However careful patient selection is essential and in challenging situations there is still a place for the abdominal route. The laparoscopic approach is an alternative which requires a mix of skills and resources. Suitable training programmes should be developed for the trainees to further increase the number of operators who can perform this type of surgery.

P.05.26

The impact and effectiveness of RCOG post-operative leaflets for total laparoscopic hysterectomy

Omanwa K.*[1], Kayani S.[1]

[1] Benenden Hospital Trust Kent United Kingdom

An enquiry on the impact of the RCOG postop leaflets for TLH on aspects of patient post-op recovery.

Advances in laparoscopic surgery and enhanced recovery practices have led to shorter hospital stays and quicker patient recovery.It is the responsibility of the clinician as well as the individual hospital’s clinical governance team that patients are given appropriate and adequate information of what to expect in the early and late post-op period. Until very recently this information was developed by clinicians. The publication of the Royal College of Obstetricians and Gynaecologists postoperative leaflets were welcomed.

From 1/2/10, prospective information was collected on return to work, driving and sexual intercourse following TLH. Our normal practice comprised of giving our hospital TLH leaflet at time of consent. At discharge, women were given the hospital leaflets and contact details of the surgeon for post-op telephone advice.

Following the publication of the RCOG leaflets, from 1/8/10, all our patients undergoing TLH received the same information as above plus a written RCOG weblink at the time of consent and discharge.

Data on 53 TLH is available. Of these, 33 patients belong to the pre RCOG leaflet group and 20 to the post RCOG information group. Data collection is on-going. Comparative data will be presented for return to work, driving and sexual intercourse following TLH.

Postop advice to gynaecology patients on when to resume normal activities has been varied and inconsistent. Patients need to be equipped with the knowledge of what and when to expect post operatively as this will enable them to plan their personal and professional commitments.

Patients found the guidance in the RCOG leaflets useful. The RCOG has maintained its high standards and taken the lead in bringing this vital information on a national forum and international domain.

P.05.27

Total laparoscopic histerectomy—the experience of 3 years

Rato I.*[1], Rodrigues G.[1], Alho C.[1], Barata S.[1], Osório F.[1], Calhaz-jorge C.[1]

[1] Hospital De Santa Maria - Serviço De Ginecologia, Av. Prof. Egas Moniz, 1649–035 Lisboa

To review the outcomes of total laparoscopic hysterectomy (TLH) performed in our department during 3 years.

A retrospective, descriptive study of all TLH performed in our department between April 2009 to April 2011 was made. A total of 113 surgeries were analyzed, in terms of operating time, uterus weight, rate and route of morcellation, rate of complications and conversion, results of pathology and length of hospital stay.

Mean age was 48,1 years (21–84), and mean age at menarche was 12,9 years; 17% (n = 19) were in post-menopause; 43% (n = 49) had a history of abdominal surgery. The most frequent indication for TLH was menorrhagia (n = 47), followed by uterine myoma (n = 27), ovarian mass with uterine pathology (n = 24), uterine malignancy (n = 4), dysmenorrhea (n = 4), urogenital prolapse (n = 4) and surgical castration because of breast cancer (n = 2). In 55% (n = 62) of cases, uni (n = 5) or bilateral (n = 57) salpingo-oophorectomy was performed. Mean surgery time was 88,8 min (40–180). Vaginal morcellation was performed in 15% (n = 17) of cases, and vaginal plus laparoscopic morcellation in 2,7% (n = 3). In terms of rate of conversion to open surgery, we report 1 case (0,9%) in our data. There was also 1 case (0,9%) of intra-operatory need of blood transfusion, and another one (0,9%) of vaginal vault dehiscence. Mean uterus weight was 235,3 g. Mean lenght of hospital stays was 3,2 days.

Our data are extremely positive, in terms of duration of surgery, complications and lenght of hospitalization, when compared with results published in recent literature. In our opinion, TLH is a feasible and safe procedure for experienced laparoscopic surgeons, and should be the alternative to open abdominal hysterectomy.

P.05.28

Total laparoscopic hysterectomy (TLH) versus total abdominal hysterectomy (TAH): a comparative study

Protopapas A.*[1], Chatzipapas I.[1], Patrikios A.[1], Athanasiou S.[1], Mousiolis A.[1], Loutradis D.[1], Antsaklis A.[1]

[1] 1st Department Of Obstetrics And Gynecology, University Of Athens, Alexandra Hospital Athens Greece

Total laparoscopic hsyterectomy is a safe operation with a short learning curve. Standardization of the technique can expand its indications in the treatment of benign gynecological conditions.

The objective of this study was to compare total laparoscopic hysterectomy (TLH) and total abdominal hysterectomy (TAH) in patients treated for benign gynecological conditions, in terms of operative time, blood loss, intraoperative and postoperative complications, and length of hospitalization.

We included our first 60 cases treated with TLH. These patients were matched for age, BMI, indication for surgery, and uterine size with 60 patients treated with TAH during the same period. For assessing our learning curve for TLH, our first 30 cases of the TLH group (group A), were matched with 30 cases of the TAH group operated by last year residents (group C), and the remaining 30 TLH cases (group B) with 30 TAH cases (group D) operated by experienced operators.

There were no statistically significant differences between all 4 groups in terms of operative or postoperative complications. Only 1/60 case was converted to laparotomy (1.7%). Mean operation time was significantly longer: for TLH than for TAH (148 vs 107 minutes, respectively, p < 0.001), for group A than for group B (163 vs 146 mins, respectively, p < 0.001), and for group C than for group D (96 vs 128 mins, respectively, p < 0.001). Mean uterine weight was significantly less: in group A than in group B (105 vs 268 gr, respectively, p < 0.001), and in group C than in group D (187 vs 389 gr, respectively, p < 0.0001). Mean hospital stay was significantly shorter for TLH than for TAH (3,5 vs 6,7 days, respectively, p < 0.001).

TLH is a safe procedure. Operation times remain longer in comparison to TAH, even after completion of the learning curve. Experience allows to significantly reducing contraindications for TLH related to uterine size.

Session P.06

* Imaging *

P.06.1

Embrioscopy: new clinical and diagnostic prospectives of the office hysteroscopy in the embrio deseases

Castellacci E.*[1]

[1] Ospedale Palagi Firenze Italy

The embrioscopy represents a new technic for the study of the ebrio desease diagnosticated by prenatal diagnosis center.The office hysteroscopy can help to define and study the pathologies diagnosticated by ultrasound imaging or invasive procedures (cvs) of the fetus in first thrimester of life.

The embrioscopy represents a new technic for the study of the ebrio desease diagnosticated by ultrasound imaging 6 cases of complete study, morphological pathologies suspected by ultrasound imaging or chromosomal abnormalities and confirmed by hystero embryoscopy the transcervical embrioscopy may confirm the presence of embrional signs of chromosomal abnormalities suspected with ultrasound imaging and confirmed by chromosomal exam (chorionic villus sampling).

This method represents a prospective collaboration of the endoscopy unit with the prenatal diagnosis in the application of the transcervical embrioscopy to confirm the suspect of ultrasound imaging abnormalities and the direct visualization of the embrional morphological abnormalities until 12 + 6 weeks.

P.06.2

Prognostic value of adnexal masses subjective ultrasonography assessment in qualification for laparoscopy

Moszynski R.*[1], Szpurek D.[1], Szubert S.[1], Michalak S.[2], Krygowska J.[1], Sajdak S.[1]

[1] Division Of Gynecological Surgery, Poznan University Of Medical Sciences Poznan Poland - [2] Department Of Neurochemistry And Neuropathology, Poznan University Of Medical Sciences Poznan Poland

Subjective ovarian tumors ultrasound assessment has high specificity but false negative results occurs in 2%. It is especially important in qualification for laparoscopy.

Appropriate assessment of adnexal masses prior to surgery is essential for selection of best procedure. Currently transvaginal ultrasonography is the most effective method for malignancy prediction. The aim of the study was to estimate the risk of false negative results in subjective interpretation of ovarian tumors ultrasound examination.

308 women diagnosed with adnexal masses were examined preoperatively with transvaginal ultrasonography between 2004 and 2010. Subjective assessment of tumor character was done by experienced ultrasound examiner. Tumors were divided in group of: certainly benign (n = 84), probably benign (n = 116), uncertain (n = 61), probably malignant (n = 47), and certainly malignant (n = 10). The percentage of false negative results was estimated among first two groups.

There was 91 malignant and 207 benign adnexal masses diagnosed in histopathology. There was four false negative results of subjective interpretation of ultrasound findings—2% (4/200); 2 malignant and 2 borderline. First was 63 years old postmenopausal woman with bilateral solid ovaries: 4.2 × 3.1 cm and 4.6 × 2.5 cm—serous adenocarcinoma. Second was 34 years old premenopausal woman with ground glass appearance cyst 19 × 11 cm—endometrioid ovarian adenocarcinoma. Third was 32 years old woman with bilocular cyst 8 × 4.5 cm—borderline mucinous tumor. Fourth was 21 years old woman with unilocular-solid cyst 4.2 × 3.2 cm—borderline serous tumor.

In the conclusion, subjective ultrasound evaluation of adnexal masses has high specificity but even in group of tumors considered as benign the malignancy could be found. In this group other risk factors and additional tests should be evaluated before qualification for laparoscopy.

P.06.3

Sign guidelines for the management of post menopausal bleeding; a holy grail or a harbinger of trouble?

Malcolm C.*[1], Allam M.[1]

[1] Colin Malcolm Glasgow United Kingdom

This study was devised to find out the incidence of biopsy-proven endometrial cancer in women presenting to our clinics with PMB who had an ET on initial TVS of between 3 and 4.9 mm, and to therefore determine whether it is a safe and cost-effective policy to subject patients in this group to hysteroscopic examination.

National guidelines for management of patients with post-menopausal bleeding (PMB) from the Scottish Intercollegiate Guideline Network, (SIGN Guideline 61), recommend transvaginal ultrasound scanning (TVS) as the first-line investigation. The cut-off for recommending hysteroscopy and endometrial sampling is an endometrial thickness (ET) >3 mm in patients not on HRT.

A retrospective analysis of case notes identified from three PMB clinic patient databases was performed. Clinical, ultrasound and histopathological data were retrieved. Data from one clinic is from September 2001 until April 2004, and the other two from September 2006 until September 2009. Women had hysteroscopy and endometrial biopsy performed when the ET >3 mm in non-HRT users.

In total, 1375 patients had TVS and measurements of ET taken. 133 patients had an ET of 3–4.9 mm. 100 of these patients were not taking HRT. 93 of these patients had endometrial sampling by means of pipelle biopsy or hysteroscopy and dilatation and curettage. There was one biopsy-proven case of endometrial carcinoma diagnosed in this series 1/93, demonstrating an incidence of 1.1%.

Our data is from a large cohort of patients presenting to PMB clinics in three centres run by two operators. Our results show that the incidence of endometrial cancer in patients who have an ET of 3–4.9 mm is low (1.1%). Our data suggest that endometrial sampling at an ET threshold of 3 mm may subject women to over-investigation with no apparent benefit in increased detection of endometrial cancer.

P.06.4

The improvement of outpatient diagnostics of benign endometrial polyps

Aghajanyan H.*[1]

[1] Sechenov Moscow Medical Academy Moscow Russian Federation

The aim is to estimate the diagnostic values of transvaginal ultrasound (TVU), saline infusion sonohysterography (SISH) and diagnostic hysteroscopy (DHS) in outpatient revealing of benign endometrial polyps.

This is a random prospective study.

TVU, SISH and DH are conducted to the random 55 women of reproductive, peri- and postmenopausal periods with the suspicion of intrauterine pathology. All the examination used blindly by different specialists.As the final diagnosis the results of 89% operative hysteroscopy (OH) and D&C and 11% hysterectomies accepted.

The benign endometrial polyps were detected in 47% (n26) patients with the following final histiologic conclusions—fibrous-glandular (n21, 80%), glandular (n1, 4%), fibrous-glandular-muscular (n2, 8%) and placental (n2, 8%) polyps. The diagnostic efficiency of conducted methods (blind to each other) peresented in table 1. No statistically significant difference between SISH and DHS received (p < 1), but the efficiency of SISH in differentiation of endometrial polyps and submucous myomas appeared low. In two cases intracavitary formations of 16 and 21 mm in diameters at SISH were erroneously interpreted as 0 type submucous myomas since they sonographically corresponded more to myometrium, than to endometrium. At both DH and OHS they were interpreted as endometrial polyps and were fully removed by D&C without the necessity of resection. The histiologic conclusion of both cases was fibrous-glandular-muscular polyp.

There is a kind of benign endometrial polyps—histologically fibrous-glandular-muscular polyp—that is not possible to distinguish from 0 type submucous myomas at SISH, because their miometrial component make them sonographically look like miometrial formations. We supose that carefull attention to the integrity of myometrial-endometrial border at SISH may help.

figure f

P.06.5

The improvement of the outpatient diagnostics of intrauterine pathology

Aghajanyan H.*[1]

[1] Sechenov Moscow Medical Academy Moscow Russian Federation

The aim of this study is to estimate the diagnostic values of the isolated and combined use of transvaginal ultrasound (TVU), saline infusion sonohysterography (SISH), endometrial aspiration biopsy (EAB) and diagnostic hysteroscopy (DH) in outpatient revealing of intrauterine pathology.

A blind prospective study of random 66 women of reproductive, peri- and postmenopausal periods planned for operative hysteroscopy (OH) and D&C with the suspicion of intrauterine pathology.

The instrumental examination of patients conducted in 2 stages—outpatient—EAB (n64), TVU (n66), SISH (n55), DH (n64) and combined DH and SISH (n64) and inpatient—OH and D&C (n66). All the technologies were used blindly—by different gynecologists.

The intrauterine pathology was detected in 75,8% (n50) patients, in 12% (n8)—were revealed more than one pathology. The final diagnoses: submucous myoma 18,2% (n12), uterine anomaly 3% (n2), intrauterine sinechia 4,5% (n3), endometrial hyperplasia without atypia 13,6% (n9), endometrial polyp 45,5% (n30) and endometrial adenocarcinoma 7,6% (n5).

The diagnostic efficiency of the isolated and combined use of TVUS, SISH, EAB, DHS in revealing of the intrauterine pathology is peresented in the table 1.

The qualitative diagnostics of intrauterine pathology in outpatient hospital is the combination of EAB, SISH and DH, which provides the right diagnosis in 100% of cases. This testifies to mutual supplementation of the applied methods. It is especially useful when plural intrauterine pathology is suspected. As it is impossible to combine EAB and SISH in one day because of possible distortion of each other’s results, we recommend the following algorythm of examining women with the supicion of intrauterine pathology: on the first day—combination of TVU and EAB, and the combination of DH and SISH on the other day.

P.06.6

3D transabdominal ultrasound. A new reliable approach to localize Essure® microinserts after hysteroscopic ambulatory sterilization

Bader G.*[1], Bouhanna P.[1], Fauconnier A.[1]

[1] Poissy University Hospital Poissy France

The objective of this study is to evaluate transabdominal 3D ultrasound as a less invasive confirmation test to localize Essure® micro-inserts after ambulatory hysteroscopic sterilization

Pelvic X-ray or HSG remain the recommanded tets to confirm the Essure® microinserts position. Previous studies have demonstrated that 3D transvaginal US is reliable for Essure® micro-inserts localization. In our study, we compared a new less invasive US technique (3D transabdominal ultrasound) to the 3D transvaginal US.

Single center prospective cohort study. 66 patients were evaluated using 3D transvaginal and 3D transabdominal US (GE, Voluson E8) to determine the position of the Essure® coils across the utero-tubal junction 3 months after the procedure. Ultrasound was performed by an expert who ignores the operative data.

55 patients (83%) were easily evaluated by 3D transabdominal US vs 62 (94%) by transvaginal 3D US. In 11 patients (17%), Essure microinserts couldn’t be identified by transabdominal route because of retroverted uterus and/or abdominal wall thickness (BMI > 30), and were then easily and properly assessed by 3D transvaginal US.

transabdominal 3D ultrasound is an interesting alternative to confirm proper placement of the Essure® microinserts. It’s an easy and reproducible technique and could replace the 3D transvaginal US in many cases. This new technique is less invasive than 3D transvaginal US, pelvic X-Ray or HSG. Further studies are needed to confirm our results and validate transabdominal 3D US as a confirmation test after Essure® hysteroscopic tubal sterilization.

P.06.7

Does three-dimensional sonography improve the diagnostic accuracy of ovarian tumors with previous inconclusive imaging?

Exacoustos C.*[2], Zupi E.[2], Luciano D.[1], Spiel M.[1], Di Giovanni A.[2], Hoffman J.[1], Zhou C.[1], Arduini D.[2]

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

In patientsi with “difficult” adnexal tumor who had a previous ultrasound MRI or CT imaging with inconclusive results. 3D PD TVS may be helpful improving the diagnostic accuracy for benign cystic-solid and solid adnexal masses.

The aim of this study was to prospectively determine the role of pre-operative 3D imaging and power Doppler (PD) transvaginal sonography (TVS) in discriminating between benign, borderline and malignant adnexal masses; in patients who had a previous 2D ultrasound MRI or CT imaging with inconclusive results.

40 women (mean age, 50.4 years; range, 17–82) with diagnoses of complex adnexal masses were evaluated by 3D PD TVS before surgery. 3D examination and surface rendering was used to evaluate the volume, morphology and vascularization of the masses. 3D PD sonography was used to assess vascularization within papillary projections and solid areas and 3D PD vascular indices (VI) were automatically calculated.

Of 40 ovarian masses 7 (17.5%) were malignant, 7 were borderline and 26 (65%) were benign. 3D TVS correctly diagnosed 23, was uncertain in 11, and was incorrect in 6 cases. Incorrect or uncertain TVS diagnosis was more common in patients with borderline (6) and benign (7) ovarian lesions. The mean VI (13.3% vs 6.2% and 4.8%; P < 0.05) was higher in malignant compared to borderline and benign tumors, however mean VI did not differ significantly between benign and borderline.

In patients with “difficult” adnexal tumors, 3D PD TVS may be helpful improving the diagnostic accuracy for benign cystic-solid and solid adnexal masses. The differentiation between borderline and benign tumors seems to relate more to the 3D irregular aspect of cystic wall or papillary surface than on VI, whereas, VI seems more significant in distinguishing borderline from malignant tumors.

P.06.8

MRI in differential diagnose of epithelial ovarian cysts

Shaparnev A.[1], Tchernukhova O.[1], Trofimenko I.[1], Tsivyan B.*[1]

[1] State City Hospital # 40 Sestroretsk, Saint-Petersburg Russian Federation

Retrospective analyses of 116 cases MRI in patients with epithelial ovarin cysts of benign and malignant nature.Difficulties in differential diagnose between cystadofibromas and malignant tumors and the main characteristic features of malignant tumors are discribed.

Ovarian cysts are widely spread. Among them epithelial cysts take more than 80%, and one of the main problems is to make differential diagnosis of benign and malignant tumor. US has low reliability in this area, Ca-125 levels are not specific, too. The aim of our study was to find out the possibilities of MRI in differential diagnosis of malignant and benign ovarian epithelial tumors.

Retrospective analyses of 116 cases of hystologically verified epithelial ovarian tumors, 47 of them were benign, 69 were malignant. In benign group 19 were serose cystadenomas, 13 mucinose cystadenomas 15 cystadenofibromas. In malignant group most of tumors were sorose-papillar adenocarcinomas with low and moderate grade of differentiation. MRI was performed on MR systems using standard protocol, then after intravenous injection of contrast investigation was repeated.

All epithelial tumors were cystical type. Differences concerned the number of cameras and septums, thickness of the walls. The main difficulties were met in diagnostics between benign cystadenofibromas and malignant tumors. All malignant tumors showed maximal accumulation of contrast in first 2 minutes with high intensity of accumulation (more then 100%) in 75% of cases, while benign tumors started to gather contrast from 3 d to 5 minutes with intensity lower than 50%.

MRI is highly reliable method to differ benign cystadenomas and cystadenofibroids from malignant tumors of similar morphology. Accumulation of contrast with pick in 1–2 minutes with more than 100% intensity in tumors with cystic-solid structure is a specific feature of malignancy.

Session P.07

* Infertility and Reproductive Medicine *

P.07.1

Thyroid dysfunction in infertile patients after laparoscopic drilling of ovaries

Panevska-gareva M.*[1], Angelova M.[1]

[1] M. Panevska-Gareva Sofia Bulgaria

The authors present their experience on hormonal disturbances of thyroid gland after operative ovarian laparoscopy.

We investigated endocrine thyroid disorders in infertile patients with PCOS after laparoscopic ovarian drilling.

For the period 2006, 2008 and 2009. were prospectively studied 41 patients with PCOS after laparoscopic drilling and no pregnancy as early as 6 months to one year in the University Hospital “Maichin dom”, Sofia. For the control group were studied 22 patients with PCOS without laparoscopy. We examined TSH, FT3, FT4, anti-thyroglobulin /TAT/ and anti-thyroperoxidase antibodies /TPO/. Patients with abnormal hormonal tests and elevated antibodies were monitored with ultrasound of thyroid gland.

From 41 patients investigated after operative laparoscopy there were established 16 patients (39.0%) with thyroid dysfunction. In 14 patients we proved subclinical hypothyroidism (34.1%). In 7 of them (17.0%) were found thyroid antibodies. Of the total of 16 patients with thyroid dysfunction, 2 patients had subclinical hyperthyroidism.

In the control group of 22 patients, thyroid dysfunction was determined in 3 patients. (13.6%). After laparoscopic drilling from 41 patients with PCOS 16 patients (76.1%) became pregnant. Only one pregnancy was miscarriage. In the control group of 22 patients two patients (4.5%) were pregnant.

The high incidence of thyroid dysfunction in 16 patients (39.0%) with PCOS and laparoscopic drilling were very provoking. Our investigation is one attempt to seek a clinical link between the recovery of ovulation of ovaries, the change of FSH and LH.

P.07.2

A review on laparoscopic ovarian diathermy (LOD) in women with polycystic ovary syndrome (PCOS)

Tang T.*[1]

[1] Consultant Gynaecologist Bradford United Kingdom

Laparoscopic ovarian diathermy is an effective second line treatment for clomifene resistant PCOS women.

PCOS is a common disorder affecting 10% of women. Women with PCOS often present with anovulatory subfertility. The current first line therapy is ovulation induction with clomifene. However, about 20% of the patients would not respond to this regime(clomifene resistance).

A Cochrane review (2007) revealed that laparoscopic ovarian diathermy is an effective second line treatment with a lower multiple pregnancy rate compared with gonadotrophin ovulation induction.

In the last few years, a number of trials investigated the effectiveness of LOD compared with other second line therapy such as metformin and aromatase inhibitors. Hence, a systematic review was conducted to update the current evidence.

Database searched in this review included MEDLINE, EMBASE and CINAHL.

Patients with a high insulin resistance or with a high serum anti-Mullerian hormone (AMH) concentrations are less likely to respond to LOD. Adjusted thermal dose based on ovarian volume may be more effective compared with a fixed dose approach.

Combined metformin and clomifene treatment is as effective as LOD. However, patients received LOD had a lower multiple pregnancy rate. Likewise, letrozole and LOD are equally effective in inducing ovulation in PCOS women with clomifene resistance.

Currently, there is no firm evidence of LOD causing premature ovarian failure; although, a small study suggested 25% of patients who had a second look laparoscopy were found to have a mild pelvic adhesion.

Laparoscopic ovarian diathermy is an effective treatment for clomifene resistant PCOS women with a lower multiple pregnancy rates compared with the other second line therapies. A better patient selection based on the status of insulin resistance may improve the clinical effectiveness.

P.07.3

Antiadhesion bariers aplication in adhesions prevention

Popov A.[1], Manannikova T.[1], Kolesnik N.*[1], Fedorov A.[1], Ramazanov M.[1], Krasnoposkaya I.[1], Chechneva M.[1], Budikina T.[1], Golovin A.[1]

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

We use 100–200 ml of Mesogel, Intercoat gel (40 ml)were aplicated in 50 cases,Adept after adhesiolises 50 patients were undergone SLL at 4–36 months. In most cases at SLL adhesion were admired but we found significant decrease (from grade 4 to 1–2). Among 58 patients with infertility pregnancy rate is 51,7% (30 patients) at 6–18 months after surgery.

In present time weir is no authorized ways of adhesions prevention after surgery and inflammation diseases. We study results of surgical treatment patient with peritoneal infertility with 3 liquid barriers Mesogel (Lintex, Russia), Intercoat (J&J, USA), Adept (Baxter, USA).

We use 100–200 ml of Mesogel among 72 infertile patients in LS surgeries on fallopian tubes and ovaries. Intercoat gel (40 ml)were aplicated in 50 cases: 20 times at LS miomectomy, 30 times at LS surgery in patients with hydrosalpinxes. We use Adept after adhesiolises in 35 patients with 2–4 previous open surgeries on pelvic organs to prevent adhesion reformation.

50 patients were undergone SLL at 4–36 months. In most cases at SLL adhesion were admired but we found significant decrease (from grade 4 to 1–2). Among 58 patients with infertility pregnancy rate is 51,7% (30 patients) at 6–18 months after surgery.

We suggest what the most perspective are liquid (gel) antiadhesion barriers. Antiadhesional gel can stay in abdomen cavity for a long time (for period of peritoneum regeneration). In addition to surgery barriers show high efficacy in complex treatment of peritoneal infertility.

P.07.4

Clinical markers for pelvic adhesions reformation

Dubinskaya E.*[1], Gasparov A.[2], Bourlev V.[3]

[1] Department Of Obstetrics, Gynecology And Reproductive Medicine Of Peoples’ Friendship University Of Russia Moscow Russian Federation - [2] Department Of Obstetrics, Gynecology And Reproductive Medicine Of Peoples’ Friendship University Of Russia Moscow Russian Federation - [3] Scientific Center For Obstetrics, Gynecology And Perinatology Named After V.I. Kulakov Moscow Russian Federation

The results of the study help to predict pelvic adhesions reformation in patients with infertility. Seven significant clinical markers were proposed. Further study needed to compare clinical and laboratory tests for the risk group classification,

The aim of the study was to evaluate clinical markers of pelvic adhesions reformation.

80 patients with laparoscopically verified pelvic adhesions at stage III–IV (AFS) and infertility were included in the study. Laparoscopic adhesiolysis and hysteroscopy were performed in all the cases. Patients were operated by the same surgeon and surgical team. All the patients were divided into two groups depending on the results of “second-look” laparoscopy in three months after. The first group consisted of 47 (59%) patients who had no adhesions or I stage of adhesions in 3 months after primary adhesiolysis. The second group consisted of 33 (41%) women with II or III staged adhesions represented. Discriminant analysis of clinical data was performed to predict pelvic adhesions reformation.

We received the positive correlation coefficient value for seven clinical markers: abortion or miscarriage (0,3207); endometrial pathology diagnosed by hystological examination (0,3302); primary surgery duration more than 60 minutes (0,4990); adhesions with bowel and omentum (0,5116); subfebrile more than two days after surgery (0,4671); hydrosalpinx presence (0,3411); ultrasound uterine tubes visualization more than 3 days after surgery (0,3912).

Our data suggest that 7 clinical criteria could be used for pelvic adhesions reformation prediction. Further study needed to compare clinical and laboratory test for the risk group classification, Furthermore, it would help to choose the patients for antiadhesion barrier usage for reduction adhesions reformation.

P.07.5

Demographic characteristics, clinical presentations and risk factors of ectopic pregnancies in 500 consecutive surgically-managed cases

Morelli M.*[1], Sankaran S.[1], Cunliffe J.[1], Odejinmi J.[1]

[1] Whipps Cross University Hospital London United Kingdom

Our study has analysed the demographics, clinical presentation and risk factors in 500 surgically managed ectopic pregnancies (EPs). This study will help with the early identification EP and facilitate the early institution of appropriate management.

The aim of the study was to compare the demographic characteristics, clinical presentation and risk factors of non-tubal, recurrent and haemodynamically unstable ectopic pregnancies with single tubal pregnancies.

Prospective cohort study of 500 consecutive women managed surgically for EP between 2003 and January2010 at Whipps Cross University Hospital, London.

31 were non-tubal EPs, 57 were recurrent, and 84 patients had significant haemoperitoneum (more than 800 ml). The overall operative laparoscopy rate was 94%, increasing to 98% in recurrent EP patients, and 84% in patients with significant haemoperitoneum.

Recurrent tubal ectopics: Patients with recurrent EP were also significantly more likely to present early than patients with a primary EP. Of all the risk factors examined, previous pelvic surgery and previous tubal surgery were the only risk factors found to be significantly associated with recurrent EP.

Non tubal ectopics: Cornual EPs were significantly more likely to present later than tubal EPs. Patients with extra-tubal EPs had significantly higher haemoperitoneum, than tubal EP(P = <0.01).

Patients with significant haemoperitoneum: The mean gestational age in the significant haemoperitoneum group was higher. Patients with significant haemoperitoneum were more likely to report vomiting (P = <0.01) and a syncopal episode(P = <0.01).

Despite advancing technology both in terms of diagnosis and treatment it is still difficult to determine the type of EP on the basis of demographic characteristics and clinical presentation. However, inferences can be made, as demonstrated by this study.

P.07.6

Determination of the anxiety level and neurotic disorders in patients with infertility

Cleveland G.[1], Klyucharov I.*[1], Yahin K.[1]

[1] Kazan State Medical University Kazan Russian Federation

Today the influence of a psychological condition of the patient on her physical health is doubtless, and it would be incorrect if attention was payed only to treatment of a somatic pathology. The complex approach regarding both patients’ physical and psychological state is necessary.

The objective of the research is to define prevalence of neurotic disorders and level of the increased anxiety in patients with infertility.

29 women receiving treatment for infertility in a gynecology department have been investigated. Data was gathered by poll method. Yahin-Mendelevich questionnaire for revealing and an estimation of neurotic conditions, Spielberger-Khanin anxiety inventory test, and Shikhan anxiety scale were used.

By the Yahin-Mendelevich questionnaire the data for painful character of changes on an anxiety scale is revealed in 5 (17,25%), on a scale of neurotic depression at 6 (20,7%), on a scale of asthenia at 3 (10,35%), on a scale of hysterical type of reaction at 4 (13,8%),on a scale of obsessive-phobic disorder at 6 (20,7%),on a scale of vegetative disorders at 5 (17,25%) surveyed patients. The data for boundary character of the found changes on these scales was found correspondingly at 10 (34,5%), 7 (24,13%), 3 (10,34%), 9 (31%), 6 (20,7%), 2 (6,9%) of 29 surveyed patients.By the results of Spielberger-Khanin test 11 (37,9%)patients showed low level, 15 (51,7%) medium level and 3 (10,34%) high level of situational anxiety. High level of personal anxiety has been found at 3 (10,34%) average level at 17 (58,6%) low level at 9 (31%) patients.17 persons have been surveyed by Shikhan method. Elevated anxiety level was found in 7 (41,17%)patients. Out of them 4 (23,52%) had clinically significant level of anxiety.

Considering high level of elevated anxiety and neurotic disorders psychological counseling should be advised in patients with Infertility.

P.07.7

Do small uterine septa, uterus arcuatus play a role in spontaneous miscarriage rate?

Kenda Šuster N.*[1], Gergolet M.[2], Campo R.[3]

[1] Dept. Ob/gyn, University Of Ljubljana Ljubljana Slovenia - [2] S.I.S.Me.R. Servizi Doberdò Del Lago Italy - [3] L.I.F.E. Leuven Belgium

The American Fertility Society has classified the arcuate uterus as a different class of congenital anomalies. It was suggested that this is a minor malformation with a benign clinical behaviour.

Aim of the present study was to verify whether there is any scientific basis for this differentiation and if not the arcuate uterus should be defined as a misnomer.

Patients with at least one early miscarriage and a uterine septum were admitted for hysteroscopic metroplasty. Patients were allocated into 2 different study groups. According to the length of the uterine septum we differentiate the “subseptate uterus group” with an indentation of minimal 1,5 cm but no complete septum and the “arcuate uterus group” with an indentation of less than 1,5 cm. The main outcome parameter studied was the miscarriage rate at the first postoperative spontaneous pregnancy. Secondary outcome parameter was the comparison of time to conception before and after surgery and the final pregnancy outcome. 96 patients were included in the study 72 patients were included in the subseptate uterus group and 24 in the arcuate uterus group. The miscarriage rate after surgery was the same in both groups with 15.8% in the subseptate uterus group vs. 16.7% in the arcuate uterus group. This was significantly lower than the miscarriage rate before surgery in both groups, 84.3% in the subseptate uterus group and of 97,4% in the arcuate uterus group. Furthermore both in the subseptate as the arcuate group the mean time to conceive spontaneously was significantly shorter after the surgery and no difference was seen between the 2 groups for the final pregnancy outcome.

According to our results, there is no evidence to support that the arcuate uterus has a different effect on the reproductive outcome in comparison to the sub septated uterus, neither before nor after surgical correction of the anomaly.

P.07.8

Essure for hydrosalpinx: results after 18 patients

Arjona Berral J. E.*[1], Velasco Sanchez E.[1], Povedano Cañizares B.[1], Lorente González J.[1], Monserrat Jordán J. A.[1]

[1] Hospital Universitario Reina Sofía Córdoba Spain

To evaluate the placement success rateof Essure for hydrosalpinx in patients with infertility, the rate of tubal oclusions three monts after procedure and the rate of pregnancies after IVF.

The optimal treatment for hydrosalpinx in infertile patients remains still unclear. Essure method offers a less invvasive approach to this patients.

Prospective study of 18 patients with unilateral other bilateral hydrosalpinx. The method was performed with a 5 mm hysteroscope in an outpatient basis. An hysterosalpingogram was performed thhree monts after procedure to evaluate tubal occlusion. No more than three IVF cicles were performed for each patient, as no more cicles are allowed in our public sanitary system.

5 patients had unilateral hydrosalpinx so only unilateral placement was performed, and in the other thirteenth patients hte hydrosalpinx was bilateral. In the 100% of patients the placement was achieved and the hysterosalpingogram showed in 100% of cases a proximal tubal occlusion.9 patients have started the cicles till now, 6 are still in waiting list, and we have loose three patients. Of the nine patients that have completed the IVF cicles, 5 pregnancies were achieved, three miscarriages and two pregnancies at term. The rate of pregancies for couples is 55,5% and the rate of term deliveries for couples is 22,2%.

The proximal tubal occlusion with Essure device is an effective and safe alternative with a minimal invasive approach for infertile women with hydrosalpinx, priot to IVF.

P.07.9

High concentrations of IFN? In infertile patients with endometrial polyposis

Granata M.*[1], Fiore E.[1], Caggiano F.[1], Lannino G.[1], Mollo A.[1], De Placido G.[1]

[1] Federico Ii University Naples Italy

In a prospective controlled study, infertile patients with endometrial polyps were found to have a significantly higher concentration of IFN-? both in serum and in biopsy samples of endometrium, than a comparable group of patients with normal uterine cavity.

The aim of this study is to investigate the molecular background involved in the formation of endometrial polyps and it’s potential role in infertility. We assessed levels of interferon-gamma (IFN-?) both in serum and in biopsy samples of endometrium from infertile patients with endometrial polyps.

Twenty-one women affected by endometrial polyposis constituted the study group (Group A) and 21 women with normal uterine cavity constituted the control group (Group B). Diagnostic hysteroscopy were performed during the early proliferative phase. In all patients an endometrial biopsy was done using a 4 mm Novak curette. Around 36 cc of peripheral blood were collected from all patients in three different test tubes of 12 ml each.

With regards to the IFN-? concentration in blood serum, group A revealed 85.7 ± 84.14 SFCs while the patients in group B showed 36.7 ± 45,55 SFCs (p < 0.05). When we analyzed the endometrial polyp biopsy samples, the mean number of spots was 39.8 ± 34.15, while in group B the value observed was statistically lower, 15.7 ± 22.34 (p < 0.05).

Present data has demonstrated that infertile patients affected by endometrial polyps present molecular alterations, represented by a statistically significant increase in the concentration of INF-?, both in the endometrium and in peripheral blood, when compared to a homogeneous group of infertile patients without endometrial pathology. Increased levels of INF-? may be the result of chronic inflammation of the endometrium, and could represent the mechanism underlying the growth of polyps and of impaired endometrial receptivity and reproductive failure.

P.07.10

Laparoscopic ovarian drilling for ovulation induction in polycystic ovary syndrome

Raposo L.*[1], Ferreira C.[1], Silva V.[1], Costa D.[1], Pipa A.[1], Martins F. N.[1]

[1] Hospital De São Teotónio Viseu Portugal

Laparoscopic ovarian drilling may be considered in women with polycystic ovary syndrome, the aim of this study is evaluate the laparoscopic drilling efficacy and safety.

Ovulatory disorders are the most common causes of infertility. The polycystic ovary syndrome is characterized by menstrual irregularity (oligoovulation and anovulation) and hyperandrogenism. Laparoscopic ovarian drilling may be considered in women with polycystic ovary syndrome who fail to ovulate despite medical treatment. The major advantages of surgery relate to the relative simplicity, safety and efficacy of the procedure. The risks are those of anesthesia, injury to the bowel, bladder, and major blood vessels, infection, and postoperative adhesion formation. The aim of this study is evaluate the laparoscopic drilling efficacy and safety.

Retrospective study involving a sample of 39 women with polycystic ovary syndrome attended in infertility consult of Hospital São Teotónio from January 1998 to December 2010.

The average age was 28.3 years old, the average time of infertility was 34.6 months (min. 12 months; máx. 36 months), 79.5% (n = 21) had menstrual irregularity, 26% (n = 10) were obese (BMI = 30 kg/m2) and 26% (n = 9) had clinical evidence of hirsutism. They were resistant to medical treatment: 20.5% (n = 8) to clomiphene citrate, 20.5% (n = 8) to clomiphene citrate and metformin, 38.4% (n = 15) to clomiphene citrate and gonadotropins, 17.9% (n = 7) to clomiphene citrate and metformin and gonadotropins, 2.5% (n = 1) to metformin. There were no cases of surgery complications. After the laparoscopic drilling 81.6% (n = 32) had medical treatment, the average time to conception was 3.4 months (min. 1 months; máx. 9 months) with 38.5% (n = 15) cases of pregnancy.

The laparoscopic ovarian drilling seems to be a safe and good therapy to polycystic ovary syndrome women resistant to medical treatment.

P.07.11

Management of interstitial pregnancies: conservative treatment as a reliable alternative to surgery

Athanasias P.*[1], Psychoulis M.[1], Hayes K.[1]

[1] St George’S Hospital London United Kingdom

Interstitial pregnancy is a rare entity with a high morbidity rate.We present a large case series of successful conservative management that resulted in fertility preservation.

Interstitial pregnancy is defined as a gestation that implants within the proximal, intramural portion of the fallopian tube and it accounts for 2–4% of all ectopic pregnancies.The management includes a spectrum of surgical or medical options. Surgical procedures include laparoscopy,laparotomy and hysteroscopy. Expectant management and Methotrexate,either systemic or local,have been described as primary treatment in those patients who are hemodynamically stable and desire future fertility.

A retrospective study was conducted at a tertiary centre. 48 women that attended the early pregnancy assessment unit were diagnosed with an interstitial pregnancy in 10 years. 36 of them complied with the Department’s criteria for conservative management and were either treated expectantly and kept under observation (4) or were given intramascular methotrexate (32).

A successful treatment was defined as no need for surgical intervention after the initial decision to treat conservatively and a final serum hCG <20 IU/L.All women treated expectantly had a successful outcome.However, 9 patients in the methotrexate group required further treatment in the form of a repeat methotrexate injection.No adverse effects were noted.

The patients that did not meet the criteria for conservative management had cornual resections predominantly laparoscopically.

Conservative management of interstitial pregnancies is safe and effective in selective cases without impairing future fertility.Laparoscopic treatment involves cornulal resection, cornuostomy or salpingotomy and it should be the preferred operative option in clinically stable patients.Cornual resection due to catastrophic bleeding sometimes might result in a hysterectomy.

P.07.12

Modern way of diagnosis and treatment of patients with ovarian apoplexy for prevention and restoration of reproductive function

Zhegulovich Y.*[1], Iefimenko A.[1], Shevchenko O.[2], Nohovska I.[1]

[1] National O.O. Bohomolets Medical University, Obstetrics And Gynaecology Department Kyiv Ukraine - [2] Military Medical Clinical Red Star Center “cmch”, Gynaecological Clinic Kyiv Ukraine

There are outcomes of conservative and operative results of 172 patients with ovarian apoplexy. Laparoscopic treatment of patients with ovarian apoplexy is most preferable in cases of planning pregnancy.

The problem of ovarian apoplexy remains valid due to the decrease of the morbidity age and non-stop growth tendency of this pathology. Our goal is to improve treatment of ovarian apoplexy and prevention of its recurrence and tuboperitoneal infertility in women planning pregnancy.

172 women with ovarian apoplexy were examined, 48 with painful type, 81- with hemorrhagic type, 43- with a mixed form. An ultrasound was performed at 100% of observations to confirm the presence of free fluid in the abdomen. 115 women were operated and 57 underwent conservative treatment. 79 patients underwent laparoscopy, 36 - laparotomy (instable hemodynamics and blood loss 500 ml). Despite the fact that the majority of patients (111–64.5%) became ill the first time, every fourth woman previously noted symptoms similar to those of ovarian apoplexy and every eighth was previously operated for ovarian rupture (laparoscopy—12, laparotomy—8). Thereafter, ovarian apoplexy in many patients occurred repeatedly, and in every eighth surgery was performed. Laparoscopy showed that women with evidence of past painful form of apoplexy and were not operated had old adhesions stage I–III (Hulka classification) and many serosocele.

For the prevention of pelvic adhesions and associated infertility in women planning pregnancy laparoscopy is to be performed even for the painful type of ovarian apoplexy.

Current status of the diagnosis, treatment and prevention of recurrence of ovarian apoplexy requires a new approach to its solution. In the absence of contraindications, laparoscopy is the primary method of treatment of this pathology in women planning pregnancy.

P.07.13

Operative laparoscopy in tubal infertility. A clinical study of 49 cases

Socolov R.*[1], Butureanu S.[1], Popovici D.[1], Neumann O.[1], Socolov D.[1], Rotaru C.[1]

[1] University Of Medicine And Pharmacy Gr T Popa Lasi Romania

We studied retrospectively the tubal infertility pathology met in our laparoscopies. In 49 cases during 2 years, there were mainly adhesions and endometriosis. The interventions (adhesiolysis, neosalpingostomy, endometrial foci resection) were without major complications, except for laparotomy coversion in 8%. Without ART, at 1 year follow-up there were 6 pregnancies—12%. Laparoscopy is able to treat tubal pathology, but it remains inferior to ART methods.

Tubal pathology, a frequent cause of female infertility, is more and more addressed by assisted reproductive techniques (ART). Unfortunately, in some cases, the ART techniques available are not suitable, because of price and/or other limitations.

Our study retrospectively assessed the cases of tubal infertility in our service in the last 2 years. There were 49 operative laparoscopies for infertility related to tubal pathology. We studied the pathology found, the intervention, the clinical data, and the duration of admittance.

There were 25 primary and 24 secondary infertilities, aged between 21 and 44 (median 30). The pathology described by laparoscopy included adnexal adhesions (27 cases, 55%), hydrosalpinx in 16%, adnexal endometriosis in 20%, and other pathology. The lesions were unilateral 55%, and bilateral 45%. The evolution of our cases was with no major complications as we performed either adhesiolysis, endometrial foci resection, or neosalpingostomy; but laparotomy was needed in 3 cases of endometriosis and 1 of severe adhesions.The patients remained in the hospital for 2 to 9 days, and the pregnancy rate (without any ART treatment that we know of) was 12% at 1 year.

In conclusion, tubal operative laparoscopy useful in patients where ART is not accessible, or to improve reproductive prognostic, but the success rate is lower than in other types of infertility.

P.07.14

PGD: our experience in screening for aneuploidies, causes of repeated failures of implantation in women undergoing IVF-ET

Piazza A. M.[1], Scozzaro A.[1], Castelli A.*[1], Valenti G.[1]

[1] Genesi Centre Palermo Italy

Chromosomal abnormalities are thought to be responsible for implantation failure. In our Centre 25 couples with repeated implantation failures were underwent to PGD cycles for aneuploidy testing.

125 embryos were biopsied, only the 18% were euploids, 82% of them were abnormal. These data show that the high rate of chromosomally abnormal embryos may have been the cause of implantation failure in their previous IVF cycles.

Chromosomal abnormalities are thought to be responsible for implantation failure, and among them, aneuploidies are the most frequent.

PGD for aneuploidy screening in infertile patients treated by ART and with repeated IVF failure will increase the chance of conceiving.

Twenty-five couples with repeated implantation failure underwent to PGD cycles for aneuploidy testing. Mean female age was 34,7 years and mean number of previous failed ART cycles was 3, 3. Ovarian stimulation was undertaken with FSHr in a long protocol with GnRH analogues.

Fertilization was affected by ICSI.

Embryo biopsy was performed on day 3 from embryos having 5 or more blastomeres.

One blastomere was removed from each embryo, analyzed using CGH array.

18 (72%) women were available for the embryo transfer and the mean number embryos per transfer was 1,4.

The other embryos were either anueploid precluding embryo transfer. 125 embryos were biopsied; 91% gave good results, of which 18% were euploid and 82% were abnormal.The most frequent chromosome abnormalities were monosomies , trisomies ,sex chromosomes abnormalities and mosaicisms.

The pregnancy rate for embryo transfer was 25,3%.

The high rate of chromosomally abnormal embryos may have been the cause of implantation failure in their previous IVF cycles.Therefore PGD cycles in that patient is a useful tool to increase the chance of ART success.

P.07.15

Phospholipids in pelvic adhesions: the new paradigm?

Plant A.*[1], Ledger V.[2], Koster G.[2], Obura Y.[1], Postle T.[1], Cheong Y.[1]

[1] University Of Southampton Southampton United Kingdom - [2] Southampton University Hospitals Trust, Biomedical Research Unit Southampton United Kingdom

This study aims to characterize and compare the composition of peritoneal fluid (PF) and plasma (PL) phospholipids in women with pelvic adhesions and a normal pelvis.

Adhesions are a significant cause of morbidity associated with chronic pelvic pain, infertility and increased surgical complications. The etiology of adhesion formation is poorly understood with, currently, no effective adhesion prevention therapy. Phospholipids are important in inflammation and studies have demonstrated altered levels in endometriosis and ovarian cancer; thus phospholipids may have a role in adhesion formation.

Women aged 18 to 65 years undergoing laparoscopic surgery at the Princess Anne Hospital, Southampton were recruited. Venous blood and PF samples were collected and analyzed for phospholipids using mass spectrometry. The pelvic cavity underwent validated adhesion scoring and patient details and demographics were recorded.

33 samples have been analyzed: 17 normal and 16 diseased. Phosphatidylserine (PS) is present in PF but not PL: PS18:0/18:1 (mean difference 22.86%, P < 0.001) and 18:0/20:4 (mean difference 9.59%, P = 0.051) increased in PF, compared to PL in the diseased pelvis. The normal pelvis showed a similar picture. PF PS profiles differ in disease, compared to normal. Relative abundance of PS18:0/20:4 increased in PF in disease and PS18:0/22:6 also increased in PF in disease (mean difference 3.99%, P < 0.05). PS18:0/18:1 decreased in disease (mean difference 8.31%, P = 0.064).

PF is not simply an ultrafiltrate of PL. PS is present in PF but not PL, indicating a local source: cells in PF or de novo synthesis in the mesothelium. Disease alters PF phospholipid profile with an adhesion profile suggesting the presence of lymphocytes and increased cell turnover. Phospholipids may be an important component of anti-adhesion therapy; this area of research should be further explored.

P.07.16

Pregnancy outcomes and perinatal results after unintended pregnancies following essure sterilization: descriptive analysis of 10 cases

Velasco Sánchez E.*[1], Arjona Berral J. E.[1], Povedano Cañizares B.[1], Ríos Castillo J. E.[1], Monserrat Jordán J. Á.[1]

[1] Hospital Universitario Reina Sofía Córdoba Spain

To describe the pregnancy outcomes and perinatal results of women with Essure® device in our hospital to evaluate the safety of the method.

The Essure® permanent birth control method was approved in 2003 for female hysteroscopic sterilization. Many studies suggest that it is a safe and effective method for female contraception. No studies have proven its safety during pregnancy, becoming important when it is used in selected cases for the treatment of hidrosalpinx prior to in vitro fertilization.

Descriptive study of pregnancies following Essure® placement in women demanding permanent sterilization. After 4500 procedures performed in our unit, 10 pregnancies in 9 women have been reported. In one patient, 2 pregnancies have been reported with four years difference (she has a unilateral placement due to a migration of one of the microinserts).

4 pregnancies finished as a first trimester abortion. From the other 6, 1 is a first trimester miscarriage in the 7th week of gestation. The other five pregnancies were follow-up in our High Risk Pregnancy Unit. No cases of preterm premature rupture membranes or preterm delivery have been reported. Four pregnancies were espontaneus eutocic delivery at 39 weeks of gestation with weights between 3040 gr till 3570 gr, apgar score 9/10 and ph up to 7,30.The other pregnancy it’s now on the 27th week with no complications. No ectopic pregnancies have been diagnosed either any malformation.

The results of our sample suggest that pregnancies with Essure® microinserts are safe with no adverse outcomes. No cases of ectopic pregnancies have been reported in any series. There is a lack of studies reporting the perinatal results following unintended pregnancies.

P.07.17

Preoperative evaluation of adhesiolysis technical difficulty (grade score system)

Dubinskaya E.*[1], Gasparov A.[1], Babicheva I.[1], Barabanova O.[1]

[1] Department Of Obstetrics, Gynecology And Reproductive Medicine Of Peoples’ Friendship University Of Russia Moscow Russian Federation

Seven preoperatively known facts (infertility duration, body mass index, infections, complicated abortions, previous surgery, “hard” and “soft” ultrasound criteria and hysterosalpingography results) correlated with adhesiolysis difficulty score. Preoperative technical difficulty grade score system for patients with pelvic adhesions was suggested.

