Abstracts of the 22nd Annual Congress of the European Society of Gynaecological Endoscopy (ESGE), 16–19 October 2013, Berlin

LAPAROSCOPIC TREATMENT OF THE PELVIC CONGESTION SYNDROME

Case reports

Video

Dimitri Sarlos*, Kots LaVonne , Magg Heimo, Gabriel Schär

Kantonsspital Aarau

Summary (4 lines): Catheter embolisation of the ovarian veins is most commonly performed for treatment of pelvic congestion syndrome. Laparoscopic ovarian vein ligation may offer a feasible alternative.

Introduction: Chronic pelvic pain combined with varicose ovarian veins is referred to as pelvic congestion syndrome. Often catheter embolisation of the ovarian veins is performed. Laparoscopic ovarian vein ligation also may be considered. A 36 year old patient presented with chronic lower abdominal pain and varicosis of the lower extremities after varicose vein surgery on both sides. MRI-phlebography showed an insufficient ovarian vein on the left side, to a lesser extent on the right side.

Material and Methods: Due to a general anxiety disorder transvenous coiling could not be considered, so a laparoscopic approach was performed. Our video shows the exposition of the ovarian veins up to their confluence with the left renal vein and the vena cava inferior respectively. Both vessels were ligated, including their inflows.

Results: No complications were experienced intra- and postoperatively. A follow up consultation 10 months later showed a significant improvement of the lower abdominal pain.

Discussion: Laparoscopic ovarian vein ligation is a yet rarely performed alternative for treatment of the pelvic congestion syndrome, if catheter embolisation is not feasible. There are not enough data to conclude on any long term results.

A NEW INTRAUTERINE ANCHORING TECHNIQUE FOR THE DELIVERY OF BIOACTIVE SUBSTANCES

Innovation in Instrumentation and Surgical Techniques

Oral

Dirk Wildemeersch*

GYNECOLOGICAL OUTPATIENT CLINIC AND IUD TRAINING C

Summary (4 lines): A novel technique for the anchoring of bioactive substances in the uterus was developed and tested for contraception and treatment of various gynecological conditions. Clinical trials suggest the high potential of the various precision intrauterine systems for use in clinical practice.

Introduction: New developments in the field of intrauterine drug delivery have the potential to challenge the oral contraceptive pill and revolutionize the use of intrauterine devices for contraception and treatment. As in other fields of medicine, precision devices and target delivery could offer significant advantages over conventional systemic or local administration of drugs. Over the years, our group tested various anchoring systems for precision long-term intrauterine contraception and treatment of various gynecological conditions.

Material and Methods: The report is based on international, multicenter clinical experience with novel anchoring technologies for long-term contraception and for the treatment of various gynecological disorders (eg, heavy menstrual bleeding, treatment of atypical hyperplasia and early endometrial cancer, dysmenorrhea and pelvic pain.

Results: The anchoring technology is easy and safe to apply as an office procedure with or without local anesthesia.

Discussion: Any intrauterine method should fit properly in the uterine cavity to obtain a high tolerance rate and continuation of use, a prerequisite to reduce contraceptive as well as treatment failure.

FERTILITY-PRESERVING TREATMENT OF CERVICAL CANCER: FEASIBILITY OF TOTAL LAPAROSCOPIC NERVE-SPARING RADICAL TRACHELECTOMY

Oncology

Poster

Tobias Weissenbacher*, Darius Dian, Klaus Friese

Ludwig-Maximilians-University Munich

Summary (4 lines): The total laparoscopic nerve-sparing and uterine artery-preserving trachelectomy seems to be an encouraging method for young patients affected by early invasive cervical cancer; this technique enables young patients to become pregnant.

Introduction: The radical vaginal trachelectomy (RVT) is currently the most utilised method to preserve fertility in early stage cervical cancer. Total laparoscopic nerve-sparing radical trachelectomy is less widely performed. Successful pregnancies following total nerve-sparing radical trachelectomy have not been described in the literature yet. Aim was to evaluate the feasibility, operative morbidity and the pregnancy rate after total laparoscopic nerve-sparing radical trachelectomy.