In this study we aimed to categorize laparoscopic adhesiolysis preoperatively according to technical difficulty.

300 patients with laparoscopically verified pelvic adhesions of different etiology were included in the study. Patients were operated by the same surgeon and surgical team. All the patients were divided into three groups depending on a visual analogue score (VAS) for difficulty rewarded by the surgeon.

Seven preoperatively known facts (infertility duration, body mass index, infections, complicated abortions, type of previous surgery, “hard” and “soft” ultrasound criteria and hysterosalpingography (HSG) results) correlated with difficulty score rewarded by the surgeon.

On the basis of the preoperatively known patient characteristics, we created an artificial point system as a reference for technical difficulty grade for laparoscopic adhesiolysis.“Low-score patients” were patients defined by scores 4–15, “medium-score patients” were patients defined by scores 16–35, and “high-score patients” were defined by scores more than 35. We subsequently evaluated whether this point system was validated when comparing this “technical difficulty grade” to VAS for difficulty rewarded by the surgeon.

Preoperative technical difficulty grade score system for patients with pelvic adhesions was suggested. It is important to use it in the future to improve quality of preoperative investigation, to better form combined surgical teams, facilitate and standardize teaching purposes, surgeon self evaluation, and patient safety.

P.07.18

Role of endoscopy in treatment of pelvic inflammatory diseases

Zhegulovich Y.[1], Iefimenko A.[1], Shevchenko O.[2], Nohovska I.*[1]

[1] National O.O. Bohomolets Medical University, Obstetrics And Gynaecology Department Kyiv Ukraine - [2] Chief Military Medical Clinical Red Star Center “cmch”, Gynaecological Clinic Kyiv Ukraine

We performed a comparative analysis of the results of conservative and endoscopic treatment of inflammatory diseases of the adnexa in women with infertility, which showed advantages of early laparoscopy for restoration of the reproductive function.

The problem of pelvic inflammatory diseases is extremely actual in women of reproductive age. Long-term and incorrect treatment leads to chronisation of a process and, consequently, infertility. Our aim was to compare the efficiency of conservative and endoscopic treatment of infertility in inflammatory processes of the adnexa.

We performed a retrospective analysis of 74 cases of infertile women (age 20–36), who underwent in-patient treatment of acute and chronic inflammation of the adnexa. 45 of them underwent a course of conservative treatment and 29- laparoscopy with further targeted antibiotic therapy. Indications for laparoscopy were: the need to confirm the diagnosis during exacerbation of recurrent and continuous salpingo-ooforitis, piosalpinx, infertility more than 1,5 years. In these cases, laparoscopy allows accurate and timely diagnosis, to obtain material for bacteriological examination, to perform salpingoovariolysis, chromotubation with antibiotics and sanitation of the pelvic cavity by ozonated solutions, afterwards hydroperitoneum with antiseptics was created.

During three years of supervision after conservative treatment pregnancy occurred in 9 women (20%), and after laparoscopic treatment—in 13 patients (44.8%).

For the treatment of patients with uncomplicated forms of pelvic inflammatory diseases laparoscopy has advantages and prospects compared with long-term conservative treatment- it expands the range of clinical diagnosis and makes targeted treatment possible, in some cases it eliminates the cause of infertility, at once it is particularly important for young patients for preservation and restoration of their reproductive function.

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

Inat Çapkin S.[1], Özyer S.[1], Karayalçin R.*[1], Özcan S.[1], Moraloglu Ö.[1], Ugur M.[1]

[1] Zekai Tahir Burak Women’S Health Education And Research Hospital Ankara Turkey

The objective of the study is to determine and compare the levels of anti-Müllerian hormone (AMH) and estradiol (E2) in serum and follicular fluid (FF) on the day of oocyte pick up (OPU) with the cycle parameters and the outcome of in vitro fertilization (IVF) treatment. Concentrations of AMH and E2 were measured in serum and FF of 43 women undergoing IVF treatment on the day of OPU.Serum AMH and FF AMH concentrations are positively correlated with implantation and clinical pregnancy rates.

The objective of the study is to determine and compare the levels of anti-Müllerian hormone (AMH) and estradiol (E2) in serum and follicular fluid (FF) on the day of oocyte pick up (OPU) with the cycle parameters and the outcome of in vitro fertilization (IVF) treatment.

Concentrations of AMH and E2 were measured in serum and FF of 43 women undergoing IVF treatment on the day of OPU.

Significant positive associations were observed between serum AMH concentrations and the total number of oocytes retrieved (r = 0.343, p = 0.024). Serum AMH and FF AMH levels on the day of OPU were significantly increased in the group of women who achieved clinical pregnancy (p = 0.017, p = 0.028). For serum AMH, a cut-off level of 1.64 ng/ml was used for the prediction of clinical pregnancy; for FF AMH, a cut-off level of 3.8 ng/ml was used for the prediction of clinical pregnancy. Serum AMH and FF AMH levels were significantly and positively correlated with implantation rate (r = 0.401, p = 0.008; r = 0.317, p = 0.039). No significant correlation was found between serum and FF AMH concentrations and fertilization rate.

Serum AMH and FF AMH concentrations are positively correlated with implantation and clinical pregnancy rates.

P.07.20

The effect of uterine artery embolisation on anti—mullerian hormone levels

Powell M.[1], Chandrasena A.*[1]

[1] Nottingham University Hospital - Queens Medical Centre Nottingham United Kingdom

Anti-Mullerian hormone (AMH) is a blood test that assesses ovarian reserve. Uterine artery embolisation is used to treat symptoms of fibroids. We measured the level of AMH before and after uterine artery Embolisation (UAE), to quantify possible effects on fertility 6 months after this radiological procedure.

The function of AMH within the ovary is to inhibit early stages of follicular development and it represents the ovarian follicular pool. UAE is a radiological treatment that is used to treat symptoms in women with fibroids. Women are counselled with different types of treatment for their fibroids. Management of symptomatic fibroids may include pharmalogical and non-pharmalogical methods.

Fifty seven women, aged between thirty five and fifty years old, were investigated. Every woman presented with symptomatic fibroids and MRI demonstrated the suitability of a UAE for the fibroids. The level of AMH was measured before the UAE and 6 months after the procedure.

The aim of this study was to try and more accurately assess the risk to a woman’s fertility of a UAE and therefore be more able to counsel her effectively when making the decision for a UAE rather than a surgical alternative. We have measured the level of AMH in 57 women before Embolisation. The age ranges were >35 , 35–40, 41–45, 46–50, >50. Results seem to suggest there is no statistically significant change in as seen in the preliminary data obtained.

There are few studies measuring fertility after Uterine artery Embolisation. We are investigating the impact of UAE on fertility. AMH is an accurate measurement of ovarian function compared to oestradiol, LH and FSH. We hope to obtain a quantitative measurement of the change in fertility, to counsel women about the procedure and provide them with more evidence base for choosing embolisation rather than more invasive methods of managing fibroids.

P.07.21

The failure of uterine transport function in patients with endometriosis

Gladchuk I.*[1], Rogachevs’kyy O.[1]

[1] 1st Department Of Obstetrics And Gynaecology, Odessa National Medical University, Odessa, Ukraine Odessa Ukraine

This study clearly demonstrates that women who were diagnosed with different localizations of endometriosis had opposite uterine transport disorders.

Uterine transport function is controlled by dominant follicle and it is hormone-dependent process because it strongly depends on levels of estradiol, thyrotropic hormone and tetraiodothyronine with less dependance on androgens and luteinizing hormone.

There were 54 women with different localizations of endometriosis and infertility observed. The mean age was 31 ± 6,2 years with mean term of infertilyty (4,7 ± 1,2 years). All women were operated using laparoscopic access. We used dynamic ultrasonography and hysterosalpingoscintigraphy to evaluate intrauterine transport function before operation.

The stages of endometriosis included minimal (15 cases), mild (22), moderate (11) and severe (6). We revealed that in 83,3% of patients who had mainly ovarian endometriotic heterotopias bilateral and contrlateral uterine transport was registered. In women with peritoneal endometriotic heterotopias uterine peristalsis was not found in 53,3% of cases or chaotic uterine peristalsis was detected. At the same time the damaged transport was in 26,7% among patients with peritoneal endometriotic heterotopias. If woman had mixed localization of endometriosis there was not found normal ipsilateral uterine transport.

It was proved that uterine transport function does not depend on stage of endometriosis but it is strongly connected with one’s localization. The failure of uterine transport function appears to be a cause of subfertility or infertility in patients with various forms of endometriosis.

P.07.22

The features of uterine peristalsis for adenomyosis

Garbuzenko N.*[1]

[1] Odessa National Medical University, Odessa, Ukraine Odessa Ukraine

Our study clarified the features of uterine peristalsis among patients with adenomyosis and myoma.

Adenomyosis is one of the most frequent causes of infertility. The failure of intrauterine sperm transport also must be taken into consideration when we manage patients with adenomyosis. The gold standard of intrauterine transport evaluation is dynamic ultrasonography and hysterosalpingoscintigraphy.

There were 184 women with infertility observed. The 1 group—85 patients with adenomyosis. The 2 group—67 women with myoma and adenomyosis. Control group—32 women with infertility caused by idiopathic and male factors. There was performed transvaginal ultrasonography and hysteroscopy.

Primary infertility had 113 women of 1 and 2 groups, secondary infertility—39 cases. 80% among those who had primary infertility (>30 years olds), 77% with secondary infertility (>34). The mean term of infertility (4,6 ± 1,1 years). Compared to control group women of 1 and 2 groups had an increase in the frequency of peristalsis during the whole cycle. 1 group had peristaltic dysfunction during periovular stage but women of 2 group had the biggest number of this disorder during the whole cycle. We performed a detailed examination of uterine transport function using hysterosalpingoscintigraphy. Normal ipsilateral transport took place in 10% of 1 group and 8% in 2 group. Bilateral transport was destroyed more frequently in 1 group than in other ones. Contrlateral transport was registed in 2 and control group but negative results were in the majority of cases in 2 and 1 group. Disperistalsis leads to destruction of endometrial basal membrane and activation of N-cadherin synthesizing system.

Adenomyosis can result in the uterine peristalsis failure. Myoma leads to peristaltic dysfunction during whole cycle and raises hyperperistalsis with an increasing rate of disperistaltic frequency in periovular period.

P.07.23

The importance of gynecologic laparoscopic day surgery

Valenti G.[1], Scozzaro A.[1], Piazza A. M.[1], Castelli A.*[1]

[1] Genesi Centre Palermo Italy

Laparoscopy lets the surgeon to do minimally invasive operations with big satisfaction of the patient. We analyzed the 146 gynecologic laparoscopies performed in Genesi Centre in Palermo (Italy) from January 2009 to May 2011. All of them were made in day surgery regimen which is very useful.

The best recovery after the operation and the minimally invasiveness allow the laparoscopy to be the pride of a day surgery center, especially in a center of Reproductive Health.

In day surgery we can perform both diagnostic and operative laparoscopy with minimal discomfort for the patient.

This review analyzes 146 laparoscopies performed in Genesi Centre in Palermo (Italy) from January 2009 to May 2011 (mean age 32,7 years). A history of prior abdominal surgery , disease or radiation therapy was determinedbefore as the mechanical bowel preparation. Cefixime 400 mg daily for 5 days after laparoscopy. We perform visit and ultrasound three day after the laparoscopy.

56% of the diagnostic laparoscopies became operative. In 58% of the cases there was prossimal tubal obstruction treated by transhysteroscopic Wallace ET catheter. We observed 17% of cases of misunderstood endometriosis and 35% of endometriomas. We operated 55% cistoadenomas, 15% dermoids and 5% benign tumours. We performed 10 tubal sterilization by double coagulation of the antimesenterial tract of the tubes and a 5 mm cut of the tubes. In the case of failure of the medical treatment for PCOD we make ovarian drilling with 40% PR. We treated 15 cases of extrauterine tubal pregnancy, 8 cases with salpingectomy, 7 with linear salpingotomy. The most fashion were the 3 cases of Didelphus uterus.

Both doctor and patient have advantages with the day surgery regimen laparoscopy. The day surgery regimen is the pride of a our day surgery center, especially because we treat Reproductive Health and we can perform both diagnostic and operative laparoscopies.

P.07.24

Thyroid dysfunction in infertile patients after laparoscopic drilling of ovaries

Panevska-gareva M.*[1], Angelova M.[1]

[1] M. Panevska-Gareva Sofia Bulgaria

The authors present their experience on hormonal disturbances of thyroid gland after operative laparoscopy.

The essence of polycystic ovary syndrome (PCOS) is unclear because of PCOS include the ovaries, pituitary and adrenal gland.

We investigated endocrine thyroid disorders in infertile patients with PCOS after laparoscopic ovarian drilling.

For the period 2006, 2008. and 2009. were prospectively studied 41 patients with PCOS after laparoscopic drilling and no pregnancy as early as 6 months to one year in the University Hospital “Maichin dom”, Sofia. For the control group were studied 22 patients with PCOS without laparoscopy. We examined TSH, FT3, FT4, anti-thyroglobulin /TAT/ and anti-thyroperoxidase antibodies /TPO/. Patients with abnormal hormonal tests and elevated antibodies were monitored with ultrasound of thyroid gland.

From 41 patients investigated after operative laparoscopy there were established 16 patients (39.0%) with thyroid dysfunction. In 14 patients we proved subclinical hypothyroidism (34.1%). In 7 of them (17.0%) were found thyroid antibodies. Of the total of 16 patients with thyroid dysfunction, 2 patients had subclinical hyperthyroidism.

In the control group of 22 patients, thyroid dysfunction was determined in 3 patients. (13.6%). After laparoscopic drilling from 41 patients with PCOS 16 patients (76.1%) became pregnant. Only one pregnancy was miscarriage. In the control group of 22 patients two patients (4.5%) were pregnant.

The high incidence of thyroid dysfunction in 16 patients (39.0%) with PCOS and laparoscopic drilling were very provoking. Our investigation is one attempt to seek a clinical link between the recovery of ovulation of ovaries, the change of FSH and LH.

P.07.25

Patient satisfaction with surgical management of ectopic pregnancy

Olowu O.*[1], Odejinmi F.[2]

[1] Oladimeji Olowu London United Kingdom - [2] Funlayo Odejinmi London United Kingdom

The participant rate was 97%. Degree of satisfactions depends on patients perception of compasion from the health care professionals and competence of the end result of care received. Objective was aimed at improving ectopic pregnancy (EP) management.

Early diagnoses of EP are now possible with high resolution transvaginal ultrasonography and improved operator skills. Management has shifted from radical to conservative methods, aimed at preserving fertility and minimising morbidity. In addition, Clinicians were more interested in women reaction to the experience of ectopic pregnancy. Therefore, patient satisfaction is now a significant attribute of quality control and health care goal.

This was a prospective observational study of all women who underwent laparoscopy surgery for ectopic pregnancy. Six weeks following surgery, a self-administered satisfaction questionnaire was completed by 180 out of 185 women treated between January 2009 and April 2011. Patient’s characteristics and their treatment were collected prospectively from the registered database of ectopic pregnancy. Information collected were socio-demographic, gynaecological, reproductive, surgical, condition of conception, ectopic characteristics and procedure and aspect of care received that may be associated with degree of satisfaction after treatment for ectopic pregnancy were assessed in the que.

Eighty percent were totally satisfied while 20% were less satisfied. Greater degree of satisfactions was associated with the way patient were received (85%), the willingness to listen (72%), provide adequate uniform explanation (90%). Lesser degree of satisfaction was associated with post operative physical pain (30%), anxiety for future fertility (35%), condition at conception (20%) and ruptured ectopic 22%.

Health care professionals need to be aware of significance of a compassionate care when attending to women following an ectopic pregnancy.

P.07.26

Essure microinserts can improve pregnancy rates in high surgical risk patients with repeated IVF failures and hydrosalpinx

Cohen S. *[1], Schiff E. [1], Goldenberg M. [1], Revel A. [2]

[1] Sheba Medical Center ~ Tel-Aviv ~ Israel - [2] Haddasa Medical Center ~ Jerusalem ~ Israel

Hydrosalpinx is known to have a negative effect on pregnancy implantation in patients undergoing IVF treatment. Salpingectomy is often recommended for these patients prior to continuation of IVF cycles. However, many patients with severe mechanical infertility have experienced multiple prior abdominal surgeries often with extensive bowel adhesions. ESSURE microinserts may be advantageous for such high surgical risk women.

The aim of this study is to assess the pregnancy rates in high surgical risk patients with repeated IVF failures and hydrosalpix who underwent ESSURE microinserts application in place of salpingectomy.

Twenty-two consecutive patients with repeated IVF failures, who were referred to surgery due to the presence of a hydrosalpgix, but considered highsurgical risk since they had undergone repeated previous abdominal surgeries or were known to have severe bowel adhesions, elected to undergo ESSURE microinserts application prior to continuation of IVF treatment.

Eight out of 22 patients who underwent IVF post the ESSURE application conceived after 1–3 cycles. One patient conceived with twins after previous 30 IVF cycle failures and 10 years of infertility and delivered at 29 weeks due to deterioration of her Crohn's disease, the other two patients delivered at term. Three patients are in the first trimester, and 2 patients had early trimester abortion, In one case we had to reinsert a second ESSURE microinsert due to one side expulsion. No other short or long term complications were encountered in our cohort.

High surgical risk IVF patients with hydrosalpinx can benefit from application of ESSURE microinserts and thereby avoid abdominal surgery. The relative simplicity of applying ESSURE microinserts suggests that this procedure may have growing role in the management of patients with hydrosalpinx and infertility.

Session P.08

* Innovation in Surgery *

P.08.1

Applications of V-Loc barbed suture in gynecological laparoscopic surgery

Wattiez A. [1], Maia S.* [1], Vazquez A. [1]

[1] Department Of Gynecology, Hôpitaux Universitaires De Strasbourg/ Ircad/eits, Strasbourg - France

Barbed suture presents barbs that serve to anchor the sutures to tissue without knots. The first one available was the Quill bidirectional barbed suture that has been used in laparoscopic hysterectomy, myomectomy and sacrocolpopexy.

Recently it has been introduced the V-Loc unidirectional barbed suture with a loop at the distal end to facilitate initial fastening.

The objective is to present our experience with V-Loc barbed suture in laparoscopic gynecological surgeries.

Material and methods: Retrospective analysis of the medical reports of the patients who were submitted in our department to laparoscopic gynecological surgeries using V-Loc barbed suture was carried out.

V-Loc barbed suture was used to close myometrial defects in laparoscopic myomectomies, vaginal cuffs in total laparoscopic hysterectomies and peritonization in laparoscopic sacrocolpopexies. Three patients submitted to a total laparoscopic hysterectomy presented post-operative vaginal bleeding.

From our early experience with V-Loc barbed suture we found that it facilitates suturing and saves operative time, making it a good tool for laparoscopic gynecological surgeries.

P.08.2

Case report of more than 60 single port procedures in one department

Holthaus B.*[1]

[1] St. Elisabeth Krankenhaus, Department Of Gynecology And Obstetrics

The Single Port surgery or Laparo-Endoscopic Single-Site surgery (LESS) Single Incision Laparoscopy Surgery (SILS) is a new technique of laparoscopy where only one single incision in the umbilicus is needed. This presentation will give a survey of more than 60 procedures in Damme.

A single institution retrospective review of all patients who underwent a single port surgery due to benign ovarian or adnexal tumors as well as benign disorders of the uterus over a period of one year. All surgeries were performed through a single port (Triport Olympus and SILS Port Covidien) by only one, experienced surgeon. The collected data comprised age, BMI, previous surgeries, procedure, length of surgery and hospital stay and complications.

65 patients were evaluated. The mean age was 39,5 years. The BMI averaged 23,15 kg/m². 47% of all women had had one or more surgery of the abdomen in the past. 40% of all procedures were performed as cystectomy, 32% as supracervical hysterectomy, 13% as adnexectomy, 13% at the fallopian tube and 2% as myomresection. No conversion to laparatomy or additional incisions were ever needed. The operative time ranged from 12 minutes to 85 minutes, in the mean 38 minutes. One complication occurred. No additional use of narcotics was needed postoperative. The average hospital stay was 3 days. The cosmetic results proved to be satisfactory to all patients.

The Single Port Surgery is a save, feasible procedure with an excellent cosmetic outcome. It is not a renovation of the laparoscopy yet it is conditioned by one single incision in the umbilicus an additional alternative of the minimal invasiv surgery. More instruments are needed to get a higher level of procedures.

P.08.3

Enseal vs normal bipolar: compared efficacy

Di Pietro C.*[1], Coppola A.[1], Di Luzio F.[1], Cinque B.[1], Bulzomi V.[1]

[1] Policlinico Casilino Roma Italy

We compared new bipolar technologies like Enseal with “normal” bipolar to evaluate the real availability of both.

Bipolar instruments of advanced technology use low voltage pulse energy that consents to obtain tissutal cooling. The Enseal uses this kind of energy that allows simultaneously sealing and dissect of vessels up to 7 mm with minimal thermal damage and tissutal desiccation associated with the possibility of cutting the tissue closed between the two poles.

Between January 2010 and May 2011 we identified 80 patients (mean age 34 years) who underwent laparoscopic procedures for benign gynaecological pathology using bipolar techology (40 with normal bipolar technology and 40 with Enseal). Analyzed data included sealing coagulation, quality of strenght, operative time, bleeding, length of stay, return to normal life style. Postoperative pain was assessed at 24 h using a visual analogue scale (VAS—from 0 to 10).

In our experience Enseal is a simple and convenient device and it allows a less operative time (20–50 minutes vs 30–80 with bipolar energy) for the possibility of coagulation and subsequent cutting in the same instrument. About sealing coagulation and quality of strenght, Enseal allows to control speed of sealing and cutting based on tissue type. In terms of thermal spreading Enseal is safe because it is confined to 1 mm outside jaws and it offers strong, uniform compression along the entire seal line. Bleeding (not significant), length of stay and return to normal life style is similar in all patients using the two different instruments (range 1–3 days and 4–7 respectively depending from surgical procedure). Postoperative evaluation of pain with VAS was 0–2 in patients treated with Enseal, 0–4 in patients with normal bipolar technology.

New bipolar technologies like Enseal are a valid alternative in these laparoscopic procedures in terms of safety during coagulation, quality of seal and operative time.

P.08.4

How can laparoscopic sacrocolpopexy be a faster and safer procedure?

Wattiez A. [1], Maia S.* [1], Vazquez A. [1]

[1] Department Of Gynecology, Hôpitaux Universitaires De Strasbourg/ Ircad/eits, Strasbourg - France

Sacrocolpopexy is a reconstructive surgery for Pelvic Organs Prolapse (POP) performed with the objective to reinforce the pelvic structures of support.

Laparoscopy with its own capacity of magnification and shaped information enables the surgeon to reach deep planes, making this way an ideal access to sacrocolpopexy.

The objective is to describe some tips and tricks for each step of the laparoscopic sacrocolpopexy which may make this procedure easier for the surgeon and safer for the patient.

Surgical technique: The surgical technique is divided in: (1) exposure, (2) promontory dissection and mesh bed preparation, (3) dissection of the rectovaginal and vesicovaginal spaces, (4) fixation of the mesh and (5) peritonization. Exposure is a critical step in sacrocolpopexy because bowel suspension gives freedom to the hand of the assistant and enables an easy fixation of the mesh in the promontory. During the dissection of the vesicovaginal space the critical point is to grasp the whole bladder and not only the overlying peritoneal fold, because this reduces the risks of bladder damage. Some tips about mesh fixation in puborectalis muscle, vagina and promontory will be given. Since the majority of ureteral complications in open sacrocolpopexy occur during peritonization, the right ureter must be clearly identified during this step.

The best way to save time in laparoscopic surgery is to avoid unnecessary maneuvers.

The clues provided can make laparoscopic sacrocolpopexy easier and safer.

P.08.5

Long-term follow up of a randomized controlled trial comparing bipolar radiofrequency endometrial ablation with hydrotherm ablation for dysfunctional uterine bleeding

Herman M.*[1], Penninx J.[1], Mol B.[2], Bongers M.[1]

[1] Maxima Medical Centre Veldhoven Netherlands - [2] Academic Medical Centre Amsterdam Netherlands

At 5 years after treatment, bipolar radiofrequency endometrial ablation system is more effective than hydrothermablation in the treatment of menorrhagia.

Previously we have reported that at 12 months after treatment bipolar radiofrequency endometrial ablation was superior over hydrotherm ablation in the treatment of menorrhagia. In this paper we evaluate the results at 5 years of follow-up.

This study was a double-blind, randomized controlled trial, which took place in a large teaching hospital in The Netherlands. A total of 160 premenopausal women suffering from menorrhagia were included. Between March 2005 and August 2007 160 women were randomly allocated to bipolar ablation or hydrotherm ablation. At 4–5 years of follow-up a questionnaire was send to all the participants to register amenorrhea rates, reinterventions and patient satisfaction.

At 5 years, the follow-up rate were 90% and 83% in the bipolar group and hydrotherm group, respectively. Amenorrhea rates were 55.4% and 35.3% in the bipolar group and the hydrotherm group, respectively (relative risk 1.5 [95% CI 1.0–2.3]). The number of surgical reinterventions was 11 versus 23 (hazard rate ratio 0.43 (95% CI 0.21–0.86)). Overall more women were satisfied in de bipolar group compared to the hydrotherm group.

The results from this follow up study showed that bipolar ablation has many advantages over hydrotherm ablation. Not only gives it a higher amenorrhea rate, it also shows less reinterventions and higher levels of satisfaction. So, the bipolar radiofrequency endometrial ablation system is more effective than hydrotherm ablation in the treatment of menorrhagia.

P.08.6

Our experience of performing laparoscopic hysterectomy by using SILS-port

Puchkov K.*[1], Andreeva J.[1], Serebryanskiy O.[1], Dobychina A.[1]

[1] Center For Clinical And Experimental Surgery Moscow Russian Federation

This paper presents our experience of laparoscopic hysterectomy by using SILS-port. 47 hysterectomies have been performed to the present moment by using SILS-port: 21 total hysterectomy, 26 subtotal hysterectomy. 11 operations have been perfomed simultaneously (with cholecystectomy). The port is located in the umbilicus area to minimize accessive injury and to improve the cosmetic effect. We consider it is necessary to perform all steps of the procedure carefully irrespective of the type of the approach. Uterus size is not larger then 10–12 weeks’ pregnancy. These are patients with symptomatic myoma (clinically manifested metrorrhagia), endometrial hyperplasia (including atypical hyperplasia), adenomyosis.

Skin incision is made through the umbilicus along the upper contour in the form of “omega” letter (incision gives the best cosmetic effect at a sufficient length). Further dissection of the anterior abdominal wall is achieved under the visual control. Elastic and flexible umbilical device (SILS-port) allows to insert 3 trocars to the abdominal cavity and to insufflate gas. All main standard stages of hysterectomy are performed by using roticulator instruments (Auto Suture). Intersection of the ligamentous apparatus of the uterus and uterine artery ligation is performed by “Force Triad” electrosurgical system. After the uterus removal the vaginal stump is sutured with the help of “Endo Stitch” device with absorbable suture (in the cases of total hysterectomy). In the cases of the subtotal hysterectomy we remove the uterus with the help of the morcellation through the port incision.

Average duration of the surgery: 20–40 minutes(we aschieve this point after 15 operation).

Average time of stay in hospital: 36–48 hours. A significant pain reduction is achieved within the nearest postoperative period (4–6 hours).

Based on our experience we can recommend this method for hysterectomy.

P.08.7

Ten-year follow up of a randomized controlled trial comparing novasure and thermachoice endometrial ablation for dysfunctional uterine bleeding

Herman M.*[1], Penninx J.[1], Mol B.[2], Bongers M.[1]

[1] Maxima Medical Centre Veldhoven Netherlands - [2] Academic Medical Centre Amsterdam Netherlands

At 10 years after treatment, bipolar radiofrequency endometrial ablation system is still more effective than balloon ablation in the treatment of menorrhagia.

Previously we have reported that at 12 months and 5 years after treatment bipolar radiofrequency endometrial ablation was superior over balloon ablation in the treatment of menorrhagia. In this paper we evaluate the results at 10 years of follow-up.

This study was a double-blind, randomized controlled trial, which took place in a large teaching hospital in The Netherlands. A total of 126 premenopausal women suffering from menorrhagia were included. Inclusion took place between November 1999 and July 2001. These women were randomly allocated to bipolar radiofrequency ablation and balloon ablation in a 2:1 ratio.

At 10 years of follow-up a questionnaire was send to all the participants to register amenorrhoea rates, reinterventions, patient satisfaction and health-related quality of life (HRQoL).

At 10 years, follow-up rate was 84% in the bipolar group and 80% in the balloon group. Amenorrhea rates were 73% in the bipolar group and 66% in the balloon group, respectively (relative risk 1.1 [95% CI 0.83–1.5]).

23 reinterventions have been performed in total, 14 in the bipolar group compared to 9 in the balloon group (Relative risk 0.8 [95% 0.39–1.7]). At 10 years of follow up more women were satisfied with the result of the bipolar ablation.

- HrQoL: follows.

At 10 years after treatment, bipolar radiofrequency endometrial ablation system is still more effective than balloon ablation in the treatment of menorrhagia.

P.08.8

Two-steps office hysteroscopy for the treatment of endometrial polyps

Cammareri G.*[1], Di Francesco S.[1], Lanzani C.[1], Turri A.[1], Rehman S.[1], Macalli E.[1], Ferrazzi E.[1]

[1] Children’s Hospital Vittore Buzzi, University Of Milan, Milan Italy

59 women with endometrial polyps larger than 15 mm were prospectively recruited. Hysteroscopic treatment of endometrial polyps by means of a 2 steps hysteroscopic removal was performed.

The minimal diameter of instruments of office operative hysteroscopy usually limits the diameter of the lesions to be treated. The aim of this study was to evaluate the feasibility of office hysteroscopic treatment of endometrial polyps larger than 15 mm by means of a two steps hysteroscopic removal.

59 women, with endometrial polyp larger than 15 mm were prospectively recruited. The procedures were performed using the vaginoscopic approach using a continuous flow office hysteroscope with an external diameter 4.5 mm and a 30° foreoblique lens (Office hysteroscope, Karl Strorz ,Germany) equipped with an operative channel of 1.8 mm with flexible coaxial bipolar electrode (Versapoint Bipolar Electrosurgical System-Gynecare).Polipectomy was completed by two steps procedures. The first procedure obtained an histologic sampling at the base of the polyp and a deep incision of the pedicle was performed without complete removal of the lesion. After 2 months the residual endometrial lesion was removed. The degree of discomfort was assessed by means of a visual analogue scale (VAS).

Median age of the study group was 58 (i.r. 47–67). Thirty-seven patients (62.7%) were postmenopausal, 8 of whom nulliparous (21.7%). The prevalence of diabetes and hypertension in postmenopause women was 3% and 56.2% respectively. The average size of polyps was 24.24 mm(i.r. 18–28.5). Median time of the procedure was 8,25 minute (5–15). The average degree of pain was 3 range (1–5). None of the women experienced severe complications during the procedure.

A planned two-steps office hysteroscopic polypectomy is a clinically feasible alternative to the traditional resectoscopic removal of large polyps even in nulliparous postmenopausal women.

P.08.9

Fluid absorption after laparoscopic surgery is related to the type of gas used

Verguts J.*[1], Corona R.[1], Declerck S.[2], Creassaerts M.[1], Timmerman D.[1], Koninckx P. R.[1]

[1] Uz Leuven Leuven Belgium - [2] Esaturnus Leuven Belgium

Fluid is absorbed after surgery depending on the type of gas and fluid used.

Absorption of Icodextrin 4% or Ringers lactate from the peritoneal cavity was never measured by ultrasound, but by other means such as aspiration by a dwelling catheter during chemotherapy for colorectal cancer (REF Hosie). This is an invasive way to measure residual volume of fluid, but lead to the assumption that Icodextrin 4% remains in the cavity for at least 96 hours, where saline was absorbed within 24 hours.

We developed a curve to accurately measure the volume of fluid in the abdominal cavity by vaginal ultrasound (REF Verguts). From this curve we could calculate the volume of fluid present in the abdominal cavity when performing a vaginal ultrasound in the post-operative phase after leaving one liter of fluid (Adept® vs. Ringer lactate) in the cavity. We compared the two absorption curves of Adept and Ringer lactate with a CO2 pneumoperitoneum and after full conditioning of the peritoneal cavity. Full conditioning consisted of 86% carbon dioxide, 4% oxygen, 10% nitrous oxide, temperature regulation at 32°C and 100% humidification.

Fluid absorption was fastest in the carbon dioxide group when Ringer lactate was used: no detectable fluid after 48 hours and the slope of the curve was the steepest. This was as expected. The slowest resorption occurred however in the carbon dioxide group where Adept® was used where we still had a pocket of fluid after 72 hours. Resorption in the full conditioning group when Adept® was used was slower then when Ringer lactate was used.

Absorption of peritoneal fluid after surgery is faster than described in literature so far. The peritoneal environment is of utmost importance in absorption of different fluids and full conditioning is a favorable factor to maintain fluid for a longer period.

P.08.10

CO2 absorption during laparoscopic surgery is related to the type of gas used

Verguts J.*[1], Corona R.[1], Declerck S.[2], Craessaerts M.[1], Vanacker B.[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 will decrease CO2 absorption.

Cardiovascular stimulation with tachycardia, arrhythmias and hypertension occur when intra-abdominal pressure (IAP) exceeds 12–14 mm Hg. CO2 pneumoperitoneum also causes hypercapnia and respiratory acidosis. Acidosis in rabbits was prevented by adding 4% of oxygen to the CO2 pneumoperitoneum63. This increase in CO2 absorption was equally decreased by adding oxygen and it is reasonable to assume that the mesothelial hypoxia causes a trauma exposing directly ECM.

In this prospective randomized trials using pure 1. CO2 or 2. CO2 + 4% of oxygen or 3. Full conditioning (86% CO2 + 10% N2O + 4% O2, T°32°C, humidification + sprinkler) we included women undergoing laparoscopy for at least one hour. Laparoscopy was standardized by adjusting the insufflation pressure to 15 mmHg. Endpoints of the trial were heart rate, blood pressure, ventilation frequency, stroke volume and end tidal CO2 (ET CO2) and they were recorded every minute.

Regarding systolic blood pressure (initial raise of 30%) and heart rate there were no significant differences between the three groups. ET CO2 had a comparable increase in the three groups of about 20% during the first 15 minutes. In the control group where 100% CO2 was used, a further increase in ET CO2 was seen. In the group where 4% of oxygen was added to the CO2 pneumoperitoneum or with full conditioning we noted a significant (p < 0.001) decrease in ET CO2 during the rest of the procedure. The three groups showed a remarkable divergence in ET CO2 starting only 15 minutes after creation of the pneumoperitoneum.

From this we may confirm that the mesothelial layer maintains its integrity. This finding also adds up to the safety of the full conditioning where hypercarbia is almost unthinkable under these conditions.

P.08.11

Introduction of new technology: a guideline for surgeon and medical company

Vleugels M.*[1]

[1] Riverland Hospital Tiel Netherlands

The ideal pathway for surgeon and medical companies to introduce new technologies in a specific health care system is described and evaluated.

Due to the increasing rate and speed of new introduced technologies, implementation, evaluation and training of surgeons is often poor with risks for patients, Introduction of a new hysteroscopic sterilization (Essure) was done according a new pathway, TARGET. The set up, performance , endpoints are presented as an example of the ideal introduction of new technolo.

Essure sterilization met was introduced according the TARGET model ; T = training , teaching of all users (n = 161) and their nurses (n = 243) was done by 5 recognized trainers in 5 centers; all trainers were trained by the initial trainer surgeon. Format and content of all centers are the same. trainers are obliged to attend twice yearly refreshment meetings with. A = users were assisted during the first procedures at their hospitals (n = 82) by one of the trainers. R = registration of data are gathered = G. Data are evaluated and T = tackling of protocol or problems to re-train users. Users are invited for annual meetings, accreditated. 250 nurses got a regional follow up training once yearly; complications and pregnancies were registered , evaluated by 2 trainers; feedback was given also to all users as learning point. At last, every user can send problems with the confirmation test or other question to the panel of trainers anonymously; each trainer gives his opinion, and these are condensed in one advice. A news letter is distributed yearly to all users.

Endpoints are pregnancies; after more than 16000 procedures the pregnancy rate is 1.4 pro 1000 procedures; cooperation between the national society , surgeons and medical companies enables this well controlled introduction.

Session P.09

* Myomectomy *

P.09.1

Are there any limitations for laparoscopic polymyomectomy?

Dubuisson J.* [1], Yaron M. [1], Eperon I. [1], Dubuisson J. [1]

[1] Head Department Of Obstetrics And Gynecology, University Hospitals Of Geneva - Switzerland

At present, the techniques used in laparoscopic myomectomy are well developed.

Preventive occlusion of uterine arteries as the initial step helps decrease blood loss, vision is improved with HD video-cameras, using electrical morcellator has never been easier and overall, surgeons are more comfortable with the technique.

The indications for laparoscopic myomectomy are well described for a single leiomyoma.

However, there is paucity of information in regard to multiple leiomyomas ablation by laparoscopy.

This presentation will discuss the precise indications and contra-indications for laparscopic polymyomectomy.

P.09.2

Fertility and pregnancy outcome following laparoscopic myomectomy

Ribic-pucelj M.*[1], Glavan S.[2]

[1] University Clinical Centre, Dep. Ob/gyn Ljubljana Slovenia - [2] General Hospital Novo Mesto Novo Mesto Slovenia

85 women underwent laparoscopic myomectomy. 67 had reproductive problems and 18 did not yet attempt to conceive. Out of 76 (89.4%) who attempted to conceive, 63 (81.9%) became pregnant 47 (74.6%) spontaneously, and 16 (25.4%) in ART. There were 53 term deliveries, 2 (3.2%) preterm, 6 (9.5%) spontaneous abortions, 2 (3.2%) voluntary terminations of pregnancy and 1 (1.6%) ongoing.

The extent to which myomas affect fertility and whether their removal improves this, remain unclear. The same is with the effect of myomectomy on implantation rate and pregnancy rates prior to assisted reproduction.

Between 1.Jan 2003 and 31.Dec 2006, a questionnaire was sent to 125 women of reproductive age who underwent laparoscopic removal of intramural myoma. 85 (68.9%) responded. Mean age of patients was 31.2 years, mean size of myoma was 5.18 cm. One ampoule of Pitressin diluted in 60 ml of normal saline was injected into the myoma. Uterus was cut with Ultracision knife. Myomas were removed from abdominal cavity with electric morcelator. Uterus was sutured with PDS-O suture.

After the surgery, 76 (89.4%) attempted to conceive. 67 women had reproductive problems and 18 did not yet attempt to conceive There were 63 (81.9%) pregnancies: 47 (74.6%) spontaneous, 1 (1.6%) following IUI and 16 (24.6%) in ART. Excluding 2 voluntary terminations of pregnancy, laparoscopic myomectomy resulted in 54 (85.7%) term deliveries, 2 (3.2%) preterm deliveries, 6 (9,5%) spontaneous abortions, 2 (3.2%) women decided for voluntary termination of pregnancy and 1 (1,6%) was still ongoing during the study. There were no complications.

Our results show high pregnancy rates following myomectomy and lower spontaneous abortion rate and preterm delivery compared to general population. It should be performed in infertile women with no other cause of infertility and in women with impaired reproductive performance.

P.09.3

Interlocking suturing in laparoscopic myomectomy; a state of art

Shams M.*[1]

[1] Maher Shams Mansoura Egypt

Laparoscopic myomectomy rather than abdominal myomectomy has been well documented as a treatment option for uterine myomas. However, laparoscopic myomectomy has many limitations, the most important one is suturing of the uterine defect. This step is a challenge even for experienced surgeons. The introduction of a simple but highly effective technique for excision of myoma and suturing using standard instrumentation in laparoscopic myomectomy.

After incision of the myometrium, the myoma pseudocapsule is separated by insertion of the dissector tip and scissors into the myoma. After completion of myoma enucleation, the surgeon makes a U-shaped hole of suture material with forceps for an interlocking suture, and the first assistant holds the stitch to maintain the suture tension throughout the repair.

From decembre 2008 to decembre 2010,68 patients with a diagnosis of uterine myoma underwent laparoscopic myomectomy by the same surgeon using the aforementioned procedure.

The mean diameter of the myoma was 6.3 cm (range, 4–9 cm), and multiple myomas were observed in cases (44.2%). As a result, the mean operative time was 75.9 min (range, 35–155 min), and the hospital stay was 2.7 days (range, 2–5 days). The blood loss was 137.2 ml (range, 50–250 ml), and the hemoglobin decline on the first day after surgery was 1.5 mg/dl (range, 0.1–3.6 mg/dl). Postoperative fever higher than 37.7°C was the most commonly observed morbidity (ten patients, 23.3%). However, no cases had conversion to laparotomy or major complications requiring reoperation or readministration during the mean follow-up period of 5.9 months (range, 3–9 months).

Laparoscopic myomectomy can be performed easily and effectively by forceps insertion and continuous interlocking suture using standard instruments.

P.09.4

Isobaric gasless laparoscopic myomectomy for multiple, medium or large uterine leiomyomas, under general or combined spinal-epidural anaesthesia: operative 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 207 isobaric laparoscopic myomectomies, between October 2005 and December 2010 in an Obstetrics and Gynaecology University Department.

Uterine leiomyomas are the most common neoplasia in women during fertile and perimenopausal age. In young women myomectomy is the first choice intervention.

Two-hundred seven women with one or more intramural or subserosal uterine myomas measuring more than 4 cm, symptomatic or progressively enlarging underwent Isobaric Gasless laparoscopic myomectomy using a subcutaneous abdominal wall lifting system and conventional surgical instruments under general or combined spinal-epidural anaesthesia.

The number of myomas removed per patient was 2.2 ± 1.9. The diameter and volume of the biggest fibroid was 7.0 ± 2.5 cm and 168.7 ± 165.6 cm3 respectively. The biggest fibroid was intramural in 76% and subserosal in 24% of the cases. The total volume of removed fibroids per patient was 193.2 ± 173.4 cm3. The endometrial cavity was never opened. The median operating time was 95 [70–125] minutes with a correlation with total volume of myomas, maximum volume and number of myomas removed. The median blood loss was 200 [100–450] mL. No intra-operative local vasoconstrictive drugs were used. Ninety-seven interventions were performed under spinal-epidural anesthesia and 110 under general anesthesia. The conversion rate to laparotomic procedure was 5.8%. Blood transfusion rate was 2%. Two major complications (1%) were observed after the procedure: two cases of haemoperitoneum respectively caused by bleeding from the major ancillary port and from the uterine suture and treated by laparotomic intervention.

Isobaric myomectomy under general or combined spinal-epidural anaesthesia is a safe and reliable procedure both for large and multiple intramural or subserosal uterine myomas.

P.09.5

Laparoscopic myomectomia: factors that influence the course of operation and early postoperative period

Mecejus G.*[1], Baužyte E.[2], Kuropatkinaite I.[3]

[1] Vilnius City University Hospital, Vilnius University Vilnius Lithuania - [2] Vilnius City University Hospital Vilnius Lithuania - [3] Vilnius University Vilnius Lithuania

The study about factors that have influence to success of removing myomas laparoscopically.

The aim of this study was to evaluate factors, that influence the course of laparoscopical myomectomy and the early postoperative period.

Retrospective analysis of women, laparoscopically operated because of subserosal and/or intramural myomas from the 1st of January to 31st of December 2010, case-records was done.We estimated quantity of myomas, the biggest myoma’s diameter, duration of operation, postoperative stay in hospital and early postoperative complications. All patients were divided into 3 groups according to the largest myoma’s diameter: I group—myoma up to 3 cm in diameter, II group—from 3 to 8 cm , III group—myoma more than 8 cm. Data were analyzed among these 3 groups.

Totally 58 laparoscopical myomectomy operations were performed during this period. We included 57 cases for analysis (in 1 case sarcoma was found). I group consisted of 9 cases, II group—40 cases, and III group—8 cases. Duration of operation in groups was 40,6 ± 18,5 min, 99,4 ± 42,02 min and 110,6 ± 36,1 min respectively. Postoperative hospitalization time was 13,6 ± 9,8 hours, 26,1 ± 8,1 hours and 30,6 ± 10,8 hours respectively. This difference in groups was statistically significant (p < 0,05). We found 7 intraoperative and early postoperative complications—excessive bleeding (6 cases) and fever more than 38°C (1 case). General complications rate was 12,3% (7 of 57 cases), most complications occured in II group (6 of 40 cases—15%).

Small myomas can be removed successfully without any risk of intraoperative and postoperative problems. Removing of fibroids more than 3 cm diameter require additional skills. These cases are associated with increased risk of intraoperative and early postoperative problems (bleeding and fever), and also with prolonged hospital stay (up to 48 hours).

P.09.6

Laparoscopic myomectomy in the peri- and postmenopause

Radosa M.*[1], Winzer H.[1], Mothes A.[1], Camara O.[1], Diebolder H.[1], Weisheit A.[1], Runnebaum I.[1]

[1] Jena University Hospital Jena Germany

Data from our study indicate that LM in the peri- and postmenopause is a safe and efficient treatment option if a patient opts to preserve her uterus.

The aim of this study was to demonstrate safeness and feasibility of LM as a surgical treatment option for patients who wish to preserve their uterus beyond their reproductive period.

We evaluated the surgical outcome and patient’s satisfaction for a total of 451 patients (85 peri- or postmenopausal women—Group A and 366 premenopausal women—Group B) who underwent LM from 1998 to 2008 at our department.

Dysmenorrhoe and infertility related to the presence of myoma in the uterus were the main reasons for myomectomy in group B, while lower abdominal pain and hemorrhage were the predominant indications in group A. The average number of fibroids removed and the size of the leading fibroid were similar in both groups. A significant difference was observed for the required surgical time for removal of fibroids between both groups (Group A: 102.8 minutes, Group B: 128.6 minutes; p < 0.01). Rates of intra—(2.21% overall) and postoperative complications (6.22% overall) were comparable for both groups. Duration of post-surgical hospitalization was shorter in Group B (4.4 days) compared to Group A (5.0 days) (p < 0.01). Evaluation of the patient’s questionnaire showed a comparable, high, satisfaction with the results of the surgical procedure in both subgroups with a significant higher number of relapses in group B (N = 46) compared to group A (N = 3).

Complication rates for laparoscopic myomectomy seem to be comparably in pre- and postmenopausal patients. In the follow-up of our study cohort, we observed a low rate of relapses associated with a high degree of patients’ satisfaction.

P.09.7

Myomectomy through laparoscopically assisted ultraminilaparotomy

Gorostiaga A.*[2], Villegas I.[1], Quílez J. C.[1], Rui-wamba M. J.[1], Arriba T.[1]

[1] Centro De Ginecología Y Medicina Fetal. Cegymf. Bilbao, Spain - [2] Centro De Ginecología Y Medicina Fetal. Cegymf. Bilbao, Spain -University Of The Pays Basque

Myomectomy is a technique advisable for symptomatic women who wish to preserve their childbearing capabilities.

Laparoscopic myomectomy has become progressively more popular, although its long learning curve and the size of the myomas, make it very difficult and sometimes impossible for non-experienced surgeons. Laparoscopically assisted ultraminilaparotomy myomectomy is a feasible alternative in cases of big myomas or reduced esperience in endoscopic suturing.

We report the results of our first 5 cases of myomectomies performed laparoscopically assisted under general anaesthesia, between January 10- September 10. All were performed by endoscopic dissection, with no vasopressin injection, after 4 trocars had been inserted (umbilical, suprailiac (2) and suprapubic). A “screwdriver” endoscopic instrument and grasping forceps were also needed and specimen were morcellated using a self-made instrument.

Sutures to repair the myometrial defects were applied through a minilaprotomy access (3–4 cm). After closure of the suprapubic wound, laparoscopy was newly used to clean the cavity and check for correct haemostasia.

The mean age of the patients was 32,2 (29–41). In three cases, more than 1 myoma was excised (in one of them, 10). All of them were intramural or intramural/subserous.

The mean size of the myomas was 5,5 cm (3–8 cm). The mean time of the surgery was 70 min (40–120 min). The time till discharge was 48 hours in 4 caese and 24 in one, with no registered intra or postoperative complications. Histopathology showed a common diagnosis of leiomyoma.

Laparoscopically assisted myomectomy is a technique that may lessen the concerns regarding regarding laparoscopic myomectomy while retaining the benefits of laparoscopic surgery. Conventional sutures allow a more proper wound closure, specially in cases of big myomas or reduced experience. By decreasing the technical demands, and thereby the operation time, and no increase in time till discharge, UMLAM may be more widely offered to patients as a modified approach for myomectomy.

P.09.8

Prediction of postoperative anemia following laparoscopic myomectomy

Cho H.*[1]

[1] Seoul National University Bundang Hospital Seongnam Republic Of Korea

Myomectomy is one of the often performed procedure to preserve fertility in women. The blood loss during myomectomy is a remaining issue for many gynecolgists. This study was designed to assess the risk factors related to blood loss during the laparoscopic myomectomy, then to sort out the high risk patients for postoperative anemia. Significant hemoglobin change (=2.0 g/dl) was associated with large size, number, long operation time. But the location and type of the myoma was not affect the hemoglobin change.

Myomectomy is one of the often performed procedure to preserve fertility in women. Among the diverse approaches to the myomectomy, laparoscopic myomectomy is one of the world widely used method. Significant blood loss after procedure is the main issue of myomectomy compared to the hysterectomy. Thus, this study was designed to assess the risk factors related to blood loss during the laparoscopic myomectomy, then to sort out the high risk patients for postoperative anemia.

A retrospective review of medical records for 167 patients who underwent laparoscopic myomectomy between 2008 and 2009 was performed. The relationship of hemoglobin change with other clinical characteristics including the mean age of patient at operation, the largest diameter, type and number of the uterine fibroids were evaluated.

Significant hemoglobin change (=2.0 g/dl) was associated with large sized myoma (=6.5 cm in the largest diameter, =33.4 cm2 in width), multiple myoma (=3) and long operative time (=92 min). (P = 0.017, 0.006, and 0.008) Though the myoma with pedunculated type or location in the broad ligament was associated with more change in hemoglobin level, there were no statistical significances. (P = 0.812, and 0.492).

Patients with risk factors for anemia after laparoscopic myomectomy should be informed and managed appropriately before surgery.

P.09.9

Pregnancy outcomes and long-term follow-up after transvaginal myomectomy by colpotomy

Rovio P.*[1], Heinonen P. K.[1]

[1] Tampere University Hospital Tampere Finland

Transvaginal myomectomy by colpotomy is a feasible operation of choice for symptomatic women with uterine leiomyomas wishing to retain the potential for childbearing. The aim here was to establish the long-term effects of the method on uterine ruptures, fertility and pregnancy outcome. Pregnancies after operation were uneventful and no uterine ruptures were detected.

Uterine leiomyomas can cause significant morbidity. Transvaginal myomectomy by colpotomy is a feasible operation of choice for symptomatic women who desire to retain the potential for childbearing and is associated with short operating time and recovery. The aim here was to establish the long-term effects of the method on uterine ruptures, fertility and pregnancy outcome.

The study group comprised 16 women with symptomatic uterine leiomyomas. The surgery was successfully performed in all patients. The mean follow-up period was 90 months (range 53—120 months). Data on possible pregnancies, infertility treatments, hysterectomies and other reoperations during the follow-up period were collected from the hospital records.

Eight (50%) out of 16 patients produced 14 pregnancies. The mean interval between the myomectomy and the first pregnancy was 27 months (range 14 to 68 months). All pregnancies were uneventful and ended in full-term delivery of a healthy infant. Uncomplicated vaginal delivery was recorded in 10, vacuum extraction in one and cesarean section in three out of 14 cases. Uterine rupture or heavy postpartal bleeding was not reported. Since the myomectomy, no hysterectomies or reoperations have been performed among the patients.

Pregnancies after transvaginal myomectomy by colpotomy were uneventful and no uterine ruptures were detected during a long-term follow-up. The method is a safe and feasible treatment option for selected patients wishing to preserve their ability to conceive.

P.09.10

Reproductive outcomes after laparoscopic myomectomy

Ito K.*[2], Asada H.[2], Arima H.[2], Tsuji-nishiyama H.[2], Furuya M.[2], Kishi I.[1], Kobiki K.[3], Yoshimura Y.[2]

[1] Saiseikai Central Hospital, Department Of Gynecology Tokyo Japan - [2] Keio University School Of Medicine, Department Of Obstetrics And Gynecology Tokyo Japan - [3] Kobiki Women’s Clinic Kanagawa Prefecture Japan

We evaluated the reproductive outcomes after laparoscopic myomectomy (LM). In this study, pregnancy outcomes were generally good. LM is relatively safe for patients who desire pregnancy.

Compared with myomectomy by laparotomy, LM reduces postoperative pain and shortens hospital stay. Additionally, LM has particularly advantage in that it could reduce the risk of postoperative adhesions when pregnancy is desired. However, it is controversial whether LM raises uterine rupture or not. The purpose of this study was to assess reproductive outcomes after LM including the risk assessment.

Among the 387 patients who underwent LM in our department between January 2005 and December 2010, 145 patients wanted to get pregnant. We evaluated the pregnancy rate, pregnancy outcomes, the contribution factors for pregnancy and pregnancy related complications.

Among the 145 patients, 74 patients (51.0%) had a total of 86 pregnancies after LM 59 pregnancies (68.6%) were spontaneous. 5 pregnancies (5.8%) were performed IUI and 20 pregnancies (23.2%) required IVF. The mean (±SD) age was 36.1 ± 3.7 years in pregnant group (74 patients), and was 38.0 ± 3.7 years in non-pregnant group (71 patients). The mean age was significantly lower in the pregnant group than in the non-pregnant group (p < 0.01). The following are reproductive outcomes; 54 pregnancies (62.8%) were term deliveries, one pregnancy (1.1%) was an early delivery (at 36 weeks), 17 pregnancies (19.8%) were spontaneous abortions, and one (1.1%) was ectopic pregnancy. 5 patients (5.8%) are in pregnancy at this time. 54 (98.2%) were delivered by Caesarean section. There were two cases of threatened premature labor, and one case of threatened rupture of uterus. There was no uterine rupture.

In this study, pregnancy outcomes were generally good. The main determinant of pregnancy rate after LM is patient age. This procedure is relatively safe for patients who want to become pregnant.

P.09.11

Results of hysteroscopic myomectomy for different types of submucous uterine fibroids

Tatarchuk T.[1], Kosey N.[1], Tutchenko T.*[1], Dzhupin V.[1]

[1] Institute Of Pediatrics, Obstetrics And Gynaecology Kyiv Ukraine

The location and size of submucous uterine fibroids influences the success of surgical treatment.

Results of type G1 and G2 hysteroscopic myomectomy are analyzed in the paper.

As long as submucous fibroids constitute a frequent cause of abnormal uterine bleeding infertility and pregnancy losses a save and effective method for their removal is needed.

While preferential position of hysteroscopic resection for G0 fibroids is proved, the most beneficial method for G1 and especially G2 fibroids remains the object of discussion.

Two groups of childbearing age patients with solitary symptomatic submucous fibroids underwent hysteroscopic myomectomy: group I included 50 patients with G1 fibroids (size 2.6–5.0 cm), group II included 42 patients with G2 fibroids (size 2.5–4.8 cm). Main outcome measures were: operating time, menorrhea relief and need for reintervention.

Mean operating time in group II was 63.5 + 6.8 min compared to 38.7 + 5.2 min in group I.

Incomplete resection was observed in 16 (32%) of group I and in 31 (73.8%) of group II patients. Menorrhea relief within 6 months follow up was achieved in 46 (92%) of group I and in 20 (47.6%) of group II patients. Need for repeated surgery was 78.6% in group II and 22% in group I.

Hysteroscopic myomectomy is more beneficial for G1 type of fibroids. To achieve higher rates of complete resection and symptom relief of G2 type of fibroids other methods or pretreatment procedures have to be considered.

P.09.12

The effectiveness of hysteroscopic myomectomy for young patients with large submucous fibroids and infertility

Aleksandrov O.*[1], Popova L.[1]

[1] Odessa National Medical University, Odessa, Ukraine Odessa Ukraine

The study demonstrates high effectiveness of hysteroscopic myomectomy with absence of complications and good reproductive outcome for young patients with large submucous fibroids and infertility.

Leiomyomas are the most common benign tumor found in women, as they affect 15–25% of women in the reproductive age group. When we use hysteroscopic myomectomy for removing of large fibroids (>3 cm) it must be controlled by laparoscopy.

There were 32 women (28–36 years olds) with large submucous fibroid (3–5 cm) observed. All patients had primary and secondary infertility caused by different factors (hormonal disorders, adhesions, male factors, idiopathic etc.). The mean term of infertility (5,6 ± 1,2 years). Hysteroscopic myomectomy was performed in all cases. In 4 cases (the tumor size >4,5 cm) this procedure was controlled by laparoscopy in order to prevent uterine perforation. The mean time of operation was 26 ± 3,2 min.

We did not reveal any complications after these operations. Two-step operations were performed in 5 cases where we could not remove whole fibroid tissue properly. Such women were operated repeatedly after 3–4 weeks. Twenty eight women have become pregnant during the next 2 years and they had deliveries through the natural passages with 3 women whom caesarean section was performed (indications included severe fetal hypoxia, dystocia and placental abruption).

Our results have proved high effectiveness of hysteroscopic myomectomy which has to be more largely used for this category of patiens. However, each case dictates what kind of surgical strategy should be used. Diagnostic laparoscopy enables to avoid many possible complications and perform laparoscopic myomectomy if it is required.

P.09.13

Uterine arteries embolization as a pretreatment before hysteroscopic myomectomy of large submucous fibroids

Tatarchuk T.[1], Kosey N.[1], Tutchenko T.*[1], Vasilchenko L.[1]

[1] Institute Of Pediatrics, Obstetrics And Gynaecology Kyiv Ukraine

Results of hysteroscopic myomectomy of large submucous G1 and G2 fibroids after pretreatment with UAE are presented.

Submucous G1 and especially G2 larger fibroids (>4 cm) constitute the limits of hysteroscopy application. Pretreatment with uterine arteries embolization (UAE) may be used for making hysteroscopic myomectomy feasible.

35 women (mean age of 42.6 ± 4.5 years) with symptomatic solitary G1 fibroids and 47 (mean age 44.1 ± 4,2 years) with G2 fibroids were included in the study. Mean diameter of fibroids was 4.75 + 1.26 cm (range: 3.5–6.5 cm). All the patients underwent UAE as a pretreatment before planned hysteroscopic myomectomy.

During 3 months post-UAE follow up there were 17 cases (48.6%) of G1 and 11 cases (23.4%) of G2 fibroid spontaneous expulsions. The later caused no major or surgical complications. Ultrasound examination of G1 and G2 fibroids that did not undergo spontaneous expulsion showed their mean size reduction by 28% and 41% respectively in 3 month after UAE. Two (4.2%) of the G2 fibroids changed their location to intramural with minimal contact with endometrium. Noteworthy, that these changes were followed by significant symptom relief so that the patients did not undergo further treatment.

18 patients with G1 fibroids and 34 patients with G2 fibroids underwent hysteroscopic myomectomy. Complete resection was achieved in 16 (88.9%) of patients with G1 fibroids and in 16 (47%) of G2. Mean time of intervention was 33.2 + 4.8 minutes. 20 cases of incomplete resection are being planned for repeated surgery.

Pretreatment with UAE is a perspective option of making large G1 and G2 fibroids hysteroscopic resection more successful. In certain cases symptom relief due to node size reduction or spontaneous expulsion after UAE makes further treatment unnecessary. Controlled studies are needed for more certain results.

P.09.14

Uterine rupture rate during pregnancy after laparoscopic myomectomy according to the suturing technique

Dowaji J.*[1], Jaenicke F.[1]

[1] University Medical Center Hamburg-Eppendorf Hamburg Germany

The suturing technique during the laparoscopic myomectomy is very important especially when used in patients with hypo fertility. We prenet here a study including 70 patients in two groups according to suturing technique using single stitches taking up the full depth of the edges of the hysterotomy in one or two layers.

The aim of this study is to evaluate retrospectively the risk for uterine rupture during a subsequent pregnancy after laparoscopic myomectomy sutured in one layer taking up the full depth of the edges of the hysterotomy or in two layers.

Seventy patients with intramural leiomyomas were operated laparoscopically due to hypo fertility reasons. The uterus was sutured with single stitches in one layer in forty patients (group I) and in two layers in the other thirty patients (group II).

These patients were followed up during the next pregnancy. The mode of delivery and obstetric outcome were also reported.

The average number of removed leiomyomas was 2 with a mean weight of 85 g. The cavum uteri was opened in 14 patients (6 in group I and 8 in group II)

Four patients (the cavum uteri was opened in all these cases) had uterine rupture during labor; three in group I (7.5%) and one in group II (3.3%).

The risk of uterine rupture during the following pregnancy is higher in deep intramural leiomyomas especially when sutured with single stitches in only one layer.

Session P.10

* Office & Diagnostic Hysteroscopy *

P.10.1

A pilot study: histological changes in premenopausal women aged 41 to 44 years

Dawood R.*[1], Dada T.[1]

[1] Buckinghamshire Healthcare Nhs Trust Aylesbury United Kingdom

Investigation of abnormal uterine bleeding (AUB), in pre-menopausal women 41 to 44 years is not defined.We hope our study will add to the current literature to ensure appropriate investigation of AUB in this age group.

The management of Abnormal Uterine Bleeding (AUB) in women over 45 years of age involves investigation by hysteroscopy/ ultrasound and endometrial sampling whilst those under 40 generally does not. Our study attempts to risk assess those between these age groups for endometrial abnormalities which may have implications for management pathways.

We conducted a retrospective analysis, over 6 years of 449 pre-menopausal women with AUB, aged between 41 and 44 years. All women had an outpatient hysteroscopy (OPH) and endometrial sampling and were entered into our outpatient hysteroscopy database. Histopathology reports were cross-linked from the pathology database and the results are presented.

The main reasons for referral to OPH were heavy and irregular menstrual bleeding. Data was available for all of the 449 patient entries.

We Stratified age groups between 41/42 years of age (group A) and 43/44 years (Group B). Both groups, A & B had a 2% incidence of abnormal endometrial pathology—Group A (4/223;1.8%) vs Group B (5/226; 2.2%). This was reported as simple or complex hyperplasia, complex hyperplasia with mild or severe atypia and adenocarcinoma. We found that the more sinister pathology ie atypical endometrial changes occurred in the older age group 43/44 years. Furthermore the two cases of adenocarcinoma occurred in women in Group B.

The overall risk of abnormal endometrial pathology in our patient series occurred in 2% with a risk of endometrial cancer of 0.4%.

NOur study suggests a 2% risk of endometrial cellular abnormality in premenopausal women with AUB in the 41–44 yr age range. These figures would suggest the investigation of these women by hysteroscopy/USS and endometrial sampling though larger studies are needed to clarify the true danger from AUB in women over 40 but under 45 years of age.

P.10.2

A prospective audit examining women’s experience of pain during out-patient hysteroscopy

Teasdale A.*[1], Holloway D.[1]

[1] Guy’S & St Thomas’ Nhs Trust London United Kingdom

The purpose of the audit is to examine women’s experience of pain during out-patient hysteroscopy, and identify factors which may influence that experience.

This audit is being undertaken in an out-patient setting. Hysteroscopies are undertaken by both medical and nursing staff.

A prospective audit of all out-patient hysteroscopies undertaken in a large London teaching hospital over a 3 month period. Practitioners completed a data sheet immediately following the hysteroscopy. Data collected includes parity, menopausal status, previous gynae surgery or known pathology, hysteroscopy findings, technique, length of procedure, pain score during and after procedure.

A prospective audit of all out-patient hysteroscopies undertaken in a large London teaching hospital over a 3 month period. Practitioners completed a data sheet immediately following the hysteroscopy. Data collected includes parity, menopausal status, previous gynae surgery or known pathology, hysteroscopy findings, technique, length of procedure, pain score during and after procedure.

Depending on findings we are hoping to tailor pre procedure advice to address individual need rather than give the same advice to all. This could potentially lead to a change in practice. If, for example, we find that women who suffer with very painful periods always find hysteroscopy very painful, perhaps we should ensure that these women always have analgesia before proceeding with the hysteroscopy.

P.10.3

A review of pain and satisfaction with outpatient hysteroscopic sterilization

Delgado Espeja J. J.*[1], Solano Calvo J. A.[1], Heron Iglesias S.[1], Martinez Parrondo N.[1], Guzman Muñoz M.[1], Zapico Goñi A.[1]

[1] Teaching Hospital Principe De Asturias. University Of Medicine Alcalá De Henares. Madrid Spain

Hysteroscopy allows to perform a sterilization method in an outpatient setting, with or without anesthesia, with a minimum discomfort and a good recovery.

To describe women’s pain and satisfaction after ESSURE placement in an office setting of a Gynecology department in a teaching hospital.

A total of 108 women who underwent hysteroscopic sterilization by ESSURE microinserts placement and indormed consent provided, from February 2010 to February 2011 at Principe de Asturias Teaching Hospital, Alcalá de Henares, Madrid, Spain.

Medical and surgery history, procedural data, feasibility, complications, type of anesthesia used, premedication, pain scale and satisfaction grade were collected.

Succesful bilateral tubal placement of ESSURE devices was achieved in 102/108 women (96,5%). There were no mayor procedure related complications recorded.

Overall, patients satisfaction was high. On a 0 to 5 scale, 68% women rated the method at 5 (highest degree).

In relation to pain assessment, the average pain score immediately postprocedure was 3,18 on a 0 to 10 scale.

ESSURE method appears to be a good alternative to laparoscopic sterilization, with high rates of patient satisfaction, good recovery and low scores of pain in an outpatient setting.

P.10.4

An outpatient hysteroscopy audit at Whipps Cross Hospital, London

Arambage K.*[1], Wong M.[1], Rodrigo K.[1], Sivarajasingam S.[1], Leitch-devlin L.[1], Hussain S.[1]

[1] Whipps Cross University Hospital London United Kingdom

We audited outpatient hysteroscopies over 18 months and compared our success rate to the RCOG Outpatient Hysteroscopy Guideline.

Consultants performed two-thirds of the hysteroscopies. The overall failure rate was 6.9%, mainly due to cervical stenosis. We recommended changes to the database, a new local protocol and a re-audit in 6 months.

Hysteroscopy is a generally safe and well-tolerated procedure, and has been performed successfully in the outpatient setting in the UK. Complications include failure, pain, bleeding and injury. This is a prospective outcome audit to determine our failure rate of outpatient hysteroscopies and the reasons.

A prospective outcome audit was conducted of all hysteroscopies done from April 2009 to October 2010 at our hospital (554 patients). Cancellations and non-attendances were excluded from analysis. The database was used to analyse referrals, outcomes, failed procedures and histology. Success was compared to the 94% rate referenced above.

Menorrhagia was the main indication for referral (45%), followed by post-menopausal (16%) and inter-menstrual bleeding (11%).

Procedures were mostly performed by a consultant (66%) or nurse practitioner (31%). 48 were abandoned, 14 of which were not indicated, giving a failure rate of 6.9%. This was attributed to cervical stenosis (18), menstruation (7) and not tolerated (7). 20 of the 34 failed hysteroscopies were referred for GA hysteroscopy.

Of 307 samples, 260 were benign while 4 were complex hyperplasia with atypia and 1 was malignant.

Abnormal uterine bleeding was the main referral indicator. Small number of hysteroscopies were performed by Registrars. Our success rate is comparable to the referenced standard with cervical stenosis the main reason for failure.

We recommend changes to the database for improved documentation and the formulation of a local policy with a re-audit in 6 months to complete the cycle.

P.10.5

Are we able to diagnose malignant endometrial pathology by hysteroscopy? Current situation in our area

Guzmán Muñoz M.[1], Delgado Espeja J. J.*[1], Solano Calvo J. A.[1], Heron Iglesias S.[1], Martinez Parrondo N.[1], Zapico Goñi A.[1]

[1] Principe De Asturias Teaching Hospital. University Of Medicine Alcalá De Henares. Madrid Spain

Hysteroscopy is an endoscopic technique which allows the study and treatment of processes affecting the uterine cavity. It is a widely used procedure in our area to diagnose any endometrial pathology.

Evaluate the effectiveness and reliability of the technique in the diagnosis of endometrial pathology, estimating pathological correlation with hysteroscopic findings, from 2005 until 2010 at the Principe de Asturias Teaching Hospital, University of Medicine, Alcalá de Henares, Madrid, Spain.

An analytical, descriptive and retrospective study composed by 391 women using a 5 mm continuous flow diagnostic hysteroscope (Karl Storz Bettocchi) with a 5 fr working channel. Data were obtained from a database created by the Department of Gynecology and analized using SPSS 15.0.

The mean age was 49 years (51% postmenopausal women). The main reason was held for dysfunctional uterine bleeding (47%). Mean operative time was 5 minutes. The main reason for not being able to complete hysteroscopy was severe cervical stenosis (2,2%) but there were no major complications associated with the procedure. We found a high correlation between hysteroscopic findings and final pathological diagnosis, coinciding both diagnoses in 86,2%. This correlation is even greater in endometrial adenocarcinoma (100%).

Diagnostic hysteroscopy is a highly effective method, considered as “gold standard” for the examination of the uterine cavity, and can prevent missed diagnosis of malignant endometrial pathology.

P.10.6

Audit of outpatient hysteroscopy in a DGH setting

Ajay B.*[1], Sabouni M.[1], Richter G.[1], Townsend P.[1]

[1] Surrey And Sussex Nhs Trust Redhill United Kingdom

Outpatient hysteroscopy is successful, safe and well tolerated procedure. It is convenient and cost effective means of diagnosing and treating abnormal uterine bleeding as well as aiding the management of other benign gynaecological conditions. Vaginoscopy reduces pain during diagnostic rigid outpatient hysteroscopy.

Outpatient hysteroscopy is an established diagnostic test widely used in UK. This procedure is commonly used in the assessment of women with abnormal uterine bleeding as well as fertility problems. Operative procedures endometrial polypectomy, removal of small submucous fibroids and removal of the intrauterine devices are also undertaken in our unit.

This is a retrospective audit of all the cases performed from June 2004 to May 2009 using the departmental register which has all the information. The aim of this audit was to see the unit’s adherence to the RCOG guidelines and to study the outcome of the procedure.

Total 1664 patients were included in this audit. The age group was from 20 to 93 years and the mean age was 52. Indications for the use of this procedure was 40% postmenopausal bleeding, 33% menstrual disorders, 8% ultrasound findings of the polyp, 6.8% had removal of intrauterine devices, 5% had abnormal smears , 3.2% had fertility problems, 3% had known fibroids(cavity assessment before surgery) and 0.4% had recurrent miscarriage. Successful procedure including diagnostic and operative was carried out in 95%. Success rate varied between the operators as the experience and skill differed. Since 2006 vaginoscopy was used as the preferred method and speculum and dilators were used only for cervical stenosis.

The use of outpatient hysteroscopy started in our unit in 2004. Initially speculum and dilators were used in all patients during the period of 2004–2005. Since 2006 vaginoscopy was the preferred method. The audit showed the unit’s policies and guidelines adhered to the RCOG guidelines.

P.10.7

Can we improve the management of patients with postmenopausal bleed (PMB)?

Singh R.*[1], Majumder K.[2], Sule M.[3], Linder 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

Use of outpatient hysteroscopy (OPH) may cut down waiting times without sacrificing accuracy. Transvaginal sonography (TVS) may be used as an effective screening tool to determine need for hysteroscopy. The mode of screening will depend on local resources and expertise. A one stop PMB clinic will help streamline patient management, optimize use of resources & improve the quality of care provided to in patients with PMB.

PMB is a common cause for referral to Gynecologists. We assessed the role of TVS, hysteroscopy, pipelle sample or combinations of the above in management of patients with PMB.

Retrospective audit of women presenting with PMB at the Ipswich Hospital, UK. 100 patients with PMB were assessed to determine care received, management protocol followed, and correlation between various investigative techniques used i.e. TVS, hysteroscopy & pipelle sampling, and histology. The results were analyzed to determine an optimal local management protocol & develop a PMB clinic.

Most patients were seen within 2 weeks of referral. An endometrial thickness of = 4 mm at TVS correlated well with absence of significant pathology. Both outpatient & inpatient hysteroscopy were successful in most patients & equally effective in detecting intrauterine pathology. Hysteroscopic findings had excellent correlation to histology. Use of OPH resulted in faster diagnosis & fewer visits to the hospital.

PMB is a common cause of anxiety & referral in postmenopausal patients. Both outpatient & inpatient hysteroscopy are equally effective. Use of OPH may cut down waiting times without sacrificing accuracy. TVS may be used as an effective screening tool to determine need for hysteroscopy. The mode of screening will depend on local resources and expertise. A one stop PMB clinic will help streamline patient management, optimize use of resources in patients with PMB & improve the quality of care provided.

P.10.8

Confirmation of Essure® placement using transvaginal ultrasound

Carnide C.[1], Moreira M.[1], Moreira C.[1], Oliveira M.*[1]

[1] Hospital Infante D. Pedro Aveiro Portugal

Hysteroscopic sterilization Essure®, is a safe and effective method of permanent contraception. The current recommendation to check the position of the Essure® device is by abdominal X-ray 3 months after insertion. We propose that transvaginal ultrasound (US) should be the first diagnostic test to confirm the correct placement of the device. It was conducted a retrospective cohort study of 100 women who had the Essure® procedure at our centre, by offering TV US in women with abdominal Rx 3 months after insertion and hysterosalpingography (HSG) when indicated.

Hysteroscopic sterilization Essure®, is a safe and effective method of permanent contraception. The current recommendation to check the position of the Essure® device is by abdominal Rx 3 months after insertion. We propose that US imaging is more suited for this purpose.

We conducted a retrospective cohort study of reproductive age women requesting permanent sterilization. It was offered a transvaginal US to the 100 patients who had the Essure® procedure at our centre. All the patients had made abdominal X-ray 3 months after insertion, and HSG when indicated.

The micro-inserts were easily distinguished by their echogenic coil-like appearance within each uterine cornua extending into the proximal fallopian tube. Retrospective analysis of medical records of the 100 patients who underwent hysteroscopic sterilization Essure® was performed. The data obtained by US (correct placement) were compared with results obtained from the abdominal X-ray and HSG.

Transvaginal US is a minimally invasive, simple and reproducible technique to assess the position of the Essure® microinsert and appears to protect most patients from the negative aspects of pelvic radiography and of HSG. TV US should be the first diagnostic test used to confirm the adequacy of correct placement of the Essure® device.

P.10.9

Correlation between endoscopic image and pathological anatomy in endometrial cancer

Curi Lehmann M. L.*[1], Triaca L.[1], Rubal A.[1], Achard A.[1], Germano G.[1]

[1] Centro Hospitalario Pereira Rossell Montevideo Uruguay

Analysis of the correlation between endoscopic image obtained by hysteroscopy and pathological anatomy in endometrial cancer.

Postmenopausia metrorrhagia is a common reason for consultation in gynecological consulting room and a form of presentation in endometrial cancer

The objective was to evaluate the role of hysteroscopy in the diagnosis of endometrial cancer.

From 5834 hysteroscopies ,2838 were selected in which endometrial biopsy was performed. From this group 137 were selected for having an image compatible with endometrial cancer or a diagnosis of cancer in the pathological anatomy.

1.7% of all hysteroscopies performed turned out to be endometrial cancer.

63% of all endometrial cancer presents clinically as postmenopausia metrorrhagia.

The evaluation in a representative group of patients about the effectiveness of hysteroscopy in the diagnosis of endometrial cancer was satisfactory, though we are convinced that it can be improved with image classification, assistance from ultrasosography and a correctly performed byopsy.

P.10.10

Diagnostic accuracy of hysteroscopy in the diagnosis of intrauterine pathology

Ferreira C.*[1], Silva V.[1], Raposo L.[1], Damasceno Costa J.[1], Santos Paulo A.[1], Pipa A.[1], Nogueira Martins F.[1]

[1] S. Teotónio Hospital Viseu Portugal

The authors evaluated the diagnostic accuracy of hysteroscopy in the evaluation of the uterine cavity pathology in 1179 hysteroscopies.The sensitivity was 96.0% for endometrial polyps,50.6% for myomas,70.9% for carcinoma and 62.0% for endometrial hyperplasia.

Combined with histological examination of an endometrial sampling,hysteroscopy is considered the ‘gold standard’ in the diagnosis of intra-uterine abnormalities.In the majority of cases,a correct diagnosis and proper choice for eventual subsequent operative strategy can be obtained.The authors evaluated the diagnostic accuracy of hysteroscopy in the evaluation of the uterine cavity pathology.

Retrospective study of 1179 hysteroscopies with follow-up endometrial sampling performed between January 2006 and April 2011 in S.Teotónio Hospital.Hysteroscopic results were compared with histological findings in order to analyse the reliability of the endoscopic procedure.

The mean age of the patients was 55.3 yrs.The main hysteroscopic findings were endometrial polyps (n = 692;58.7%), endometrial hypertrophy (n = 262;22.2%), malignancy (n = 78;6.6%) and submucosal myomas (n = 62;5.3%).The relevant histopathological results were endometrial polyp (n = 574;48.7%), simple/complex hyperplasia without atypia (n = 108;9.2%), simple/complex atypical hyperplasia (n = 21;1.8%), carcinoma (n = 79;6.7%) and leiomyoma (n = 77;6.5%).The sensitivity and specificity of hysteroscopy was respectively 96.0% and 76.7% for endometrial polyps, 50.6% and 97.9% for myomas, 70.9% and 98.0% for carcinoma,and 62.0% and 82.7% for endometrial hyperplasia.The positive predictive value of hysteroscopy was 79.7% for polyps,62.9% for myomas,71.8% for carcinoma and 30.5% for hyperplasia.

Hysteroscopy showed a good diagnostic accuracy for the exploration of the uterine cavity,specifically for polyps and carcinoma,firming its role in establishing diagnosis and therapy of intrauterine abnormalities.

P.10.11

Diagnostic hysteroscopy and breast cancer

Giannone E.*[1], Giannone L.[1], Candelori E.[1], My V.[1]

[1] Ospedale S.Maria Terni Italy

We analyze patients treated with tamoxifen, compared with women undergone surgery because of a previous breast cancer, but never treated with tamoxifen, in order to determine the incidence of pathologic changes in the endometrium caused by tamoxifen and to analyze the efficacy of diagnostic hysteroscopy in the evaluation of these side effects.

Tamoxifen, a non-steroidal antiestrogen, is used successfully in the adjuvant therapy of ER + breast cancer, but in the long-term administration it causes several uterine changes. For this reason women must be under careful surveillance.

Tamoxifen group (51 patients) and control group (55 patients) underwent office hysteroscopy followed by endometrial biopsy.

In the tamoxifen group, hysteroscopy showed an atrophic endometrium, a cystic atrophy and a hypotrophic endometrium in 51.1%, in 8.9% and in 4.4% of patients respectively; an atrophic endometrium with polyps, a hyperplastic endometrium and a proliferative endometrium in 24.4%, in 4.4% and in 2.2% of cases respectively; an intramural myoma in 2.2% and a hyperplastic endometrium with polyps in 2.2% of patients. Biopsy confirmed the results of hysteroscopy in 73.7% of cases.

The control group showed an atrophic endometrium and a hypotrophic endometrium in 85.5% of cases and only in the 14.5% of cases it showed pathologic uterine changes; while the biopsy showed insufficient tissue (13%), an atrophic endometrium (81.9%), a hyperplastic endometrium (3.4%) and a proliferative endometrium (1.7%).

The treatment with tamoxifen leads to a higher incidence of uterine pathology, even if not statistically significant (tp = 0,42). Hysteroscopy represents the best second level method in the diagnosis of endometrial abnormalities because it offers a direct view of the uterine cavity and allows to reveal focal lesions and to make biopsies.

P.10.12

Do post-menopausal women with abnormal trans-vaginal ultrasound scan but no vaginal bleeding need hysteroscopic assessment?

Laiyemo R.*[1]

[1] Hannah Brown, Uzma Ghaffer, Tolu Adedipe, Sian Jones Bradford United Kingdom

This study suggests that the incidence of endometrial cancer in postmenopausal women with abnormal trans-vaginal scan but no vaginal bleeding is low and endometrial thickness > = 11 mm seems reasonable to use as cut-off for referral for hysteroscopic assessment.

Endometrial thickness (ET) of 4–5 mm is used as cut off above which hysteroscopic assessment is indicated in postmenopausal women with vaginal bleeding (10% cancer risk).The risk of cancer in postmenopausal women without vaginal bleeding but abnormal trans-vaginal scan (TVS) is unknown and there is no agreed ET above which referral is indicated in these women.Smith-Bindman et al (2004) proposed ET =11 mm as the cut off above which referral for hysteroscopic assessment is indicated in these group of patients.They estimated the risk of cancer is 6.7% if ET > = 11 mm and <0.002% if <11 mm in these women.

Retrospective cohort study of postmenopausal women with abnormal TVS but no bleeding referred for outpatient hysteroscopy between January 2008 and December 2010.

63 women identified.

2 cases of cancer out of the 63 patients giving an incidence of 3.17% (95% CI: 0.3%, 11%).

ET range 2.8 mm to 40 mm.

22 cases had ET >11 mm of which 2 were malignant giving a risk estimate for endometrial cancer of 9.1% (95% CI :1.1%, 29.2%).

Both malignant cases had ET  11 mm (21 and 27 mm).

61 patients had benign pathology—40.98% had atrophic endometrium (AE). 59.02% had benign polyp (BP).

The results from our study are consistent with the conclusions of Smith-Bindman et al. Our study gives a risk estimate of 9.1% compared to 6.7% (Smith-Bindman). ET is on average ,thicker in BP than AE (p = 0.00135). Incidence of endometrial cancer is 3% in our study.

An agreed threshold of ET in postmenopausal women with abnormal TVS but no bleeding will reduce unnecessary referrals for hysterosccopy.

P.10.13

Don’t miss a horn! A technique to biopsy both uterine horns in a uterus bicornis or septate uterus

Dacco’ M. D.*[2], Petrakis P.[1], Moustafa M.[1], Krishnamurthy G.[1], Tsimpanakos I.[1], Spinillo A.[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

We describe the use of the H Pipelle® endometrial sampler to ensure that both horns of a bicornuate uterus are biopsied in a patient with postmenopausal bleeding.

Endometrial cancer can develop in either or both horns of a bicornuate or septate uterus. When investigating a patient with potential endometrial carcinoma, it is essential to biopsy both cavities.

We report a patient aged 52 years who presented with postmenopausal bleeding. She had a history of breast cancer and was being treated with Tamoxifen. Ultrasound scan showed a bicornuate uterus with endometrial thickness of 9 mm and 10 mm in the two horns. Hysteroscopy confirmed the uterine anomaly with normal looking endometrium in both horns.

We took an endometrial biopsy from both cavities using a H Pipelle®. We positioned the hysteroscope in the right cavity, inserted the H Pipelle® into it through the diagnostic sheath after withdrawing the optic and performed a biopsy. We re-hysteroscoped the patient placing the hysteroscope into the left cavity to allow biopsy of that side using the same technique. Histopathology showed proliferative endometrium in the left horn and was inadequate from the right horn.

It is recommended that women presenting with recurrent postmenopausal bleeding or postmenopausal bleeding associated with abnormal ultrasound findings or risk factors should undergo endometrial sampling to exclude atypia or malignancy.Biopsies may be obtained by performing the procedure under ultrasound control, or using an operating hysteroscope and biopsy forceps. The former needs the inconvenience of a full bladder while the latter tends to provide very little tissue for analysis. These inconveniences are avoided by our technique; we feel that failure to obtain adequate tissue for histological diagnosis from one side was related to the thinness of the endometrium.

P.10.14

Endometrial assessment in patients with breast cancer treated with tamoxifen

Santos M.*[1], Ruivo P.[1], Fernandes S.[1], Rego J.[1], Marques A.[1], Botto I.[1]

[1] Maternidade Bissaya Barreto Coimbra Portugal

One of the side effects of tamoxifen (TAM) treatment in patients with breast cancer appears to be its proliferative effect on the endometrium.

Retrospective study to define the ultrasound(US)/hysteroscopy(HSC) correlation to propose a practical approach for endometrial surveillance of these patients.

TAM is a drug of proven efficacy in reducing recurrences and increasing global survival in patients with breast cancer. It is also a human carcinogen with recognized effects in the endometrium such as adenocarcinoma, hyperplasia and polyps.

Frequently, endometrial changes in US are alarming and do not have histophatological confirmation.

The aim of this study is to define the US/HSC correlation of endometrial changes in women with breast cancer TAM-treated.

This involved 57 patients with 74 episodes of endometrial changes at US who underwent subsequent HSC.

Data were analyzed using Statistical Package for the Social Sciences 17.

Mean age was 54 years. Median time to US changes was 24 months.

US showed: endometrial thickening(41,9%),heterogeneous endometrial thickening(37,8%),endometrial polyp(16,2%) and focal endometrial thickening(4,1%). HSC showed: endometrial polyp(50,0%),cystic atrophy(25,7%),atrophic endometrium(16,2%),endometrial hyperplasia(2,7%),endometrial adenocarcinoma(2,7%),proliferative endometrium(1,4%) and submucosal myoma(1,4%). Pathology showed: endometrial polyp(41,9%),cystic atrophy(23,0%),atrophic endometrium(20,3%),endometrial hyperplasia(9,5%),submucosal myoma(2,7%),endometrial adenocarcinoma(1,4%) and secretory endometrium(1,4%).

The correlation between US and HSC was 55,4%.

In our study there was a low correlation between US and HSC which conducted a large number of patients to unnecessary HSC.

An optimal endometrial monitoring approach is necessary where sonohysterography can have a place since increases US specificity in endometrial assessment.

P.10.15

Endometrial assessment in patients with breast cancer treated with tamoxifen

Santos M.*[1], Ruivo P.[1], Fernandes S.[1], Rego J.[1], Marques A.[1], Botto I.[1]

[1] Maternidade Bissaya Barreto Coimbra Portugal

One of the side effects of tamoxifen (TAM) treatment in patients with breast cancer appears to be its proliferative effect on the endometrium. Retrospective study to define the ultrasound(US)/hysteroscopy(HSC) correlation to propose a practical approach for endometrial surveillance of these patients.

TAM is a drug of proven efficacy in reducing recurrences and increasing global survival in patients with breast cancer. It is also a human carcinogen, with recognized effects in the endometrium such as adenocarcinoma, hyperplasia and polyps. Frequently, endometrial changes in US are alarming and do not have histophatological confirmation.

The aim of this study is to define the US/HSC correlation of endometrial changes in women with breast cancer TAM-treated. This involved 57 patients with 74 episodes of endometrial changes at US who underwent subsequent HSC. Data were analyzed using Statistical Package for the Social Sciences 17.

Mean age was 54 years. Median time to US changes was 24 months. US showed: endometrial thickening(41,9%),heterogeneous endometrial thickening(37,8%),endometrial polyp(16,2%) and focal endometrial thickening(4,1%). HSC showed: endometrial polyp(50,0%),cystic atrophy(25,7%),atrophic endometrium(16,2%),endometrial hyperplasia(2,7%),endometrial adenocarcinoma(2,7%),proliferative endometrium(1,4%) and submucosal myoma(1,4%). Pathology showed: endometrial polyp(41,9%),cystic atrophy(23,0%),atrophic endometrium(20,3%),endometrial hyperplasia(9,5%),submucosal myoma(2,7%),endometrial adenocarcinoma(1,4%) and secretory endometrium(1,4%). The correlation between US and HSC was 55,4%.

In our study there was a low correlation between US and HSC which conducted a large number of patients to unnecessary HSC. An optimal endometrial monitoring approach is necessary where sonohysterography can have a place since increases US specificity in endometrial assessment.

P.10.16

Histeroscopic polipectomy performed in office: studying the possible influence of several factors in the duration of the procedure

Neves J. P.*[1], Arteiro D.[1], Martinho M.[1]

[1] Centro Hospital São João, E.P.E. Porto Portugal

The aim of our study was to determine the influence of polyp characteristics and operator skills or fatigue in the duration of office histeroscopic polipectomy. We failed to demonstrate the relationship between the factors considered and the duration of the procedure.

The histeroscopic polipectomy performed in the office is a common therapeutic approach to uterine polyps. We studied the impact of several factors in the duration of the procedure, a surrogate measure of its difficulty and of the technical skills or fatigue of the operator.

Retrospective analysis of the clinical files of patients submitted to polipectomies (using mechanical or bipolar energy) in office at our institution between October 2009 and June 2010. We studied the relationship between characteristics of polyps (location, >1 polyp, polyp >2 cm, sessile polyp) and measures of operator technical skills (resident or specialist) or fatigue (procedures performed in the second half of the working period or whether the procedure was one of the last two performed in the working period) and longer procedure durations (duration superior to the average procedure duration of the sample, 19 minutes).

71 patients were submitted to polipectomy in office setting (61 using scissors and 10 using bipolar energy). We found no statistical differences between polyp characteristics and measures of operator skills or fatigue.

Our study failed to demonstrate any differences between several polyp characteristics and measures of operator skills or fatigue in the duration of histeroscopic polipectomies performed in office. The small sample size and the retrospective nature of the reported procedure duration registered in the clinical files may have influenced the results.

P.10.17

Hysteroscopic evaluation in patients with thickened endometrium on ultrasound

Silva V.*[1], Ferreira C.[1], Raposo L.[1], Damasceno Costa J.[1], Santos Paulo A.[1], Pipa A.[1], Nogueira Martins F.[1]

[1] S. Teotónio Hospital Viseu Portugal

The authors evaluated the hysteroscopic appearance of the endometrium and the pathological findings in 1158 cases of sonographically thickened endometrium. Malignancy was diagnosed in almost 10% of cases. The most common finding was endometrial polyp.

Endometrial cancer ranks fourth as the most common form of cancer in women, accounting for approximately 3,4 deaths per 100.000 women per year,in Portugal.A thickened endometrium on ultrasound indicates an increased risk of uterine cavity pathology.In theses cases, a diagnostic hysteroscopy should be performed. The authors evaluated the hysteroscopic appearance and the pathological findings in cases of sonographically thickened endometrium.

Retrospective study of 1158 women with thickened endometrium on ultrasound, who underwent diagnostic hysteroscopy, between 2006(January) and 2011(April). 550 women(47%) had registry of a conclusive histological examination.

The mean age of the women was 59,8 years. Hysteroscopy suggested the presence of intrauterine polyps in 592 women (51%),normal endometrium in 215 (19%),hipertrofic endometrium in 158 (14%),leiomyoma in 60 (5%),malignancy in 51 (4%) and uterine malformations in 24 (2%).

Of 550 histological examinations, polyps were diagnosed in 293 cases (53%),normal features in 114 (21%) and endometrial hyperplasia in 69 (13%).In 48 women (9%) an endometrial carcinoma was diagnosed and,of these,33 cases had been previously suspected on diagnostic hysteroscopy(histeroscopic sensibility:72%).

On histologic examinations, malignancy was diagnosed in almost 10% of cases. The most common histeroscopic and histologic finding in patients with thickened endometrium were endometrial polyps. Hysteroscopy represents an easy,safe and effective method for the investigation of women with thickened endometrium on ultrasound,and to determine which patients will require biopsy or surgical intervention.

P.10.18

Hysteroscopic sterilization: predictive factors of essure device placement failure

Solano Calvo J. A.*[1], Delgado Espeja J. J.[1], Guzmán Muñoz M.[1], Heron Iglesias S.[1], Martinez Parrondo N.[1], Zapico Goñi A.[1]

[1] Principe De Asturias Teaching Hospital. Universidad De Medicina Jalcalá De Henares. Madrid Spain

Hysteroscopic sterilizations is a less invasive method than laparoscopic technique but could be impossible to perfom in different situations.

To examine the factors associated with placement failure of ESSURE microinserts after a year of introduction in a public teaching hospital.

A retrospective study of 108 women seeking tubal sterilization, who provided informed consent, performed in a public office setting in Príncipe de Asturias Teaching Hospital, Alcalá de Henares, Madrid, Spain.

Data about medical and surgery history, procedural data (number of spirals left, feasibility), non or local anesthesia used, premedication; pain assessment, satisfaction degree, were collected.

The mean age of patients was 37,7 years (+/− 4,24). The mean body mass index 29,73. (+/− 5,27). Mean parity 2,2 (+/− 1,1). Mean number of spirals left: right tubal ostia: 3,88 and left tubal ostia: 2,41.

Total procedure averaged time was 9 minutes (+/− 4,92). The microinserts were placed successfully in 102/108 patients (94,4%).

The failure rate for the device placement observed was 5,5%, and was not significantly associated with any data collected, except suboptimal tubal ostia view.

Hysteroscopy sterilization is an easy and minimal invasive method that could be a good alternative to laparoscopic approach because of its high reliability and low rate of complications.

P.10.19

Hysteroscopic tubal occlusion—the experience of Centro Hospitalar da Póvoa de Varzim/Vila do Conde

Sousa R.*[1], Coelho F.[1], Assunção F.[1], Lino C.[1], Aroso A.[1]

[1] Centro Hospitalar Da Póvoa De Varzim e Vila Do Conde Póvoa De Varzim Portugal

Evaluate the success rate of hysteroscopic tubal occlusion(HTO) since this procedure was introduced at our centre.

This permanent birth control method has the benefit of not being necessary any type of incision,the possibility of being performed in an outpatient setting with local or no anaesthesia.However it is necessary to maintain an effective contraceptive method for 3 months,until bilateral tubal occlusion is confirmed.

Retrospective analysis of all women submitted to HTO between November 2008 and February 2011 at our centre.

A total of 75 HTO were performed.The average duration of the procedure was 16.9 min.(minimum of 10 min.;one case of 60 min.).Some of the most extended procedures were due to difficulties in insertion of the coils (described in 5 cases),having also other interventions being performed in the same procedure time,as a hysteroscopic polypectomy. 4 cases had unilateral insertion, of which one was submitted to tubal ligation in the same procedure time and three in a second surgical time.In 41% a pelvic X-ray was done as confirmation test 3 months later,33% had a hysterosalpingography,19% had 2 confirmation tests and 7% did not perform any.59 cases of bilateral tubal occlusion were confirmed,with only 3 cases of unilateral tubal occlusion(in 8 cases results were unknown).After the procedure all women were asymptomatic.

Considering the cases where the results of the confirmation tests are known and including the case where tubal ligation was carried out during the same procedure time,a success rate of 94% was achieved.The intervention failed in only 6%,having no major complications,lateral effects,complaints or pregnancies,although there are only 2 years of follow-up.We can conclude that HTO with the insertion of microcoils is a safe and effective method of definite family planning carried out at our centre.

P.10.20

Hysteroscopic tubal sterilization with essure device: what happen after?

Velasco Sanchez E.*[1], Arjona Berral J. E.[1], Povedano Cañizares B.[1], Monserrat Jordán J. A.[1]

[1] Hospital Universitario Reina Sofía Córdoba Spain

To evaluate the method in terms of satisfaction and quality of life in women one year till six years after procedure.

Once it has been stablished the feasibility of the sterilization with Essure microinserts it’s time to study the impact of the method in womens life years after procedure.

Prospective randomized study of 500 patients in which Essure was performed between 2003 and 2009, trhrough a questionnary self validated, performed three months after placement and years after placement, comparing the results at short(three months), medium(2–3 years) and long term (five-six years). We evaluate satisfaction, menstrual disorders, sexual life, and regret of the method.

89,4% of patients are highly satisfied at short term, increasing till 99,5% at long term. Only 1,4% of women refered menstrual disorders three months after procedure, being excessive uterine bleeding the most frequent disorder. 94,4% of patients refered changes in sexual life, all of tem in terms of improvement of their sexual life. 3 patients regret the procedure.

The hysteroscopic tubal sterilization with Essure microinserts increase patients satisfaction after the three months waiting period, and it’s not associated with menstrual disorders. It should be considered the first line method in women desiring permanent contraception.

P.10.21

Importance of diagnostic hysteroscopy on the evaluation of intracavitary polyps

Curi Lehmann M. L.*[1], Triaca L.[1], Rubal A.[1], Achard A.[1], Germano G.[1]

[1] Centro Hospitalario Pereira Rossell Montevideo Uruguay

Evaluation of intracavitary polyps by hysteroscopy at the consulting room.

Polyps are a very frequent pathology during para and postmenopausia , a fact that motivates implementation of hysteroscopy to determine its nature.

From a total of 6000 hysteroscopies, 527 patients were selected for having one or more intracavitary polyps upon endometrium whithout any other pathology. These patients were 27 to 83 years old.

Those features assessed were:

  1. 1-

    Age at the time of presentation

  2. 2-

    Indication of hysteroscopy

  3. 3-

    Incidence of malignancy on those polyps

Endometrial polyps appears more frequently during paramenopausia and early postmenopausia. Generally, bleeding is a frequent symptom but they can be asymptomatic. Polyps can be malignant even when they look endoscopically innocent.

Because of this we believe they must be resected for a thorough pathological study, especially those who caused bleeding after menopause.

P.10.22

Management of post-menopausal bleeding (PMB) in a rapid access clinic

Faiza Y.*[1], Macnab W.[1], Majmudar T.[1]

[1] Hinchinbrooke Healthcare Nhs Trust Huntingdon Pe29 6nt Uk United Kingdom

One-stop rapid access clinic is feasible in assessing women with PMB.

The aim of this study is to assess the feasibility of a ‘one-stop’ clinic in the assessment of PMB and to determine the incidence of endometrial disease (endometrial cancer, endometrial hyperplasia, and endometrial polyps).

A retrospective review of 305 women with PMB, attending the rapid access clinic between 11.11.08–23.3.11.

Using an ultrasound threshold of endometrial thickness (ET) <5 mm, 38.7% of women were discharged. 187 (61.3%) women with ultrasound features suggestive of endometrial disease (ET = 5 mm, ET undefined, ET <5 mm with irregular endometrium or fluid in the endometrial cavity) were offered outpatient hysteroscopy +/− endometrial biopsy +/−polypectomy. The incidence of benign endometrial polyps was 20% in women with PMB, and the incidence of benign polyps and endometrial hyperplasia or cancer in the presence of an abnormal ultrasound USS is 33% and 12.8% respectively. The sensitivity of ultrasound scan in detecting endometrial disease is 45.4%. 81.2% had an outpatient hysteroscopy and 72% had polypectomy at the same visit. 87% of cases were either discharged or had definitive treatment at the one-stop visit.

Ultrasound scan is essential in triaging women with PMB. Hysteroscopy allows to identify endometrial polyps which can be missed if only a pipelle biopsy is obtained. HyCoSy, too would help to identify polyps, but if detected would then need removal by hysteroscopy. Hysteroscopy and poylpectomy can be carried out successfully in most patients in an outpatient one-stop setting.

P.10.23

One stop care pathway in gynaecology—from good to better?

Suchetha M.*[1], Wong S.[1], Kyula J.[1]

[1] Glasgow Royal Infirmary Glasgow United Kingdom

One-stop hysteroscopy clinics has shown to be running effectively. It has also reduced the number of ultrasound scan performed and hysteroscopy required.

One-stop hysteroscopy clinics have been widely available in the UK. Some hospitals even taken a further step to have the consultation, ultrasound scan, diagnostic hystersocopy performed by one doctor in one visit. This study aimed to assess how efficient this type of clinic was being run.

Information on women who had attended the one-stop hysteroscopy clinic within a teaching hospital in January 2011 was collected retrospectively. The data was stored and analysed using the SPSS package.