Material and Methods: Seven women with early stage cervical cancer underwent a total laparoscopic radical trachelectomy combined with either sentinel and/or pelvic lymphadenectomy; in three cases, additional para-aortic lymphadenectomy was performed. After frozen sections of t.

Results: The pathologic tumour classification was International Union Against Cancer (UICC) pT1a2 (FIGO Stage pIA2) in one case and UICC pT1b1 (FIGO Stage pIB1) in six cases. Two cases were adenocarcinomas, and five cases were squamous cell carcinomas. Two patients got pregnant after total laparoscopic nerve-sparing radical trachelectomy.

Discussion: A total laparoscopic nerve-sparing radical trachelectomy is a feasible method of treating cervical cancer that does not increase morbidity and allow successful pregnancy.

FERTILITY OUTCOME AND RECURRENCE RATE AFTER ENDOSCOPIC SURGERY OF 222 DERMOID CYSTS

Infertility and Reproductive Medicine

Oral

Johanna Schaefer*, Ibrahim Alkatout, Thoralf Schollmeyer, Liselotte Mettler

University Kiel

Summary (4 lines): We analyzed the medical records of 222 dermoid-patients at the Department of Gynecology in Kiel, from 1995 to 2004. Almost all women were treated by laparoscopy and those wishing to have children became mostly pregnant. The recurrence-rate of dermoids was as small as expected.

Introduction: Ovarian dermoid cysts are common lesions accounting for up to 10-20% of all ovarian tumors. These cysts develop mainly in the female reproductive years. Since 90% of the dermoid cysts were removed by laparoscopy, it was the aim of this evaluation to find out in which way this technique can affect the ovary and may impair fertility.

Material and Methods: Out of a total of 3220 patients with ovarian cysts 222 patients presented a histology of a dermoid. By use of questionnaires we investigated the pregnancy outcome and the recurrence-rate of patients with dermoids. The response rate was 47,3%. We used the chi-square test and the fisher-test to evaluate exploratory the coherences between the variables that could interfere with the pregnancy outcome or recurrence rate.

Results: 88% of the women with a postoperative desire to have children became pregnant. There was no correlation between postoperative fertility and intraoperative spilling of dermoids cyst (p=0,12). We detected a recurrence rate of 7% (7of 105). One case of malignancy (mucous cystadenocarcinoma) was found five years after laparoscopy.

Discussion: Our study demonstrates that laparoscopic enucleation of dermoids not only reduces the hospital stay and wound healing, but also spares the ovary. In women wishing to become pregnant laparoscopic cyst enucleation should be the treatment of choice. Further research could concentrate on other aspects in this huge amount of data.

WHAT APPROACH TO NERVE DISSECTION IS BEST WHEN PERFORMING NERVE-SPARING SEGMENTAL RECTAL RESECTION FOR ENDOMETRIOSIS?

Innovation in Instrumentation and Surgical Techniques

Oral

James English*, Clark Jeremy, Moth Philippa

brighton & Sussex University Hospitals

Summary (4 lines): Radical surgery for rectal endometriosis causes significant neurological damage. With no established protocol available, we propose two different strategies varying in radicality which are dependent on the severity of disease.

Introduction: There is now substantial evidence that nerve-sparing segmental rectal resection for endometriosis with total mesorectal excision combined with a 6-7 cm colonic J-pouch reduces the incidence of bladder dysfunction and ‘anterior resection syndrome’ and preserves the function of the internal anal sphincter. However, what is not clear is whether we should routinely remove the mesorectum or just what sort of dissection we should perform in attempting to preserve the nerves.

Material and Methods: 178 women presenting to a tertiary referral unit for severe endometriosis since 2000 in whom a nerve-sparing approach was adopted when performing an anterior rectal resection. We have developed two modes of neuro-dissection dependent on severity of disease.