262 women had attended the clinic. Majority were referred by their general practitioners. 36% were referred for post menopausal bleeding including unscheduled bleeding on HRT, 49% for menstrual problem, 3% with mirena fitting concerns and 13% with non menstrual issues. After consultation, 78% required and had ultrasound scan. Only 15% required and had hysteroscopy. 206 women were at their first visit: 57% were able to be discharge after their first visit with reassurance and treatment given if required; 20% required in-patient or daycase investigation / treatment, 15% required further appointment and 7% were referred to other clinics. Excluding 15% of women with non vaginal bleeding issues , over 80% can be discharged from the clinic after 1–2 visits.

This clinic has been running efficiently. The need of ultrasound scan was reduced and the need of hysteroscopy minimized. Inappropriate referrals should be diverted to other clinics to ensure clinic resources were being used wisely. However, women who required more than one visit should not be looked upon as failure, as there were patients’ need and administration need to consider.

P.10.24

Outpatient hysteroscopy: the aberdeen royal infirmary experience

Jido T.*[1], Saleh S.[1]

[1] Aberdeen Royal Infirmary Aberdeen United Kingdom

Retrospective analysis of case notes of patients undergoing hysteroscopy both as outpatient procedure and in theatre showed outpatient hysteroscopy in our unit is safe, effective and successful. We advocated for expansion of the service to provide for all eligible patients.

Outpatient hysteroscopy (OPD) for assessment of endometrial cavity can be successfully employed with benefit to patients and the health care system.

Retrospective analysis of case records for patients undergoing hysteroscopy in Aberdeen Royal Infirmary.

A hundred and forty-seven of hysteroscopy procedures were analysed. Forty seven patients (32%) had out patient hysteroscopy and 68% in theatres under anaesthesia.

The success rate of outpatient hysteroscopy was 87.2% as compared to 94% of those in theatre. The failed cases in OPD were due to poor patient tolerance (12.8%) as opposed to false passage 4%, failed intubation 1% and uterine perforation 1% among cases done in theatre.

Menstrual disorders were the indication in 93.6% of OPD and 55% of theatre cases. In the OPD group detected endometrial pathology was adequately treated in 25% of cases, and planned appropriately in 75%. All the OPD patients had their procedure same day and were discharge obviating hospitalisation and considerable waiting time for the other group.

OPD hysteroscopy is a safe, effective alternative method of assessment of endometrial cavity in our patients. We recommended expansion of the service from its current form to cater for more patients.

P.10.25

Outpatient hysteroscopy: outcome study

Leah M.*[1], Hunter D.[1]

[1] Royal Victoria Hospital Belfast United Kingdom

This aim of this study was to determine the clinical effectiveness of outpatient hysteroscopy in our department. Our results indicate that the procedure is well tolerated, has a low failure rate and has good diagnostic accuracy.

Outpatient hysteroscopy is a safe, well tolerated and cost effective technique indicated for the evaluation of abnormal uterine bleeding and for the diagnostic work up of reproductive problems. In our unit this procedure is carried out in main theatre prior to the elective theatre list, using flexible hysteroscopes and CO2 distension.

This was a small retrospective chart review. Twenty consecutive patients were selected from the operative log. Information was collected from the notes and collated.

The indication for the procedure was for abnormal uterine bleeding (45%), recurrent miscarriage (40%), post menopausal bleeding (10%) and abnormal discharge (5%).

The failure rate for the procedure was 15%, reasons for failure were stenosed cervix and poor view. There were no complications reported. A biopsy was taken in 30% of patients. Diagnosis at hysteroscopy corresponded with pathology in all cases.

60% of patients required no further follow up and 20% were reviewed at clinic. A hysteroscopy under general anaesthetic was required in 20% of patients.

Our results show that the procedure has a good success rate and in this small group there were no complications. Patients with PMB accounted for only 10% of procedures, this would suggest an under use of the procedure for this indication and a reliance on GA hysteroscopy. The high percentage carried out for assessment of recurrent miscarriage reflects the clinical interest of the consultant in charge. The location for the procedure is not ideal and not recommended by the recent RCOG college guideline No. 59.

P.10.26

Pain evaluation in office hysteroscopy

Arteiro D.*[1], Neves J. P.[1], Moreira A.[1], Martinho M.[1]

[1] Hospital De São João Porto Portugal

To evaluate the amount of pain experienced during office diagnostic hysteroscopy and factors influencing it.

Office hysteroscopy is now a valuable but potentially painful tool to evaluate uterine cavity. Recent changes to the technique rendered it feasible in office setting and improved patients’ tolerance. However some concerns still persist and can limit its’ acceptance and widespread use.

For 2 months a prospective study was conducted to evaluate pain during office diagnostic hysteroscopy. Pain was determined after the procedure, using a visual analog scale. All procedures were performed using 3.5 mm hysteroscopes, vaginoscopic approach and saline. Data related to patient’s parity, menopausal status, previous uterine procedures, medication, knowledge of the procedure and whether it was performed by her attendant gynaecologist were analyzed.

44 consecutive women were evaluated. Mean age in this group was 55 years (28–86). Patient’s perception of pain was categorized in light (0–1), moderate (2–3) and severe (4–5) pain. 36% experienced light, 50% moderate and 14% severe pain. 23(52%) women were post-menopausal and 4(17%) received postmenopausal hormone therapy. 8(18%) took analgesics 1–2 h prior procedure and 3(7%) were infertile. 38% had at least one vaginal delivery. 20(45%) exams were performed by the patients’ attendant gynaecologist. Post-menopausal and infertile patients seamed to experience more severe pain. Vaginal deliveries, prior uterine procedures and knowledge about the procedure were associated with less degree of pain. No statistical differences were found for pain scores.

Our study was underpowered to show any statistical significant differences in women’s pain perception for diagnostic office hysteroscopy and is our intention to continue it, due to the importance of accurately determine the level of pain and factors influencing it,in order to facilitate elaboration and evaluation of premedication protocols.

P.10.27

Postmenopausal bleeding: findings and accuracy of hysteroscopy and histopathology in the diagnosis of endometrial cancer

Vanin C.[1], Crispi C.[2], Kato S.[2], Dibi R.[1], Almeida S.[1], Pessini S.*[1]

[1] Universidade Federal De Ciencias Da Saude De Porto Alegre Porto Alegre Brazil - [2] Instituto Fernandes Figueira - Fiocruz Rio De Janeiro Brazil

This study was designed to study the hysteroscopic findings in postmenopausal bleeding patients. The findings were classificated as suggestive of malignancy or not. The sensitivity and specifity for endometrial cancer was 93,8% and 97,7%.

The primary symptom of endometrial cancer is uterine bleeding. Hysteroscopy with endometrial biopsy is the gold standard assesment in women with suspected endometrial cancer. This study was designed to determine the prevalence of hysteroscopic findings in postmenopausal bleeding patients and to analyze the association between the hysteroscopic and histopathologic findings in patients with endometrial cancer.

Records of 507 patients with postmenopausal bleeding submitted to hysteroscopy and endometrial biopsy were evaluated. They were divided into two groups with respect to time of menopause: up to five years and more than five yeas. The hysteroscopic findings were classified as suggestive of benignity, malignancy or premalignant disease. The data was correlated with histopathologic findings. Chi-square test and odds ratio were used to analyze the data, applying the SPSS statistical program. Significance level of 5%.

The study,was performed at CHSCPA, an educational hospital.

Hysteroscopic findings were endometrial polyps (40.0%) and atrophic endometrium (33.9%). Histopathological findings were: material absent (47,1%), polyp (16,4%) and atrophy (5,2%). 41 cases were suggestive of endometrial cancer (8.1%) and 30 (73.2%) were confirmed by histology. Hysteroscopy’s sensitivity for diagnosis of endometrial cancer was 93.8%, specificity was 97.7%, positive predictive value was 73.2% and negative predictive value was 99.6% (p < 0.001).

Hysteroscopy is considered an excellent method to endomerial cancer diagnosis but the oriented biopsy is still very poor to correlate histopathologic and hysteroscopic findings.

P.10.28

Prostaglandins prior to hysteroscopy: a randomized controlled trial

Moiety F.*[1], Azzam A.[2]

[1] Alexandria Regional Centre For Women’S Health And Development Alexandria Egypt - [2] University Of Alexandria Alexandria Egypt

A randomized trial of misoprostol before diagnostic hysteroscopy demonstrates a benefit over control in the ease of cervical dilatation, cervical diameter at the start of the procedure and time taken till dilatation to Hegar number 6 with low risk of cervical tears. Rectal misoprostol appears advantageous over sublingual one. However, postoperative adverse effects as pain and bleeding occur more with misoprostol groups.

Prostaglandins, having a dilator effect on the cervix, especially Porstaglandin E1 analogue (misoprostol), were used to facilitate entry of the hysteroscopic instruments, shorten the procedure time, and to minimize postoperative pain.

Subjects& Methods: 212 premenopausal patients undergoing hysteroscopic procedures were randomly allocated into 3 groups: Group 1: n = 71; sublingual misoprostol (400 μg) was given 2 hours before the procedure. Group 2: n = 71; Rectal misoprostol (400 μg) was given 2 hours before the procedure. Group 3: n = 70; control group; no medications were given.

Mean size of cervical dilatation at the start was significantly wider in group I,II in comparison to control group. Cervical dilatation, was easier in the misoprostol groups compared to the control one with significant difference between group II and III. Also, misoprostol treated groups showed significant reduction in the mean time of Hegar dilatation to number 6 compared to control group. All patients required cervical dilatation except 4 patients in the sublingual misoprostol group.

Rectal misoprostol appears advantageous than sublingual one. However, postoperative adverse effects as pain and bleeding occur more with misoprostol groups.

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

Darwish A. M. M.*[1], Sayed E. H.[1]

[1] Woman’S Health University Center, Assiut University, Egypt Assiut Benin

Office hysteroscopy is valuable in abnormal uterine bleeding.

Objectives: to estimate the effect of adding office hysteroscopy (OH) to the preoperative diagnostic work-up in abnormal uterine bleeding (AUB) on the diagnostic accuracy.

A total of 295 patients more than 35 years with abnormal uterine bleeding. The patients had vaginal sonography, office hysteroscopy and office endometrial biopsy on one stop bases. MAIN OUTCOME MEASURE(S): The diagnostic accuracy of each method in diagnosing focal lesion and endometrial hyperplasia. Combined hysteroscopy and biopsy were taken as the gold standard for diagnosing focal lesion while endometrial biopsy alone was the gold standard for diagnosing endometrial hyperplasia.

Office hysteroscopy was superior to other methods for diagnosing focal lesion with about half of the focal lesions failed to be diagnosed with the other two methods. Office hysteroscopy was superior to vaginal sonography in diagnosing endometrial hyperplasia.

Office hysteroscopy is indispensable tool for diagnosing abnormal uterine bleeding and without its use half of the focal lesions could be missed. Office setting and the one stop approach greatly facilitate the use of the combination of office hysteroscopy with vaginal sonography and office endometrial sample.

P.10.30

The development of a nurse consultant led one stop procedure clinic

Holloway D.*[1], Teasdale A.[1]

[1] Guys And St Thomas’ Nhs Foundation Trust London United Kingdom

To show the development of a one stop outpatient procedure nurse led clinic that includes hysteroscopy.

The nurse led procedure clinic has developed from 1990. Its concept was developed while perusing a Masters in Advanced Health Care Practice, for which this was the dissertation. There was no bespoke training and the formal courses that were undertaken include the nurse hysteroscopy course at Bradford and a non medical prescribing qualification.

The service started with one practitioner and 2 clinics a week and after a successful business case we employed a Clinical Nurse Specialist to undertake hysteroscopy training. Since she has qualified as a hysteroscopist we have an increase in patients in clinics and 3 clinics a week. We undertake all aspects of management for the women and have a follow up clinics, results and email and phone service. We offer training to medical staff in outpatient hysteroscopy.

In 2010 we saw 1198 women within this service and performed 616 hysteroscopies, which included diagnsotic and operative. other procedures performed included insertion 68-IUS/IUCD insertions, 46- removal of cervical polyps, 37 colposcopies and 144 other procedures(including vulval tags, cysts and biopsies). from this clinic many women are discharged and treated on the same day.

This service is income generating and the patient satisfaction is high.

This service has moved hysteroscopy to outpatients that has freed up space in Day Surgery for more complex operations and shows increased patient and nurse satisfaction. We are currently expanding into operative hysteroscopy such as hysterscopic sterilisation and ablations. This shows an effective service accomplished by using education, training, business planning and project management skills and utilising the 4 components of the nurse consultant role, clinical, education, service development and research.

P.10.31

The role of hysteroscopy in the analysis of postmenopausal patients without hormone terapy that had endometrial thicness

Pinheiro W.*[1], Pereira A. K. C.[1], Soares Junior J. M.[1], Ejzemberg D.[1], Gherpelli P.[1], Ricci M. D.[1], Baracat E.[1]

[1] University Of Sao Paulo Sao Paulo Brazil

The authors studied 2061 post- menopausal patients,without hormone terapy, who had endometrial thickness, in the period between january 1995 to december 2010.the endometrial thickness above 4 mm, in post- menopausal patients, is an indirect sign of endometrial proliferation, when appearing at a time no compatible with estrogenic activity and thus suspect of being a risk for endometrial câncer.

Find of endometrial thickness up by 4 mm ultrasound examinations, indicates that the investigation of medical conditions likely endometrium should be investigated and method with the hysteroscopic with endometrial biopsy must be made mainly in postmenopausal women without hormone therapy replacement.

The thickness of the endometrium in these patients was among the smallest 5 mm up to 26 mm. our findings were: normal since that is the atrophic endometrium, proliferative endometrium, adenomyosis,polyps, myomas, synechiae,hyperplasia and adenocarcinoma. Hysteroscopy allow the diagnosis of changes to existing endocavitarias well as scoring endometrium, allowing one adequacy therapeutic faces these medical conditions.

The authors conclude that hysteroscopy and endometrial biopsy is the gold standard for definitive diagnosis and terapeutic in the findings of ultrasound for endometrial thickness.

P.10.32

The use of self-administered vaginal misoprostol before office hysteroscopy: no pain or no gain?

Meyer J. W.*[1], Meyer F.[1], Brito A.[1], Moutinho J. F.[1], Martinez De Oliveira J.[1]

[1] Centro Hospitalar Cova Da Beira Covilhã Portugal

Objective: To evaluate the impact of 200 micrograms of self-administered vaginal misoprostol at home on preoperative night for cervical ripening in both premenopausal and postmenopausal women before office hysteroscopy and compare with no medication use.

The effectiveness of administering misoprostol prior to hysteroscopy in achieving cervical dilatation and reducing complications has been studied in the last ten years but its use or nonuse is still not consensual.

Methods: The women were randomised to either 200 micrograms of self-administered vaginal misoprostol at home or no medication use. All the patients answered a questionnaire minutes before the procedure and minutes after. All the the procedures were performed by the same doctor. The questionnaires were applied by nurses. Anxiety before and after the procedure, abdominal cramps and other side effects, pain during the procedure were questioned.

Vaginal misoprostol applied the day before office hysteroscopy at the dose of 200 micrograms facilitate hysteroscopic approach in pre menopausal nulliparous women. There was no difference in multiparous and post menopausal women. The number of side effects and complications were few, but pelvic cramping, uterine bleeding and anxiety was reported significantly more often in the misoprostol group.

In premenopausal women, misoprostol resulted in a higher rate of side effects, including vaginal bleeding and cramping with a very limited benefit in facilitating the procedure in nulliparous patients. In post menopausal women no benefits were observed. The use of 200 micrograms before office hysteroscopy showed no better results in office setting hysteroscopy.

P.10.33

Unintended pregnancies after Adiana® sterilization

Coolen A.*[1], Bongers M.[1], Thurkow A.[2], Emanuel M.[3], Timmerman E.[4], Ruhe I.[5], Veersema S.[6]

[1] Máxima Medical Centre Veldhoven Netherlands - [2] St. Lucas Andreas Hospital Amsterdam Netherlands - [3] Spaarne Hospital Hoofddorp Netherlands - [4] St. Franciscus Hospital Roosendaal Netherlands - [5] Flevoziekenhuis Almere Netherlands - [6] St. Antonius Hospital Nieuwegein Netherlands

Analysis of four pregnancies after Adiana® sterilization.

The aim of this study is to analyse cases of unintended pregnancies after Adiana® sterilization.

A retrospective case series analysis of 4 cases of unintended pregnancies after Adiana® sterilization that were reported in the Netherlands until April 2011. Data on the hysteroscopic Adiana® sterilization procedures and post procedure confirmation tests were reviewed and analysed by all authors. The causes of pregnancies were determined.

Four patients became pregnant after Adiana® sterilization. One patient was a non-compliant patient who was pregnant before a HSG was conducted. She failed to use alternative contraception. In another case a technical non optimal HSG showed tubal occlusion. Misinterpretation could have been possible. In the other two cases, correctly performed HSG’s showed tubal occlusion, which are probably false positive results.

It is remarkable that in 3 out of 4 pregnant patients, one of the Adiana® devices could not be visualized on the ultrasound. No clinical management decisions were made using ultrasound results conform the Adiana® protocol.

Four pregnancies occurred after Adiana® sterilization in The Netherlands. The majority of pregnancies are associated with the inability to visualize one of the devices on the ultrasound followed by a false positive HSG result. Tubal occlusion as shown on the HSG might be a sign of tubal spasm. Moreover the Adiana® device is not radiopaque and not visible on the HSG. Although the devices are easy to visualize on the ultrasound, the ultrasound cannot show patency or occlusion and ultrasound results are not included in the Adiana® protocol. The risk of pregnancy after Adiana® sterilization could be reduced when presence and position of the device and tubal occlusion could be evaluated at the same time.

P.10.34

As women accept office hysteroscopy

Cammareri G.[1], Lanzani C.[1], Ratti M.[1], Cirillo F.*[1], Zampogna G.[1], Ferrazzi E.[1]

[1] Ospedale V Buzzi Milano Italy

We evaluate the acceptability, anxiety and pain of office hysteroscopy witout sedation. Anxiety is measured with STAI score and pain with VAS. We included 70 women: 45,7% made an operative histeroscopy and 54,3% diagnostic. We also evaluate the corelation of pain and scholarity, job, age, indications and all the operative parameters. We found significant correlations between VAS and schooling , waiting time and operative procedure against diagnostic. In conclusion, office hysteroscopy is safe, acceptable and reliable without sedation. But it is importance: don’t make the women wait.

Office hysteroscopy with the new concept of “see and treat” is a safe and cost effectiveness approach.

And the same time, there are still same controversies in the acceptability of the procedure without any pain control.

We conducted a prospective analysis of 70 consecutive office hysteroscopies, between September and October 2010 in a university-affiliated medical centre. We measured STAI score for anxiety before, VAS for pain after hysteroscopy and waiting time before hysperoscopy.

70 women with indication of atypical blood loss (60%) or endometrial thickening (40%), mean age 46.0 years, medium-high schooling (secondary school or graduation 69%) and mostly employed (77%).

45,7% was operative histeroscopy and 54,3% diagnostic.

Waiting time was in 36% more than 1 hour, in 40% between 40 minutes and 1 hour and in 17% between 20 and 40 minutes. Duration of the exam was in 79% less than 10 minutes, in 20% between 10 and 20 minutes. Mean STAI score was 42. Range of measured VAS was between 0 and 8, mean was 3.5: 49% of patients referred no pain.

We found significant correlations between VAS and schooling (p = 0.04), waiting time (p = 0.007) and operative procedure (p = 0.05) against diagnostic.

In conclusion, office hysteroscopy is safe, acceptable and reliable without sedation. But it is importance: don’t make the women wait.

P.10.35

10 year retrospective study of treatment of endometrial hyperplasia

Dadi H. *[1], Togobo M. [1], Balachandra P. [1], Jones S. [1]

[1] Bradford Teaching Hospital ~ Bradford ~ United Kingdom

Aim: To examine management options for women with endometrial hyperplasia

This study examined various management options for endometrial hyperplasia and specifically highlighted the safety and efficacy of levonorgestrel intrauterine system in the management of women with endometrial hyperplasia.

Retrospective case note review of all women with endometrial hyperplasia from 1999–2009. A total of 206 patients with a mean age was 53.31 years, parity was 2.54 and mean BMI was 36. Presenting symptom was predominantly postmenopausal bleeding in 53% however 5% patients were asymptomatic with an incidental scan diagnosis.

Mean endometrial thickness was 15 mm. Majority were simple hyperplasia without atypia (45%), followed by complex hyperplasia without atypia in 36% and atypical hyperplasia in 19%. Initial management was surgery in 28%. Systemic progestogens were given in 13% and 1% received aromatase inhibitors. 44% patients were managed using levonorgestrel intrauterine system (LNG-IUS)

9% (18 out of 206) developed endometrial cancer, all of which were stage I endometrial adenocarcinoma. Of those patients who developed endometrial ca, 5% had pre-existing simple hyperplasia without atypia, 28% had complex without atypia and 67% had complex with atypia.

Of those patients treated with Mirena, the initial histology was simple hyperplasia without atypia in 37%, complex hyperplasia without atypia in 47% and atypical hyperplasia in 8%. Only 2.4% women progressed to endometrial carcinoma stage 1 within 2 years of follow up, 98% developed normal or progestogenic endometrium.

In this retrospective study we examined 206 patients with endometrial hyperplasia. Of 44% treated with Mirena IUS, endometrial histology reverted back to normal in 98% by 6 months and only 2.4% patients in this group developed endometrial carcinoma within 2 years follow up.

Session P.11

* Oncology *

P.11.1

Assessment of the radical in the management of the high risk of endometrial cancers

Martínez Lamela E.*[1], Molero Vílchez J.[1], Sancho Garcia S.[2], Expósito Lucena Y.[3], Rivera Garcia M. T.[1], Gonzalez Paz C.[1]

[1] Hospital Universitario Infanta Leonor Madrid Spain - [2] Hospital Universitario Ramón Y Cajal Madrid Spain - [3] Clínica Toco-Gyn Alcalá De Henares Spain

Descriptive study of our results in the treatment of high risk adenocarcinoma of endometrium. Review of the current and comparative therapeutic orientation.

Evaluation of the radical in the management of adenocarcinomas of high-risk and role of the laparoscopic techniques.

Database SELENE, consultation of Gynecology Oncology, record of the Committee of cancer hospital. Revision PUBMED, MEDLINE. We have treated 13 patients with carcinoma of endometrium (EC) high risk (endometrioid type I, staging IbG3, II G3, III–IV and any type II), corresponding to 19% of EC of our series. The median age was 67,61 years (51–86 years). The most common was the carcinosarcoma (5 cases, 38,46%), followed by the EC type I (3 cases) clear cell carcinoma and endometrioide EC staging IBG3 (3 cases).

Staging surgery was possible in 76,92% of cases, being the most used laparoscopic technique (66.6%). We carry out extraperitoneal lumboaortic lymphadenectomy, transperitoneal pelvic lymphadenectomy, peritoneal biopsy of suspicious areas, omentectomy, and laparoscopic hysterectomy and double anexectomía. We do not perform an appendectomy except macroscopic affectation of it. Palliative vaginal surgery for bleeding due to the anaesthetic high-risk was conducted in two cases. In all cases they received adjuvant treatment with radiotherapy or radio-quimioterapia in locally advanced stages. The final stages were: IA 1 case, IB 5 cases, II 2 cases, IIIA 2 cases, IIIC1 2 cases and IVB 1 case. The results of the radicalism of the linfadenectomías according to the number of nodes removed was an average of stigmatising 12,33 pelvic nodes (6–18) and 6.87 lumboaórticos. (3–13).

In the high risk of relapsed endometrial adenocarcinomas do maximum citorreducción surgery that improves overall survival of patients with advanced stage disease.

P.11.2

Cervical cancer review in our community hospital in the last ten years

Garcia Pineda V.[1], Rodriguez Garnica M. D.[1], De Valle Corredor C.[1], Gonzalez Gea L.*[1], Zapico Goñi A.[1], Fuentes Castro P.[1], Heron Iglesias S.[1]

[1] Principe De Asturias Hospital. Alcala University Madrid Spain

Follow up and treatment of cervical cancer.

The aim of this study is to review our case-serie of cervical cancer in the last ten years.

A retrospective and descriptive study was conducted over 105 patients being diagnosed of cervical cancer between 2000–2010. Patients were divided in early stages (IA1-IB1) and advanced stages (IB2-IVB). This later group was subdivided in two groups whether they were (IB2-IIA2) or (IIB-IVB) for thorough follow up analyzes.

Mean age was 51.50 ± 1,3 (26–81). The most frecuent hystological finding was scamosus with 79 patients(75%). Forty six patients (40.5%) were considered as early stages while 59 (57.7%) patients were staged as advanced cases. Most prevalent stage was IB1: 41 (36.9%) patients. In early stage group, 37 (80,4%) patients were surgically managed where laparoscopy was the standard procedure. Fifty two patients (88.1%) in the advanced group were initially managed by chemo-radiotherapy. In this group, a first step surgical approach was done in 7 cases (11,9%), these cases were IB2-IIA2 stages. In early stages, excluding 3 patients (6,5%) lost for follow up, 31 patients (67,4%) are disease free , relapses have been seen in 8 women (17,4%) and 4 (8,7%) died. In advanced cases, lost for follow up were 11 cases (18,6%), 23 patients (39%) are disease free, 11 cases (18,6%) of relapses and 14 (23,7%) died.

When advanced cases are subdivided in two groups: (IB2-IIA2) or (IIB-IVB), excluding 11 patients (18,6%) lost, follow up shows: in the first group 5 patients (50%) are disease free, relapses have appeared in 2 patients (20%) and 3 patients (30%) died.

The follow up of the second one shows that 18 patients (42,8%) are disease free, relapses have appeared in 9 patients (21,4%) and 11 patients died (26%).

Most cases of early stage cancer are suitable for surgical laparoscopical approach while nowadays standard chemo-radiotherapy should be used in advanced.

P.11.3

Cervical cancer’s screening in the population of “ESPAÇO JOVEM”

Reis P.*[1], Brandão M.[1], Santos J.[1], Carinhas M. J.[1], Oliveira T.[1]

[1] Centro Hospitalar Do Porto Porto Portugal

Found out the more frequent cytological alterations in this population and to review the necessity to modify our protocol.

“ESPAÇO JOVEM” is a center of attendance for young people, with many activities as information on sexuality, contraception, gynecological routine and psychological support. The team is constituted by a gynecologist and a psychologist.

Retrospective Study of the clinical processes of 68 young female that came to ESPAÇO JOVEM, between January 2004 and December 2008, and had been conducted to the Cervical Pathology Unit for repetition ASC-US, LSIL and HSIL (111 young had been conducted, having appeared only 68). The studied variables had been: age, coitarche, number of sexual partners, results of the colposcopy and cervical biopsy and clinical orientation.

The cytological alterations had been: 48 cases with LSIL (70.6%), 15 with ASC-US (22%) and 5 with HSIL (7.4%). The cases with HSIL had appeared in an interval between 1 and 11 years after the coitarche.

Were performed 10 conization for cervical biopsy with CIS (1), CIN3 (3), CIN2 (5) and HPV without displasia after discordance between cytology, colposcopy and biopsy (1). The histological exams of the cones were: HPV without displasia (1), CIN1 (1), CIN2 (5), CIN3 (2) and CIS (1).

It was chosen to follow-up, without treatment, the remaining cases. In 3 of these cases conization was performed in the end of one year of follow-up.

In the studied population we met a significant percentage of high degree lesions (15%), however, many convoked young, does not appear to the appointment in the Cervical Pathology Unit.

These factors let us to the conclusion that our behavior (opportunist screening) will be for keeping.

P.11.4

Conditional laparoscopic staging in intermediate risk endometrial cancers

Molero Vílchez J.*[1], Martínez Lamela E.[1], Sobrino Mota V.[2], Moro Martin M. T.[3], Casado Fariñas I.[1], Lorente Ramos R.[1]

[1] Hospital Universitario Infanta Leonor Madrid Spain - [2] Clinica Toco-Gyn Alcalá De Henares Spain - [3] Clínica Toco-Gyn Alcalá De Henares Spain

Descriptive study of the results in the treatment of intermediate risk endometrial adenocarcinomas in our Center between April 2008 and January of 2011.

Assessment of the role of pelvic lymphadenectomy and intraoperative biopsy in adenocarcinoma of endometrium of intermediate-risk in the context of a conditional staging.

Database SELENE, consultation of Gynecology Oncology, record of the Committee of Cancer Hospital. Revision PUBMED, MEDLINE.

In our series, try 23 cases (EC) endometrial endometrioide carcinomas (type I) of intermediate risk (IAG3, IB G1–G2, G1–G2 II), involving a 41,81% of adenocarcinomas type I, and by 34,32% compared to all EC.

To avoid excess morbidity and to perform the laparoscopic surgery in staging (78,26%),our protocol agreed in Committee of Gynecologic Tumors was the realization of pelvic lymphadenectomy with intraoperative biopsy (IOB) in those cases that the previous staging Imaging (MRI and CT) revealed no lymph node involvement in no strings. If intraoperative biopsy in pelvic lymphadenectomy is positive, lymphadenectomy lumboaórtica would be held at the same time. In any case there was lymph node involvement in IOB or deferred study. Globally were a number of removed nodes of 13.41 nodes (rango:6–30). Three cases of incomplete vaginal surgery were: one case of atypical glandular hyperplasia after no suspicious Hysteroscopy, and two cases for medical surgical risk of patients, so they chose palliative surgery to avoid her continued bleeding.

The preoperative study should address what are patients with intermediate risk EC which must be subjected to a radical lymphadenectomy pelvic and paraaórtica, and which are susceptible of a more conservative attitude, allowing a laparoscopic approach.

P.11.5

Contribution of the laparoscopyc technique in the ovarian cancer

Molero Vílchez J.*[1], Martínez Lamela E.[1], Expósito Lucena Y.[2], Gallego Pastor E.[2], Lorente Ramos R.[1], Martin Marino A.[1]

[1] Hospital Universitario Infanta Leonor Madrid Spain - [2] Clínica Toco-Gyn Alcalá De Henares Spain

Descriptive study of ovarian cancers in our Center between April 2008 and January of 2011.

Assess the radicalism of the citorreducción.

Database SELENE, consultation of Gynecology Oncology, record of the Committee of cancer hospital. Revision PUBMED, MEDLINE.

We review a major series of 56 cases of ovarian cancer with a mean age of presentation of 56.1 years (18–88 years). The most frequent histological types were the serosopapilar cistoadenocarcinoma (17 cases, 32 per cent) followed by indiferet cancers in very advanced stages (7 cases) and of the mucinous and endometrioides (4 cases). More frequent in our presentation stages were stages IA (14 cases), staging IC (13 cases).

The surgical technique chosen was the open surgery, prior assessment laparoscopic operability, staging and primary (31 cases, 89%) or interval citorreduccion; by limiting the laparoscopic to assess the operability prior to citorreducción or for staging of tumors in early stages or borderline 4 cases (11%). Involved surgically 41 patients, a suboptimal in 3 cases, complete in 8 and optimal surgery was made in 30 cases. With regard to the radical lymph node removal, were conducted in 17 cases pelvic lymphadenectomy and lumboaórtica, and in one case only paraórtica. The average regrowth nodes was pelvic nodes 9.4 (2–20) and 10.1 paraortic nodes (3–33). Ovarian borderline tumors accounted for 26% of ovarian tumors, the remove seoropapilar the most common (8 cases) followed by the mucinous (5 cases).

The valuation laparoscopic operability before a citorreducción in advanced stages of ovarian cancer, prevents the realization of suboptimal surgeries.

P.11.6

Could laparoscopic lymphadenectomy be avoided in early stages of endometrium cancer?

Zapico A.*[1], Martinez Gomez E.[1], Garbayo P.[1], Cajal R.[1], Martinez N.[1], Couso A.[1]

[1] Universitary Hospital Principe De Asturias. School Of Medicine. Alcala University. Alcala De Henares, Madrid. Spain

Study of 86 consecutive patients with endometrium cancer and new surgical stage Figo 2009 IaG1G2.

To evaluate the endometrium cancer surgical results in early stages with a complete FIGO laparoscopic approach

A retrospective study between 1996 and 2010, over 86 consecutive patients with endometrium cancer and new surgical stage Figo 2009 IaG1G2. All patients had a laparoscopic (LPS) approach. We have studied different items such as epidemiological data, diagnosis procedures, surgical access, operating time, conversion rate, complications rate, hospital stay, transfusion rate, pathological findings, FIGO stage and survival rate. Statistical analysis was done using SPSS 15.O.

Mean age was 61.20 + 1.04 (36–83) years and mean BMI 31.36 + 0.67 (19.83–56.58)kg/m². Endometrial cancer risk factors were seen in 57(66.27%) patients. The initial surgical access was LPS in 86(100%) patients. Lymphadenectomies were performed in all cases. Conversion into laparotomy was necessary in 8 (9.3%). Operating time was LPS 152.91+ 2.91(50–285) minutes. Hospital stay was LPS 5.67 + 1.1(1–19) days. Postoperative complications were 18(20.93%). Haemoglobin balance was 2.58 + 0.16(0.4–6.8). Global transfusion rate was 6 cases (7%). Readmission rate was 3 cases (3.48%). Nodes collected were 15.06 + 1.44 (2–24). Nodes affected 0 (0%). Pathological types were endometrioid in 83(96.5%) cases. Survival rate at 5th year was 80 patients (93.02%). Median follow up was 35.70 + 3.60 (1–114) months. Medical causes of death were described in all cases without cancer relation.

Although successful laparoscopic staging is feasible in endometrium cancer, when preoperative diagnosis and operative utero findings are less than IbG2, lymphadenectomies could be avoid because of the good prognosis of these patients and the low affected nodes rate.

P.11.7

Definitive laparoscopic surgical treatment in patients with early ovarian cancer

Jakimovska M.*[1], Cvjeticanin B.[1], Kobal B.[1]

[1] Gynecology Clinic, University Clinical Centre Ljubljana Ljubljana Slovenia

We represent a retrospective analysis of 5 patients with early ovarian cancer (EOC) admitted to University Medical Centre Ljubljana surgically completely managed by laparoscopy (LPSC).

LPSC management of EOC has constituted a controversial issue since it was first described. Although most study results are encouraging, the sample size is still too small to be able to draw definite conclusions.

2 years retrospective analysis of 5 patients having laparoscopy for suspect adnexal mass that demonstrated to be early ovarian cancer (FIGO stage I and II). We present preoperative clinical data, laparoscopic surgical steps and definitive treatment strategies.

Median age was 51 years. 4 patients had preoperatively elevated Ca125, 4 had subtle symptoms, 1 had abdominal pain. 4 patients had two step laparoscopic procedures. At first laparoscopy evaluation of suspect adnexal mass was performed with 1 cistectomy, 1 unilateral 2 bilateral adnexectomies. After definitive hystopathologic results a second laparoscopy in all but one patient was performed after average period of 7 days resulting in :LAVH (N = 1), omentectomy (N = 4), peritoneal biopsy(N = 4), lymphadenectomy LPL (N = 3), appendectomy (N = 2), unilateral adnexectomy (N = 1). In one patient complete surgical management was conducted as one step laparoscopic procedure (LAVHA, LPL, and omentectomy), according to macroscopic appearance of the disease and comfirmed by frozen section. Medical records were discussed by oncologic-gynecologic expert team that determinated laparoscopic procedures as final surgical treatment. All patients underwent further chemotherapy, 1 as neodjuvant after first laparoscopy and 4 after second laparoscopy.

Laparoscopy can be treatment of choice in patients with EOC, if it is performed by skilled surgeon. This should encourage studies with larger sample sizes to confirm the validity of laparoscopic management of EOC.

P.11.8

Discordance in the pre-surgical staging and final histologic study in endometrioides adenocarcinomas of low risk

Molero Vílchez J.*[1], Martínez Lamela E.[1], Gallego P.[2], Casado Fariñas I.[1], Gimeno Aranguez M. M.[1], Lara Alvarez M. A.[1]

[1] Hospital Universitario Infanta Leonor Madrid Spain - [2] Clínica Toco-Gyn Alcalá De Henares Spain

Descriptive study of endometrial cancers treated in our Center between April 2008 and January of 2011.

The discordance between preoperative study and the final hystological study.

Database SELENE, consultation of Gynecology Oncology, record of the Committee of cancer hospital. Revision PUBMED, MEDLINE.

For treatment at early stages of endometrioides of low-risk adenocarcinomas (type I, Ia G1-2 Stadium) was scheduled surgery with pre-surgical staging of stage IA G1-G2 in 29 patients (80%laparoscopic approach), of which the low risk with definitive histology was confirmed in 18 cases.

In cases with final stage IA G1-G2, hysterectomy and double anexectomy was conducted vaginal approach in 5 cases, open surgery in 1 case and by laparoscopy in 12 cases (66%). In 8 patients laparoscopic pelvic lymphadenectomy (LF) partnered on suspicion of pelvic lymph node involvement by TAC, which is not confirmed in any case (the average regrowth nodes was 15,37 gg.(9–28). The unconformity in the pre-surgical staging (CT, MRI) on the pathological final stage was 37%. Demonstrates the great utility of the intraoperative biopsy of the degree of infiltration myometrial in stages of low-risk, decreasing unconformity to 17,24%. When the myometrial invasion was greater than 50 per cent (in 6 cases), was performed LF with BIO that was negative for malignancy in all cases; 1 if lymph node infiltration in deferred study. The radical was an average of 19,33 removed nodes (11–30).

Intraoperative biopsy of hysterectomy in low-risk EC helps to reduce the morbidity tried a laparoscopic approach that has shown better perioperative results unchanged in the long term prognosis of the disease.

P.11.9

Endometrial cancer—the gold standard investigation??

Priyanka S.*[1], Majmudar T.[1]

[1] Hinchingbrooke Hospital Cambridge United Kingdom

About 4500 women in the UK develop endometrial cancer each year. Most cases develop in women in their 50s and 60s. It rarely develops in women under the age of 50. Fortunately, most women are diagnosed at an early stage as they present at an early stage with post-menopausal bleeding which can be investigated further with USS, hysteroscopy or endometrial biopsy.

It is a retrospective review of endometrial cancer at DGH in last 5 years aiming at finding out the sensitivity of US (what percentage of EC cases had an abnormal endometrium on US), sensitivity of hysteroscopy (what percentage of EC cases had a suspicious looking cavity), sensitivity of Pipelle (what percentage of Pipelle biopsies were negative for cancer), the accuracy of pre-op grading and staging and the proportion of laparoscopic surgery in treatment.

It was retrospective collection of data from intranet system of patients diagnosed with endometrial cancer during the period of August 2004 to Nov 2010 Total number of cases—81).

The sensitivity of the US was 83.95% in determining endometrial cancer cases with abnormal scans. The sensitivity of hysteroscopy in determining the suspicious endometrium in cases of the endometrial cancer was 64.60%. The sensitivity of determining abnormal endometrium by Pipelle biopsy was high at 95.25%. The accuracy of preoperative grading and staging was 56.8% and 44.44% respectively.

The study suggested that the endometrial Pipelle biopsy was a more sensitive method to diagnose endometrial cancer than hysteroscopic appearance of the endometrium though the preoperative grading of the biopsy compared to the postoperative grading of the histology of the specimen had low sensitive value. The tumour staging by the MRI compared to the operative staging had low sensitive value, especially stage 2 being downstaged to stage 1A.

P.11.10

Endometrium cancer and laparoscopic approach in elder

Heron S.[1], Martínez N.[1], Guzman M.[1], Martinez Gomez E.[1], Estevez M.[1], Zapico A.*[1]

[1] Universitary Hospital Principe De Asturias. School Of Medicine. Alcala Universitary. Alcala De Henares, Madrid. Spain

Study of surgical access in patients over 75 years with endometrium cancer.

To evaluate the morbidity and feasibility of the different approaches for the treatment of the endometrial cancer in patients over 75 years old.

A descriptive and retrospective study from 1996 to 2010 of 268 consecutive patients that have been diagnosed of endometrial cancer. All the patients over 75 years old were selected, 41 (15.29%). We have defined two surgical approach groups: laparocopy (LPS) 29 (70.7%) and laparotomy (LM) 12 (29.3%) patients. We analyzed different factors such as: age, body mass, previous surgery, type of surgery, peroperative complications, laparotomy conversion rate, convalescence average, transfusion rate, FIGO stadio, histological study and recurrence and survival rates. We carry out a stadistical study using SPPS 15.0 computer analysis.

There were not statistical differences for body mass index (BMI) or age in these two surgical approaches. The mean age was LPS 78.79 + 0.76(68–88), LM 78 + 0.67 (75–83) and BMI was LPS 30.40 + 0.81(23.04–41.31) and LM 32 + 1.2(21–41.2). Four patients 9.77% had previous abdominal surgery, 48.77% (20 patients) had endometrial risk factors like hypertension or mellitus diabetes. The surgical access was 29(70.7%) in LPS and 12(29.3%) in LM. Lymphadenectomy was feasible in 25(86.2%) LPS and in 7(58.3%) LM. Laparotomy conversion rate was 4 (13.77%). The operative complications rate was 7.31% (2 LPS 6.8%, vs 1LM 8.33%) and postoperative 26.82% (7 LPS (24.15%) vs 4 LM 4(33%)) no differences were observed amongst groups. Hospital stay was shorter (<0.01) for LPS 6.32 + 0.47(2–14) than LM 9.32 + 1.07(3–33); no differences were found in transfusion rate, readmission or survival rate amongst the different surgical approaches.

The laparoscopy approach is feasible in the most of the cases. Age is not a contraindication, in our experience, for laparoscopic lymphadenectomy approach.

P.11.11

Failure of minimal invasive pipelle endometrial sampling in women presenting with postmenopausal bleeding

Visser N. C.*[1], Breijer M. C.[1], Herman M. C.[2], Timmermans A.[3], Pijnenborg J. M.[1]

[1] Tweesteden Hospital Tilburg Netherlands - [2] Maxima Medical Center Veldhoven Netherlands - [3] Academic Medical Center Amsterdam Netherlands

Pipelle biopsy frequently results in inadequate samples. Only nulliparity, higher age and hypertension were independently associated with inadequate samples. As Pipelle sampling avoided hysteroscopy in 57.3%, it is still advised in the primary work-up for women presenting with postmenopausal bleeding (PMB).

Patients in whom a Pipelle biopsy is nondiagnostic, cannot be reassured without further testing. The aim of our study was to determine which patient’s and doctor’s related factors affect adequacy of Pipelle biopsy in women with PMB.

Women presenting with PMB in whom Pipelle biopsy was performed were prospectively collected (n = 211). Inadequate Pipelle was defined as: technical failure or insufficient tissue for histological diagnosis. Multivariate logistic regression was performed to evaluate the independent effects of doctor’s (training level) and patient’s (age, BMI, years since menopause, parity, HRT, hypertension, diabetes, anticoagulance use and endometrial thickness) characteristics on inadequate samples.

In 33 (15.6%) women sampling failed, and in 57 (27.0%) the amount of tissue was insufficient. In majority of the women (57.3% (n = 121)) a hysteroscopy could be avoided. Eight women with a technical failed Pipelle, and five women with an insufficient sample were subsequently diagnosed with endometrial cancer (EC). Three cases of EC were missed after benign Pipelle (1.4%). Nulliparity and higher age were associated with a higher technical failure rate (p < 0.05 and p < 0.01 resp.). Hypertension was associated with insufficient samples (p < 0.05).

Nulliparity, hypertension and higher age are the only factors independently associated with inadequate Pipelle. Future research should focus on selecting patients in whom Pipelle will fail to optimize the work-up for patients with PMB.

P.11.12

Influence of systematic pelvic lymphadenectomy on the outcome of patients with early stage

Kwack H.*[1], Ji E.[1], Ryu K.[2], Park D.[1]

[1] Saint Vincent’S Hospital, The Catholic University Of Korea Seoul Republic Of Korea- [2] Saint Mary’S Hospital, The Catholic University Of Seoul Republic Of Korea

The goal of this study was to evaluate the influence of surgical staging procedure, including systematic pelvic lymphadenectomy on the outcome of early stage endometrial cancer patients. Total 349 eligible patients who were proved histologically and thought preoperatively (clinically) to be with FIGO stage I endometrial carcinoma were included. The results showed no evidence of benefit in the overall, disease specific and disease-free survival for systemic pelvic lymphadenectomy in women with stage I endometrial cancer.

The goal of this study was to evaluate the influence of surgical staging procedure, including systematic pelvic lymphadenectomy on the outcome of early stage endometrial cancer patients.

From 1995 through 2005 in four clinics of the Catholic University, total 349 eligible patients who were proved histologically and thought preoperatively (clinically) to be with FIGO stage I endometrial carcinoma were included. The Kaplan-Meier test and the Cox’s proportional hazard test were applied for survival analysis and logistic regression. A p < 0.05 was used as statistically significant.

There was no significant difference regarding overall survival (HR = 1.55 [95%CI.558-4.331]; p = 0.399), disease specific survival (HR = 3.36 [95%CI.816–13.826]; p = 0.093) and disease free survival (HR = 1.26 [95%CI.547-2.883]; p = 0.592) with and without lymphadenectomy.

The results showed no evidence of benefit in the overall, disease specific and disease-free survival for systemic pelvic lymphadenectomy in women with stage I endometrial cancer. Further studies with more number of patients are needed to confirm the efficacy of systematic lymphadenectomy in early stage endometrial cancer.

P.11.13

Laparoscopic ovarian transposition in treatment of cervical cancer of locally advanced stages

Antipov V.[1], Novikova E.[1], Demidova L.[1], Shevchuk A.*[1], Kadieva E.[1]

[1] The Hertzen Research Oncological Institute Moscow Russian Federation

The quality of life of young patients with locally advanced cervical cancer (LACC) can be improved using laparoscopic ovarian transposition. This procedure can be used before starting radiation therapy without any significant delays of special treatment due to fast rehabilitation of patients.

Nowadays the primary treatment for LACC is radiation therapy with following permanent ovarian function failure and consequently significant decreasing the quality of life of young patients. The aim of this study is to assess the feasibility and effectiveness of laparoscopic ovarian transposition with the purpose of preservation of ovarian function in patients with LACC.

Since 2007 we performed such operations in 46 patients with squamous cell carcinoma of the uterine cervix FIGO stage IB2-IIIB before pelvic irradiation. The mean age of the patients was 34.5 years. Laparoscopic ovarian transpositions were performed bilaterally, ovaries were transposed to the paracolic gutters and fixed to abdominal wall with titanic staples. After pelvic irradiation 42 (91,3%) patients underwent radical hysterectomy, other patients received radiation therapy only. During follow-up hormonal status was assessed and ultrasound examination of transposed ovaries was performed.

The mean operating time was 98,5 min. No intraoperative or postoperative complications related to the procedure were observed. At the mean follow-up of 23,8 months, there were no cases of ovarian metastasis. Ovarian function preservation was achieved in 67,4% of the cases.

With ovarian laparoscopic transposition, ovarian function can be preserved in patients with LACC requiring first line radiation therapy. Laparoscopic ovarian transposition is a simple, safe and effective procedure for preserving ovarian function and to improve quality of life in premenopausal women, especially for those less than 45 years old.

P.11.14

Laparoscopic approach in patients with endometrium cancer and bmi over 35

Martinez Gomez E.[1], Zapico A.*[1], Fuentes P.[1], Arnanz F.[1], Guzman M.[1], Heron S.[1]

[1] Universitary Hospital Principe De Asturias. School Of Medicine. Alcala University Alcala De Henares, Madrid Spain

A retrospective study, over 54 consecutive patients with endometrium cancer and BMI over 35 were studied.

To evaluate the different surgical approaches and morbidity in patients with Body Mass Index (BMI) over 35 kg/m² and endometrium cancer.

A retrospective study between 1997 and 2010, over 54 consecutive patients with endometrium cancer and BMI over 35 were studied. Two groups were defined, whether laparoscopic (LPS) or laparotomic (LPM) approach were used. We have studied different items such as epidemiological data, diagnosis procedures, surgical access, operating time, conversion rate, complications rate, hospital stay, transfusion rate, pathological findings, FIGO stage and survival rate. Statistical analysis was done using SPSS 15.O.

Mean age was LPS 62,40 + 2,80(49–75) vs LPM 66 + 4,28 (52–81)years and mean BMI LPS 40.50 + 0.95 (35.1–52,20) vs LPM 39.10 + 0.66(35.33–49) kg/m2. No differences were observed. Endometrial risk factors were seen in 26 (48.14%) patients. The initial surgical access was LPS in 31 patients (57.40%) and LPM in the remaining 23 cases (42.59%). Lymphadenectomy was possible in 23 (74.2%) of LPS group vs 11 (47.82%) cases in LPM group. Conversion into laparotomy was necessary in 5 (16.12%) patients mainly due to anesthesical problems. Hospital stay was shorter for LPS 5,78 + 1,35 (2–15) vs LPM 7.70 + .2(4–33)days (p < 0.001). Haemoglobin balance was better (p < 0.001) for LPS 2,11 + 0,90(0,7-3,8) vs LPM 2.83 + 0,32 (0,8–5,2) gr/dl. Global transfusion rate was 6(11.11%), no differences were achieved between both groups. Nodes collected were 14.06 + 1.44 (2–21) LPS vs 13.52 + 2.2(2–21) LPM (p = 0.47). Survival rate was similar (p = 0.29).

BMI should not be considered as a contraindication for the laparoscopic approach. In addition successful laparoscopic staging shows lower hospital stay and morbidity.

P.11.15

Laparoscopic contribution to cervical cancer treatment in a district universitary hospital

De Valle Corredor C.[1], Rodriguez Garnica D.[1], Garcia Pineda V.[1], Gonzalez Gea L.[1], Esteve M. D. L. C.[1], Zapico Goñi A.*[1]

[1] Hospital Universitario “principe De Asturias” Madrid Spain

Laparoscopy has become a widespread procedure in the management of cervical cancer.

Laparoscopic management of cervical cancer includes radical trachelectomy, radical hysterectomy and lumbo-aortic staging prior to chemo-radiotherapy.

From November 2002 to December 2010, 91 cases of cervical cancer has been managed in our Department. Laparoscopic Radical Hysterectomy (LRH) was performed in 50 (55,5%) cases. In 10 (11,9%) cases with clinical stage over IB2 a laparoscopic lumbo-aortic retroperitoneal (LLR) was done.

In LRH group, mean age was 48,43 + 1,56 years and mean IMC was 26,44 + 0.8 vs LLR group mean age was 46,90 + 4.73 years and mean IMC was 25,41 + 0.8 LRH mean operating time was 241,9 + 9,3 vs 105 + 2.1 for LLR (p < 0.01). Intraoperative complications were seen 5 (11%) cases of LRH, 2 bladder injuries, 1 bowel injury, 1 ureteral damage and 1 adhesion syndrome. These lthree cases were converted into laparotomy. No intraoperative complications were seen in LLR group. Postop follow up showed complications in 4 (8%) cases. One ureteral stenosis 1 bowel burning injury and 2 cases of fever.. No postoperative complication was seen in LLR group. Mean nodes collected were 13.6 + 0.9 in LRH and 9,7 + 1,3) in lumboaortic staging. In LLR group scanner was suspicious of nodal involvemente in 1 of 8 cases. However in 4 of this 7 cases histological findings showed nodal metastasis, showing a low sensibility of scanner to evaluate aortic nodal status. Final histology was 43 (71,6%) epidermoid 14 (23,3%) adenocarcinoma and 3 (5%) adenosqamous.

Laparoscopic has shown to be a reliable technique for radical hysterectomy in early stages of cervical cancer. In advanced cases a surgical staging may done to set out radiotherapy.

P.11.16

Laparoscopic cystectomy-in-a bag of an intact cyst: is it feasible and oncologicaly safe after all?

Protopapas A.*[1], Chatzipapas I.[1], Mousiolis A.[1], Athanasiou S.[1], Patrikios A.[1], Loutradis D.[1], Antsaklis A.[1]

[1] 1st Department Of Obstetrics And Gynecology, University Of Athens, Alexandra Hospital. Athens Greece

Laparoscopic cystectomy-in-a bag is an excellent techique for tumors <8 cm. For larger tumors previous evacuation of the cyst with the adnexa into the endoscopic sac is recommended to avoid spillage.

In this study we prospectively investigated whether laparoscopic cystectomy of an intact cyst performed in an endoscopic bag is oncologicaly safe in tumors measuring <10 cm.

Our technique involved introduction of a water-proof endoscopic bag without an external manipulator, into the peritoneal cavity, and placement of the involved adnexa into the bag. Laparoscopic cystectomy was performed without previous evacuation of the cyst, making an effort to keep the adnexa inside the sac throughout the procedure, using 3 accessory trocars. Any leakage was recorded.

We used the above technique in 70 cases with non-endometriotic adnexal cystic tumors. In 58 patients cystic swellings were unilateral, and in 12 bilateral. In 43 cases, cysts had the ultrasonographic characteristics of a cystic teratoma, 22 cases had cysts with anechoic contents (17 unilocular, 5 multilocular), and 5 cases presented with intracystic papillary projections. Mean diameter of the cysts was 5,8 cm (range: 3,5–9,5). In 44/82 adnexae cystectomy was completed without rupture, whereas in the remaining 38/82 cases the cyst ruptured. Minimal to small spillage occurred despite every effort only in 4 cases with large (>8 cm) cystic teratomas. Two cysts of 3,5 and 5,5 cm in diameter, in the no-spillage group proved to be serous borderline tumors. We had no intraoperative or postoperative complications.

The above technique of ovarian cystectomy appears to be safe for cystic tumors with a diameter <8 cm. Manipulation of larger tumors with the adnexa into the sac may be more difficult, and in such cases previous paracentesis and evacuation of the cyst contents should be considered to avoid spillage in case of rupture.

P.11.17

Laparoscopic detection of sentinel lymph nodes in patients with endometrial cancer: preliminary results

Gonzalez Gea L.*[1], Zapico Goñi A.[1], Fuentes Castro P.[1], Heron Iglesias S.[1], Guzman Muñoz M.[1], Martinez Parrondo N.[1], Cajal Lostao R.[1]

[1] Principe De Asturias Hospital. Alcala University Madrid Spain

Sentinel node detection in endometrial cancer.

The aim of this study was to set feasibility of laparoscopic intraoperative sentinel node detection in low and intermediate-risk endometrial carcinoma.

From September 2010 to May 2011, 12 consecutive patients with endometrial cancer were scheduled for laparoscopic staging according to FIGO including sentinel node (SLN) biopsy pelvic and/or paraaortic lymphadenectomy, hysterectomy and bilateral salpingo-oophorectomy. First step of the procedure consisted of injection of Isosulfan or methylene blue dye into the cervix and into the subserosal miometrium at the fundus.

Mean age was 64,3 + 3,2 (48–83) years. Mean body mass index was 26,75 + 1,4 (20,81–32,02). Dye uptake into pelvic lymphatics occurred in 11 of the 12 patients (91, 7%). The average of SLN retrieved was 1.9 per patient (range 1 to 5). Among the 11 patients with at least one SLN detected, pelvic location of the SLN was bilateral in 6 cases (45,5%) and unilateral in 5 cases (54,5%). The most frequent location of SLNs included interiliac nodes (44%) followed by obturator nodes (30%). Only one patient (9,1%) has a sentinel node micrometastasis at definitive histology. No blue lymph nodes were identified in paraaortic area in the 2 patients when paraaortic lymphadenectomy was performed. No anaphylactic reactions occurred after blue dye injection and there were no surgical complications related to SLN biopsy. Four patients (33%) with grade 1 tumour at preoperative histology had grade 2 at final exam. Radiological stage by MRI was correct in 10 cases (83,3%) and underestimated in 2 patients with stage Ia in MRI with postoperative Ib staging.

Blue dye Sentinel lymph node mapping is a feasible and safety procedure in low-intermediate risk endometrial cancer and may be a reasonable option between systematic lymphadenectomy and no dissection at all.

P.11.18

Laparoscopic paraortic and pelvic lymphadenectomy and radical hysterectomy in a patient with cervical cancer 6 months after primary chemo—radiation

Kavallaris A.*[1], Zygouris D.[2], Chalvatzas N.[1], Terzakis E.[2]

[1] 4 Th 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 a 43-year old patient, who was diagnosed with cervical cancer St. Ib2. The patient underwent Paraortic and Pelvic Lymphadenectomy (31 Lymph nodes) and laparoscopic nerve-sparing Radical Hysterectomy six months after the completion of chemo radiation for a positive 3–4 cm lymph node. We believe it is important to perform lymphadenectomy in cases of cervical cancer as the chemo radiation seems not sufficient in preventing lymph node metastasis.

Cervical cancer is the fourth most common gynecological cancer affecting especially young women. Even in the early—stage of the disease the recurrence rate is high and the prognosis poor.

We present the case of a 43-year old patient, who was diagnosed with cervical cancer St. Ib2, after a loop excision. A computed tomography (CT) was performed for the pre treatment staging and revealed no lymph node metastasis. The patient was primary treated with Chemotherapy (carboplatin—paclitaxel) and Radiotherapy. Six months after the completion of chemo radiation a CT detected a 3–4 cm lymph node in the area of the left external iliac artery. The patient underwent Paraortic and Pelvic Lymphadenectomy (31 Lymph nodes) and laparoscopic nerve-sparing Radical Hysterectomy.

The pathology examination revealed 1 lymph node metastasis and no cancer cells in the uterus.

Chemotherapy and radiation may lead to complete remission of the primary tumor, but their effect on the lymph nodes is not satisfactory. Moreover the pre treatment CT does not detect positive Lymph nodes in 30%, which after the end of the treatment may recur. We believe it is important to perform lymphadenectomy in cases of cervical cancer as the chemo radiation seems not sufficient in preventing lymph node metastasis.

P.11.19

Laparoscopic radical surgery in initial stages of the cervical cancer

Martínez Lamela E.*[1], Molero Vílchez J.[1], Martin Marino A.[1], Gonzalez Paz C.[1], Hernández Aguado J. J.[1]

[1] Hospital Universitario Infanta Leonor Madrid Spain

Descriptive study of cervical cancers treated in our Center between April 2008 and January of 2011.

Assess the results of radical surgical techniques.

Database SELENE, consultation of Gynecology Oncology, record of the Committee of cancer hospital. Revision PUBMED, MEDLINE.

The average age of our 33 patients with cervical cancer was 49.8 years (18–88). The most frequently found histological type was the squamous cell carcinoma by 64 per cent of the cases. 10 Cases of adenocarcinoma of cervix (30% of the total) were distributed in 3 cases of adenocarcinoma in situ microinfiltrante and 7 cases of adenocarcinoma infiltrating.

The most common stage of presentation in our series was the stage IIB (9 cases), to those who recommended treatment with radiotherapy. Surgically involved 10 patients: in 5 occasions was total hysterectomy for being early, and cases in other 5 radical hysterectomy type III of Piver with nerve preservation (Querleu-Morrow C1). The choice of surgical technique was the laparoscopic in 70% of cases. On the radical lymphadenectomy in pelvic lymphadenectomy took place in 5 cases, with an average of lymph nodes removed from 21.4 (16–36 nodes); lymphadenectomy lumboaórtica was held in 3 cases, two of them in the context of rescue after primary treatment with radiotherapy and the third surgery was performed an extraperitoneal paraaórtica lymph node staging to match fields of radiotherapy in a stage IIIA. The nodes removed lumboaórticos average was 11.5 (11–12 nodes).

Laparoscopic surgery allow their treatment with a similar to the laparotómica via radical, but with less morbidity for the patient.

P.11.20

Laparoscopic salpingoohrectomy in management of breast cancer; novel resurgence

Shams M.*[1], Roshdi H.[2]

[1] Maher Shams Mansoura Egypt - [2] Hossam Roshdi Mansoura Egypt

The aim of this study to evaluate the feasibility and the outcome of laparoscopic salpingoophrectomy in premenpausal women with cancer breast as well as evaluation of microtmetastsis of both ovaries.

Endocrinal manipulation had been reported to have role in the treatment of a locally advanced breast cancer until it was eventually replaced by pharmacological oophrectomy Recentally the use of surgical oophrectomy as clinical trails have shown a clear benefit as adjuvant treatment in improving the prognosis of estrogen receptor positive breast cancer in premenopausal women.

We analyzed 53 women underwent laparoscopic c salpige oophrectomy for breast disease 9 cases with previous laprotomy, Setting mansoura university hospital surgery and gynecology department.

Fify thee (53)patients had laparoscopic oophrectomy with average age 47 year(range 32 year up to 72 year)the most common indication on is adjuvant endocrine treatment for cases with breast cancer cases(34 cases). 5 cases had ovarian micrometatasis 1 patient had laproscpic resetionof metastatic breast cancerto the ovary. 2 cases has peritoneal micrometastasis ,6 women had known BRCA1 orBRCA2 mutations, 2 had a family history of ovarian cancer and 3 others had a family history suggestive of hereditary breast cancer but no known mutation, laparoscopic surgery has generated far greater interest were safely carried out for endcrinological manipulation of the ovaries in premenopausal women with hormone responsive early cancer breast when compared to medical oophrectomy in addition to the value of early discovery of micrometatasis of the ovaries in cases of cancer breast as well as combined breast oncological and /or reconstructive surgery and laparoscopic salpingoophrectomy.

P.11.21

Laparoscopic techniques in the treatment of endometrial cancer

Martínez Lamela E.*[1], Molero Vílchez J.[1], Salazar Arquero F. J.[1], Hernández Aguado J. J.[1], Rivera Garcia T.[1], Lara Alvarez M. A.[1]

[1] Hospital Universitario Infanta Leonor Madrid Spain

The preoperative study should address are the patients who must be subjected to a radical lymphadenectomy pelvic and paraaórtica. Intraoperative biopsy of hysterectomy in EC pelvic lymphadenectomy in EC of intermediate-risk and low risk helps to reduce the morbidity tried a laparoscopic approach that has shown better perioperative results unchanged in the long term prognosis of the disease.

Descriptive study of endometrial cancers treated in our Center between April 2008 and January of 2011. Critical appraisal of the treatment.

Database SELENE, consultation of Gynecology Oncology, record of the Committee of Cancer from the Hospital. Revision PUBMED, MEDLINE.

We review our series of 68 cases of Carcinoma of endometrium (EC), with a median age of 67,10 (24–88), the most frequent histological type was the endometrioid type I 55 cases (82%) followed by the carcinosarcoma (5 cases).

The histological types of high degree, type II, were 3 cases of carcinoma cell and 1 case of seroso-papilar. In 64,70% of cases are diagnosed in early stages (stage IA, 21 cases and stage IB, 23 cases), most of low degree, G1 (34 cases, 50%); by the therapeutic objective is to make surgical treatment appropriate for the best results cancer with less morbidity for the patient. In our casuistics, 79,4% of cases of EC, could intervene being the choice of technique the laparoscopic via (70%). He appealed to the vaginal route in 15% of cases, with a palliative intention, for the high-risk surgical patients. In addition to total hysterectomy and double anexectomía. 38 lymphadenectomy (24 cases pelvic and in 14 cases of pelvic and paraórtica) with an average of 13.6 gg removed pelvic lymph nodes were in total. (3–30) and nodes nodes of 9.3 (2–17).

The adequacy of therapeutic attitudes in the endometrial cancer in stages of low risk and intermediate risk reduces the morbidity of radical surgery, while maintaining the same outcome.

P.11.22

Laparoscopy hysterectomy in endometrial carcinoma: is it possible to avoid the uterine manipulator? 2 years report

Fuster Rojas S. I.*[1], Soler Ferrero I.[1], Rodríguez Tárrega E.[1], Gurrea Soteras M.[1], Domingo Del Pozo S.[1], Boldó Rodá A.[1], Pellicer Martínez A.[1]

[1] Spain Valencia Spain

In the literature, some concerns have arisen about the possibility of increasing the vaginal relapse rate with the use of endouterine devices in the laparoscopy hysterectomy of endometrial carcinoma.

In our institution we have decided not to use any uterine manipulator in laparoscopy hysterectomy in endometrial carcinoma during the last 2 years.

We compared and analyze retrospectively the surgical time and complications rate in two differents historical moments of patients with endometrial carcinoma.

The first one was studied in a laparotomy policy (although there were some by laparoscopy); the second one in a LPS policy (separating the first year of learning courve).

Group 1: Jan 08-march09 (usual procedure): n = 63. Laparoscopic 14, staging 57%, 2 ending vaginal aproach, no recurrence; laparotomic 47: 3 complications, 6 recurrence. Surgical medium time: 3:09 vs 2:20

Group 2: April 09–May 10 (learning curve without manipulator): n: 56. Laparoscopic 32(staging 46%), Medium time 2:24 h, Laparotomic 19: medium time: 1:49 h. Complications LPS:1 vesical injury, 3 converted to laparotomy, 6 ending by vaginal approach. LPT: 1 intestinal perforation, 2 recurrence each group.

Group 3: June 10–March 11 (without manipulator): n = 30. Laparoscopic 13 (staging 53%), laparotomic:12, One intestinal perforation in the laparoscopic, and one urethral fistula in laparotomic, 8 ending by vaginal approach. Surgical medium time 1:59 h VS 2:19 h respectively. No recurrence.

There are any significance difference between the studied group.

The laparoscopy hysterectomy with double adnexectomy without uterine manipulator in the endometrial Adenocarcinoma is feasible in our centre with similar surgical times, without increasing complications. It will be needed a long-term follow-up to assess the vaginal incidences of relapse in these patients.

P.11.23

Laparotomy staging of early-stage endometrial cancer

Yoo H. J.*[1], Seo S.[1], Kang S.[1], Lim M. C.[1], Park S.[1]

[1] Research Institute And Hospital, National Cancer Center Goyang, Gyeonggi Republic Of Korea

Laparoscopic staging of clinically early endometrial cancer (MRI had less than half myometrial invasion) is a standard method at our center. We investigated the reasons for laparotomy staging of clinically early endometrial cancer. The reasons are mainly to have other combined tumor. Age, body mass index and uterine volume are not big portion to make the decision of the operation method.

Laparoscopic staging of clinically early endometrial cancer (MRI had less than half myometrial invasion) is a standard method at our center. We investigated the reasons for laparotomy staging of endometrial cancer by reviewing the surgical management of clinically early endometrial cancer patients.

The retrospective analysis evaluated patients that had laparotomy staging and laparoscopic staging as management of early endometrial cancer. Patients were identified by our institution’s database and data were collected by review of their medical records. Data were collected on demographics, pathology, and information for patients.

From January, 2001, through March, 2011, 73 early endometrial cancer patients were identfied. Among these, 65 patients (89.0%) had staging via laparoscopy and 7 patients (9.6%) had staging via laparotomy. Only one case (1.4%) was converted to laparotomy from laparoscopy. The reasons for laparotomy were co-operation of double primary cancer 3/8 (37.5%); ovarian cancer 2, colon cancer 1, non-endometrioid pathology 2/8 (25.0%); clear cell carcinoma 1, papillary serous carcinoma 1, other combined huge mass in uterus 1/8 (12.5): huge myoma 1, atrophic vagina and cervix 1/8 (12.5%). The reason that was converted to laparotomy from laparoscopy was an extremely obese (12.5%).

The reasons for laparotomy staging of clinically early endometrial cancer are mainly to have other combined tumor. Age, body mass index and uterine volume are not big portion to make the decision of the operation method.

P.11.24

Ovarain transposition: functional outcomes

Gubbala P. K.*[1], Walton K.[1], Pathiraja P.[1], Ind T.[1]

[1] The Royal Marsden Hospital London United Kingdom

A systematic review on ovarain tarnsposition in the treatment of gynaecological malignancies was carried out on article identified through medline search.

Ovarian transposition can be performed in patients with pelvic malignancies who require pelvic irradiation in an attempt to preserve normal ovarian function. However, papers report variable results. We have performed a systematic review of the literature to assess the efficacy of oophoropexy.

Studies were identified through a Medline search of articles published between 1/1/1980 31/12/2009 with the following search criteria; ‘ovary transposition’ or ‘ovarian transposition’ or ‘oophoropexy’. The following information was documented from each study (authors, year of study, type of study follow up duration, type of ovarian transposition, retention of ovarian function, incidence of metastasis and ovarian cysts).

A total of 159 titles were identified.21 articles were reviewed.

In the 21 studies, 818 patients had their ovaries transposed; 738 underwent open transposition and 80 laparoscopic. In two studies, the ovaries were transposed to subcutaneous tissue. 43 patients had vaginal cancer, 10 had ovarian dysgerminoma, one had pelvic sarcoma and the remaining patients (764) had cervical cancer.

A total of 418 (51%) patients had surgery alone, 144 (17.6%) had brachytherapy and 256 (31.2%) had external beam radiotherapy with or without brachytherapy. The follow up ranged from two to 65 months. A total of 639 (78.11%) patients had their ovarian function preserved;110 (13.4%) patients developed ovarian cysts; and two (0.25%) suffered metastasis to the transposed ovary.

The outcomes of the papers studied had conflicting results and much of the data concerning ovarian function includes patients who never went on to have radiotherapy. There were varied results with regard to development of ovarian, cysts and metastasis to the transposed ovaries.

P.11.25

Radical vaginal trachelectomy (Dargent’s operation): initial experience in North of Portugal

Ferreira H.*[1], Lopes C.[1], Alves A.[1]

[1] Hospital Da Arrábida Porto Portugal

Cervical cancer, one of the leading causes of cancer related deaths in females, is the most common genital tumor in Portugal. We report our experience with vaginal radical trachelectomy and laparoscopic pelvic lymphadenectomy as a valuable fertility-preserving treatment option for young women with early-stage cervical disease.

Cervical cancer is one of the leading causes of cancer related deaths in females in both developed and developing countries. In Portugal, it’s the most common genital tumor. Fertility preservation has become an important component of overall quality of life of young cancer survivors. Dargent pioneered the use of vaginal radical trachelectomy and laparoscopic pelvic lymphadenectomy as a valuable fertility-preserving treatment option for young women with early-stage cervical disease. Accumulating data confirm that overall oncological and obstetrical outcomes are very promising. In Portugal, the experience with this procedure is short and recent. We report our experience, from the North of the country.

Data on patients undergoing radical vaginal trachelectomy with pelvic laparoscopic lymphadenectomy were collected in a retrospective database.

Four women with early-stage cervical cancer were operated. Ages range from 25–32 years. FIGO stage were IB1(3 cases) and IA2 (1 case). Histology: 3 squamous and 1 adenocarcinoma. All nullipara. Median BMI was 24 kg/m2. The median OR time was 140 min (range, 120–160 min). Median hospital stay was 4 days (range 3–7). One woman got pregnant spontaneously 12 months after the procedure and delivered by cesarean section at 33 weeks. We report dysmenorrhea and irregular menstruation in 1 case.

In conclusion, we have a small number of cases but our experience reflects a very promising role for this approach in Portuguese clinical practice, where cervical cancer takes a very prevalent place in gynecological oncology.

P.11.26

Retroperitoneal laparoscopic lymphadenectomy and gynaecological malignancies

Zapico Goñi A.*[1], Fuentes Castro P.[1], Gonzalez Gea L.[1], Garcia Pineda V.[1], Rodriguez Garnica D.[1], De Valle Corredor C.[1], Garbayo Sesma P.[1]

[1] Principe De Asturias Hospital. Alcala University Madird Spain

Seventeen cases report of left side retroperitoneal approach to lumboaortic lymphadenectomy.

Extraperitoneal laparoscopic lymphadenectomy is an increasing procedure in gynaecologic malignancies.

Seventeen patients were operated on for cervical, endometrium or ovarian cancer between June 2009 and May 2011. Extraperitoneal left-sided approach was performed to assess the lumboaortic lymph node status.

Mean age was 49 (30–70) years. The median BMI was 25,9 (19–37). Malignancy consisted of cervical cancer in 10 patients, endometrial cancer in 3 patients, ovarian cancer in 3 patients and 1 patient with ovarian and endometrial cancer. The average tumour diameter in cervical cancer by MRI was 45.15+/−20 cm. Clinical staging of cervical cancer was 3 cases of IB2 and 7 cases stage IIA or greater. In this 10 cases, node status was assessed prior to chemo-radiotherapy. In endometrial and ovarian cancers, lumboaortic lymphadenectomy was the first step of a complete surgical staging, the procedure was changed into a transabdominal approach to complete the FIGO staging. Mean operation time was 160 min (90–300 min). The mean paraaortic lymph node harvested was 7,19 (2–15) and the mean pelvic lymph node removed was 7 (1–12). Aortic nodal metastasis were detected in 17,6% of the patients (n = 3) but only one has a positive pre-operative CT scan. One patient had disruption of the peritoneum that can be repaired by laparoscopy so there was no conversion into transperitoneal approach for lumboaortic lymphadenectomy. There were no postoperative complications and the median hospital stay was 2,62 + 1,5 days. No transfusions were required. Up to date, 14,6 + 2,5 months follow-up, there have been two pelvic recurrences and one lung metastasis, all of them in cervical cancers.

Left side retroperitoneal approach to lumboaortic lymphadenectomy seems to be a feasible procedure in gynaecological malignancies.

P.11.27

Role of laparoscopic surgery in the management of endometrial cancer. A multi-centre audit

Jadoon B.*[1], Kehoe S.[1]

[1] John Radcliffe Hospital Oxford United Kingdom

.Audit design: This is a part of regional audit. In total four hospitals; John Radcliffe Hospital, Stoke Mandeville Hospital, Royal Berkshire and Great Western Hospital in Swindon were involved. Our data presents the results from John Radcliffe and Stoke Mandeville Hospital.

Aim: To evaluate LVH in proven or suspected endometrial cancer of our units with regard to

  1. 1:

    Theatre time

  2. 2:

    Length of hospital stay

  3. 3:

    Need to convert and

  4. 4:

    Complication rate

Current evidence on the safety and efficacy of laparoscopic hysterectomy (including laparoscopic total hysterectomy and laparoscopically assisted vaginal hysterectomy) for endometrial cancer is adequate to support the use of this procedure provided that normal arrangements are in place for clinical governance, consent and audit.

Total Number of patients:71

Design: Retrospective analysis

Source: MDT Performa plus case notes

Time period: 01/04/08 to 31/03/09

Conclusion:

  • Laparoscopic hysterectomy is suitable alternative to TAH.

  • Complication rate is much lower in laparoscopic group.

  • Length of surgery and hospital stay was less in laparoscopic group than in laparotomy group.

  • Only 9%of patients had LAVH.57% of patients had abdominal hysterectomy.

  • No additional criteria could be identified which might alter the decision for or against the laparoscopic approach.

Laparoscopy for surgical treatment of uterine (endometrial) cancer is safe, and when successfully completed reduces hospital stay by 50 percent, and contributes to a better quality of life from the patient’s perspective.

P.11.28

Sentinel lymph node detection in early stage cervical cancer patients: comparison of minimally invasive and open procedure

Klat J.*[1], Sevcik L.[1], Graf P.[1], Simetka O.[1], Jaluvkova Z.[1], Kraft O.[1]

[1] University Hospital Ostrava Czech Republic

The purpose of this study was to investigate the feasibility of sentinel node (SLN) detection through laparoscopy. Tthese results from laparoscopic group were compared with group of patients with SLN detection performed by laparotomy. The detection rate and side specific detection rate was 94,1% and 85% in the laparotomy group, and 93,9% and 89,4% in the laparoscopy group. Laparoscopic detection of SLN in cervical cancer is a feasible minimally invasive technique with high detection rate and with comparable results to laparotomy.

The purpose of this study was to investigate the feasibility of SLN detection through laparoscopy in patients with early cervical cancer and the results of laparoscopic SLN dissection were validated by subsequent laparotomy. Furthermore, these results from laparoscopic group were compared with group of patients with SLN detection performed by laparotomy.

Between May 2004 and December 2009, a total number of 203 women (median age 46,2 years) with cervical carcinoma FIGO Stage Ia2–IIa underwent a SLN procedure via laparotomy, and between March 2009 and May 2010, 36 women (median age 39,6 years) with cervical carcinoma FIGO Stage Ia2–IIa underwent a SLN procedure via laparoscopy. Intracervical injection of technetium-99 m as well as blue dye was used for lymphatic mapping. In the both groups of patients after SLN detection all patients underwent complete pelvic lymphadenectomy with abdominal radical hysterectomy.

The detection rate and side specific detection rate of SLN was 94,1% and 85% in the laparotomy group, and 93,9% and 89,4% in the laparoscopy group. The laparoscopic detection of SLN was aborted in three cases due to firmly pelvic adhesions.

Laparoscopic detection of SLN in cervical cancer is a feasible minimally invasive technique with high detection rate and with comparable results to laparotomy.

P.11.29

Short term results of laparoscopic radical hysteroctomy for endometrial adenocarcinoma

Amodeo M.*[1], Salazar I.[1], Rodriguez B.[1], Serrano R.[1], Garcia Vidal E.[1], Romo J. M.[1], Caballero V.[1]

[1] Hospital Nuestra Señora De Valme Sevilla Spain

To evaluate the results of the Laparoscopic Radical Hysterectomy(LPC) for early stage endometrial carcinoma.

The FIGO introduced a system of anatomical-surgery staging for endometrial carcinoma (Total hysterectomy + bilateral salpingo-oophorectomy + pelvic and lumbo-aortic lymph node dissection).Laparoscopy has shown to be capable of implementing all steps of the surgical staging system in accordance with this guidelines.In our study, we have compared the surgical treatment of endometrial carcinoma with laparoscopic versus laparotomy.

We have compared 12 LPC performed in the period March 09–June 10 for endometrial carcinoma in the Valme Hospital with other 20 Laparotomy Radical Hysteroctomy(LPT) performed in the same period and randomly selected. Both groups were homogeneous in age,histology,stage and histological grade.

The average time of procedure was lower in LPT,214 min, than in LPC,250 min.A lymphadenectomy was performed in every case.In the LPT,this was extended to the pelvis in 80% of the cases and paraaortic extension in 20%.In LPC,pelvic lymphadenectomy was performed in 90% of the cases and paraaortic extension in 10%.The average length of stay in hospital was 9.43 days in LPT and 6.73 days in LPC.After surgical complications accounted for up to 71% in LPT and 20% in LPC.The most common complication in LPT is the hernia on scar(35.7%)and in LPC, is the vaginal vault haematoma(18.2%).

None of the LPC required a transfusion of hemoderivatives,vs 7.1% of the LPT. An continuous intravenous analgesia was needed in every LPT;this only happened in 40% of the LPC.

LPC for early stage endometrial carcinoma achieves the same objectives of resectability and staging than with LPT.

The average length of stay in hospital is reduced by an average of 2.7 days.

The complications following surgery and the need for analgesia are widely reduced with the LPC.

P.11.30

Should we centralize care for the patient suspected of having ovarian malignancy?

Peggy G.*[1], Roy K.[2], Gérard B.[3], Leon M.[4], Ben Willem M.[5]

[1] Department Of Obstetrics And Gynecology, Máxima Medical Centre Veldhoven Netherlands - [2] Department Of Obstetrics And Gynecology, Academic Hospital Maastricht Maastricht Netherlands - [3] Department Of Obstetrics And Gynecology, Maasland Hospital, Sittard Netherlands - [4] Department Of Obstetrics And Gynecology, Radboud University Nijmegen Medical Centre Nijmegen Netherlands - [5] Department Of Obstetrics And Gynecology, Academic Medical Centre Amsterdam Netherlands

Centralised care for patients with ovarian malignancy results in better outcome. In this study, we assess the costs and effects of centralised and regular care for women with an ovarian malignancy in the Netherlands. We conclude that in women with an adnexal mass, a diagnostic strategy prior to the decision for surgery by a general gynaecologist or a gynaecological oncologist provides the best balance between costs and effects.

Outcome of ovarian cancer is better when surgery is provided by a gynaecological oncologist than by a general gynaecologist. However, when all patients with an adnexal mass have to be operated by oncologists, this requires a change in the organisation, which generates additional costs. We assess the costs and effects of centralised and regular care for women with an ovarian malignancy in the Netherlands.

We considered three strategies. In the first strategy, patients were operated by a general gynaecologist (general care strategy). In the second strategy, patients were operated by a gynaecological oncologist (specialized care strategy). In the third strategy, evaluation of the adnexal mass took place prior to surgery by means of the Risk of Malignancy Index (diagnostic strategy). Patients at high risk for malignancy were supposed to be operated in a specialized care setting, whereas low risk patients were supposed to be operated in a general care setting.

Mean life expectancy of a patient with an ovarian malignancy in the general strategy was 2.7 years, in the diagnostic strategy 3.0 years and in the specialized strategy 3.1 years. The incremental costs to gain one additional life year with specialized surgery as compared to the diagnostic strategy were € 61,871 per LYG.

In women with an adnexal mass, a diagnostic strategy prior to the decision for surgery by a general gynaecologist or a gynaecological oncologist provides the best balance between costs and effects.

P.11.31

The effectiveness of laparoscopic ovarian transposition in patients treated with pelvic radiotherapy and chemotherapy

Riris S.*[1], Turkgeldi E.[1], Turkgeldi L.[1], Cutner A.[1], Macdonald N.[1], Olaitan A.[1], Saridogan E.[1]

[1] University College London Hospital London United Kingdom

Prospective study of 27 patients undergoing laparoscopic ovariopexy and/or ovarian transposition at UCLH between 2002–10, before they received treatment for their malignancy.The effectiveness of this surgery on reducing the risk of premature menopause was subsequently assessed.

Ovarian transposition and ovariopexy can reduce injury to ovarian tissue due to radiotherapy.The ability of surgery to reduce premature menopause after chemotherapy ranges from 16–90% but remains unknown when chemo and radiotherapy are combined.

27 patients underwent laparoscopic unilateral or bilateral ovariopexy and/or ovarian transposition before receiving cancer treatment.All patients had radiotherapy whereas patients with cervical cancer also received chemotherapy.21/26 received chemotherapy in addition to radiotherapy.Ovarian function was assessed by measuring the hormone profile or by confiriming cycle resumption.

6 patients were excluded.From the remaining 21,8 developed ovarian failure(42%) and 13(58%) had normal ovarian function.Of the 8 that became menopausal,7 were treated with combination chemoradiation for cervical cancer.7/10 treated for cervical cancer became menopausal(70%).Among those with Hodgkin’s Lymphoma 3/6 became menopausal and in patients with soft tissue cancers none became menopausal(0/9).All women above 29 years old became menopausal(5/5), whereas 3/14 who were below 29 years became menopausal after treatment.

Overall, 58%of patients retained ovarian function. In cervical cancer this figure was 30%,which is lower compared to reported studies,probably due to combination chemoradiation as opposed to radiotherapy alone.Retained ovarian function is higher in malignancies other than cervical.Age is a significant determinant of retained ovarian function following treatment for malignancy.Surgery is safe and can be offered to women prior to treatment for malignancy.

P.11.32

The outcome of laparoscopic radical hysterectomy (LRH) and pelvic lymphadenectomy in patients with early invasive cervical cancer

Jihad D.*[1], Fritz J.[1]

[1] University Medical Center Hamburg-Eppendorf Hamburg Germany

A retrospective study to analyse 50 cases of laparoscopic radical hysterectomy in patients with early invasive cervical cancer evaluating the procedure (feasibility, duration, blood loss and complications) with a follow-up of 36 months.

To evaluate retrospectively feasibility and oncological outcome of laparoscopic radical Hysterectomy (LRH) in patients with Ib1 stage cervical cancer.

Fifty patients with cervical cancer (stage Ib1) were evaluated. These patients were treated with LRH and pelvic lymphadenectomy. Adjuvant therapy was not necessary.

The radical Hysterectomy was performed using the harmonic scalpel.

The postoperative complications were registered. Median Follow up of 36 months.

Disease-free Survival (DFS) and Overall Survival (OS) were also analysed.

Median duration of surgery was 280 min. Median number of resected pelvic lymph nodes was 21. Median blood loss was 150 ml. No intraoperative complications and no conversion to laparotomy.

One patient needed a second surgery for postoperative bleeding. One patient had an ureterovaginal fistula after the operation. Three patients had a recurrence after a median follow up of 36 months. OS was 98%.

The LRH is feasible with excellent surgical and oncological outcome which is comparable to patients treated with laparotomy.

P.11.33

Total laparoscopic hysterectomy—providing efficiency within an oncology service

O’ Neill A.*[1], Maher_ N.[1], Wrynn A.[1], Boyd B.[1], Walsh T.[1]

[1] Mater Misericordiae University Hospital, Eccles Street, Dublin 7

Since Harry Reich introduced laparoscopic hysterectomy in the late 1980’s, many studies have demonstrated that this procedure is associated with decreased blood loss, shorter duration of hospital stay, faster post-operative recovery and less abdominal wound infectious morbidity when compared with abdominal hysterectomies.

Total laparoscopic hysterectomy (TLH) is a proven safe and effective surgery for many benign gynaecological conditions. It now holds a place in the management of early endometrial and early cervical cancers. Our Unit has traditionally managed these cancers with laparotomy and abdominal hysterectomy.We sought to audit our experience with the introduction of total laparoscopic hysterectomy to our Unit.

TLH was introduced in our hospital in September 2009. A retrospective cohort study was performed from September 2009 to May 2011 to review the length of hospital stay and incidence of operative laparoscopy complications, as well as analgesia requirements in the immediate post-operative period. Individual charts were reviewed and we recorded the womens’ age, body mass index (BMI), indication for surgery, pre- and post-operative haemoglobin values, duration of hospital stay, and any intra-operative or post-operative complications.

118 patients underwent TLH from September 2009 to May 2011 with an average age of 51.4 years. The average BMI was 27.8. Thirty five of these patients had early endometrial or cervical malignancies. Three of these women also underwent laparoscopic pelvic node dissection for endometrial malignancies. A further 11 patients had risk-reducing surgery for carrying BRCA or HNPCC mutation. One of these women had early tubal neoplasia on her histopathology. The remainder of the women underwent TLH for benign pathologies, or recurrent cervical intra-epithelial neoplasia.

Three women were converted to an open procedure due to difficulty with significant intra-abdominal adhesions. Despite this, the average length of stay was still under 2 days. 1 woman required opiate analgesia. An average drop in haemoglobin of 0.6 g/dL was recorded. There were no cases that needed to return to theatre. There were three readmissions for vault haematoma, all managed conservatively. Two women were treated post-operatively for urinary tract infection. No other significant morbidities were noted, and specifically no wound infections.

The relative reduction in hospital stay has obvious benefit to the patient, but more importantly to bed management at local hospital level, and health economics at a national level.

Our study shows that TLH is a safe procedure, with a low risk of significant operative complications, which requires minimal post-operative analgesia. International studies have shown its benefit for obese women with endometrial cancer who have higher peri-operative risks with laparotomy.

With expanding waistlines becoming a national epidemic and belt tightening becoming a national necessity, we should consider this surgery as first line for many gynaecology patients who require hysterectomy.

P.11.34

UTROSCT: 2 cases report

Castellacci E.*[1]

[1] Ospedale Palagi Firenze Italy

We report 2 cases of rare tumor (uterine tumor resembling ovarian sex cord tumor) histologically diagnosticated after hysteroscopic polipectomy.

Uterine tumors resembling ovarian sex cord tumors (UTROSCTs) are rare neoplasms.

Uterine tumors resembling ovarian sex cord tumors (UTROSCTs) are rare neoplasms of uncertain malignancy, affecting either pre or menopausalUTROSCTs are distinguished into two separate groups: endometrial stromal tumors with sex cord-like elements (Group I), which have an unfavorable prognosis; and UTROSCT proper (group II), with more than 40% sex cord-like differentiation and less endometrial component, which are biologically less aggressive than the tumors of the other group. women.

2 women 50 and 55 years old came to our attention for hypermenorrea. They were subjected to ultrasound examination showing endometrial pathology and underwent to office polipectomy. Histology showed monomorphic proliferation of cellular elements arranged in a delicate taste and bays and surrounded by eosinophilic stroma, suggestive for sex cord derivation , like UTROSCT.According to both patients, clinical and diagnostic examinations were performed at 3 and 6 months.

All the examinations were negative except for the office hysteroscopy at 6 month that showed a new polip at the site of the former polip.

The histological examination confirmed the previus diagnosis of UTROSCT.

Abdominal histerectomy with bilateral salpingo-oophorectomy was performed.

Histological examination of the surgical specimen shows secretive endometrium with diffuse adenomiosis area without further neoplastic proliferation.

The ovaries were free of significant pathological disorders, that confirms the endometrial derivation of the cancer.

In our cases the diagnosis of UTROSCT was made by hystological examination and the managment in line with previous cases described in the literature.

P.11.35

Vaginal radical trachelectomy—recurrence and pregnancy rates

Pessini S.*[1], Silveira G. P. G.[1]

[1] Universidade Federal De Ciencias Da Saude De Porto Alegre Porto Alegre Brazil

Radical trachelectomy with laparoscopic lymphadenectomy and parametrectomy is a treatment option to a cervical cancer in patients who desire to preserve fertility. We elected 12 patients to surgery but in 2 it was aborted. We reported the recurrence and the obstetric outcomes in patients submited to surgery.

Radical trachelectomy follow the current concepts of conservative and minimal invasive surgery. Daniel Dargent proposed and began the radical trachelectomy with laparoscopic pelvic lymphadenectomy and parametrectomy. The surgery is indicated for patients who desire to preserve the fertility, tumor less 2 cm, FIGO IA2 to IB1, epidermoid or adenocarcinoma histology without lymphovascular invasion. The aims are to describe our cases and to analyze the oncologic and obstetrics outcomes.

From october 2000 to may 2011 we elected 12 patients. One was aborted by positive sentinel node and another by involvement of the up cervical channel. Age, parity, tumor hystology, FIGO stage, lymph nodes, oncologic and obstetrics results were the factors analyzed.

Patients age ranged from 19 to 35 years. Six patients didn’t have children, and three had one. The histology was epidermoid in seven, and adenocarcinoma in two patients. FIGO stage was IB1 in eight patients and IA2 in one. The mean of lymph nodes was 21,9 (4 to 29).

Oncologic results: One recurrence.

Obstetrics results: 6 pregnancies in 3 patients, with 3 live births (baby at home) and 3 with concept loss. Five patients attempting pregnancy (with anticonception).

The radical trachelectomy with laparoscopic lymphadenectomy and parametrectomy, in early invasive carcinoma of the cervix, in our experience, has a raisonable pregnancy rate, according the international data.

P.11.36

Which is the meaning of ASC-US in the population of ESPAÇO JOVEM?

Reis P.*[1], Brandão M.[1], Santos J.[1], Carinhas M. J.[1], Oliveira T.[1]

[1] Centro Hospitalar Porto Porto Portugal

Found out which is the meaning of repetition ASC-US, in the population of ESPAÇO JOVEM.

ASC-US represents >90% of the ASC cases and suggests low-grade squamous intraepithelial lesion but it is qualitative and quantitatively insufficient for its definitive diagnosis. After such cytological result we must perform new cytology or HPV test or colposcopy. According to the protocol of our service, we repeat cytology.

Retrospective Study of the clinical processes of 15 young female, that came to ESPAÇO JOVEM between January 2004 and December 2008 and had been conducted to the Cervical Pathology for repetition ASC-US on cervical cytologies. The studied variables had been: age, coitarche, number of sexual partners, results of the colposcopy and cervical biopsy, HPV test and posterior cytologies.

Population age varied between 18 and 25 years. The coitarche occurred between the 15 and 20 years with an average of 17 years. Number of sexual partners varied between 1 and 6. Of the 11 carried through colposcopy, 8 were of low degree, 2 with cervicitis and 1 with typical transformation zone. Ten cervical biopsies were performed, 4 with the result of HPV without dysplasia, 3 with the CIN1 result, 2 with Chronic Cervicitis and 1 Not Satisfactory.

Curiously, it had a case whose trajectory was: colposcopy of low degree, biopsy with CIN1 and cytology ASC-US; later cytology with NILM, HPV test positive, follows not satisfactory colposcopy, endocervical curettage without alterations, cytology ASC-H.

It carried through conization and laser vaporization whose histological exam showed CIN1 in the edges of ectocervix and CIN3 in the edges of endocervix. It made new conization whose histological showed edges of ectocervix with CIN1 and endocervix, free.

ASC-US represents >90% of the ASC cases and suggests low degree lesion but it does not eliminate the hypothesis of high degree lesion.

P.11.37

Incidental adnexal malignancies during routine laparoscopic surgery

Vilos G.*[1], Ho H.[1], Vilos A.[1], Marks J.[1], Akira S.[1], Abu-rafea B.[2]

[1] Department Of Ob/gyn, The University Of Western Ontario London Canada - [2] King Saud University Riyadh Saudi Arabia

1319 laparoscopic adnexal surgeries were performed. The rate of adnexal malignancy detected was 1.4%. Inadvertent laparoscopic surgery in malignant pathology did not affect long term outcome in the majority of women.

Adnexal surgery is frequently required in women of all ages. Since there are no accepted discriminatory tests to identify malignancy preoperatively, it is inevitable that adnexal malignancy will be encountered inadvertently which may or may not be recognized intra-operatively.

Retrospective cohort (Canadian Task Force classification II-3). Women (mean age, 45.3y) with breast cancer, pelvic pain and/or mass. University-affiliated teaching hospital. From January 1990 through June 2011, the senior author (G.A.V.) performed 1319 laparoscopic adnexal surgeries in 1114 women. Among these, there were 864 adnexectomies (bilateral-205, Rt-270, Lt-389) and 250 oophorocystectomies 16 malignancies were encountered, (1.4%, 14 adnexae, 2 cysts): ovarian; 1 serous, 1 endometrioid adenocarcinoma, 1 immature teratoma, 2 granulosa cell, 1 Sertoli-Leydig; 1 fallopian tube papillary-serous adenocarcinoma; 9 borderline ovarian (5 serous, 4 mucinous), were subsequently detected. Six women had staging hysterectomy/adnexectomy (1 port-site metastases), 5 laparoscopic contralateral adnexectomy/appendectomy as indicated (2 cysts borderline), 5 no further surgery. At 2–15y (median 6.5y), 15 are alive (1 recurrent granullosa-cell); 1 lost to follow.

  1. 1.

    During routine laparoscopic adnexal surgery, malignancies were encountered at a frequency of approximately 1.4%.

  2. 2.

    Inadvertent laparoscopic surgery in malignant adnexae did not adversely affect long-term outcomes in the majority of women.

Session P.12

* Operative Hysteroscopy *

P.12.1

An analysis on 409 cases of removal IUDS for postmenopausal women

Xia E.*[1]

[1] Hysteroscopic Center, Fuxing Hospital, Capital Medical University Beijing China

Many methods used together the IUD removal for postmenopausal women within 1 year after menopause is important.

To evaluate the methods and appropriate time to remove IUD of postmenopausal women.

From Jan. 2004 to Dec.2008 there were 2175 women asked to remove their IUD. Among them there were 409 postmenopausal women of whom the methods and best time of removal IUD was analysed.

Under cervical pretreatment, routine method and/or B ultrasonography monitoring hysteroscopic surgery IUDs of 409 postmenopausal women were removed successfully.

For postmenopausal women the best time to remove IUD was within 1 year after menopause and pretreatment of cervix was needed?

P.12.2

Bipolar endometrial ablation compared with hydrothermablation for dysfunctional uterine bleeding: impact on long term patients’ health related quality of life

Penninx J.*[1], Herman M.[1], Mol B. W.[2], Houterman S.[1], Kruitwagen R.[3], Bongers M.[1]

[1] Maxima Medical Centre Veldhoven Netherlands - [2] Amc Amsterdam Netherlands - [3] Maastricht University Medical Centre Maastricht Netherlands

Bipolar endometrial ablation compared with Hydrothermablation: impact on long term patients’ health related quality of life. Both significantly improved health related quality of life in women with dysfunctional uterine bleeding.There was no association with health related quality of life between the two groups.

We have previously demonstrated that amenorrhea rates and patient satisfaction 12 months after bipolar radio frequency ablation are superior to the results after Hydrothermablation in the treatment of dysfunctional uterine bleeding. Now, we compared health related quality of life after bipolar ablation and Hydrothermablation in patients with dysfunctional uterine bleeding.

160 Women with menorrhagia were randomly allocated to bipolar radiofrequency ablation or Hydrothermablation. All were asked to complete quality of life questionnaires at baseline, 4 weeks, 6 months, 12 months and 4–5 years after randomisation. The menorrhagia outcomes questionnaire (MOQ), Shaw questionnaire, pictorial chart score, medical outcomes study Short-Form (SF-36) and Euroqol before randomisation, and each follow-up visit after randomisation were selected to evaluate quality of life.

Health related quality of life improved significantly over time in both groups at all domains, with 10 to 20 points (scale:0 to 100). None of the dimensions showed a significant difference between both groups, neither was there a significant interaction between time and treatment effect.

Bipolar endometrial ablation and Hydrothermablation both significantly improved health related quality of life in women with dysfunctional uterine bleeding. Tthere was no association with health related quality of life between the two groups. These data urge to reassess the validity of health related quality of life questionnaires in the evaluation of menorrhagia.

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

Gergolet M.*[1], Kenda Šuster N.[2]

[1] S.I.S.Me.R. Servizi Doberdò Del Lago Italy - [2] Dept. Ob/gyn, University Of Ljubljana Ljubljana Slovenia

We compared the results of hysteroscopic septoplasty using a 16 Fr. mini resectoscope versus a 24 Fr. resectoscope. Metroplasty using the 16 Fr. seems to present some advantages such as the possibility to avoid cervical dilatation and to increase the compliance of the patients.

We compared the results of hysteroscopic septoplasty using a 16 Fr. mini resectoscope versus a 24 Fr. resectoscope.

71 women were included in this prospective study. 29 women underwent metroplasty with the 16 Fr. mini operative monopolar resectoscope, whereas in 42 patients a 24 Fr. resectoscope was used. We compared the outcomes on three classes of variables: surgeon’s evaluation on the procedure patient’s compliance and preliminary clinical results.

Seven patients (24,1%) in the 16 Fr. group needed a cervical dilatation. In the 24 Fr. group, all the 42 patients of needed a cervical dilatation. Only 4 patients (13.8%) in the 16 Fr. group needed pain killers at home, whereas 18 patients (42.9%) in the 24 Fr group used common analgesics at home. Mean time for discharge from the setting was shorter in the 16 Fr. group. After metroplasty 11 patients (37,9%) in the 16 Fr. group and 15 patients (35.7%) in the 24 Fr. group did not conceive (n.s.). One patient (5.6%) in the 16 Fr. group and 2 patients (7.4%) in the 24 Fr. group experienced a spontaneous miscarriage. Eleven patients in the 16 Fr. group and 15 patients in the 24 Fr. group delivered at term, remaining ongoing pregnancies in both groups are not threatened for preterm delivery.

Metroplasty using the 16 Fr. seems to present some advantages such as the possibility to avoid cervical dilatation and to increase the compliance of the patients in front of similar clinical outcomes after the procedure.

P.12.4

Complications of hysteroscopy. Retrospective study

Sokol P.*[1], Gracia M.[1], Cardona M.[1], Jou P.[1], Nonell R.[1], Carmona F.[1]

[1] Hospital Clinic Barcelona Spain

The aim of this study was to estimate rate of hysteroscopy-related complications. Data was obtained from all hysteroscopic procedures from years 2006–2010. Complication rate from all the procedures was 0.99%. Diagnostic procedures had lower complication rate than operative procedures.

The aim of this study was to estimate the incidence of complications of diagnostic and operative hysteroscopic procedures in our centre and to describe their nature.

Data on complications was recorded in our centre from last 4 years. We took into consideration all patients submitted to diagnostic or operative hysteroscopy that took place in outpatient clinic or operating theatre.

44 complications occurred among 4455 hysteroscopic procedures (rate 0.99%). Diagnostic procedures had 16-fold lower complication rate (0.17%) than operative procedures (rate 2.72%), p < 0.05. Operative hysteroscopies performed in outpatient clinic had 5-fold lower complication rate (1%) than procedures carried out in operating theatre (5.2%), p < 0.05.