Results: We demonstrate that dissection of the superior hypogastric plexus is readily achievable with limited mesorectal involvement; in these cases it may not be necessary to perform a more radical dissection of the sacral/inferior hypogastric plexuses; however, dissection of these latter nerves is required with severe mesorectal disease and/or neurological involvement.

Discussion: This presentation includes a short video of each technique to demonstate the two techniques described. With close rectal dissection, dissection of the superior hypogastric plexus is needed. Very severe disease with mesorectal involvement is likely to require a much more radical approach to nerve-sparing dissection before rectal resection.

MRI AND FROZEN SECTIONING FOR EVALUATING RISK FACTORS IN ENDOMETRIAL CANCER STAGED LAPAROSCOPICALLY OR LAPAROTOMICALLY

Oncology

Poster

Ho-Suap Hahn*, Song Heung-Seop, Lee In-Ho, Kim Tae-Jin, Lee Ki-Heon, Shim Jae-Uk, Lim Kyung-Taek

Cheil General Hospital

Summary (4 lines): Both surgical staging approaches including laparoscopy and laparotomy showed no differences in surgical outcomes in endometrial cancer. MRI and intraoperative frozen sectioning can be used to accurately identify low-risk patients who do not need comprehensive surgical staging and may prevent unnecessary lymphadenectomy.

Introduction: To compare laparoscopy with laparotomy and analyze the accuracy of magnetic resonance imaging (MRI) and intra-operative frozen sectioning (IFS) for predicting the low- and high-risk patients and risk factors associated with lymph node (LN) metastasis in surgically staged endometrial cancer patients.

Material and Methods: The medical records of 175 endometrial cancer patients who underwent comprehensive surgical staging including pelvic and para-aortic LN dissection between January 2008 and July 2011 were retrospectively analyzed. Results of MRI and IFS of the uterus for the evaluation of risk factors were correlated with final pathology and we compared laparoscopy with laparotomy.

Results: Of the 175 patients who were surgically staged, 55(31.4%) were treated by open surgery and 120(68.6%), laparoscopically. None of laparoscopic group were converted to abdominal surgery. Our results showed a high specificity and negative predictive value of MRI and IFS for the evaluation of myometrial invasion and cervical stromal invasion.

Discussion: The results indicate that MRI and IFS may be useful for the evaluation of risk factors associated with LN metastasis in endometrial cancer patients, and both surgical staging approaches including laparoscopy and laparotomy showed no differences.

EVALUATING THE EFFECT OF CERVICAL DILATATION PRIOR TO OPERATIVE HYSTEROSCOPY TO WEEK OF SUBSEQUENT DELIVERY

Surgical Hysteroscopy

Poster

Péter Török*, Lampé Rudolf, Daragó Péter, Farkas Eszter

UDMHSC Dept. of Obs & Gyn

Summary (4 lines): Instrumental cervical dilatation prior operative hysteroscopy does not increase the risk for preterm birth.

Introduction: Nowadays diagnostic and operative hysteroscopy is an integral part of infertility work-up. For the operative interventions dilatation of the cervix is needed. The aim of this study was to evaluate the effect of cervical dilatation on the later obstetrical outcome.

Material and Methods: 1975 operative hysteroscopy procedures were studied of a 10-year period in the two departments. 66 patients with any kind of obstetrical events after hysteroscopy were enrolled. Groups were created based on obstetrical history and type of surgery. Week of

Results: There was no significant difference between the week of delivery of the hysteroscopy and control group patients. Also no statistical difference was found between week of delivery of groups created on the base of neither obstetrical history, nor type of surgery.

Discussion: Patients who have operative hysteroscopic intervention prior to their pregnancy irrespectively of their previous obstetrical history have no increased risk for preterm delivery because of the cervical dilatation.