The most frequent surgical complications were fluid overload of distension medium that happened in 10 cases (rate 0.7%) and post-discharge visits in emergency unit that occurred in 7 cases (rate 0.5%).

Diagnostic hysteroscopies had low complication rate, indicating that they are safe procedures to evaluate intrauterine pathology. The incidence of complications was lower among operations carried out in outpatient clinic than in the operating theatre. The rate of complications of operative hysteroscopies from our study was similar to rates described in recent prospective studies.

P.12.5

Endometrial ablation: comparative study of novasure© and thermachoice© using the outcome measure of hysterectomy one year after procedure

Fakulujo O.*[1], Nicholls R.[2], Rieck G.[1]

[1] Ysbyty Gwynedd Hospital Bangor United Kingdom - [2] Luton And Dunstable General Hospital Luton United Kingdom

A comparative study between Novasure© and Thermachoice© endometrial ablation was done between June 2006 and June 2010, with a focus on sunsequent hysterectomy. There were 213 endometrial ablations and 29 subsequent hysterectomies (22 from the balloon ablation arm and 7 from the Novasure© arm of the study) The results suggest a lower rate of hysterectomy following Novasure© ablation, though this was not statistically significant.

Menorrhagia can have a huge impact on women’s life. The current recommendations by NICE advocate the use of minimal invasive procedures when medical treatment has failed.

At Ysbyty Gwynedd, a district hospital in North Wales, two devices suitable in the treatment of dysfunctional uterine bleeding are in use. One device works with bipolar radiofrequency energy (NovaSure©) and the other device destroys the endometrium thermally (Thermachoice©).

This was a retrospective case-control study comparing two methods of endometrial ablation. The cases were identified from the theatre database. The outcome was based on review of the electronic and medical hospital notes (Clinic letters, pathology reports).

There were 213 ablations between June 2006 and June 2010. These included 128 balloon ablations (Thermachoice© and thermablate©) and 85 radiofrequency impedance device therapy. The follow-up period ended in June 2011.There were 29 hysterectomies with 22 from the Thermachoice group and 7 from the Novasure group.

There appears to be a lower rate of hysterectomies in the radiofrequency group although this was not statistically significant. The data may be an underestimation of the hysterectomy rates as women may have had hysterectomies undertaken privately or in another region. The follow-up period of one year is rather short and some women may present later with recurrence of Menorrhagia.

P.12.6

Endometrial ablation: a service evaluation of treatment outcomes at three years

Pennington S.*[1], Connor M.[1]

[1] Sheffield Teaching Hospitals Nhs Foundation Trust Sheffield United Kingdom

Current PCT guidance is to offer endometrial ablation for initial surgical management of menorrhagia. Studies have shown certain risk factors may affect success rates of ablation, suggesting that hysterectomy may be better first-line management for patients who are at higher risk of requiring additional tresatment (Longinotti et al, 2008). Known predictors of treatment outcomes may help clinicians with preoperative patient counselling (El-Nashar et al, 2009).

To assess impact of identified risk factors upon the likelihood of undergoing hysterectomy following endometrial ablation.

To enhance service provision and treatment outcomes by tailoring advice regarding surgical management of menorrhagia to individuals’ risk factors.

A retrospective study of all patients undergoing radio-frequency (Novasure) or thermal balloon (Thermachoice or Thermablate) endometrial ablation in our unit between 1st April 2007 and 31st March 2008. Analysis of inpatient and outpatient data generated information regarding patient age at time of ablation, parity, preoperative dysmenorrhoea, presence of fibroids, sterilisation, further therapeutic surgeries and time interval of these from initial ablation.

During the 12 months, 160 procedures were undertaken: 85 (53%) as inpatients (59 (69%) Novasure, 26 (31%) Thermachoice); 75 (47%) as outpatients (74 (99%) Novasure, 1 (1%) Thermablate). Treatment outcomes will be used to assess whether the presence of certain pre-operative risk factors correlate with an increased incidence of subsequent hysterectomy.

The results in our unit will be discussed in comparison to published data. Results may help to guide future counselling of patients regarding likelihood of successful endometrial ablation based on each patient’s individual risk factors.

References:

Longinotti M K. et al 2008, Obstet Gynecol. 112: 1214–20.

El-Nashar S A. et al 2009, Obstet Gynecol. 113: 97–106.

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

Heckel S.*[1]

[1] Hospital St Joseph - St Luc Lyon France

We report a retrospective study including 40 women who underwent endometrial thermocoagulation by CAVATERM and ESSURE® sterilisation in the treatment of functional uterine haemorrhage and show that this outpatient combined procedure appears to be safe and effective with a success rate in 95% of cases.

Functional uterine haemorrhages concern 25% of women of reproductive age. Conservation techniques of endometrial destruction, called second generation, have replaced hysterectomty and hysteroscopic endometrail resection due to their greater safety with equivalent efficiency. The use of a permanent contraception is imperative due to the risks incurred for a subsequent pregnancy.

Retrospective study of 40 patients treated for functional uterine bleeding by the procedure CAVATERM in an outpatient setting. 17 patients (42%) had received permanent contraception according to ESSURE® remotely of the operation. For the remaining 23 cases (58%), hysteroscopic ESSURE® sterilization was performed during the procedure before the intra-uterine balloon therapy.

No relevant intraoperative complications were registered and mean follow up was 27 months. The data obtained showed an overall success rate of 95%. The rate of permanent amenorrhoea post thermocoagulation in women after 3 years was 50%.

The out-patient procedure combining endometrial thermocoagulation with CAVATERM and ESSURE® sterilisation appears to be an effective and minimally invasive alternative to hysterectomy for the treatment of functional uterine haemorrhage unreceptive to medical treatment. To our knowledge, this is the first study combining these two techniques reported in literature.

P.12.8

Hysteroscopic removal of intrauterine foreign bodies—a ten years experience

Miskin A.*[1], Argade K.[2]

[1] Royal Gwent Hospital Newport United Kingdom - [2] Maher Endoscopy Clinic Kolhapur India

In our study, series of patients over the period of ten years with intrauterine foreign bodies on hysteroscopy were studied. A diagnostic hysteroscopy followed by a wire loop resection is invaluable in the management.

Prolonged retention of intrauterine foreign bodies is a recognised cause of secondary infertility. In our study a series of patients over the period of ten years with intrauterine foreign bodies were studied.

In ten years 3000 hysteroscopies were performed. All the patients showed hyper-echoic areas on the transvaginal sonography which were suspected from symptoms like menorrhagia, pelvic pain and infertility. These patients had a diagnostic hysteroscopy to visualize uterine cavity followed by operative hysteroscopy to retrieve foreign bodies.

Hysteroscopic findings were, missing IUCD’s in 30 patients, 1 with wooden abortion stick, 5 with fetal bones, 1 with broken tip of Karman cannula and Bony metaplasia in 3 patients.

All the foreign bodies were removed by hysteroscopic forceps and the bony metaplasia were resected to avoid recurrence. All patients after procedure conceived except 2 patients with bony metaplasia.

Retained fetal bones should be considered in all patients with infertility, dysfunctional uterine bleeding and pelvic pain. The most widely accepted theory to explain ossification is that it represents retained fetal bones or chronic inflammation. Transvaginal sonography helps in the exact localization of intrauterine foreign bodies. A diagnostic hysteroscopy followed by an operative procedure using a wire loop resectoscope is invaluable in the management. Clear documentation that the cavity is clear must be confirmed by reintroducing hysteroscope after attempts at bone removal are complete.

P.12.9

Hysteroscopic sterilization with Essure®—5 years of our experience

Moreira M.*[1], Carnide C.[1], Abreu R.[1], Maia S.[1], Moreira C.[1], Oliveira M.[1]

[1] Serviço De Ginecologia-Obstetrícia - Hospital Infante D.Pedro Aveiro Portugal

The authors’ objective consists in evaluating retrospectively the results and complications of hysteroscopic tubal sterilization with the Essure® device.

Hysteroscopic sterilization, performed by the bilateral placement of the micro-insert Essure® into fallopian tube lumens, is a safe and effective method of permanent contraception. This method, approved for use in the United States in 2002, has become widespread in recent years, as well as experience in its use.

Retrospective analysis of medical records of 297 patients who underwent hysteroscopic sterilization using Essure® between February 2006 and April 2011 was performed.

This device was applied in 297 patients. The mean age of the patients undergoing the procedure was 37.4 years. Permanent contraception was the reason of choice for 89.5%. Successful bilateral device placement was achieved in 292 women (98.3%) during the first attempt and in five (1.7%) during the second. Initially the procedures were performed under general anesthesia in an operating room (53.2%). Since 2009 most of the women underwent placement of Essure® in an outpatient setting and without sedation, using only oral ibuprofen (46.8%). Patients who underwent pelvic radiography after 3 months to confirm the position and alignment of the micro-inserts, 86,7% was considered satisfactory and 2 presented an abdominal ectopic placement of the device. Hysterosalpingography was performed in 43 cases of unsatisfactory placement and confirmed bilateral tubal occlusion in 40.

In our series, the hysteroscopic tubal sterilization with the provisions of Essure®, showed to be an effective procedure with low morbidity. One of the limitations of this method, general anesthesia, was overcome. This procedure can be safe and effectively performed in an outpatient basis with a low rate of complications. Women should be instructed to return for the follow-up visit.

P.12.10

Operative hysteroscopy with bipolar resectoscope: efficacy and safety

Rego J.*[1], Macaes A.[1], Santos M.[1], Aguas F.[1], Geraldes F.[1]

[1] Maternidade Bissaya Barreto Coimbra Portugal

78 cases of hysteroscopic bipolar resections were studied. The objective was to assess the efficacy and safety of operative technique. We reported that was effective in 78,2% with 89,7% clinical improvements. We confirmed that was a safe procedure (98,7%).

Hysteroscopy is considered a major revolution in Gynecological clinical practice over the last decade and has become an indispensable aid in the diagnosis and treatment of abnormal uterine bleeding and intrauterine pathology.

Retrospective descriptive study of 78 cases of hysteroscopic bipolar resections. Patient characteristics, presence of polyps, submucosal myomas, synechiae and/or uterine septum, other diagnostic tests and results concerning complications and symptom relief were evaluated.

The mean age of women was 47,2 years. The majority were multiparous (78,2%). Around 30% were menopaused. 73,1% had symptoms and the most frequent was menorrhagia (30,8%). 7,7% had infertility problems. Most frequent medical pathology were hypertension (12,8%) and obesity (10,3%). 62,8% did a transvaginal ultrasound (TVUS) and a hysteroscopy; 12,8% did TVUS, hysteroscopy and sonohysterography; 11,5% did TVUS only. Anatomic pathology revealed submucosal myomas (51,3%), polyps (33,3%), polyp and submucosal myoma (7,7%), uterine septum (2,6%), polyp and uterine septum (1,3%) or polyp and synechiae (1,3%). There was only one case of uterine perforation as immediate complication. The mean follow-up time was 9 months. 89,7% reported clinical improvements. Posterior TVUS evaluation revealed that the procedure was complete and there was no more lesion in 78,2%. 10,3% had residual lesion; in 6,4% appeared a new lesion and in 2,6% the lesion wasn’t removed. Posterior hysterectomy was necessary in 6.4%.

In our study, the method was effective in 78,2% and 89,7% reported clinical improvements. We confirmed its safety with only 1,3% of immediate complications.

P.12.11

Outpatient operative hysteroscopy service under LA using conventional resectoscopes: development of personnel and policies

Bruen L.*[1], Hill S.[1], Penketh R.[1]

[1] Cardiff And Vale University Health Board Cardiff United Kingdom

An out patient operative procedure clinic using traditional theatre equipment requiring a fundamental change in practice was developed. Development of staff skills, policies, protocols and a patient pathway aided this successful transition.

A pilot study of operative hysteroscopy under LA in theatre using resectoscope and glycine validated transfer to clinic. An award from the Health Foundation enabled this innovation.

Development of policies, protocols, patient care pathway, clinic documentation and staff training in theatre skills were required.

Policies ranged from referral criteria through to privacy and dignity; LA monitoring , surgical scrubbing, gowning, gloving, to swab, instrument and needle count were designed to suit this environment.

Staff training was crucial. Project team member SH, the lead outpatient nurse, attended theatre to gain experience and knowledge. A major driver for transfer of this service was cancellation due to list overrun which occurred on several visits although the procedures observed identified patient acceptability.

In reality practical training commenced in clinic. SH scrubbed with LB an ex-theatre nurse and acquired the skills to ensure procedures complied with theatre guidelines. SH then led the training of the out patient team.

Essential to the patient’s experience was the vocal local who supports the woman during the procedure. Training was given and the technique was adapted to the needs of the varying clientele.

Outpatient nurses have acquired new skills to perform this role as well and efficiently as an experienced theatre scrub nurse. Implementation of protocols and documentation ensured patient safety.

Much has been learnt resulting in new skills and knowledge. The service has been in operation for 12 months and prospective audit identified benefits for the patient, staff and hospital.

P.12.12

Reproductive outcome after hysteroscopic septoplasty in patients with complete septate uterus

Luchini S.*[1], Persico P.[1], Gentile C.[1], De Marzi P.[1], Giardina P.[1], Candiani M.[1]

[1] Irccs Ospedale San Raffaele Milano Italy

This is a restrospective study on the efficacy of hysteroscopic septoplasty in women with complete septate uterus. We found that this procedure is safe and effective with a subsequent pregnancy in 13/24 women (54%). We observed a total of 26 pregnancy.In Patients with an history of primary infertility before surgery septoplasty is not always able to modify the reproductive outcome.

The aim of this study was to evaluate reproductive outcome after hysteroscopic septoplasty in women with complete septate uterus.

Hysterocopic septoplasty was performed in 30 women aged 16–36 after a short term treatment with gonadotrophin releasing hormone analogues. Septum resection was executed with reseptoscope and intracervical portion of septum was always spared.

Hysteroscopic septum resection was performed on 11 (37%) patients with history of primary infertility, 6 (20%) with secondary infertility (4 with recurrent abortion)and in 13 (43%) with occasional diagnosis. During hysteroscopy we found associated anomalies in 16 patients (52%): 12 vaginal septa, 2 polyps and 1 synechia. In 1 (3%) woman intraoperative perforation occurred and in 3 (10%) occurred minor complications.After surgery 24 patients desired pregnancy and 13 achieved conception (54%). They had a total of 26 pregnancies. Of these 12 (54%) were carried to term, 2 (10%) ended in preterm delivery and 8 (36%) ended in spontaneous abortion.11 patients did not obtained pregnancy, in 6 cases (54%) there was an history of primary infertility before surgery. 3 patients are actually in a program of medical assisted reproduction and 2 women refused any further clinical assessment about their fertility.

Hysteroscopic septoplasty is an effective and safe procedure with a low rate of intra and postoperative complications.In Patients with an history of primary infertility septoplasty is not always able to modify the reproductive outcome.

P.12.13

Success rate of the Adiana® Permanent Contraception system in clinical practice

Robarts P. J.*[1]

[1] Department Of Obstetrics And Gynaecology, St John’s Hospital Chelmsford United Kingdom

This report shows that the Adiana Permanent Contraception system represents a safe and effective method of hysteroscopic sterilization.

The Adiana Permanent Contraception system is a safe, effective hysteroscopic sterilization method that can be performed as a day case. During the procedure a trabeculated silicone matrix is inserted in each fallopian tube. Subsequent tissue in-growth into the matrix occludes the tube. Tubal occlusion is confirmed with a hysterosalpinogram (HSG) 3 months post procedure.

Ninety one Adiana procedures were performed by one obstetrics and gynaecology practice in the UK from March 2009 through June 2011. All procedures were performed in hospital as day cases. Placement rates, HSG results, adverse events and pregnancies were documented.

Patients were 31–42 years of age. Of the 91 procedures, 53 (58%) were performed under local anesthesia. No perforations or other adverse events occurred. Bilateral placement was successful for 90 of 91 patients (98.9%); in one patient neither fallopian tube could be cannulated.

HSG results are available for 77 of the 90 patients with bilateral placement. Of the remaining 13 patients, 7 are awaiting the 3 month HSG, 5 did not return and 1 patient elected alternative contraception. 73 out of 77 patients (94.8%) had bilateral occlusion at 3 months post procedure. Unilateral patency was seen in 2 patients at 6 months. An additional 2 patients showed bilateral occlusion at a repeat HSG performed at 6 months, for a total of 75 out of 77 (97.4%) patients with confirmed bilateral occlusion.

There have been no reported pregnancies in the patients relying on Adiana for permanent contraception; one pregnancy occurred in a non-relying patient. A high rate of bilateral occlusion was observed; no serious adverse events and no pregnancies occurred in relying patients who underwent the procedure through our clinical practice.

P.12.14

The acupuncture as auxiliary hysteroscopic surgery in cases of sterilization intratubarea—essure

Pinheiro W.*[1], Pereira A. K. C.[1], Soares Jr J. M.[1], Ejzemberg D.[1], Pinho F.[1], Baracat E.[1]

[1] University Of Sao Paulo- Brazil Sao Paulo Brazil

The authors studied the symptomatology of patients with under essure tubal sterilization on an outpatient basis.

This is a pioneer in study world because there is no work in literature relevant to refer this association and acupuncture hysteroscopy ambulatory.

The tubal sterilization through hysteroscopic at ambulatory is widespread in almost all of europe as indicators of the to around 95 percent good and acceptance by patients. but women referred a percentage of discomfort and pain due to colic uterine contractility.

The period january to march 2010 we analyzed 20 patients with clinical co morbidities indication for sterilization these women presenting the absolute contraindications to your account anesthesia systemic diseases. were then submitted to acupuncture ten minutes before the procedure for putting the essure.

All 20 patients who were under the methods are with her tubes blocked without complication whether the introduction of essure or even in the postoperative.

Acupuncture as a method for analsegia uterine contractions revealed is a success because any of these women reported no pain or discomfort.

The essure tubal sterilization by is undoubtedly a method of easy and rapid application pouquisimas with complications. literature reports that approximately around 5 percent of patients had migration or drilling tubaro.

We had no discomfort, than the complication beyond pain or in this case series due to our acupuncture concurrently not made this.

P.12.15

The number of curettages and uterine evacuations as a predisposing factor for the severity of intrauterine adhesions

Papadakis E.*[1], Grigoriadis C.[1], Sofoudis C.[1], Gregoriou O.[1]

[1] National University Of Athens, 2nd Department Of Obstetrics-Gynecology, Aretaieion Hospital Athens Greece

Although uncommon, women without any predisposing factors may have intrauterine adhesions.

Our aim was to assess the potential correlation between stage of intrauterine adhesions and number of curettages in women who were diagnosed with intrauterine adhesions by hysteroscopy.

We reviewed the patients records of fourteen(14) women who were submitted to hysteroscopy for various reasons(e.g infertility, postmenopausal bleeding, polyps) and to whom intrauterine adhesions were diagnosed. None of the patients had history of pelvic inflammatory disease or pelvic infection after delivery. Thirteen patients had a positive history of curettages and evacuations(C + E) for first trimester abortions and miscarriages. The number of C + E varied from one (1) to eight(8) among these women.Our research included patients from 1/1/2009 to 1/3 2011.

The classification for intrauterine adhesions of the American Society For Reproductive Medicine was used in order to assess the severity of adhesions. For postmenopausal women their menstrual pattern until menopause was used for staging.

We divided the 14 women into two subgroups according to the number of C + E:

Group A: = <2 curettages and evacuations

Group B: >2 curettages and evacuations

Eight (8) women were classified to Group A. Seven (87,5%) of them had Stage I intrauterine adhesions and one with no C + E history had Stage III.

Six (6) women were classified into Group B. In these women staging varied from I to III:

−1 had 8 C+E and Stage III adhesions

−1 had 7 C+E and Stage III adhesions

−2 had 5 C+E and Stage II adhesions

−2 had 3 C+E and Stage III adhesions

Patients with up to two curettages and evacuations(7 women of group A) were found with mild adhesions. Although uncommon, women without any predisposing factors may have intrauterine adhesions , such as the eighth patient of Group A.

P.12.16

Small diameter hysteroscopic morcellator for operative hysteroscopy: a first case series

Emanuel M. H.*[1], Hamerlyck T. W. O.[2], Abdulkadir L.[3], Schoot B. C.[3]

[1] Spaarne Hospital Hoofddorp Netherlands - [2] Ghent University Hospital Ghent Belgium - [3] Catharina Hospital Eindhoven Eindhoven Netherlands

The small diameter hysteroscopic morcellator, now available, appears promising as a fast, and well supported, ambulant operative hysteroscopic technique.

The hysteroscopic morcellator (HM), using a 9-mm hysteroscope, has proven to be a fast, safe and easy technique for removal of intrauterine lesions under anaesthesia. In an office setting, smaller diameter instruments are needed, as well as painless techniques. Recently, a small diameter HM became available.

A first series of procedures in 23 patients was performed at two teaching hospitals in the Netherlands. All patients had evidence of an intrauterine polyp, myoma or residual placental tissue. Procedures were performed in the operating room, with or without anesthesia, or in an ambulant setting. Normal saline was used for irrigation and distension. Morcellation was performed using a HM with a 2.9 mm rotary blade, and a 5-mm hysteroscope, with a 5.6 mm sheath and 0-degree optic (TRUCLEAR, Smith & Nephew, Andover, USA).

Patients had a median age of 48 years. Cervical dilatation was necessary in only 2 patients due to cervical stenosis. In 17 patients operating time was recorded meticulously, with a median of 6 minutes (range 2–26 minutes). Fluid loss, as recorded in 16 patients, ranged from 0 to 2000 mL (median 210 mL). There were no conversions to classical operative hysteroscopy, no complications occurred, and in all cases removal of the intrauterine abnormalities was complete. The 8 patients who did not receive anaesthesia underwent the procedure without experiencing pain that made them to ask for the procedure to be stopped. In all cases tissue was available for pathology analysis.

The small diameter HM appears promising as a fast, safe, and well supported, ambulant operative hysteroscopic technique. Prospective research comparing the small diameter HM with other ambulant techniques is needed to confirm these findings.

Session P.13

* Operative Risk Management *

P.13.1

An audit on the consent process for laparoscopic surgery

Matanhelia M.*[1], Nama V.[2], Ind T. E. J.[2]

[1] St George’S University Of London London United Kingdom - [2] St George’S Hospital, London London United Kingdom

Documentation of consent for laparoscopy was compared to RCOG guidelines. Results showed wide variation in the quality of written consent, showing a need to improve the consent process.

Valid consent is essential in patient counselling. Royal College of Obstetricians and Gynaecologists (RCOG) guidelines state that a woman must understand “the nature of the condition for which it is being proposed, its prognosis, likely consequences and risks of receiving no treatment at all”. The RCOG has published guidelines on the documentation of consent. We audited the quality of written consent for laparoscopy against RCOG guidelines.

A prospective audit was done at St. George’s Hospital. RCOG Consent Advice No.2 was used as the standard. 27 consent forms were audited and compared RCOG guidelines.

All forms had the procedure name and its benefit described. 23/27 (85%) documented damage to bowel, 22/27 (81%) had damage to bladder and only 13/27 (48%) had damage to major vessels. No forms documented failed entry, and port-site hernia was mentioned on only 3/27 (11%) of forms. Among minor complications, only wound infection was mentioned consistently, on 25/27 (93%) forms. Wound bruising and shoulder tip pain were not documented and laparotomy was mentioned in 25/27 (92%) of cases.

There is wide variation in the quality of written consent. Despite guidelines, some serious risks are poorly documented, and only wound infection was recorded consistently. This shows deficiency in the quality of consent. Previous work with similar results states that this is medico-legally unacceptable. Reasons for poor documentation include lack of access to guidelines and insufficient space on the form. Alternative ways of consenting for laparoscopy should be considered. Pre-printed forms do not ensure explaining all risks to the patient. Electronic forms involving a compulsory tick on all aspects by both patient and doctor might be appropriate.

P.13.2

Laparoscopic complication evaluation from 1990 to 2010

Rodriguez Garnica M. D.[1], De Valle Corredor C.[1], Garcia Pineda V.[1], Gonzalez Gea L.[1], Fuentes Castro P.[1], Zapico Goñi A.*[1]

[1] Hospital Universitario “príncipe De Asturias” Madrid Spain

Laparoscopic complications rate is related to the learning curve.

Laparoscopic procedures starting up programs have usually been related to an increasing complication rate when compared to traditional approach. Therefore, some changes in the department global learning curve should be related to the widespread of the procedure to all the team members.

Obstetrics and gynaecology department of a General District Hospital. Retrospective review from 1990 to 2010 of 1986 laparoscopies. Evaluation of the complication rate according to the starting up, teaching and formal standarization of this technique.

One hundred eighty-five procedures over 1986 were due to malignant diseases. The remaining 1801 laparoscopies were mainly due to adnexal benign pathology, myomas, ectopic pregnancy, etc.. Global complication rate was 7,97%. A first complications rate peak was seen at the beginning of the experience. However, after a downgap, widespreading of the technique among the others team members became into an increasing number of complications. Following this the rate came down to the baseline level. The same trade was seen after 1999 when oncological procedures come into a new indication for laparoscopic approach.

Global department laparoscopic complication rate is firmly related to learning curve and it will be modified when introducing new procedures or new surgeons.

P.13.3

Laparoscopy and body mass index: do the obese have a higher risk?

Gonçalves A.*[1], Marques C.[1], Antunes I.[1], Simões M.[1], Ribeiro F.[1], Pereira A. P.[1]

[1] Maternidade Dr Alfredo Da Costa Lisbon Portugal

Retrospective study comparing surgical outcome between obese,overweighted and normal weighted women submitted to laparoscopic surgery.

Obesity is an emerging epidemy and its prevalence has increased dramatically.

Once laparoscopic surgery is becoming the goldstandard approach of almost every gynechological pathology,it is very important to know if the obese are a higher risk population for this type of surgery.Accordingly it will be possible to adjust peri and postoperative procedures as a way of improving clinical care.

Study of women who underwent laparoscopic tube ligation(bipolar electric coagulation)between January 2009 and April 2011 in our institution.The initial population was divided in three groups according to their BMI(A–normal or underweight BMI < 25;B–overweight BMI 25–29,9;C–obese BMI = 30).Medical and surgical variables were determined and further compared between each group in order to evaluate their statistical significance(P < 0,05).

Overall 175 women were studied(A n = 77;B n = 58;C n = 40).Surgical outcomes evaluated included surgery and anesthesia duration,intra and postoperative complications,need for re-hospitalization,technique of acess to the abdominal cavity,number of accessory ports and rate of convertion to laparotomy.

Although there was an increase in surgery duration(A: 30,9′;B: 32,3′;C: 33,0′),anesthesia duration(A: 43,5′;B: 44,2′;C:46,1′)and intraoperative complications(A: 15,6%;C: 20%)these differences were not statistically significant.Comparing group A with group C there was a higher need for open laparoscopy(p = 0,014).No woman was re-admitted nor was there convertion to laparotomyNo statistical difference was found in postoperative complications and number of acessory ports.

Obesity increases the need for open laparoscopy.The trends observed may become more evident in more complex surgical procedures.According to this study,obese do not seem to be at higher risk during laparoscopy.

P.13.4

Outcome of hysteroscopic myomectomy and polypectomy—a case series

Kar A.*[1], Davey M.[1], Moors A.[1], Umranikar S.[1]

[1] Princess Anne Hospital Southampton United Kingdom

Results of a retrospective case series study,in a teaching hospital, looking at outcome of hysteroscopic myomectomy & polypectomy,done as a daycase procedure.

Hysteroscopic surgery is a minimally invasive procedure used for treatment of menstrual disorders, infertility and postmenopausal bleeding(PMB).

Retrospective study of patients who had transcervical resection of submucosal fibroids(TCRF) and polyps(TCRP)during Oct 2007–Aug2010.Cases with TCRE were excluded.Data was collected by review of notes & electronic database.

72 patients had TCRF(47) or TCRP(25) over 34 months.

Mean age:45 years(30–62 yrs).

Indications for surgery:abnormal uterine bleeding(63%),infertility(14%), PMB(19%),Post-embolisation(4%),coincidental(1%).

89% had preoperative pelvic ultrasound or Hycosy.

Submucosal fibroids(ESGE classification): Type0(70%), type1(26%), type2(4%)

Complication rates were low.Average blood loss:16 mls(<5–800 mls).

Mean duration of follow up:4 months(0–12 months).

Symptom improvement at follow up:59% with abnormal uterine bleeding and 86% with PMB.

70%with infertility had successful primary resection.20% conceived thereafter, all ending in term deliveries No patient had a miscarriage.

11% had further procedures like endometrial ablation,repeat TCRF or hysterectomy.Failure of symptom resolution were higher in the presence of type2 fibroids, size >5 cm,menometrorrhagia or recurrent endometrial polyps.

Histology showed benign leiomyoma or endometrial polyp in all except 2 cases.

Hysteroscopic myomectomy & polypectomy is an effective daycase procedure for symptomatic fibroids,polyps particularly with appropriate patient selection.It can be done as one or two step procedure where preservation of fertility is important and also in abnormal uterine bleeding and postmenopausal bleeding to reduce hysterectomy rates with its accompanying morbidities/cost.Any specimen resected should be sent for histology to rule out malignancy.

P.13.5

Safety of the optical access trocar in gynecologic laparoscopic surgery

Lee S.*[1]

[1] Gachon University Gil Hospital Incheon Republic Of Korea

XCEL trocar can be safely used in gynecologic laparoscopic surgery.

Trocar related complication still remains a complication of laparoscopy. The purpose of this study is to determine whether the optical access trocar can be used to establish a safe entry.

We retrospectively assessed the safety of XCEL trocar (Ethicon Endo-Surgery) 12 mm blunt-tipped optical access trocar in 350 women.

The mean age of the patients was 41.0 ± 9.3 years. The mean height was 158.4 ± 5.3 cm and the mean body weight was 57.4 ± 8.8 kg. The mean BMI was 22.9 ± 3.4. 116 patients (33.1%) had a history of abdominal surgery. Among these 116 patients, 35 patients had undergone 2 more abdominal surgeries. Complications are as follows; ureteral serosal injury (1 case), readmission due to gastroenteritis (2 cases), readmission due to fever (1case), readmission due to bleeding at vaginal stump (1 case). But, there were no complications associated with XCEL trocar.

Trocar related complications associated with use of XCELTM trocar are rare. XCEL trocar can be safely used.

P.13.6

Thermal endometrial ablation, to repeat or not to repeat?

Gossage K.*[1], Davies M.[1], Batra S.[1]

[1] Nhs Manchester United Kingdom

We conducted an audit at Fairfield Hospital on thermal balloon ablations (TBAs). This highlighted the use of repeat TBAs. Literature review demonstrated limited guidance on repeating TBA.

Menorrhagia is experienced by 4–9% of women. Before the 1990’s the only definitive treatment was a hysterectomy of which 60% of women underwent. Once ablative techniques were established the number of hysterectomies significantly declined. We conducted an audit of TBAs and found a small number of patients had undergone repeat procedures.

Retrospective audit looking at all TBAs carried out in 2009–10.

We looked at 80 notes. 8 women had a repeat TBA. Repeat procedures were conducted between 18 months to 10 years after the first. The primary ablation was typically considered a ‘success’ however, menhorragia returned. The main indication for re-treatment was unsuitability for surgery, usually due to body mass index (BMI). The patients were keen for a repeat procedure, despite higher risk of complications. The results have been positive, but the numbers are small.

There are few studies on repeat TBAs and consequently few guidelines. Manufactures are undecided on advising clinicians. It is an important issue as 2 in 5 women will require further treatment within 5 years of their first treatment. The current repeat TBA rate is 5–11%. Advantages include, the use of TBA in women who are unsuitable for surgery, success rates and improving symptoms to ‘buy time’ before the menopause. However, the cost difference between a hysterectomy and a repeat TBA narrows with time, the risk of complication is three times higher and failure of a repeat procedure will still require a hysterectomy.

Currently we practice via case by case. However, as patients continue to re-present, we need evidence, from a risk management perspective, to support repeating TBAs and subsequently gain support from Clinical Governance leads.

Session P.14

* Robotics *

P.14.1

Improving patient turnover with robotic surgery

Elkington N.*[1], Hassan A.[1]

[1] Frimley Park Hosspital Nhs Foundation Trust Surrey United Kingdom

Robotic surgery gives surgical benefits but is costly and can be more time consuming. Efficiency and turnaround of patients in theatre therefore becomes of paramount importance. The initial experience of a robotic program at a district general hospital is presented.

Robotic surgery offers surgical benefits such as a better surgical view, increased ‘dexterity’, greater precision, the benefit of 3 operating ‘arms’, easier intra-corporeal suturing and less surgical fatigue. Robotic surgery is still evolving but it is likely that it will become an important tool in the surgical armamentarium. However, set-up, docking and un-docking can take longer than open and laparoscopic surgery.

The experience of the first 145 cases at Frimley Park Hospital were analysed with regard to factors affecting patient turnaround.

Many factors influence the efficiency and turnaround of open, endoscopic and robotic surgery. Specific to robotic surgery important factors to address are: patient selection, type of operation, training, teamwork, robotic set-up, docking times, operating efficiency and undocking.

Suitable patients and surgical cases should be chosen appropriate to the surgeon’s level of experience. Surgeons and theatre staff need to be appropriately trained to use the robot and initially mentored by an Intuitive representative. A trained and consistent theatre team ensures more efficiency if team members. They should have specific understood roles and be familiar with setting up the robot, docking and undocking. The surgeon can be more efficient at the console if they are familiar with laparoscopic procedure, understand and can use the controls and can maintain a good surgical view and haemostasis, Audit of all the robotic procedures enables trends to be analysed and further improvements made.

P.14.2

LPS robotic-assisted surgery for endometrial cancer: preliminary results of the side-docking approach

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

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

To evaluate the feasibility of side-docking approach with only two operative robotic arms using the da Vinci Robotic Surgic System for the treatment of endometrial cancer.

Robotic surgery is the latest innovation in the field of minimal invasive surgery. Robotic treatment of endometrial cancer is well recognized and it seems to improve dexterity and depth perception and reduce counterintuitive motions.

Between June 2010 and July 2011, a total of 12 patients affected by stage I endometrial cancer were prospectically enrolled on the study. LPS robotic-assisted extrafascial hysterectomy + frozen section ± pelvic lymphadenectomy were performed with left side docking approach, two operative robotic arms and uterine manipulation.

Endometrial carcinoma stage: 4 stage IA G1, 5 stage IB G2 and 3 stage IB G3.

Median operating time was 165 minutes. Sistematic pelvic lymphadenectomy was performed in 9 cases. Median number of lymph nodes removed was 25. No intraoperative complications.

The treatment of endometrial cancer using the Side-docking of the Robot with only two robotic operative arms is feasible and with good results in term of operative time, complications, number of removed lymph node and costs.

P.14.3

Robotic hysterectomy learning curve of two laparoscopic experienced gynecologists

Kots L. A.*[1], Sarlos D.[1], Schär G.[1]

[1] Kantonsspital Aarau Aarau Switzerland

The learning curve supposedly is one of the advantages of robotics. To verify this we recorded the chronologic development of operating times from the first to the most recent robotic hysterectomy for 2 experienced gynecologists. The resulting learning curves are well in agreement with learning curves from other robotics studies with plateaus between 20–50 cases at similar operating times.

Robotic surgery has become a well established procedure. Often an improved learning curve is cited as an advantage.

The aim of this study is to establish the learning curve of robotic hysterectomy for two surgeons from the Kantonsspital Aarau.

With data from a prospective study we recorded the development of operating times from the first to the most recent robotic hysterectomy for 2 experienced gynecologists. Mean operating times for the first 5 (group1) and the last 5 surgeries (group2) were compared. Also development of docking times were recorded.

Operating times ranged from 192 to 48 min. For surgeon1 mean operating time was 108 (all surgeries) with 103 (group1) respectively 107 min (group 2). Mean docking time was 9.1 (group 1) respectively 8.8 min (group 2).For surgeon 2 mean operating time was100 (all surgeries) and 114(group1) respectively 88.5 min (group 2). Mean docking time was 9.8 (group 1) and 8 min (group 2).

A different development of the learning curves for both surgeons was seen. This could be explained by a different absolute number of cases. Both flows are well in agreement with learning curves from other studies on the robotic approach with plateaus between 20–50 cases. Compared to other publications operating times for both surgeons are quite low due to the experience in laparoscopy. Thus potential for improvement is limited and operating times probably correlate to other factors like uterus size and technique.

P.14.4

The introduction of robotic surgery into a district general hospital

Elkington N.*[1], Perkins R.[1], Beynon G.[1]

[1] Frimley Park Hospital Nhs Foundation Trust Surrey United Kingdom

Robotic surgery offers the surgeon and patient a number of potential benefits. Frimley Park Hospital is one of 24 UK hospitals to have purchased a da Vinci robot. Two gynaecologists, two colorectal surgeons and one urologist have been trained. Between them they have performed a total of 145 cases since April 2009. The initial robotic utilisation and case-load is reported.

Robotic surgery provides advantages such as increased ‘dexterity’ and precision, a 3-Dimensional view, enhanced cameral control, three operative arms and less surgical fatigue. Surgeons from a variety of disciplines have realised the benefits of robotic surgery over open and laparoscopic surgery and are in the process of purchasing or starting up a robotic program.

The initial use of a da Vinci robot since April 2009 at a district general is analysed. The number and type of operations is reported.

Five surgeons have been trained to use the da Vinci robot; two gynaecologists, two colorectal surgeons and one urologist. Key theatre staff also received intensive training alongside the surgeons. One hundred and forty-five operations have been performed; 46 gynaecological, 39 colorectal and 56 urological. All surgeons have been enthusiastic about the surgical and patient benefits and the types of cases being performed are expanding.

The role of the da Vinci robot is evolving. It has applications for a number of surgical disciplines. Surgeons and theatre staff first need to be appropriately trained to perform robotic surgery. They then need to select appropriate patients for surgery appropriate to their level of skill and experience. Use of the robot needs to be incorporated into the theatre timetable, surgeons’ current job plan and case-load.

Session P.15

* Single Access Surgery *

P.15.1

A case of salpingectomy in less surgery for GEU in obese woman: no more limits?

Surico D.[1], Leo L.[1], Nupieri I.*[1], Galli L.[1], Vigone A.[1], Surico N.[1]

[1] Advanced Gynaecological Oncology Centre, Department Of Obstetrics And Gynaecology, University Of Eastern Piedmont Novara Italy

Until now, one of limitation of LESS Surgery is considered the patient’s body mass index (BMI). The literature describes that LESS surgical approch can be successfully used to treat ectopic tubal pregnancy in selected patients, with a body mass index under to 28.2 kg/m2. This case report shows the possibility to perform LESS surgery also in obese women, with a BMI major of 30 kg/m2, without intra-operative or post-operative complications.

This case report describe the first case of LESS Surgery for ectopic pregnancy in a patient with a BMI of 38.3 kg/m2.

A 31 years-old woman at six weeks and five days of gestational age presented to our department for genital bleeding. Her BMI was 38.3 kg/m2.Laboratory investigations found a B-hCG levels of 4292 mUI/mL. Transvaginal ultrasound examination demonstrated hemoperitoneum and a right falloppian tube enlarged by a mass of 11 × 12 mm; inside, there was a 3.4 mm embryo with cardiac activity. The patient was candidate for an urgent single port salpingectomy with LESS Port (X-Cone; Storz). The right salpingectomy was performed with a bipolar instrument (Gyrus Clamp, Gyrus M.).

It was found the right tube hyperemic and enlarged for the presence of ectopic pregnancy. Estimated intra-operative blood loss was 20 ml. Operative time was 30 minutes, without intraoperative or postoperative complications. Post-operative pain was managed using intravenous morphine sulphate (10 mg) with ketorolac (60 mg) in elastomer. Time of hospitalization was 24 hours. The cosmetic result was excellent. Histopathological analysis confirmed falloppian tube pregnancy.

The operative time, intra-operative blood loss and hospital time are comparabile to conventional LPS and in agreement with the literature. Single-port laparoscopic salpingectomy can be performed to treat patient with tubal pregnancy without complication, also if she has a BMI major of 30 kg/m2.

P.15.2

Bilateral adnexectomy in an animal model comparing conventional laparoscopy and single port access

Gracia M.*[1], Sisó C.[1], Sarmiento L.[1], Martinez M. A.[1], Carmona F.[1]

[1] Hospital Clinic Barcelona Spain

The aim of this study was to compare the surgical stress response associated with LESS surgery(Single Port)and conventional laparoscopy.

Glucose and cortisol are used as markers of pain and surgical stress in veterinary medicine.Surgical trauma causes a proportional response increasing hypermetabolism,myocardial oxygen demand,pulmonary function and altering the immune response.

Twenty female pigs(30 Kg)underwent laparoscopic adnexectomy,conventional laparoscopy and SPA (N = 10 each group).Before surgery and at 2,4 and 20 h post adnexectomy blood samples were collected for measurement of stress response:serum glucose and cortisol.The animal’s subjective response to surgical trauma established by observing cyclical behavior: urination-deposition,intake,mobilization,sounds and the assessment of its general condition.

TheOT for the laparoscopic group was slightly higher(29 min)compared to SPA group(28 min)without differences(p = 0.736).We found statistically significant differences in favor of lower blood loss in Single Port Access,p = 0.002.

Objective data of surgical stress,glucose and cortisol ,were lower in the conventional laparoscopic approach at all recorded intervals, with statistically significant differences only in the immediate postoperative period (2 h)for glucose levels,p = 0.026.

All subjective parameters related to recovery and general condition have shown better results in Single port group(differences not significant).

The restoration of physiological function, the presence of urinary and deposition was introduced previously in the single port group.

Evolution:was favorable in most animals except an hematoma in the umbilicus in the conventional group and only a case of herniation in the SPA group.

In this study,in an animal model,we demonstrated that LESS techniques,including Single Port are feasible and safe laparoscopic approaches, comparables tostandard techniques.

P.15.3

Direct insertion of primary trocar by railroad method at gynaecological laparoscopy, a study of 7000 cases

Miskin A.*[1], Miskin R.[2], Argade R.[2], Argade K.[2], Argade A.[2], Argade M.[2]

[1] Royal Gwent Hospital Newport United Kingdom - [2] Maher Endoscopy Clinic Kolhapur India

To find the effectiveness and safety of direct insertion of primary trocar.

Approximately 250 000 women undergo laparoscopic surgery in the UK each year. The majority are without problems but serious complications occur in about one in 1000 cases. Our study aims to find the effectiveness and safety of direct insertion of primary trocar.

During the period of year 2000 to 2011 a total of 7000 laparoscopies were performed by our team. Laparoscopy was done for various indications.

Initially abdominal wall was grasped and elevated. The primary trocar 5 mm was inserted in a controlled manner verticallly to the skin, through the incision at the thinnest part of the abdominal wall, in the base of the umbilicus. Followed by this a 5 mm metal rod was passed through the trocar after removal of cannula. A 10 mm trocar was then threaded over the metal rod in the abdominal cavity and the metal rod was removed and a 10 mm telescope was introduced. The primary trocar was inserted either supraumbilical or by Palmar’s entry technique in suspected cases of adhesions.

Out of 7000 cases, there were 2,450 cases with history of either one or more caesarean sections. The complications identified were of injury to mesenteric artery in 2 cases(0.02%), bowel injury three(0.05%) cases and injury to omentum in 15 cases. Most of the complications were managed laparoscopically and only in one case patient required laparotomy. Almost all of the cases with omental injury were with a history of abdominal surgery.

Direct trocar entry method is now a widely accepted and safe method of trocar insertion. In the experienced hands it is the most rapid method of entry and can be safely used. Six randomised controlled trials have compared verres needle with direct trocar entry. Although Meta analysis does not show any safety disadvantage from using this method.

P.15.4

Feasibility of single-port access laparoscopic-assisted vaginal hysterectomy compared with conventional laparoscopic-assisted vaginal hysterectomy: a systemic review

O’donovan J.*[1], O’donovan O.[2]

[1] Newcastle University Newcastle United Kingdom - [2] Peninsula College Of Medicine And Dentistry Plymouth United Kingdom

A systemic review comparing single-port laparoscopic-assisted vaginal hysterectomy (spLAVH) with conventional laparoscopic-assisted vaginal hysterectomy (cLAVH).

Single-port access surgery is a recently proposed term used to describe various techniques aiming at performing laparoscopic surgery through a single incision concealed within the umbilicus. This article will review the feasibility of spLAVH compared with cLAVH, taking into consideration operative times, intra and post-operative complications and post-operative pain.

A systematic review of the literature was performed in May 2011, searching Medline and Embase databases. A “free-text” protocol using the terms “Single port laparoscop*”, “Single port surg*”, “Single incision laparscop*” and “Single port access” were applied and these results were narrowed using the terms “gynaecol*” or “womens health”. 44 records were retrieved from the Medline database and 113 from the Embase database. Two of the authors reviewed the records to identify comparative studies. A cumulative analysis was conducted using Review Manager software v.4.2.

Six comparative studies were identified in the literature search. There were no statistically significant differences in operative time, estimated blood loss, immediate post-operative complications or length of hospital stay. Not all studies reported post-operative pain, however the three that did showed spLAVH was assosciated with reduced post-operative pain. There were reports of improved patient satisfaction scores in terms of cosmetic outcomes when comparing spLAVH to cLAVH.

spLAVH is a feasible, safe and effective alternative to cLAVH. There is a need for comparative prospective studies to evaluate the benefits of this new procedure.

P.15.5

Transumbilical single-incision laparoscopic adnexal surgery

Gorostiaga A.* [1], Villegas I.[2], Quílez J. C.[2], Rui-wamba M. J.[2], Ibarrola R.[2], Arriba T.[2]

[1] Centro De Ginecología Y Medicina Fetal. Cegymf - Bilbao, Spain -University Of The Pays Basque - [2] Centro De Ginecología Y Medicina Fetal. Cegymf - Bilbao, Spain

Laparoscopic surgery is probably nowadays the gold standard for adnexal surgery. Since the first laparoscopic procedure, encouraging efforts to reduce the wall trauma have been done, either by reducing the number of trocars or the size of the ports.

Single incision laparoscopic surgery (SILS) is a new surgical approach described as a unique access through a multiple instrument access port. Despite its potential advantages, it has not spread widely among gynaecologic surgeons due to technical difficulties. We present our preliminary results with this technique 16 patients operated of adnexal surgery (cystectomy or adnexectomy) between September 2010–March 2011 in our Unit performed with SILS (Covidien). This device consists of a flexible soft-foam port with accessory channels for up to three laparoscopic instruments. We used a 30° 7 mm laparoscope (STORZ), an articulated grasping forceps (Roticulator), an ultracision device and a uterine manipulator. CO2 was insufflated through another channel at the lateral port of the SILS device.

All the patients were operated with the same technique and by the same two surgeons (Gorostiaga, Villegas) and specimens were removed through the umbilical port, either inside an endobag or once the SILS port had been removed. Fascia was always closed by three 0-poliglactyn sutures.

The mean operating time was 52 mins and 14 patients were discharged satisfactorily in 24 hours and 2 in 48 hours. Neither intraoperatory nor postoperatory complications were detected and all the patients had at least a 2 month follow-up period. Histopathology showed 4 fibrotecomas, 5 serous cistadenomas, 1 dermoid cyst, 2 mucinous cistadenoma and 4 simple serous cysts.

SILS access have been proposed as it offers evident advantages: cosmetic results, less incisional pain and reduced time till discharge. In our experience, we conclude these advantages are clear but some criticism can be remarked, as the increase of costs and the time of operation, due to a restricted freedom of movement that leads to a frequent non-ergonomic position of the instruments.

In our series, SILS appears as a very promising approach for benign conditions. It allows to decrease trocar related complications and improve patient recovery and cosmetics and the surgeon always has the possibility to “go back” to a standard laparoscopy if difficulties arise.

P.15.6

Minimally invasive management of a huge ovarian cyst by laparoscopic extracorporeal approach through a single-site incision

Yi S.*[1], Lee H.[1], Ju D.[1], Lee S.[1], Sohn W.[1]

[1] Department Of Obstetrics & Gynecology, Gangneung Asan Hospital, University Of Ulsan College Of Medicine Gangneung Republic Of Korea

We introduce minimally invasive management of a huge ovarian cyst by laparoscopic extracorporeal approach through a single-site incision.

Recent technical advances in laparoscopy have offered methods that are acceptable for very large adnexal cysts. However, the multiple puncture sites used in conventional laparoscopy may decrease patient satisfaction with the cosmetic outcome and increase trocar-associated complications.

A 15-year-old girl visited our clinic with complaints of abdominal distension. Transabdominal sonography revealed an 18-cm cystic mass. The laparoscopic procedure was performed using general anesthesia. A 2.0-cm vertical skin incision was made at the umbilicus and an Alexis® wound retractor XS was inserted. The surface of the cystic mass was exposed through the wound retractor in the umbilical port. Two traction sutures were applied at the corners of the cystic surface. Cystic fluid was aspirated with an OCHSNER trocar, while pulling the traction sutures. The collapsed cystic mass was then extracted through the wound retractor. The ovary was then replaced into the abdominal cavity after ovarian repair. Saline irrigation was performed under laparoscopy, and the umbilical wounds were sutured.

The use of the laparoscopic extracorporeal approach through an umbilical port appears safe for the removal of huge pelvic masses.

Adnexal cysts with the largest diameter exceeding 10 cm on preoperative imaging studies were categorized as large adnexal cysts. Regarding large pelvic masses, one difficulty in laparoscopy is the limited operative field. To overcome this problem, the surface of the cystic mass was exposed through a wound retractor and cystic fluid was aspirated with an OCHSNER trocar. The umbilical port using a wound retractor would allow less postoperative wound scar, without the limitation of a laparoscopic procedure.

P.15.7

Simultaneous operations using single-port laparoscopy

Iefimenko A.*[1], Iarotskyi M.[1], Iarotska I.[1], Ioffe O.[2], Tarasyuk T.[2], Dorogaya E.[1]

[1] National O.O. Bohomolets Medical University, Obstetrics And Gynaecology Department Kyiv Ukraine - [2] National O.O. Bohomolets Medical University, Surgery Department Kyiv Ukraine

This topic describes the performance of simultaneous operations using single-port laparoscopy, their high efficiency for the treatment of combined surgical and gynecological pathology, and improved cosmetic effect compared to conventional laparoscopy.

The aim of our study was to optimize surgical treatment, duration of surgery, total blood loss and early recovery during the single port laparoscopy in patients with combined surgical and gynecological pathology.

We performed simultaneous operations in 15 patients aged from 38 to 46 years for the combination of such pathologies as calculous cholecystitis (12), inguinal hernia (1), umbilical hernia (2) with gynecological diseases- ovarian cysts (7), endometriosis (2), subserous uterine fibroids(4), and 2 adnexectomies. Our patients were operated using Karl Storz Single port X-cone equipment, of a typical procedure, the average duration was 97 min for cholecystectomy, 95 min for hernioplasty, gynecological procedures- 31 min. Operations were performed without placement of drainage tubes and additional trocars, without any intra-and postoperative complications. Patients were discharged 3 days after in satisfactory condition. All of them were examined with the use of ultrasound of the abdomen and pelvis at the day 6 and 30, that showed the effectiveness of surgical treatment, and the examination of postoperative scar showed an excellent cosmetic result.

This study has demonstrated the feasibility and effectiveness of simultaneous single-port laparoscopic operations on abdominal and pelvic organs, without any complications and a significant increase in the duration of operations, as well as an excellent cosmesis.

We think that single-port laparoscopy is safe and feasible for treatment of combined surgical and gynecological pathology, as it is effective, does not increase the operative time and gives a good cosmetic effect.

P.15.8

Single access laparoscopy: analysis of initial experience

Craig E.*[1], Menninger I.[1], Moohan J.[1]

[1] Altnagelvin Hospital Derry United Kingdom

We present our initial experience using single access laparoscopic surgery for the treatment of benign adnexal pathology in gynaecological surgery.

Single access surgery is a burgeoning component of single access surgery. We evaluate our recent experience with introducing it into a Altnagelvin Hospital, Northern Ireland.

Retrospective case series of 3 patients requiring adnexal surgery for different indications. One patient had a salpingectomy for an ectopic pregnancy, another underwent bilateral salpingo-ophorectomy as completion surgery for early endometrial cancer,and the third patient had a large dermoid cyst removed. An inverted omega shaped (O)incision of approximately 3–4 centimetres in length was made on the inferior aspect of the umbilicus. An open entry technique was performed, the single port was inserted and rapid pneumo-peritoneum achieved. The rectus sheath was closed using interrupted Vicryl ®sutures. The skin was closed continuously in two patients, the third had an interrupted closure.

There were no major complications. No cases required insertion of a secondary port. Each patient recovered well and were discharged on the first post-operative day. Minimal pain was reported. There was an excellent cosmetic result. Estimated blood loss was the same as for the multi-port equivalent. Overall operating time was slightly longer than for traditional laparoscopy, however following port insertion the actual surgery took a similar length of time.

Additional evidence is needed to evaluate safety and long- term outcomes of this new approach. Our case series demonstrates that Single Access Laparoscopy is a safe and feasible approach to treat adnexal disease. Tailored instruments would be beneficial to overcome issues of laterality and ‘chop-sticking.’ It is expected that improvements will be seen in operating time as familiarity with the port and insertion technique increases.

P.15.9

Single incision laparoscopic surgery (SILS) in early endometrial cancer: technique and initial report

Baiocco E.*[1], Mancini E.[1], Corrado G.[2], Lodovico P.[3], Cimino M.[1], Stefano S.[1], Saltari M.[3], Vizza E.[1]

[1] Department Of Surgery, Gynecologic Oncology Unit, National Cancer Institute “regina Elena” Rome Italy - [2] Department Of Oncology, Division Of Gynaecologic Oncology, Catholic University Campobasso Italy - [3] Department Of Surgery, Section Of Gynaecology And Obstetrics, “tor Vergata” University Rome Italy

The purpose of this study was to assess the feasibility of SILS for the surgical treatment of early endometrial cancer.

Endometrial cancer is the most common gynecologic malignancy. Minimally invasive surgical techniques have been utilized with increasing frequency in its management. Recently, single incision laparoscopic surgery (SILS) has been introduced in the treatment of benign gynecological diseases. The purpose of this study was to assess the feasibility of SILS for the surgical treatment of early endometrial cancer.

Ten patients, affected by early endometrial cancer, underwent, from July 2009 through July 2010, radical hysterectomy type A and bilateral salpingoophorectomy through 2–3 cm incision with the SILS TM Port Multiple Instrument Access Port that allowed up to three laparoscopic instruments (three 5 mm cannulas or two 5 mm and one 12-mm cannula) to be used simultaneously through separate flexible channels. Standard straight 5 mm laparoscopic instruments and a 5 mm Ligasure were used.

Conversion to a multi—access standard laparoscopic technique was not required in any patient. The mean operative time was 119 min, with the median drop of Haemoglobin of 1.5 g/L before and 24 hours after operation. The mean length of hospital stay was 2. No intra-operative and early (within 30 days) post-operative complications were reported.

Single incision laparoscopic surgery for the treatment of the early endometrial cancer is feasible, safe and effective and the procedure could be learned over a short period time. Furthermore this approach may result in a scarless effect and a reduction of postoperative pain.

P.15.10

Single port access laparoscopy assisted vaginal hysterectomy(SPA-LAVH) for benign gynecological diseases: our initial clinical experiences

Choi Y.*[1], Eun D.[1], Shin K.[1], Jung B.[1], Choi J.[1], Park J.[1]

[1] Eun Hospital, Duam-Dong Gwang-Ju Metropolitan City Republic Of Korea

We have performed 55 cases of SPA-LAVH using home-made single port system.

The postoperative course was uneventful in all patients and the cosmetic results were excellent.

We report our initial 55 cases experience of SPA-LAVH using homemade single port three-channel system.

We have used home-made single port three-channel system using Alexis® wound retractor and surgical glove.

We have performed SPH-LAVH regardless of past history of pelvic surgery in 55 patients for benign gynecological diseases, including uterine myoma (17 cases), adenomyosis (19), adenomyosis coexisting myoma (14), adenomyosis coexisting ovarian huge cyst (4) and tuboovarian abscess (1).

The median operative time, the largest dimension of uterus, weight of the uterus were 83.6 minutes (range 50–135), 10.8 cm (range 6–13), 293 gram (range 91–750) respectively.

The decline in hemoglobin from before surgery to postoperative day 1 was 1.8 g/dL(range 0.7–4.3).

18 patients have past history of abdominopelvic surgery as like Caesarean section, appendectomy, ovarian cystectomy, salpingectomy or laparoscopic tubal ligation.

All procedures were successfully completed without any extra-umbilical puncture or conversion to standard laparoscopic surgery.

The postoperative course was uneventful in all patients and the cosmetic results were excellent.

The SPA-LAVH was safe and the procedure could be learned over a short period of time.

The homemade single port system offers reliable and cost-effective access for single port surgery.

But instrumental clashing and limited range of motion are troublesome for some procedure as like reconstruction.

Past history of pelvic surgery is not a contraindication for single port surgery but central obesity is troublesome for secure a route for port system through small intra-umbilical incision.

P.15.11

Single–port access hand-assisted laparoscopic surgery (SPA-HALS) for benign large adnexal tumor

Cho H.[1], Roh H.*[2], Lee S.[2], Kwon Y.[2], Ahn J.[2]

[1] University Of Inje College Of Medicine, Haeundae Paik Hospital Pusan Republic Of Korea- [2] University Of Ulsan College Of Medicine, Ulsan University Hospital Ulsan Republic Of Korea

SPA-hand assisted laparoscopic surgery (SPA-HALS) is a unique attempt to provide similar surgical outcomes with the advantages of SPA-pure laparoscopic surgery (SPA-PLS) in benign large adnexal tumor, and to reduce the spillage rate.

To present the feasibility and technique of SPA-HALS in benign large adnexal tumor, we compared the surgical outcomes of SPA-HALS with that of SPA-PLS.

Between March 2009 and February 2011, 139 patients have undergone SPA adnexal surgery. SPA-PLS was performed on all patients that were candidates for conventional laparoscopic adnexal surgery. However, SPA-HALS was primarily performed on patients with large adnexal tumors. We analyzed the demographics and surgical outcomes, and compared 43 patients with SPA-HALS and 96 patients with SPA-PLS. All cases were performed by a single surgeon (H-J Roh).

Median size of adnexal tumor in SPA-HALS was longer than in SPA-PLS (SPA-HALS: 10.9 cm; SPA-PLS: 6.3 cm; p < 0.001). There were only 4 cases (10.3%) of spillage in SPA-HALS, whereas 33 cases (31.3%) of spillage occurred in SPA-PLS (p = 0.005). The relative risk of spillage among patients subjected to SPA-PLS was 4.43 (95% CI 1.45-13.53). Adnexal conserving surgery was more frequently performed in SPA-HALS than in SPA-PLS (76.7% vs. 43.8%, p < 0.001). Additional procedure was frequently performed in SPA-PLS (16.3% vs 33.3%, p = 0.043). Median estimated blood loss was significantly lower in SPA-HALS (50 ml vs. 105 ml, p = 0.001). Operation time (75 min vs. 70 min), complication (0% vs 3.1%), and postoperative hospital stay (2 vs. 2) were not different between two groups.

SPA-HALS extracorporeal adnexal surgery allows for thorough evaluation of peritoneal structure and complete surgery in benign large adnexal tumor while retaining the advantages of SPA adnexal surgery. Furthermore, this technique may reduce the intraperitoenal spillage rate of benign large adnexal tumor.

P.15.12

Single-port laparoscopy: when is it indicated?

Kostov P.*[1], Lanz S.[1], Günthert A.[1], Mueller M.[1]

[1] University Hospital Bern Switzerland

Single-port laparoscopy seems to be the right choice for adnexal surgery. It’s minimal invasive with maximal aesthetic result.

Single-port laparoscopic surgery has been introduced a few years ago putting the aesthetic aspects in the first place. Aim of the current study is to define indications for this type of surgery.

In our department we have introduced the SILS (Single Incision Laparoscopic Surgery) System. It’s a single 3-port trockar (5-12 mm) requiring 25 mm intraumbilical incision. We use a 90 cm long 5 mm 30° Optic, 1 straight and 1 curved instrument. We performed 30 SILS for adnexal masses. In 7 cases, due to adhesions or visual restriction, an additional 5 mm trockar was required. Large ovarian cysts were reduced before introducing the SILS trockar. In those cases, we performed a punction with aspiration of the cyst contents, avoiding dissemination of the cyst liquid into the abdomen.

The main procedure was an adnexectomy (25/30), followed by cystectomy (4/30) and a biopsy only (1/30) in the case of a pseudomyxoma peritonei. After a learning curve of 5–7 SILS operating time became similar to that for standard laparoscopy. All masses have been extracted in an endobag with in-bag morcellation if required without intraabdominal tumour rupture. In two cases the histological result determined a borderline ovarian tumour, in one a pseudomixoma peritonei and one a dysgerminoma. In the remaining cases, benign histological results were confirmed. Aesthetically, all umbilical scars demonstrated a primary healing at six week follow-up.

Single-port laparoscopy for adnexal surgery combines the advantages of being minimal invasive with larger abdominal access and maximal aesthetic result. By technical difficulties it’s always possibile to introduce an additional trockar. The 25 mm incision allows extraction of specimens even of larger sizes using in-bag morcellation. The intraumbilical scar remains hidden with excellent aesthetic result.

P.15.13

Single-port versus three-port laparoscopic surgery for benign adnexal tumor

Jong-hyeok K.*[1], Jeong-yeol P.[1], Yu-ran P.[1], Dae-yeon K.[1], Yong-man K.[1], Young-tak K.[1], Joo-hyun N.[1]

[1] Asan Medical Cener Republic Of Korea Republic Of Korea

None

The aim of this study was to compare the surgical outcomes between single-port versus three-port laparoscopic adnexal surgery in a large retrospective cohort.

All consecutive patients who tried single-port (n = 301) or three-port (n = 584) laparoscopic surgery for benign adnexal tumor were included in this retrospective analysis.

Six patients (2.0%) in single-port group required additional ports, and no one in three-port group required additional ports (P = 0.001). No one in both groups required laparo-conversion. There were no between-group differences in menopause, parity, body mass index, and previous abdominal surgery, nor were there between-group differences in the diagnosis of adnexal tumor and type of adnexal surgery. However, three-port group were significantly older (37 years vs. 35 years, P = 0.001) and had significantly larger tumor (5.9 cm vs. 6.6 cm, P = 0.001) than single-port group. There were no differences in operating time (89 min vs. 93 min, P = 0.053), estimated blood loss (79 vs. 88, P = 0.105), mean hemoglobin level change (1.2 mg/dL vs. 1.3 mg/dL, P = 0.165), transfusion requirement (2.7% vs. 2.6%, P = 0.890), and transfusion amount (1.8 pints vs. 2.4 pints, P = 0.287). However, single-port group had significantly less postoperative pain sores at POD 0 (4.6 vs. 4.8, P = 0.017) and POD 1 (2.3 vs. 2.5, P < 0.001), less analgesics requirement at POD 0 (14.1% vs. 34.8%, P < 0.001) and POD 1 (13.7% vs. 28.3%, P < 0.001), and postoperative hospital stay (2.0 days vs. 2.2 days, P < 0.001). Perioperative complications occurred in 4 (1.5%) and 6 (1.0%) patients, respectively (P = 0.570).

Single-port surgery was as feasible as three-port surgery. It was more minimally invasive surgery with more favorable operative outcomes in terms of postoperative pain, analgesics requirement, hospital stay and cosmetic outcome.

P.15.14

Single-port versus three-port laparoscopic-assisted vaginal hysterectomy for benign or precancerous uterine disease

Jeong-yeol P.*[1], Yu-ran P.[1], Dae-yeon K.[1], Jong-hyeok K.[1], Yong-man K.[1], Young-tak K.[1], Joo-hyun N.[1]

[1] Asan Medical Center Republic Of Korea Republic Of Korea

The aim of this study was to compare the surgical outcomes between single-port versus three-port laparoscopic-assisted vaginal hysterectomy (LAVH) in a large retrospective cohort.

All consecutive patients who tried single-port (n = 355) or three-port (n = 544) LAVH for benign or precancerous uterine disease were included in this retrospective analysis.

Six and (1.7%) one patient (0.3%) in single-port LAVH group required additional ports and laparo-conversion, respectively, and each one patient (0.4% and 0.4%) in three-port LAVH group required additional ports and laparo-conversion (P = 0.064). There were no between-group differences in age, menopause, parity, body mass index, and previous abdominal surgery, nor were there between-group differences in the diagnosis of uterine disease and uterus weight. There were no differences in operating time (120 min vs. 119 min, P = 0.545), mean hemoglobin level change (1.4 mg/dL vs. 1.4 mg/dL, P = 0.614), transfusion requirement (8.7% vs. 9.8%, P = 0.596), and transfusion amount (2.5 pints vs. 2.4 pints, P = 0.625). However, single-port LAVH group had significantly less estimated blood loss (110 vs. 135, P < 0.001), less postoperative pain sores at POD 0 (4.9 vs. 5.3, P < 0.001) and POD 1 (2.4 vs. 2.6, P = 0.006), less analgesics requirement at POD 0 (23% vs. 46.8%, P < 0.001) and POD 1 (23.6% vs. 41.6%, P < 0.001), and postoperative hospital stay (2.3 days vs. 2.5 days, P = 0.005). Perioperative complications occurred in 12 (3.4%) and 23 (4.2%) patients of single-port and three-port LAVH groups, respectively (P = 0.512).

Single-port LAVH was as feasible as three-port LAVH. It was more minimally invasive surgery with more favorable operative outcomes in terms of estimated blood loss, postoperative pain, analgesics requirement, hospital stay and cosmetic outcome.

Session P.16

* Teaching and Training *

P.16.1

Appendicectomies in gynaecology

Perovic M.*[1], Kovoor E.[1], Chappatte O.[1]

[1] Maidstone And Tunbridge Wells Nhs Trust Tunbridge Wells United Kingdom

Incidental findings of abnormal appendixes are commonly seen in gynaecological conditions like endometriosis. The aim of this study was to identify indications and outcomes of appendicectomies performed by gynaecologists.

Abnormal appendix is commonly seen at the time of laparoscopy for suspected pelvic disease and its removal often requires help of surgeons. This may cause further delay or a re operation especially when surgical help is not immediately available. This can be avoided in most situations if gynaecologists are trained to perform the operation. The aim of this study was to identify indications and outcomes of appendicectomies performed by gynaecologists in a Distric General Hospital (DGH).

Retrospective study done at Pembury hospital from 1998–2009. Case notes of 53 consecutive patients who had appendicectomy were available. Variables studied were indications for appendicectomy, type of surgery (laparotomy or laparoscopy), histology, hospital stay, complications and follow up results in patients with chronic pelvic pain.

Laparoscopic appendicectomy was performed in 31 and laparotomy in 22 patients. Two patients in the laparoscopy group needed conversion due to adhesions and retrocaecal position of appendix. Pelvic pain, ovarian cysts and endometriosis were the commonest indications for surgery. Laparotomies were performed predominantly for malignancies and ovarian cysts as part of staging.

Hisologically abnormal appendix was seen in 70% of cases.Conversion rate in our series was 2/31 (6.4%) for laparoscopic appendicectomies.

Appendicectomy in the hands of trained gynaecologist was safe with no increase in complications. Abnormal appendices at the time of laparoscopy should be removed as it is often associated with abnormal pathology. Patients with chronic right iliac fossa pain may benefit from appendicectomy if no other significant disease is found.

P.16.2

Dedicated consultant-lead EPAU service reduces surgical intervention in ectopic pregnancies

Lawin-o’brien A.*[1], Shahid A.[1], Bhaskaran L.[1], Deo N.[1], Funlayo O.[1]

[1] Whipps Cross University Hospital London United Kingdom

Dedicated Consultant lead service reduces sugical intervention in Ectopics. A shift towards medical or expectant management reduces in-patient stay,cost and improves patient satisfaction.

Ectopics can be managed surgically, medically or expectantly. Benefits of non-surgical management include reduced cost, less surgical complications, preservation of tubes. Our data compared management prior and after appointment of a dedicated EPAU consultant.

Data on a total of 765 Ectopic pregnancies seen between 2000 and 2011 were collected and analysed. Initially data prior to appointing a dedicated EPAU Consultant in 2009 was compared to the following year. Data was stratified into two groups:prior and post appointment. In this longitudinal study rates of surgical versus non-surgical management of Ectopics were compared between the two groups.

There was a marked shift in the balance between surgical and non-surgical treatments that coincided with introduction of an EPAU Consultant. In the year prior to appointment 3 patients (6.6%) were treated non-surgically, 42 (93.3%) were treated surgically. After introduction of a dedicated consultant, 2009,10 patients (10.1%) were treated non-surgically,89 (89.89%) patients were treated surgically. In 2010, 28 patients (27.18%) received non-surgical treatment, 75 patients (72.81%) were managed surgically. Dedicated EPAU Consultant input reduced in-patient surgical management of Ectopics.

In approriately selected patients surgical management of Ectopic pregnancies is undesirable. Alternative strategies can reduce cost, surgical complications and improve patient satisfaction. Our data demonstrates that dedicated consultant input can impact decision making. This study is limited by it’s retrospective nature. However, encouraging results should inform further investigation in order to derive maximum benefit for our patients and the trust.

P.16.3

Effectiveness of a hands-on education program in improving gynaecological residents’ laparoscopic skills

Mousiolis A.[1], Protopapas A.*[1], Hatzipappas I.[1], Athanasiou S.[1], Liappi A.[1], Koutroumanis P.[1], Antsaklis A.[1]

[1] 1st Ob-Gyn Clinic Of Alexandra University Hospital Athens Greece

Results of a hands-on gynecology course in self-evaluation and actual performance of laparoscopic skills.

Aim of the study was the evaluation of the effectiveness of a gynecologic endoscopy course in enhancing residents’ proficiency and self-confidence in laparoscopic surgery.

The course included theoretical sessions and practical skills enhancement through practice in both pelvic trainer and animal laboratory settings. Acquired skills evaluation was based on timing a procedure (pig nephrectomy) as well as resident self-evaluation of laparoscopic proficiency at the beginning and end of the program. 33 residents participated.

Correlation of self evaluation and actual performance was high (Pearson r = −0.0524, p < 0.05). Mean score of self assessment of laparoscopic skills before/ after the dril was for trocar insertion: 2.27/ 2.94, orientation: 2.06/ 2.91, diathermy: 2.12/ 2.79, tissue manipulation: 1.85/ 2.61, knot tying: 1.55/ 2.33, total score: 9.3/ 12.09. Their belief about their future in laparoscopy was 1.88/ 2.15. All of the paired comparison differences before and after the drill were statistically significant (p < 0.05). Regarding actual performance in pig nephrectomy drill, mean operation time was 1.715. Regarding gender differences, men in general performed better than women (p < 0.05). Regarding evaluation of benefits by the hands-on course, in a 0–3 scale, a high level of satisfaction was noted (mean = 2.42).

A structured program emphasizing skills enhancement is effective in improving residents’ performance in laparoscopic surgery. Self-evaluation is related closely to actual skills and therefore can be used as a marker for performance. Curriculum of laparoscopic training within residency should be restructured accordingly. Such programs can help residents get familiarized with laparoscopy techniques and provide motivation for further training.

P.16.4

Etiology and management of heavy menstrual bleeding: prevalence results from a single clinic

Kroese A.[1], Bongers M.*[1], Toub D.[2]

[1] Máxima Medisch Centrum Veldhoven Netherlands - [2] Gynesonics, Inc. Redwood City, Ca United States

The prevalence of various causes of heavy menstrual bleeding (HMB) was estimated from a retrospective study of women attending a single clinic.

There are many potential etiologies of heavy menstrual bleeding (HMB), the frequencies of which are not well established. It is also unclear how often various interventions are used to manage HMB. We sought to estimate the frequencies of such causes and treatments among women presenting to a single HMB clinic.

Retrospective chart review of premenopausal women with a complaint of HMB who presented to a single menstrual bleeding clinic in The Netherlands prior to April 2011. Patient names were removed prior to chart accession to preserve patient confidentiality. Women who were postmenopausal and/or 50 years of age or older were excluded from consideration. Hysteroscopy records and transvaginal sonography results were used to establish if structural abnormalities of the uterus were present and to delineate fibroid location and type, if so noted in the medical record. Additional imaging, such as magnetic resonance scans to confirm an impression of adenomyosis, was also taken into account. The management of each patient was recorded, if known.

This case series is ongoing. Results are anticipated to include a minimum of 100 premenopausal patients evaluated for HMB.

It is important to understand the relative frequencies of several etiologies of HMB, as well as how often one treatment modality is chosen over another. This study, localized to a single center, is intended to provide estimates regarding how often women presenting with HMB have associated conditions such as adenomyosis and fibroids, and how they are managed.

P.16.5

First year of endoscopic procedures in our hospital. review

Roig Casaban N.*[1], Bernabeu Cifuentes A.[1], Paredes Rios A.[1], Navarro Campoy C.[1], Gil Raga F. J.[1]

[1] Hospital De L’Horta Manises Valencia Spain

Objective: To analyze the endoscopic surgery results in our hospital in its first year.

Method: Retrospective study from 1/1/2010 to 12/31/2010, which included 474 patients undergoing surgery in our hospital. Those who undergo an endoscopy approach where included, being 242 interventions performed in 240 patients. Statistical analysis SPSS 17.0. was used.

Results: A total of 108 hysteroscopies were performed, of them 77 (71.2%) where polypectomies (on suspicion of polyps by ultrasound or by discovery during diagnostic hysteroscopy), 7 (6.5%) where tubal sterilization (Essure application), 6 (5.5%) submucosal myomas resection, 4 (3.7%) IUD removal and 14 (13%) for diagnosis of endometrial pathology (usually a consequence of abnormal bleeding).

The rest of the surgeries, 134 in total, were laparoscopies. Eighteen of those (13.4%) where tubal sterilization, 5 (3.7%) salpingectomies (for hydrosalpinx), 58 (43.3%) oophorectomies or ovarian cystectomy (most commonly, endometriomas), 26 (19.4%) where hysterectomies for benign conditions (fibroids or simple endometrial hyperplasia), 6 (4.5%) hysterectomies for malignant disease (radical surgery with lymphadenectomy), 17 (12.7%) myomectomies (subserosal or intramural fibroids with a desire to preserve the uterus) and 4 (3%) other procedures (adhesiolysis or chromopertubation).

Conclusions: During the first year of operation, ??51% of surgeries were endoscopic procedures: 44.6% by hysteroscopy and 55.4% laparoscopic. Despite being a good result, our goal is to improve given the many advantages of endoscopic procedures comparing with the abdominal or vaginal approach.

P.16.6

Implementation of laparoscopic Virtual Reality Simulation (VRS) training

Burden C.*[1], Mcdermott L.[1], Appleyard T.[1]

[1] Southmead Hospital, North Bristol Trust Bristol, Uk United Kingdom

Pilot feasibility study to assess the feasibility of implementing laparoscopic VRS into gynaecology training in the UK.

Laparoscopic VRS training in gynaecology has been shown to increase operating skills to that of a more experienced surgeon and decrease operating time. The European Working Time Directive has put extra pressure on surgical training, therefore trainees feel unconfident in their laparoscopic skills. The feasibility however of integration of laparoscopic VRS training into the curriculum for UK trainees has not yet been assessed.

The study involves both a quantitative and qualitative component. Str1 and Str2 Gynaecology trainees (n = 9) undertook a pre-validated training program on the simulator, LapSim, comprising of basic skills and a complete salpingectomy. Semi-structured group interviews were subsequently undertaken with all trainees. Main outcome measures included the number of trainees able to complete the programs in six months, duration of training sessions and trainees opinions on the feasibility and barriers to the implementation of VRS training.

66.7% of participants completed 6 out of 10 tasks. Average time spent on LapSim was 9 hours and 54 minutes. LapSim was felt to be a good simulator, and trainees enjoyed the self-directed learning in a non pressurised environment. Trainees felt it improved their camera skills, depth perception, and confidence in theatre. Lack of sensation/ haptic feedback was noted.

Overall feedback on laparoscopic VRS training was very positive although a number of barriers and negative aspects were highlighted. Suggested improvements to inform the integration of laparoscopic VRS training into the core curriculum for UK trainees in gynaecology, include a focused mapping of specific RCOG skill requirements to simulated tasks and increased direct personal feedback.

P.16.7

Introducing enhanced recovery into gynaecological surgery at a district general hospital

Smith Walker T.*[1], Hindley J.[1], Stocker M.[1]

[1] Torbay District General Hospital Torquay, Devon United Kingdom

Enhanced recovery (ER) was introduced at Torbay Hospital to improve our patients experience and enable them to recover sooner following elective gynaecological surgery.

Enhanced recovery has significant benefits for both patient and hospital. Its allows patients to recover sooner from elective procedures and improve their overall quality of care. As a secondary outcome they have a shorter hospital stay and make more efficient use of the hospitals resources.

We have adapted the principles of enhanced recovery taken from the experience of those used in colorectal surgery and introduced them into our practice. Specific ER pathways have been developed for our 4 main procedures, Laparoscopic/vaginal/abdominal hysterectomies and vaginal repairs. Specialized information is provided for the patient so they are prepared pre-operatively and the staff educated in how to carry our effective ER.

We measured patient experience through questionnaires, their length of stay and the proportion admitted on day of surgery. This is an ongoing study.

The initial results are promising. In the first month (April), for the stated procedures are:

Median length of stay 1 day

Admission on day of surgery 97.7%

Those going home on the expected day of discharge %:

Laparoscopic Hysterectomy 100% (1 day)

Abdominal Hysterectomy 75.9% (2 days)

Vaginal Hysterectomy/Repairs 84% (1 day)

The initial feedback from the patients indicates a high level of satisfaction.

Enhanced Recovery has been embraced by the consultant body and initial results look promising. The reduced hospital stay and reduced morbidity/mortality for the patient is of significant benefit to both hospital and patient. Enhanced Recovery is also championed by the Department of Health and is seen as the future for all elective procedures. Further information is being gathered and will be available for presentation at the time of the conference.

P.16.8

Laparoscopic simulation models for advanced laparoscopic training- innovative techniques

Raza A.*[1], Richardson R.[1]

[1] Consultant Chelsea And Westminster Hospital

Laparoscopic Simulation has become an integral part of the training and assessment due to fundamental changes in the current education programme.

Reduced working hours, shorter hospital stay and increased patients demands have made it difficult for trainees to have sufficient time and opportunity to learn laparoscopic skills. Dry model simulation provides opportunity to rehearse and learn from mistakes without risks to patients.

The practice helps to improve the eye and hand coordination long with difficult skills such as intracorporeal suturing. However the challenges of simulation are the provision of cheap, cost effective and practical dry models.

We have designed and produced dry models which are cost effective and easily reproducible. These dry models mimic the clinical conditions such as ectopic pregnancy, fibroids, salpingectomy and salpingotomy and lateral pelvic wall. These innovative designs reflect the real life scenarios and help trainees to learn skills such as dissection, use of endoloops, cystectomies and excision of peritoneum

These dry models are made by different foam materials, small clips and wooden board. Trainees can easily make them with easy instructions and reuse the materials in various forms. We have described various techniques to make these simulation models.

P.16.9

Opinions on laparoscopic surgical skills training in medical students

Reus E.[1], Harrity C.*[1], Ahmed S.[1], O’sullivan R.[1], Prendiville W.[1]

[1] National Clinical Skills Centre Dublin Ireland

There is little emphasis on surgical skills teaching to medical students. A laparoscopic skills training course was provided to undergraduate students and their opinions were recorded.

The undergraduate medical curriculum has traditionally focused on basic sciences applied to medicine and study of disease processes and treatment. Recent changes in the curriculum have placed increasing emphasis on clinical skills, with earlier patient contact during the program. Teaching surgical skills and techniques is typically reserved for postgraduate level.

A single day laparoscopic course was provided to 17 undergraduate medical students, progressing from basic to intermediate level skills. A questionnaire was completed at the end of the course to assess the participants’ opinions.

17 questionnaires were returned (100%). 47% of participants were unsure of their future medical specialty, but 9 students had decided (2 obstetrics and gynaecology, 3 surgery, 1 internal medicine). All 17 students enjoyed the course, and would recommend it to a colleague. 15 students felt that the course would benefit their medical career, and 8 reported that it would help influence their future choice of specialty. All 17 participants would like to participate in further laparoscopic skills courses. 100% of participants stated that it was beneficial to teach practical surgical skills to medical students, and 15 would like to see this formally included in the undergraduate curriculum.

There is a demand for surgical skills teaching among medical students, and in certain cases this may help the participant to choose their future specialty. Surgical skills teaching could have the potential to be a a popular addition to the undergraduate curriculum.

P.16.10

See and treat hysteroscopy: our teaching experience with residents

Germano G.*[1], Dorner C.[1], Miranda L.[1], Lanz C.[1], Valeta J.[1], Vargas D.[1]

[1] Hopital Central De Las Fuerzas Armadas Montevideo Uruguay

We present 127 procedures done in the last 12 month in the Endoscopic Office of the Hospital Central de las Fuerzas Armadas, Montevideo, Uruguay.

These procedures were performed by 5 residents in their second and third year of training.

All procedures were performed without speculum or tenaculum, distension media were saline solution.

There were performed 36 polypectomies, 5 with Versapoint, the others with Bettocchi System; 3 myomectomies, two of them with Versapoint, (1, 5 and 2 cm respectively). 41 targeted biopsies, 20 internal os adhesiolisys, 10 IUD extractions , and 2 resections of vaginal polyps.

Discussion: the difficulties of training residents, were: time of resection, hiperhidration of the endometrial tissue, the difficulty of polyps extractions,(4 patients); patient pain; and the impossibility of obtaining tissue in patients whit endometrial atrophy, in 5 cases. 14 patients were derivate for resection in operating room because of length of the polyps or fibroids higher than 3 cm (3 cases). 3 were derivate to general anesthesia due to the pain. No complications occurred in our patients.

Conclusions: the training resident are capable of doing all the procedures in a safe way, and the most important problem is the time of the procedures, with the difficulty of extracting the tissue due to the endometrial hydration, and the discomfort of the patients due to the same issue. The pain and need of cervical anesthesia were the same as in those patients treated by experienced surgeons.

P.16.11

Surgical management of ectopic pregnancy

Maydanovych S.[1], Rawal N.*[1], Phillips K.[1]

[1] Hull Royal Infirmary Hull United Kingdom

Retrosceptive audit of surgical management of ectopic pregnancy over seven years in a University teaching Hospital. Increasing number of cases was performed laparoscopically and laparotomy was performed only in 13.33 cases. 95% of the surgeries were performed during day time by laparoscopically trained staff.

Royal college of Obstetricians and Gynaecologists (RCOG), in its guideline states that a laparoscopic approach to the surgical management of tubal pregnancy, in the haemodynamically stable patient, is preferable to an open approach. However, laparoscopic management is not available to all women in United Kingdom.

We undertook a retrospective study looking at the surgical management of ectopic pregnancies over a period of seven year (January 2004–December 2010) in a University teaching Hospital and compared this with the recommended RCOG guidelines 2004. Cases of surgically treated ectopic pregnancy were identified from the theatre log and case notes of these women were reviewed.

A total of 450 cases of ectopic pregnancy were managed surgically over these seven years. Notes of 15 women couldn’t be retrived. Of 435 case notes, 377 women had laparoscopic treatment (86.66%)for ectopic pregnancy and 58 women had laparotomy(13.33). In 2009 and 2010 over 90% of cases were managed laparoscopically.

45.27% of operations were performed by the consultant whereas 54.73% were performed SpR’s and clinical fellows. The main reason for laparotomy were haemoperitonium, extensive adhesions due to previous surgery and cornual ectopic. Only 4.9% of procedures were done after 9 pm.

Discussion

Our study reveals progress achieved in surgical management of ectopic pregnancies in our unit and our adherence to the RCOG guidelines over years. High ethos of laparoscopic surgery and increased training opportunities in MAS for the junior doctors in our unit have helped us to achieve this.

P.16.12

Surgical management of ectopic pregnancy in ni—a multi-centre analysis

Hunter D.[1], Mccomiskey M.*[1]

[1] Royal Jubilee Maternity Service Belfast United Kingdom

Annual audit data from a major teaching hospital from 2004–2009 showed an increase in the uptake of laparoscopy for the management of ectopic pregnancy.The audit confirmed that utilisation of laparoscopy for the surgical management of ectopic pregnancy was satisfactory at a regional level and trainees performed the majority of surgeries.

Aims were to examine clinical findings and trends in surgical management of patients presenting to Northern Ireland gynaecology units with ectopic pregnancy.

An agreed data collection proforma for all patients with ectopic pregnancy was populated by each emergency gynaecology unit in Northern Ireland.

Completed audit forms were received/collected for 40 patients from 8/10 units. Presenting symptoms varied (pain (36/40, 90%), vaginal bleeding (29/40, 73%), collapse (3/40, 8%)). A gestational sac or pseudosac was visualised in 18/40 (45%) cases and the presence of free fluid within the Pouch of Douglas was reported in 21/40 cases (53%). 34/40 (85%) cases were managed laparoscopically with the primary surgeon being a consultant in 15/40 (38%) of cases. Trainees at St 6–7 (13/40, 33%) and St 1–5 (11/40, 28%) undertook the remaining procedures in both supervised (21/24, 88%) and independent (3/24, 12%) capacities. Of the 6 laparotomies, 2 (33%) were converted from laparoscopy, 3/6 (50%) were direct laparotomies and 1 (17%) was a case of return to theatre for post-operative bleeding after laparoscopy.

Definitive laparoscopic management rate has risen further from 53% (2004/2005), to 77% (2006) and further still to the figure presented here. Although we cannot draw from the data above, this is likely to be the result of more accessible training courses and local training in laparoscopy. Gynaecology registrars are performing the majority of the procedures, mainly in a supervised capacity. Patients and gynaecologists-in-training will benefit from this progress.

P.16.13

The benefits of a take-home trainer on the development of laparoscopic surgical skills

Harrity C.*[1], Prendiville W.[1], Ahmed S.[1], Reus E.[1], O’sullivan R.[1]

[1] National Clinical Skills Centre Dublin Ireland

A single day laparoscopic skills course was provided, followed by random allocation of a take-home trainer to half of the group. At 8 weeks the participants were reassessed, and the group with the take-home simulator demonstrated a significantly greater ability to perform a laparoscopic suture (376 s Vs 822 s, p = 0.002).

Laparoscopic training is provided in a variety of formats, including live surgery demonstrations, practical courses, virtual reality simulators, animal models, and box trainers. A take-home trainer allows the trainee the opportunity to practise regularly in their own time, develop their skills, and learn new techniques.

17 participants with no prior laparoscopy experience were recruited and provided with a 10 hour laparoscopic skills session, progressing from basic techniques to laparoscopic suturing and intracorporeal knots. At the end of the session the students were timed at completing a single laparoscopic suture with intracorporeal knot. The participants were randomly allocated to either receiving a take home trainer for 8 weeks, or no further training(n = 17, Intervention group = 9, control group = 8). All students were reassessed 8 weeks later, and the time taken to complete a laparoscopic suture was recorded.

At the end of the session there was no significant difference in time between the groups (Intervention group = 601 s, control group = 618 s). At the 8 week point, the intervention group (take home trainer) demonstrated a 38% improvement in the time, while the control group (no further training) demonstrated an increase of 33%. There was a significant difference in mean suture times at this point: 376 sec Vs 822 sec, p = 0.002.

The use of a take-home trainer in addition to a laparoscopic training session, leads to improved development and retention of skills when compared to a training course alone.

P.16.14

The profiling of a laparoscopist

Chipeta H.[1], Tang T.*[1]

[1] Bradford Royal Infirmary Bradford United Kingdom

With a move from open to laparoscopic gynaecological surgery there is acknowledgement that the skills necessary to become a good lapsroscopic surgeon are considerably different to those needed to be a good open surgeon, including having good sense of depth perception and hand-eye co-ordination. We propose looking at the current literature to see whether a ‘good’ laparoscopic surgeon can be trained or whether ‘natural ability’ is key to excellence.

Laparoscopic training is increasing in demand amongst trainee gynaecologists. We propose the question of whether a good operative laparoscopist can be created through dedicated teaching or whether there is an inate ability in a few trainees that make them more likely to become good laparoscopic surgeons.

A search of the current literature pertaining to profiling of laparoscopic surgeons.

Pending

To see whether there is any merit in profiling potential laparoscopic trainees prior to embarking on a career in laparoscopic surgery.

P.16.15

The usefulness of the apprenticeship model in gynaecological oncology training

Saso S.*[1], Chatterjee J.[1], Farthing A.[1], Ghaem-maghami S.[1]

[1] Imperial College London London United Kingdom

Surgical training is based on an apprenticeship model. We have evaluated it by focusing on the time required for a trainee to complete a single common gynaecologic oncological operation and how this changes with training.

Since the introduction of the European Working Time Directive, trainees are faced with a reduction in operating time needed to gain practical surgical experience. Planning of theatre lists needs to take into account the greater length of time required for a trainee to learn how to perform a particular operation. This report examines the learning curve for subspecialty trainees (SSTs) who already have significant surgical experience.

118 patients diagnosed with endometrial cancer (all histology types) underwent total laparoscopic hysterectomy and bilateral salpingo-oopherectomy between 2003 and 2010. Patients in Group I (67 patients) were operated on by the consultant gynaecologist and in Group II (51 patients) by trainees.

Mean patient age and BMI was 64 years and 30 kg/m2 in Group I and 65 years and 30 kg/m2 in Group II. Mean operation times for Groups I and II were 63 ± 33 and 105 ± 45 minutes respectively (p < 0.05). This difference was also significant when comparing each SST individually with the trainer. Group I had a lower intra-operative estimated blood loss (EBL) compared to Group II. With respect to SST training, significant improvement was revealed when comparing the average operation time between Year 1 and Year 2 of training. There was an evident reduction in EBL in Year 2.

We believe that it may be suitable to halve the numbers of patients on the operating list to allow adequate training for a complex laparoscopic procedure. Such a model would have significant cost implications. We also conclude that this model leads to significant improvement in trainee operating times in the second half of training and that it is acceptable with respect to patient safety outcomes.

P.16.16

Ultrasound education for trainees in obstetrics and gynaecology in South east Wales

Edwards J.*[1]

[1] Cardiff University Cardiff United Kingdom

Given the increasing use of ultrasound, it was decided to evaluate trainee satisfaction with ultrasound education in South-east Wales to ensure that it meets the defined standard. SE Wales ultrasound education is largely compliant with Royal College recommendations but has scope for improvement.

Ultrasound has become ubiquitous in obstetrics and gynaecology of late; consideration must be given to education programmes to ensure safe, competent ultrasound practitioners. International guidelines regarding minimum ultrasound competencies for trainees were introduced in the late 1990s; formal ultrasound learning objectives were introduced nationally only with the new training curriculum in 2007. The success of this has not been formally evaluated, however the literature suggests that evaluating ultrasound training curricula has positive outcomes.

Questionnaires were distributed to run through trainees in south-east Wales. It covered completion of mandatory ultrasound modules, training adherence to RCOG learning objectives, depth, and learning opportunities available. Opinion on perceived problems and suggestions for improvement were also sought.

Although trainees felt that ultrasound education covered RCOG objectives, it was not of sufficient depth for independent practice. Learning opportunities available were felt adequate, but impeded by busy rotas and lack of supervision and interest. Suggestions for change included appointing dedicated ultrasound co-ordinators.

Trainees felt that busy rotas resulted in deficiencies in basic skills. This could be circumvented by introducing a deanery wide basic ultrasound skills day to ensure minimum competence. A lack of awareness about the role of the ultrasound co-ordinator was highlighted; consideration must be given to extending this role. Trainees should take responsiblity for their own education as part of continuing professional development.

Session P.17

* Technical Tricks and New Instrumentation *

P.17.1

A shaver-like system (SLS) for intrauterine pathology treatment, preclinical investigation

Klyucharov I.*[1], Hassanov A.[1], Samigullova A.[1]

[1] Kazan State Medical University Kazan Russian Federation

Some limitations of intrauterine surgical technologies including fluid overload, uterine perforation, lack of visualization and long learning curve still exist. We present our preclinical experience with intrauterine SLS.

Hysteroscopy with application of mechanical, monopolar, bipolar and laser energy is frequently used in gynecologic practice. One of the perspective technologies for destruction and simultaneous removal of some intrauterine lesions is SLS. We investigated effect of SLS on presented intrauterine pathology: polyps, submucous myomas after hysterectomy, performed for the other indications.

Design of the study was approved by the local ethical committee, and all patients gave their informed consent. We have used recently removed uterus, clamped both tubal ostia and introduced 9,5 mm hysteroscope with 4,0 mm operating channel for SLS. Once visualized the pathological site we introduced the rigid shaving system connected to the motor drive unit and to the roller pump into the operative channel and started the procedure. Appropriate fluid flow and intrauterine pressure as well as aspiration were set in order to have good visualization.

20 cases were investigated: 10 myomas (type1) size ranged 20 × 45 mm and 10 polyps size ranged 5–35 mm. all polyps were successfully resected. The mean time for polyps’ resection was 4′20?. All resection of myomas were unsuccessful due to the mechanical characteristics of myomatous tussue and shaver’s knife capabilities.

Traditional intrauterine surgical technologies associated with the following risks: excessive intravasation of fluid, perforation, uncontrolled monopolar leakage current and related burns, obscured visual field due to debris during resection, perforation and cervical laceration. Intrauterine SLS seems to prevent most of complications. Further investigation on cutting capabilities of knife needed to improve results.

P.17.2

Minimizing abdominal incisions in laparoscopic reproductive surgery

Ventura N.*[1], Häberlin F.[1], Hornung R.[2]

[1] Fiore, Frauenklinik, Kantonsspital St. Gallen Switzerland - [2] Frauenklinik, Kantonsspital St. Gallen Switzerland

Women undergoing reproductive surgery want to have maximized chance for future fertility and best possible cosmetic results. Using the proposed surgical approach, these goals can be easily realized requiring only minor additional instrumentation.

The surgical trend is supporting minimally invasive surgery. In reproductive gynaecological surgery, it is very important that surgery is as gentle as possible and spares all reproductive organs. The aim is to present a concept for a new standard in minimally invasive laparoscopic surgery.

Our approach includes:

  • Reduction of the umbilical trocar from 10 mm to a 5 mm laparoscope.

  • Reduction of the manipulation trocars from 5 to 3 mm.

  • Using a vaginal trocar (12 mm) for tissue extraction.

  • Reduction in abdominal insufflation pressure from 14 to 8 mm Hg.

In this way we have performed, with no technical difficulties, ovarian cyst enucleation, adnexectomy, endometriosis excision and/or ablation, enucleation of smaller myomata (max 25 mm).

We achieved very good cosmetic results. So far no complications have been reported. There was no need for any longer operation time. It could be shown that the above mentioned procedures could be done with 3 mm instruments and the tissue could be extracted vaginally with absolutely satisfactory results.

Women undergoing reproductive surgery are not only mostly young and otherwise healthy, they are often in the prime of their lives, both personally and professionally. Their goal is to be able to return to normal life as soon as possible, avoiding prolonged hospital stays and convalescence, with maximized chance for future fertility. Using a surgical approach such as proposed, these goals can be realized without surgeons needing to learn new technical skills, and requiring only minor additional instrumentation. In our experience to date, patients have a very low morbidity and are pleased with the cosmetic result.

P.17.3

Mini-site practice in gynecological endoscopy

Plekhanov A.*[1], Tatarova N.[1], Ryabinin G.[1]

[1] Russian Railways Hospital; Saint-Petersburg State Medical Academy Named After I.I. Mechnikov Saint-Petersburg Russian Federation

We have performed 270 Mini-Site surgeries on various surgical and gynecological diseases.

One of the main goals of surgeons is a decrease in the trauma of surgeries and, in particular, in securing swift access to the targetted organs. Technical and technological progress over the last few decades—the invention of micro-video-cameras, new light sources, video-screens—have facilitated the development of endo-video-surgery technology.

Between 1998–2010 we have performed 270 Mini-Site surgeries on various surgical and gynecological diseases (“GIMMI™ Rusland Endovideosurgery” set was utilized). Microsurgery instruments were used for the following operations: diagnostic laparoscopy, endocoagulation of endometrioid geterotopy, salpingoovariolizis, biopsy of the ovary, cystectomy, tubectomy, sterilization.

Drawing on our own experience and relying on the available literature we can conclude that Mini-Site contraindications are general illnesses and conditions which are contraindications for the planned surgery, anesthesia and karboksiperitoneum (including pregnancy, inflammatory changes of the anterior abdominal wall, obes?).

Ultra-thin instruments have increased flexibility that is why they can be recommended to be set up at an angle towards the aimed organ and not perpendicular to the anterior abdominal wall.

Other advantages of the Mini-Site include the absence of a huge post-surgery scar; a visual increase of the working space—the surgical area with elements of micro-surgery; lower pain during the post-surgery period; absence of the post-surgery enteroplegia; lower immune-suppression which is particularly important for patients with diseases of the immune system; decreased risk of the post-surgery adhesions; shorter hospitalization, labor and social rehabilitation periods.

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

Roman H.*[1], Auber M.[1], Mokdad C.[1]

[1] University Hospital Rouen France

Compared to plasma energy ablation, cystectomy is responsible for a significant loss of ovarian parenchyma and a significant reduction in AFC.

To compare the loss of ovarian parenchyma following ovarian endometrioma ablation using plasma energy vs. cystectomy, using three-dimensional (3D) ultrasound.

This is a retrospective study on a series of patients presenting with a unilateral ovarian endometrioma >30 mm, free from prior ovarian surgery, who were managed by the same surgeon over two different periods of time.

From January 2008 till December 2009 every patient was treated by cystectomy using an ovarian tissue sparing technique. Ablation using plasma energy was carried out from January to November 2010 based on an original technique involving in most cases the ovarian cyst eversion. We measured the surface in longitudinal section, the volume and the number of antral follicles (AFC) of both ovaries during a post-operative ultrasound evaluation that was conducted 9 to 25 months after the cystectomy and 3 to 5 months after ablation.

Of the 151 women operated for ovarian endometriosis over the time periods mentioned earlier, 15 operated by cystectomy and 10 operated by ablation met the inclusion criteria and presented comparable preoperative characteristics. Women managed by cystectomy showed a statistically significant reduction of ovarian volume (0.005), ovarian surface (0.005) and CFA (<0.001) when compared to those operated by ablation using plasma energy. The multivariate analysis showed that the relationship between the change in ovarian parameters and the surgical technique was independent on confounding factors.

This results must be taken into account in the therapeutic decision for women attempting pregnancy, especially if there are other risk factors for ovarian failure postoperatively.

P.17.5

Prevalence and possible treatment modalities of lipomesosalpnix in infertility: a preliminary study

Darwish A. M.*[1]

[1] Woman’S Health University Center, Assiut University, Assiut, Egypt Assiut Ecuador

Lipomesosalpnix is a possible cause of infertility.

Objective: (a) To estimate the proportion of mesosalpngeal adipose tissue condensation (lipomesosalpnix) among infertile women subjected to diagnostic laparoscopy and (b) to test the feasibility and efficacy of some novel treatment modalities.

Design: (a) cross sectional and (b) longitudinal study.

Setting: A specialized endoscopic center.

Patient(s): All infertile women scheduled for diagnoastic/therapeutic laparoscopy during the period between July 1994 and August 2010 were included in this study.

Intervention(s): Preoperative transvaginal ultrasonography as well as BMI for all cases. Laparoscopic documentation of mesosalpingeal condensation of adipose tissue (a). Histopathologic assessment of the adipose tissues of some cases. Bipolar needle coagulation Vs injection of 5 mL of Dermastabilon into the lipomesosalpnix (b). MAIN OUTCOME MEASURE(S): (a) number of cases with unilateral or bilateral lipomesosalpnix and (b) complete disappearance of the mass on proper treatment on second look laparoscopy.

Results: Lipomesosalpnix was confirmed in 145 cases (5.7%) out of 2563 cases examined by laparoscopy. In all but 7 cases, lipomesososalpnix was diagnosed bilaterally (99.7%). There was insignificant correlation between those cases and high BMI when compared to the rest of cases. Infertility was unexplained by laparoscopy in 621 cases (24.3%) while laparoscopy diagnosed etiologic factors in 1942 (75.7%) cases. Lipomesosalpnix was seen in 46 (7.4%) and 79 (3.9%) of the unexplained cases and explained cases respectively without a statistically significant difference (P 0.48). Unexplained infertility cases (46 cases) were divided into two groups according to the treatment modality. Bipolar needle coagulation was performed in 29 cases while 5 mL of Dermastabilon was injected into the lipomesosalpnix in 17 cases. Spontaneous pregnancy was achieved in 4 cases with unexplained infertility within 6 months following bipolar coagulation of lipomesosalpnix. Second look laparoscopy was performed for few cases (ongoing part).

Conclusions: Despite being a rare laparoscopic finding, lipomesosalpnix should be reported and documented specially in cases with unexplained infertility. Whether to treat lipomesosalpnix or not and by which means require more studies with proper second look laparoscopy.

P.17.6

Safety for pregnant patients with acute appendicitis of laparoscopic appendectomy performed by an expert gynecologic laparoscopist

Kim N. H.*[1], Kim Y. H.[1], Lee S. Y.[2], Ju W.[1], Eom J. M.[3], Choi J. S.[3], Lee J. H.[3], Kim S. C.[1]

[1] Ewha Womans University, College Of Medicine Seoul Republic Of Korea- [2] Gwandong University Cheil Hospital Seoul Republic Of Korea- [3] Kangbuk Samsung Hospital, Sungkyunkwan University School Of Medicine Seoul Republic Of Korea

LA performed by an expert gynecologist can be a safe and effective method for treating acute appendicitis during the first and second trimester of pregnancy.

The aim of this study was to investigate the clinical efficacy and safety of LA during pregnancy by comparing the operative and obstetric outcomes of patients who during pregnancy underwent LA performed by an expert gynecologic laparoscopist (LA group) with those of patients underwent an open appendectomy (OA) by a general surgeon (OA group).

In this retrospective study, we evaluated all patients consecutively who had undergone appendectomy for acute appendicitis during pregnancy from January 2000 to December 2010. Twenty-eight patients underwent OA and 15 were treated by LA. We reviewed the clinical charts and analysed the data for each patient’s age, parity, body mass index, gestational age at appendectomy, type of appendectomy, operating time, hemoglobin change, hospital stay, histopathological results, postoperative analgesics, complications, and obstetric outcomes.

There were no significant differences between the OA and LA groups in terms of clinical characteristics, hospital stay, hemoglobin change, return of bowel activity, complication rates, gestational age at delivery, and birthweight. However, there were significantly shorter operating time and less usage of postoperative analgesics in LA group.

LA performed by an expert gynecologist can be a safe and effective method for treating acute appendicitis during the first and second trimester of pregnancy.

Session P.18

* Urogynaecology *

P.18.1

Do anatomical defects after immediate repair of obstetric anal sphincter injuries correlate with urinary and bowel symptoms?

Siddiqui J.*[1], Kanwar S.[1], Phillips K.[1], Duthie G.[1]

[1] Castlehill Hospital Hull United Kingdom

To correlate anatomical defects on endo-anal ultrasound after primary repair of obstetric anal sphincter injuries with urinary and bowel symptoms.

Women were assessed at three months following the primary repair of third and fourth degree tears between August 2008 and November 2009.

243 women sustained obstetric sphincter injuries (OASIS) in this time period. They were sent specific bowel and urinary symptom questionnaires and offered endo- anal ultrasound.

There were 7470 deliveries. 70% were normal deliveries, 5% forceps, 2% ventouse and 23% caesarean section.

Amongst the obstetric anal sphincter injuries, there was a 23% episiotomy rate, 17% forceps rate and a 2% ventouse rate. The incidence of OASIS was 3.2% of all deliveries and 4.2% of all vaginal deliveries. 7 had fourth degree tear and 110 had third degree tears. A sphincter defect was seen in 21 women (18%).

There was statistical significance between endo-anal defects and stress incontinence (p-0.026).

Primary surgical treatment of obstetric anal sphincter injuries is associated with severe bowel leakage symptoms in one in five women, and the development of urinary symptoms was statistically significant in the defect group. The development of bowel symptoms does not seem related to sphincter defect on ultrasound.

In our study, 17% of the obstetric sphincter injuries were delivered by forceps delivery compared to 2% delivered by ventouse. Neither was a statistically significant risk factor for OASIS. It may be that previous studies have overstated the risk factor of forceps delivery in obstetric anal sphincter injury.

The endo-anal ultrasound is useful investigation in this group of women as our study shows that the symptomatic women are not necessarily those with the defects.

P.18.2

Prevalence and perception of urinary problems among women with high BMI

Gupta A.[1], Hammonds H.*[1], Robati S.[1], Goodman J.[1]

[1] Maidstone Hospital U.K United Kingdom

Aim

1) To determine the prevalence of urinary problems in women with BMI >30.

2) To report these women’s perception of their symptoms and the effect of their weight.

Epidemiological studies document overweight and obesity as an important risk factor for urinary incontinence in women. There is now valid documentation for weight reduction as a treatment for urinary incontinence in this group of patients. (1).

Weight loss of between 5%–10% body weight was sufficient for significant urinary incontinence benefits. Thus, weight loss should be considered as an initial treatment for incontinence in overweight and obese women (2).

An anonymous questionnaire was distributed amongst members of Slimming World with BMI >30 in Maidstone (UK). A total of 150 women participated in this study.

52 women (34.6%) acknowledged that they had urinary symptoms; however, a further 47 women acknowledged urinary problems. Overall 97 (64.6%) women had urinary problems.

Of women questioned, 65 (43%) complained of stress incontinence, 47 (31%) complained of urgency and 41 (27.3%) had both.

Only 30/97 (31%) of women thought their urinary problems were weight-related. Nineteen (19.5%) women thought their problems had improved with weight reduction.

Our survey clearly suggests that there is a high prevalence of both stress and urge incontinence in overweight women. However, only a small percentage of these women were aware that this was weight related.

Education and motivating women to lose weight should be the first line of prevention and treatment of urinary symptoms in overweight women.

References

1) The impact of obesity on urinary incontinence symptoms, severity, urodynamic characteristics and quality of life. Richter HE et al. J Urol. 2010 Feb:183(2):427–9.

2) Improving urinary incontinence in overweight and obese women through modest weight loss. Wing RR et al. Obstet Gynecol 2010 Aug;116(2 Pt 1):284–92.

P.18.3

Tension free vaginal Tape—Abbrevo for treatment of stress urinary incontinence: preliminary results

Gauthaman N.[1], Karpouzis C.*[1], Papanikolaou K.[2], Attilia B.[1], Woldman S.[1], Patwardhan M.[1]

[1] Queen Elizabeth Hospital London United Kingdom - [2] Hammersmith Hospital London United Kingdom

Tension free Vaginal Tape (TVT)-Abbrevo is a refined transobturator tape procedure for treatment of stress urinary incontinence, which has been recently introduced in the UK. Studies have shown it to be as effective as the TVT-Obturator (TVT-O)tape with significantly less postoperative groin pain.

TVT- Abbrevo is a new refined obturator tape, which is shortened to 12 cm of prolene mesh. The tape requires less dissection than the traditional TVT-O procedure. It is reported to cause less pain in the immediate postoperative period and similar cure rates at one year when compared with the TVT-O procedure. The aim of this study is to assess the potential advantages of this new tape.

A retrospective study of 35 women suffering from Stress Urinary Incontinence (SUI) who underwent the TVT- abbrevo procedure from November 2010 to April 2011 at two centres were included in the study. The outcomes we looked at were the operative complications, recovery postoperatively, incidence of groin pain and resolution of symptoms at 6 weeks check in the clinic 35 patients who underwent the procedure were followed up retrospectively. No intraoperative complications were recorded. All patients went home on the same day of the procedure with minimum analgesia. At 6 weeks follow up one patient did not have resolution of symptoms and 2 patients reported urinary urgency symptoms. None reported groin pain or discomfort at 6 week follow up.

TVT-Abbrevo insertion requires less dissection and the shorter length of the tape ensures less postoperative pain. It is reported in the literature that the TVT—Abbrevo tape procedure appears to be efficient and safe as the original technique with less postoperative groin pain. In our study of 35 patients none reported groin pain postoperatively. However, long-term follow up data is awaited.

P.18.4

The outcome of the transobturator tape (TOT) procedure during the follow-up of 6.5 years

Heinonen P.*[1], Ala-nissilä S.[2], Laurikainen E.[2], Räty R.[3], Kiilholma P.[1]

[1] Turku University Turku Finland - [2] Turku University Hospital Turku Finland - [3] Lohja Hospital Lohja Finland

The transobturator tape is effective and safe after 6.5 years follow-up.

The aim of our follow-up study is to report the subjective and objective outcome of outside-in transobturator technique (TOT) (Monarc®) in long-term follow-up.

This is a follow-up study concerning 191 patients operated on in Turku University Hospital between May 2003 and December 2004 by using TOT. SUI was diagnosed with a positive stress test, the Urinary Incontinence Severity Score (UISS) and the Detrusor Instability Score (DIS). Of the patients 126 (66%) had SUI, 65 (34%) had MUI and 32 (17%) had recurrent incontinence. Eighty five (45%) patients underwent concomitant surgery. After a mean of 6.5 years evaluation included a gynecological examination and a supine stress test. Subjective outcome was evaluated with UISS, DIS, a visual analogue scale (VAS), a questionnaire of subjective evaluation of continence, EuroQoL-5D, EQ-5D VAS and short versions of IIQ-7 and UDI-6. Objective cure was defined as negative stress test and an absence of reoperation for SUI during the follow-up period.

A total of 138 (72%) of the 191 patients were evaluated. The mean age was 65 years and mean BMI was 28. The patients with BMI over 30 had significantly higher scores in IIQ-7, UDI-6, VAS, UIS and DISS. The satisfaction with the operation was similar in both groups. The subjective cure rate was 86% and objective cure rate was 84%. Twenty (15%) failures included 8 (6%) patients with subsequent TVT-procedure and 12 (9%) patients with positive stress test. Patients with MUI were less satisfied with the operation and had significantly higher scores in all questionnaires (p < 0.0001) than the patients with genuine SUI.

Regardless of the patients with MUI or BMI > 30 having weaker results the subjective and objective cure rates were maintained high over the follow-up period of 6.5 years.

P.18.5

The role of Gynemesh in vaginal mesh repair of anterior paravaginal genital prolapse defects

Singh R.*[1], Singh V. P.[2], Ravikanti L.[2]

[1] Palmerston North Hospital Palmerston North New Zealand - [2] Waikato Hospital Hamilton New Zealand

The use of prosthetics enables simultaneous repair of all anterior vaginal prolapse defects & faster & more precise surgery. Our technique is a quick, safe, reliable & less expensive than mesh systems & with fewer complications than most other techniques.

4–10% of women report prolapse but upto 50% of multiparous women are affected. Traditional repair has a 22–70% failure rate & distorts anatomy & function of the lower genital tract. Patients now have longer life spans, are increasingly aware of options available & have a greater expectation of return to good quality of life (QOL).

Retrospective analysis of 114 patients at Waikato Hospital, Hamilton, New Zealand. Single operator/supervisory surgeon & >6 month follow up. Subjective & objective results & changes in their QOL analysed. These were compared with international data.

95.6% of patients between 41–70 years of age. 22.8% of patients presented with stage 2, 68.4% with stage 3 and 7.9% with stage 4 prolapse. 36% had previous surgery, 28% had urinary stress incontinence (USI), 16.7% had urge symptoms, & 9.7% mixed urinary symptoms. 66.7% needed both ant & post mesh repair, 15.8% a Monarc sling in addition, while 14% needed only ant Gynemesh repair. Subjective cure rate:100%, Objective cure rate: 92%. 14 patients had denovo USI & were successfully treated. Complications were mostly transient & minor. These compare favourably with other teams worldwide.

The use of prosthetics enables simultaneous repair of all anterior vaginal defects of prolapse & concomitant surgery to be faster and more precise. Use of prosthesis have gained acceptance over time but challenges remain. Our technique is a quick, safe, reliable & less expensive than mesh systems & with fewer complications than most other techniques. Complications decreased as our skill & expertise improved. Patients had significant improvement in their QOL.

Authors’ Index

A

Abderrahim A. 312; 368

Abderraouf S. 312; 368

Abdulkadir L. 540

Abdullah Z. 264

Abdullahi N. 77

Abraão M. 42

Abramyan K. 81

Abreu R. 533

Abu Mussa A. 204

Abu-rafea B. 35; 91; 357; 523

Achard A. 460; 472

Achard J. 101

Acharya S. 151

Adedipe T. 126

Afifi Y. 159; 178; 188; 263

Afors K. 143; 145; 262

Aghajanyan H. 392; 394

Aguas F. 534

Ahmad G. 62

Ahmed S. 577; 581

Ahn J. 564

Ajay B. 457

Akira S. 523

Akladios C. Y. 97; 220

Al Chami A. 204

Al Farsi Y. 333

Al Hassan J. 204

Al Khaduri M. 224; 333

Al-amoosh H. 374

Alanbay I. 287

Ala-nissilä S. 596

Albis Florez E. D. 49; 114; 133; 146; 550

Alcocer J. 89; 183; 197; 253; 254; 258; 291; 355

Aldakhil L. 85

Aleksandrov O. 290; 448

Alexis B. 60

Alho C. 296; 386

Alkatout I. 150

Allam M. 375; 391

Almeida S. 478

Alobaid A. 85

Al-omari I. 331

Alves A. 184; 511

Amaral J. 176; 184

Amato N. A. 50

Amin T. 378

Amini L. 203

Amodeo M. 515

Anastasiu D. 231

Andou M. 45; 185; 196; 221; 228; 229; 250

Andreeva J. 235; 430

Andreou A. 207

Angelova M. 399; 422

Angioni S. 202; 343

Anschuetz J. 84

Antipov V. 499

Antosiak B. 102

Antsaklis A. 387; 502; 571

Antunes I. 544

Appleyard T. 574

Arambage K. 65; 455

Arduini D. 37; 396

Arena I. 343

Argade A. 556

Argade K. 532; 556

Argade M. 556

Argade R. 556

Arima H. 179; 446

Arjona Berral J. E. 277; 406; 414; 471

Armengol-debeir L. 349

Armitage R. 332

Arnanz F. 500

Aroso A. 470

Arriba T. 360; 443; 558

Arteiro D. 184; 280; 467; 477

Asada H. 179; 446

Assunção F. 470

Atalla R. 331

Athanasia P. 143

Athanasias P 145; 262; 303; 409

Athanasiou S. 387; 502; 571

Athanatos D. 86; 358

Attilia B. 260; 595

Auber M. 208; 347; 589

Aufenacker T. 323

Avgoustinakis E. 207

Awala A. 275

Aziz K. 267

Azzam A. 479

B

Babicheva I. 415

Bader G. 168; 395

Badwey A. 339

Baglioni A. 201

Baig M. K. 63

Bailey J. 40

Baiocco E. 562

Bajka M. 144

Balci O. 210

Ballard K. 139; 153

Ban Frangez H. 78

Banerjee C. 232

Banker M. 248

Bannier M. 138

Barabanova O. 415

Baracat E. 482; 538

Barahona M. A. 154

Barata S. 47; 296; 386

Barbieri F. 233

Bardis N. 180

Barreto S. 369

Barri-soldevila P. 212

Barri-soldevila P. N. 46

Baser I. 287

Basu S. 375

Batra S. 547

Baum S. 365

Baužyte E. 441

Bavananthan T. 373

Beckmann M. W. 64

Behrens R. 361

Ben Brahim F. 168

Ben Willem M. 516

Berkes E. 344

Bernabeu Cifuentes A. 309; 573

Bernad E. 231

Bernardo L. 42

Berner E. 68

Berton S. 93; 379

Beynon G. 227; 552

Bhalla R. 111

Bhaskaran L. 570

Bianchi S. 201

Bigatti G. 201

Bilalović N. 36

Billi H. 358

Bimpa K. 282

Binda M. M. 147

Birch J. 351

Biscaia I. 276

Bjornsson S. 67

Blikkendaal M. 163; 321

Bogani G. 69

Boggs E. 193; 234

Bokor A. 344

Boldó A. 98

Boldó Rodá A. 217; 508

Bolis P. 69

Bongers M. 124; 429; 431; 484; 526; 572

Bonilla M. 291

Borgato S. 93; 379

Borghero A. 93

Boto T. 73

Botto I. 465; 466

Bouchra F. 312; 368

Bouhanna P. 395

Bourdel N. 101; 347

Bourlev V. 402

Boyd B. 519

Brandão M. 489; 522

Bratic D. 314

Breijer M. C. 497

Bridoux V. 52; 211; 326; 330; 349

Brierley G. 279

Brito A. 483

Broekmans F. 109; 140

Brolmann H. 118

Bruen E. 127

Bruen L. 336; 535

Bruni F. 48; 59; 345

Bruni L. 215

Budikina T. 401

Bulzomi V. 427

Burden C. 574

Buss J. 192

Buttarelli M. 138

Butureanu S. 411

Byrne D. 161; 177; 182; 362

Byrne H. 262

C

Caballero V. 515

Caggiano F. 294; 407

Cajal Lostao R. 503

Cajal R. 492

Calhaz-jorge C. 296; 386

Camara O. 84; 106; 300; 334; 442

Cameron M. 41

Cammareri G. 79; 107; 135; 432; 440; 485

Campo R. 53; 405

Campos R. 121

Candelori E. 462

Candiani M. 328; 337; 536

Canis M. 101

Cannone F. 138

Çapar M. 173; 190; 210; 219; 222

Capobianco A. 337

Caputo A. 50

Cardona M. 528

Carinhas M. J. 489; 522

Carmona F. 528; 555

Carnide C. 459; 533

Carpenter T. 139

Carranza Martínez J. M. 213

Carreras R. 308

Carri G. 49; 114; 133; 146; 550

Carvajal A. 319

Carvalho J. 273

Casado Fariñas I. 490; 494

Casarin J. 69

Casorelli A. 147

Casper R. 357

Castellacci E. 307; 389; 520

Castelli A. 82; 412; 421

Ceccaroni M. 48; 59; 345

Cerda S. 319

Chalvatzas N. 286; 504

Chandrasena A. 418

Chappatte O. 569

Charalampos K. 260

Charnock M. 218

Chatterjee J. 583

Chatzipapas I. 387; 502

Chatzirafail V. 240

Chauvet-degot M. 194

Chechneva M. 81; 401

Chen Y. 100

Cheong Y. 40; 413

Chilcott I. 378

Chipeta H. 582

Cho H. 364; 444; 564

Choi J. 563

Choi J. S. 591

Choi Y. 563

Christie J. 267

Chugunova N. 33

Chykyda H. 382

Cimino M. 562

Cinque B. 427

Cirillo F. 79; 107; 135; 440; 485

Clarizia R. 48; 59; 345

Cleveland G. 404

Coelho F. 470

Cofelice V. 49; 114; 133; 146; 550

Cohen S. 43

Çoksuer H. 287

Condeco R. 369

Conforti A. 294

Connell R. 302

Connor M. 530

Coolen A. 124; 484

Coppola A. 427

Corbett B. 37

Corona R. 94; 147; 433; 434

Corrado G. 562

Correia L. 276

Cosmi E. 93; 379

Costa A. R. 176

Costa D. 408

Couso A. 492

Craessaerts M. 94; 434

Craig E. 164; 561

Craina M. 231

Creassaerts M. 433

Crispi C. 478

Cromi A. 69

Crouch N. 378

Cubal A. 273

Cubal_ R. 283

Cunha A. L. 280

Cunliffe J. 403

Curi Lehmann M. L. 460; 472

Cusido M. 292

Cusidó M. 212

Cusidó M. T. 46

Cutner A. 517

Cvjeticanin B. 493

D

Da Costa C. 326

Dacco M. 104

Dacco M. D. 123; 165

Dacco’ M. D. 108; 162; 464

Dada T. 279; 452

Dadi H. 57

Dae-yeon K. 566; 567

D’agostino G. 93

Damasceno Costa J. 461; 468

Darwish A. M. 590

Darwish A. M. M. 480

Datta M. 269

Dauplat J. 101

Dautun D. 97

Davey M. 545

Davies M. 547

Davis N. 123

Dawood R. 452

De Andrés Cara M. 277

De Bruin A. 329

De Lange M. 159; 178; 263

De Marzi P. 536

De Placido G. 48; 59; 294; 345; 407

De Valle Corredor C. 488; 501; 512; 543

Declerck S. 94; 433; 434

Del Corso A. 50

Delgado Espeja J. J. 454; 456; 469

Delgado J. J. 284

Demidova L. 499

Deo N. 157; 570

Dessole M. 202; 343

Devlin K. 375

Dewilde R. 42

Deyl R. 297

Di Francesco S. 79; 107; 135; 432; 440

Di Giovanni A. 396

Di Luzio F. 427

Di Pietro C. 427

Di Puppo F. 328; 337

Diamanti K. 186

Dibi R. 478

Diebolder H. 84; 106; 300; 334; 442

Dighe V. 332

Dijkhuizen P. 323

Dimitriou E. 180

Dinsdale M. 111

Disu S. 275

Djakonovic Maravic M. 324

Dobychina A. 235; 430

Dokic M. 314; 324

Dokmeci F. 289

Domingo Del Pozo S. 217; 508

Domingo S. 98

Dorner C. 578

Dorogaya E. 560

Dowaji J. 450

Drampyan A. 340

Dresner M. 372

Dubinskaya E. 402; 415

Dubuisson J. 192; 226; 242; 311; 437

Dueholm M. 75

Duffy J. M. 62

Duthie G. 593

Dzhupin V. 447

E

Eberhard M. 192

Edwards J. 584

Eijkemans R. 109

Einarsson J. I. 199; 237; 245; 247

Ejzemberg D. 482; 538

El Kassar Y. 335

Elkington N. 549; 552

Elsapagh K. 375

El-tawab S. 128

Emanuel M. 124; 484

Emanuel M. H. 74; 540

Enekwe A. 288

English J. 38; 63; 175

Eom J. M. 591

Eperon I. 311; 437

Erdemir R. 142

Erian J. 56

Eshraga F. 77

Esposito A. 346

Esteve M. D. L. C. 501

Estevez M. 496

Eun D. 563

Evelyne M. 156; 241

Exacoustos C. 37; 396

Exalto N. 74

Expósito Lucena Y. 487; 491

F

Fabris A. 379

Facey L. 373

Faik S. 269

Faiza Y. 473

Fakulujo O. 529

Fan Y. 283

Farooq H. 371

Farthing A. 583

Fasching P. 64

Fatemi H. 109

Faticato A. 50

Fauconnier A. 168; 395

Fauser B. 109

Fedorov A. 51; 81; 401

Fehr P. M. 192

Fernandes S. 465; 466

Fernando L. 308

Ferrari S. 328; 337

Ferrario C. 201

Ferrazzi E. 107; 135; 432; 485

Ferrazzi E. M. 79; 440

Ferreira C. 408; 461; 468

Ferreira H. 511

Ferreira S. 184

Ferreira_ H. 283

Fiaccavento A. 50; 233

Figueiredo O. 273

Finall A. 127

Fiore E. 294; 407

Flanagan V. 67

Florin Andrei T. 363

Florio P. 49

Formenti G. 69

Fornelos G. 121

Frappell J. 160

Frigo S. 172

Fritz J. 377; 518

Fuentes Castro P. 488; 503; 512; 543

Fuentes P. 500

Fukuoka K. 272

Funlayo O. 570

Furuya M. 179; 446

Fuster Rojas S. I. 217; 508

Fuster S. 98

G

Gaber M. 159

Gabriel B. 47; 261

Gahler M. 163

Gallagher B. 367

Gallego P. 494

Gallego Pastor E. 491

Galli L. 243; 554

Garavaglia E. 328; 337

Garbayo P. 492

Garbayo Sesma P. 512

Garbin O. 172; 191; 194

Garbuzenko N. 420

Garcia Pineda V. 488; 501; 512; 543

Garcia Vidal E. 515

Garcia-erdeljan M. 35; 357

Garruto Campanile R. 218

Garvin G. 91

Gasparov A. 402; 415

Gassen D. 297

Gauthaman N. 595

Geense W. 323

Gennaro S. 268

Gentile C. 536

Georgiou N. 120

Geraldes F. 534

Gérard B. 516

Gergolet M. 405; 527

Germano G. 460; 472; 578

Ghaem-maghami S. 583

Gherpelli P. 482

Ghezzi F. 69

Ghim Poh P. 67

Ghosh D. 362

Ghulmiyyah L. 204

Giampaolino P. 48

Giannice R. 218

Giannone E. 462

Giannone L. 462

Giardina P. 337; 536

Giatrakou M. 134

Gil Raga F. J. 309; 573

Gimeno Aranguez M. M. 494

Giné L. 154

Giunta G. 49; 114; 133; 146; 550

Gkrozou F. 120

Gladchuk I. 66; 419

Glavan S. 438

Godinjak Z. 36

Golash A. 198

Goldenberg_ M. 43

Golovin A. 401

Gómez - Arrue Azpiazu J. 213

Gonçalves A. 544

González Alastuey P. 213

Gonzalez Gea L. 488; 501; 503; 512; 543

Gonzalez J. 284

González Pastor C. 213

Gonzalez Paz C. 487; 505

González Ramos P. 213

Goodman J. 594

Gordts S. 53

Gorduza V. 281

Gorostiaga A. 360; 443; 558

Goss Nielsen G. 352

Gossage K. 547

Gourcerol G. 330; 349

Gracia M. 528; 555

Graf P. 514

Granata M. 294; 407

Gray T. G. 129

Graziosi P. 34

Greco P. 268

Gregoriou O. 119; 539

Griffiths A. 127

Grigore M. 281

Grigoriadis C. 119; 539

Gubbala P. K.510

Guerra T. 32

Güler A. E. 287

Gulumser C. 122

Günthert A. 192; 565

Gupta A. 302; 594

Gurrea M. 98

Gurrea Soteras M. 508

Gusnyan V. 301

Guzman M. 496; 500

Guzman Muñoz M. 454; 503

Guzmán Muñoz M. 456; 469

Guzmann D. 365

H

Häberlin F. 587

Hada T. 45; 185; 196; 221; 228; 229; 250

Haimovich S. 308

Hamerlyck T. W. O. 540

Hamid A. 312; 368

Hammonds H. 302; 594

Hansen E. S. 75

Hapuarachi S. 331

Hardwick C. 67

Harrity C. 577; 581

Hartmann B. 131

Harvey J. 351

Hassan A. 549

Hassanov A. 586

Hatzipappas I. 571

Hawthorn R. 67

Hayes K. 409

Heckel S. 531

Heinonen P. 596

Heinonen P. K. 445

Herman M. 429; 431; 526

Herman M. C. 497

Hermans R. 99

Hernández Aguado J. J. 505; 507

Heron Iglesias S. 454; 456; 469; 488; 503

Heron S. 496; 500

Herter L. 297

Hidalgo G. 319

Hiemstra E. 141

Hill N. 56

Hill S. 127; 535

Hindley J. 575

Ho H. 523

Hoffman J. 396

Hohl M. K. 192

Holloway D. 453; 481

Holthaus B. 426

Holvey N. 332

Hooker A. 118

Hornung R. 587

Hough J. 351

Houterman S. 526

Houvenaeghel G. 138

Huchon C. 168

Hudelist G. 38; 63

Hudgens J. 255

Hugo V. E. 110

Huirne J. 118

Hunter D. 476; 580

Hussain S. 455

I

Iarotska I. 560

Iarotskyi M. 560

Ibarrola R. 558

Idrizbegović E. 36

Iefimenko A. 410; 416; 560

Immerzeel P. 132

Inat Çapkin S. 417

Ind T. 137; 145; 303; 352; 510

Ind T. E. 143

Ind T. E. J. 542

Ioffe O. 560

Istre O. 70; 112; 181

Ito K. 179; 446

J

Jadoon B. 513

Jaenicke F. 450

Jagasia N. 41

Jakimovska M. 493

Jaluvkova Z. 514

Jamieson R. 155

Jänsch K. 288

Janse J. 140

Jansen F. W. 141; 152; 163; 321

Jardon K. 101

Jean-christophe N. 60

Jeon S. 383

Jeong-yeol P. 566; 567

Ji E. 498

Jido T. 475

Jihad D. 377; 518

Jones B. 57

Jones R. 227

Jones S. .. E. 126

Jong-hyeok K. 566; 567

Joo-hyun N. 566; 567

Jou P. 528

Jourdan I. 230; 236

Ju D. 559

Ju W. 591

Jung B. 563

Justin W. 187

K

Kadieva E. 499

Kalampokas T. 119

Kanao H. 45

Kang S. 509

Kanwar S. 593

Kapoor D. 55

Kar A. 545

Karamshi M. 123

Karatayli R. 210

Karavida A. 207

Karayalçin R. 417

Karima F. 312; 368

Karnad R. 279

Karpouzis C. 595

Kasius J. 109

Katharina R. 363

Kato S. 478

Katsanikos S. 282

Kaufman Y. 88

Kaushik S. 137; 143; 145; 352

Kavallaris A. 103; 286; 504

Kavvadias B. 120

Kayani S. 54; 374; 382; 385

Kazuo M. 322

Keckstein J. 38

Keedwell R. 161

Kehoe S. 513

Kenda Šuster N. 405; 527

Kent A. 54; 230; 236; 367

Keskin U. 287

Khachaturyan M. 340

Khalil A. 361

Khan R. 111

Khazali S. 139

Kiilholma P. 596

Kim K. S. 304

Kim N. H. 298; 591

Kim S. 304

Kim S. C. 591

Kim Y. H. 591

Kishi I. 179; 446

Klat J. 514

Klein O. 88

Klimanov A. 301

Klyucharov I. 265; 404; 586

Kobal B. 493

Kobiki K. 179; 446

Kocbulut E. 289

Koehler A. 334

Kolesnik N. 81; 401

Kolhe S. 315

Kondi-pafiti A. 119

Kondrup J. 206; 209; 223; 256; 257

Koninckx P. R. 94; 147; 433; 434

Korakianitis E. 91

Kosey N. 447; 449

Koster G. 413

Kostov P. 200; 565

Kothari A. 378

Kots L. A. 249; 551

Koutroumanis P. 571

Kovaleva M. 33

Kovoor E. 569

Kozak R. 91

Kozhakov V. 66

Kraft O. 514

Krasnopol’skaya I. 51

Krasnopol’skaya K. 51

Krasnopolskaya I. 81

Krasnoposkaya I. 401

Krishna A. 352

Krishnamurthy G. 104; 108; 162; 165; 464

Krishnamurthy G. B. 123

Kroese A. 572

Kruitwagen R. 526

Krygowska J. 390

Kunde K. 371

Kuropatkinaite I. 441

Kwack H. 498

Kwiatkowsski F. 101

Kwon Y. 564

Kyriajos P. 260

Kyula J. 474

L

La Chapelle C. 152

Laiyemo R. 271; 463

Laiyemo R. O. 126

Lambaudie E. 138

Landi S. 233

Lanhoso A. 176; 184

Lannino G. 407

Lanz C. 578

Lanz S. 565

Lanzani C. 79; 107; 432; 440; 485

Lara Alvarez M. A. 494; 507

Larrain D. 101

Lasmar B. 39

Lasmar R. 39

Laurikainen E. 596

Lavasidis L. 120

Lawin-o’brien A. 570

Lawther R. 164

Lazar R. 281

Le Bouedec G. 101

Leah M. 476

Leather A. 73

Ledger V. 413

Lee H. 559

Lee J. H. 591

Lee K. 383

Lee S. 546; 559; 564

Lee S. Y. 591

Lee T. S. 304

Lefebvre G. 193

Legit C. 371

Leitão C. 369

Leitão S. 176; 184

Leitch-devlin L. 455

Lelli F. 215

Leo L. 243; 554

Leon M. 516

Lermann J. 64

Leroy J. 342

Levy B. 166

Liang Z. 100

Liappi A. 571

Lieng M. 68

Liew Y. E. 266

Lim M. C. 509

Lim S. 383

Linder A. 458

Lindsay P. 127

Lino C. 470

Lissak A. 88

Litta P. 93; 379

Littlechild S. 111

Liu Q. 61

Ljubic A. 324

Llantrisant.. 306

Lo J. 63

Lodovico P. 562

Logutova L. 81

Lokman M. 188

Lopes C. 511

Lord J. 187

Lorente González J. 277; 406

Lorente Ramos R. 490; 491

Lotfallah H. 318

Lou Mercadé A. C. 213

Louden K. 361

Lourenço C. 283

Loutradis D. 387; 502

Lu D. 61

Luchini S. 536

Luciano A. 37

Luciano D. 37; 396

Lucky S. 266

Ludwig B. 334

Lukovich P. 344

Lundorf E. 75

Lundorff P. 381

Lunko T. 290

Lupascu I. 281

Luyer M. 99

M

Macaes A. 534

Macalli E. 107; 432

Macalli E. A. 79; 440

Macdonald N. 517

Macdougall N. J. J. 267

Machado A. I. 276

Maciolek-blewniewska G. 102

Macnab W. 473

Magalhães J. 280

Mage G. 101

Magos A. 104; 108; 123; 162; 165; 464

Maher P. 41

Maher_ N. 519

Mahmoud A. 210

Maia S. 89; 197; 253; 254; 258; 342; 355; 425; 428; 533

Majchrzak D. 102

Majmudar T. 473; 495

Majumder K. 73; 458

Mak F. K. 176

Makedos A. 186

Malafaia S. 121

Malcolm C. 391

Malheiro L. 280

Malhotra A. 187

Malinowski A. 102

Mañalic L. 32

Manannikova T. 51; 81; 401

Mancebo G. 308

Mancini E. 562

Manukyan Z. 340

Maricic Z. 314

Maricosu G. 202; 343

Marinakis G. 367

Marino G. 346

Marinovskij E. 75

Marks J. 357; 523

Markus W. 363

Marpeau L. 211; 326; 330; 341; 349

Marques A. 465; 466

Marques C. 276; 544

Marta G. 284

Martí L. 154

Martin Marino A. 491; 505

Martinez De Oliveira J. 483

Martinez Gomez E. 492; 496; 500

Martínez Lamela E. 487; 490; 491; 494; 505; 507

Martinez M. A. 555

Martinez N. 492

Martínez N. 496

Martinez Parrondo N. 454; 456; 469; 503

Martinho M. 280; 467; 477

Martins F. N. 408

Marujo A. 276

Matanhelia M. 542

Mathiasen O. 75

Mathiopoulos D. 134

Maydanovych S. 579

Mccarthy L. 372

Mccomiskey M. 580

Mcdermott C. 193

Mcdermott L. 574

Mcilwaine K. 41

Mcmurray D. 375

Mecejus G. 441

Meier G. 239

Meier R. M. 319

Meireles I. 273

Melis G. 202; 343

Melis M. 343

Mencaglia L. 49; 114; 133; 146; 202; 550

Menéndez J. M. 284

Mengerink B. 366

Menninger I. 561

Mereu L. 49; 114; 133; 146; 202; 550

Mettler L. 150

Meyer F. 483

Meyer J. W. 483

Mezzi G. 328

Mgaloblishvili I. 270

Mgaloblishvili M. B. 270

Michael V. 110

Michalak S. 390

Michel V. 138

Michels W. 334

Michot F. 211

Mikos T. 207

Milagre M. 297

Miles A. 63

Minelli L. 48; 59; 345

Mira R. 369

Miranda C. 319

Miranda L. 578

Miranda-mendoza I. 319

Misiaka D. 186

Miskin A. 532; 556

Miskin R. 556

Misra G. 198

Mitsis T. 240

Mittal A. 175

Mohamed E. 77

Mohan M. 278

Mohan S. 378

Mohr S. 192

Moiety F. 479

Mokdad C. 347; 589

Mol B. 109; 429; 431

Mol B. W. 526

Molero Vílchez J. 487; 490; 491; 494; 505; 507

Møller C. 75

Mollo A. 294; 407

Moloney S. 117

Momen A. 85

Monod P. 156; 241

Monserrat Jordán J. A. 406; 471

Monserrat Jordán J. Á. 414

Moohan J. 164; 561

Moon H. 298

Moors A. 139; 545

Moraloglu Ö. 417

Moreira A. 477

Moreira C. 459; 533

Moreira M. 459; 533

Morelli M. 403

Morgado P. 176

Moro Martin M. T. 490

Morris E. 160

Moszynski R. 390

Mothes A. 84; 106; 300; 442

Mousiolis A. 387; 502; 571

Moustafa K. 116

Moustafa M. 104; 108; 123; 162; 165; 464

Moutinho J. F. 483

Mpalas C. 120

Mpalinakos P. 180

Mudan S. 262

Mueller M. 200; 565

Mueller M. D. 192

Muet F. 156; 241

Munro M. 166

Munshi S. 248

Murwan O. 77

My V. 462

N

Nabag W. 77

Nagako S. 322

Nakazawa A. 272

Nalawade A. 153

Nama V. 137; 143; 145; 542

Nappi L. 268

Narang L. 72

Nassif J. 47; 204; 261

Navarro Campoy C. 309; 573

Neis F. 288

Nellore V. 67

Ness J. 330

Neukomm C. 200

Neumann O. 411

Neves J. P. 467; 477

Newman T. 40

Nicholls R. 529

Nieto A. 284

Nitu R. 231

Nivedita G. 260

Nnochiri A. 264

Nobuya T. 322

Noe G. 232

Nogueira Martins F. 461; 468

Nohovska I. 410; 416

Nonell R. 528

Novikova E. 499

Ntinou Z. 186

Nunes C. 273

Nupieri I. 243; 554

Nyirady P. 344

O

O Flynn H. 62

O’ Neill A. 519

Oboh A. 376; 380

O’brien P. 267

Obura Y. 413

Odejinimi F. 65

Odejinmi F. 157; 293; 423

Odejinmi J. 403

O’donovan J. 295; 557

O’donovan O. 295; 557

Odukoya S. 269

Ofuasia E. 72

Ohta Y. 185; 196; 228; 250

Oji V. C. 275

Okamura T. 272

Olaitan A. 517

Oliveira C. 184; 273

Oliveira M. 459; 533

Oliveira P. 176

Oliveira T. 489; 522

Olowu O. 157; 293; 423

Omanwa K. 385

Oppelt P. 64

Ø

Ørtoft G. 75

O

Osorio F. 261; 296

Osório F. 386

Ostrovsky L. 88

O’sullivan R. 577; 581

Ota I. 45

Ota Y. 45; 229

Ouhtit A. 333

Owien G. 305; 306

Özcan S. 417

Öztürk M. 287

Özyer S. 417

Ozyurek E. 142

P

Pados G. 86; 186; 358

Paim C. 297

Palmer E. 122

Panayotidis C. 177; 182

Pandey S. 218

Pandravada A. 151

Panevska-gareva M. 399; 422

Pansini-murrell J. 299

Papadakis E. 119; 539

Papanikolaou K. 595

Paredes Rios A. 309; 573

Park C. 383

Park D. 498

Park H. 383

Park J. 563

Park S. 509

Parker S. 122

Paschopoulos M. 120

Pascual M. A. 46; 292

Pasic R. 255

Pastor Oliver C. 213

Patel P. 248

Pathak M. 122

Pathiraja P. 218; 510

Patrikios A. 387; 502

Patwardhan M. 260; 595

Patwardhen A. 127

Pedersen L. K. 75

Peggy G. 516

Pellicer A. 98

Pellicer Martínez A. 217; 508

Penketh R. 127; 336; 535

Pennington S. 530

Penninx J. 429; 431; 526

Pereira A. K. C. 482; 538

Pereira A. P. 544

Perez A. 292

Perfilev A. 51

Perkins R. 552

Perovic M. 569

Persico P. 328; 337; 536

Pessini S. 297; 478; 521

Peter I. 110

Petrakis P. 104; 108; 123; 162; 165; 464

Petronijevic M. 314

Petrovskiy Y. 66

Phillips K. 62; 579; 593

Piazza A. M. 82; 412; 421

Pigne A. 168

Pijnenborg J. 366

Pijnenborg J. M. 497

Pina C. 176

Pinheiro W. 482; 538

Pinho F. 538

Pinto E. 176; 184

Pipa A. 408; 461; 468

Pirarba S. 343

Pistofidis G. 180

Pizov R. 88

Pla M. J. 154

Plant A. 413

Plekhanov A. 588

Pomel C. 101

Ponce J. 154

Pontis A. 146; 202

Popov A. 51; 81; 401

Popova L. 448

Popovici D. 411

Porter S. 356

Postle T. 413

Povedano Cañizares B. 277; 406; 414; 471

Powell M. 55; 315; 418

Prasciolu C. 49; 114; 133; 146; 550

Prendiville W. 577; 581

Prietzel-meyer N. 137; 352

Pringle S. 67

Priyanka S. 495

Protopapas A. 387; 502; 571

Psychoulis M. 409

Puchkov K. 235; 430

Puga M. 319

Puig O. 32

Puttemans P. 53

Q

Quílez J. C. 360; 443; 558

Qvigstad E. 68

R

Rabischong B. 101

Radojicic V. 31

Radosa J. 365

Radosa M. 84; 106; 300; 334; 365; 442

Rae D. 151

Ragavan M. 111

Rajesh S. 356

Ralf R. 363

Ramazanov M. 51; 81; 401

Rao R. 117

Raposo L. 408; 461; 468

Rasteiro C. 273

Ratnavelu N. 375

Rato I. 296; 386

Ratti M. 485

Räty R. 596

Ravikanti L. 354; 597

Rawal N. 579

Raychaudhuri R. 129

Raza A. 576

Readman E. 41

Rebelo C. 121

Redondo C. 253

Rego J. 465; 466; 534

Rehman S. 79; 107; 432; 440

Reis P. 283; 489; 522

Renner S. 64

Reus E. 577; 581

Rhemrev J. 163

Ribeiro F. 544

Ribic-pucelj M. 438

Ricardo L. 42

Ricci M. D. 482

Richardson R. 576

Richter G. 457

Rieck G. 529

Rigo J. J. 344

Ríos Castillo J. E. 414

Riris S. 517

Rivera Garcia M. T. 487

Rivera Garcia T. 507

Rix S. 64

Robati S. 302; 594

Robarts P. J. 537

Roberts R. 267; 306

Rockall T. 230; 236

Rodeck C. 95

Rodrigo K. 455

Rodrigues G. 296; 386

Rodrigues M. 121

Rodriguez B. 515

Rodríguez E. 98

Rodriguez Garnica D. 501; 512

Rodriguez Garnica M. D. 488; 543

Rodriguez I. 46; 292

Rodriguez N. 212

Rodríguez Tárrega E. 217; 508

Rogachevs’kyy O. 419

Rogerson L. 372

Roh H. 564

Roig Casaban N. 309; 573

Rollo D. 135

Romaguera E. 98

Roman H. 52; 208; 211; 244; 326; 330; 341; 347; 349; 589

Rombaut S. 212

Romeo V. 37

Romo J. M. 515

Rosales M. 201

Rosen D. 320

Roshdi H. 506

Rossetti A. 195; 252

Rota G. 346

Rotaru C. 411

Rothmund R. 288

Roussos D. 86

Rovere-querini P. 337

Roviglione G. 48; 59; 345

Rovio P. 445

Roy K. 516

Roy S. N. 153

Rozhkovska N. 66

Rubal A. 460; 472

Ruffo G. 48; 59; 345

Ruggiero A. 195; 252

Ruhe I. 124; 484

Ruivo P. 465; 466

Rui-wamba M. J. 360; 443; 558

Runnebaum B. 84

Runnebaum I. 106; 300; 334; 442

Ryabinin G. 588

Ryu K. 498

Rzyska E. 303

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S R. 305

Sabouni M. 457

Sabourin J. 347

Sabrià E. 154

Saccardi C. 93; 379

Sadek K. 40

Safina V. 265

Sahu B. 55

Said T. H. 335; 353

Sajdak S. 390

Salazar Arquero F. J. 507

Salazar I. 515

Saleh S. 475

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Salwa E. 77

Samigullova A. 265; 586

Sancho Garcia S. 487

Sankaran S. 403

Santos J. 489; 522

Santos M. 465; 466; 534

Santos Paulo A. 461; 468

Sara B. 363

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Sarlos D. 239; 246; 249; 551

Sarmiento L. 555

Saska G. 60

Saso S. 583

Sastry A. J. 155

Satkunaratnam A. 234

Satomi S. 322

Savoye G. 330; 349

Savoye-collet C. 326

Sawalhe P. S. 170

Sawsane E. H. 368

Sayed E. H. 480

Schär G. 239; 246; 249; 551

Scheele F. 118

Schiff E. 43

Schollmeyer T. 150

Schoot B. C. 540

Schoot D. 99

Schreuder H. 140; 141

Scozzaro A. 82; 412; 421

Scripcaru D. 281

Seed P. 371

Seidman D. 43

Semple C. 164

Seo S. 509

Serebryanskiy O. 235; 430

Sereno P. 276

Serra C. 308

Serrano R. 515

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Shacaluga A. 336

Shahid A. 122; 157; 570

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Shankar L. R. 305; 306

Shaparnev A. 87; 169; 397

Sharma S. 278

Shawki O. 224

Shepherd J. 137

Shevchenko O. 285; 410; 416

Shevchuk A. 499

Shi G. 61

Shin J. 310

Shin K. 563

Shnaider I. 88

Shreeve N. 40

Siddiqui J. 593

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Silveira G. P. G. 521

Simetka O. 514

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Simón M. 292

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Singh R. 73; 178; 263; 354; 458; 597

Singh V. P. 354; 597

Sinha D. 373

Sioutas A. 282

Sisó C. 555

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Soares Junior J. M. 482

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Socolov D. 411

Socolov R. 411

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Solomayer E. 365

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Sommella C. 215

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Spiel M. 396

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Stefano S. 562

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Stiggelbout A. 141

Stochino Loi E. 343

Stocker M. 575

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Suarez E. 32

Suaud O. 326

Suchetha M. 474

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Surico D. 243; 554

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Swingler R. J. 267

Syed Hashim S. 318

Szpurek D. 390

Szubert S. 390

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Takashi K. 322

Tanaka S. 272

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Tang T. 400; 582

Tarasyuk T. 560

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Taskin S. 289

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Ter Haar J. 366

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Thomas A. 38

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Timmerman D. 433

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Timmermans A. 497

Tinelli A. 38

Tolikas A. 282

Tomazevic T. 78

Toub D. 76; 572

Townsend P. 457

Tozzi R. 218

Trehan A. 57

Treharne A. 148

Triaca L. 460; 472

Trinick S. 129

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Trofimenko I. 397

Trompoukis P. 47; 261

Trovão A. 176

Tsakos E. 282

Tselos E. 317; 350

Tsiaousi I. 134

Tsimpanakos I. 104; 108; 123; 162; 165; 464

Tsivyan B. 87; 169; 397

Tsolakidis D. 86; 358

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Tuech J. 52; 211; 326; 330; 341; 349

Tugushev M. 301

Turkgeldi E. 517

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Tutchenko T. 447; 449

Twijnstra A. 321

Tzitzimikas S. 207

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Uccella S. 69

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Uhl B. 288

Umranikar S. 545

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Ustinova E. 265

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Valkenburg M. 53

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Van Der Wurff A. 366

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Vanacker B. 434

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Vargas D. 578

Varma R. 76

Vasilchenko L. 449

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Vautravers A. 191

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Vega Omen O. 217

Velasco Sanchez E. 406; 471

Velasco Sánchez E. 277; 414

Vellacott I. 332

Venetis C. 86

Ventura N. 587

Verguts J. 94; 147; 433; 434

Vesely M. 262

Vidakovic S. 324

Viganò P. 328

Vigone A. 243; 554

Villegas I. 360; 443; 558

Vilos A. 35; 91; 357; 523

Vilos G. 35; 91; 357; 523

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Vincent A. 60

Vindla S. 117

Visotsky M. 370

Visser N. C. 497

Vizza E. 562

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Vleugels M. 132; 166; 435

Vrekoussis T. 120

Vrzic-petronijevic S. 314

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Wachter M. 131

Walsh T. 519

Walton K. 510

Waters N. 367

Watson A. 62

Watson N. 378

Wattiez A. 47; 89; 97; 183; 191; 194; 197; 220; 253; 254; 258; 261; 291; 342; 355; 425; 428

Weisheit A. 442

Wenger J. 192

Wetter P. 92

Whitlow B. 317; 350

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Wolfram R. 172

Wong M. 455

Wong S. 474

Wrynn A. 519

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Xia E. 130; 525

Xu H. 100

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Yao S. Z. 80

Yap J. 159

Yaron M. 437

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Yeoh L. S. 153

Yevdokymova V. 274

Yi S. 559

Yong-man K. 566; 567

Yoo H. J. 509

Yoshiaki O. 221

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Young S. 160

Young-tak K. 566; 567

Yuko T. 322

Yu-ran P. 566; 567

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Zampogna G. 79; 135; 440; 485

Zapico A. 284; 492; 496; 500

Zapico Goñi A. 454; 456; 469; 488; 501; 503; 512; 543

Zaragoza M. 351

Zemskov Y. 51; 81

Zhegulovich Y. 410; 416

Zhou C. 396

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Zygouris D. 103; 286; 504

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Abstracts. Gynecol Surg 8 (Suppl 1), 1 (2011). https://doi.org/10.1007/s10397-011-0694-4

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