INTRACAPSULAR MYOMECTOMY IN INFERTILITY SURGERY, AN UPDATE

Myomectomy

Oral

Liselotte Mettler*, Thoralf Schollmeyer, Alkatout Ibrahim

University Hospitals Schleswig-Holstein

Summary (4 lines): Results of our study and many international series demonstrate the feasibility of laparoscopic and hysteroscopic myomectomy as a technique leading to remission of symptoms and a low rate of complications.

Introduction: Many times the question is asked if intramural or subserous myomas affect infertility at all. It is understood that submucous myomas seriously interfere with implantation.

Material and Methods: Uterine myomas are very common in women of reproductive age and their diagnosis does not always require surgery. In 2275 cases of intramural and partly subserous myomas laparoscopic intracapsular myomectomy was performed and in 425 cases submucous fibroid.

Results: In 2700 intramural and partly subserous laparoscopic myomectomies we found an improved fertilization and pregnancy rate after the surgical procedure and therefore definitely advise myomectomy in infertility. In consecutive pregnancies no uterine rupture occurred, however, in 37 deliveries a placental problem had to be solved. Hysterectomy was never necessary.

Discussion: When surgery is indicated in cases of myoma, laparoscopic or hysteroscopic surgery is the primary choice. Depending on the alternatives available to the surgical team, the endoscopic treatment may be conventional laparoscopic, robotic resectoscopic, using single or multiple ports with NOS or NOTES, or hysteroscopy, according to the location.

ACUTE ABDOMEN IN INTERSTITIAL PREGNANCY, AN EMERGENCY LAPAROSCOPIC TREATMENT

Case reports

Poster

Francesca Salvagno*, Picardo Elisa, Canuto Emilie Marion, Benedetto Chiara, Marchino Gian Luigi, Marco Mitidieri

Sant'Anna Hospital, University of Torino

Summary (4 lines): The present case report to demonstrate a laparoscopic approach to treat interstitial cornual pregnancy in emergency.

Introduction: Interstitial ectopic pregnancy develops in the uterine portion of the fallopian tube , account for 2–4% of all ectopic pregnancies and have potential to cause life-threatening haemorrhage at rupture. The mortality rate for a woman diagnosed with such a pregnancy is 2–2.5%. Diagnosis of interstitial pregnancy is made by ultrasound.

Material and Methods: This is a case report of 32year-old woman, Gravida 0 Parity 0 ectopic1. She presented to the emergency obstetrical room complaining acute abdominal pain. There was history of 9 weeks pregnancy but no pelvic ultrasound scan was performed before the access.

Results: Transvaginal ultrasound scan demonstrated a gestational sac with viable foetus in the right interstitial region. Moreover there was ultrasound evidence of haemoperitoneum. She was transferred to operating room and an emergency laparoscopy surgery was performed . The postoperative course was uneventful, the patient was discharged two days after the surgery.

Discussion: Interstitial pregnancies present a difficult management problem with no absolute standard of care in literature. Laparoscopic technique is under study with favorable results. For our personal point of view a treatment via laparoscopy could be performed both in elective and in emergency cases.

SURGICAL THERAPY OF ENDOMETRIOMAS AND ITS IMPACT ON RECURRENCE AND PREGNANCY RATES: A LONG-TERM FOLLOW-UP

Endometriosis: Surgery

Oral

Lara Valeska Maul*, Schollmeyer Thoralf, Alkatout Ibrahim, Peters Göntje, Mettler Liselotte

Department Obstet. Gynec. Kiel

Summary (4 lines): The study was designed to identify prognostic factors for surgical (laparoscopic) ovarian endometrioma enucleation and recurrence of endometriomas. Possible malignant degenerations are discussed.

Introduction: The benign proliferative but not invasive disease, endometriosis, is a challenge in gynecological diagnosis and treatment. There is a great need to improve pre- and postoperative therapy since endometriosis is a common chronic disease without current complete treatment options. The current endometriosis classifications based on lesion’s type and location has only a limited prognostic value in terms of clinical aspects as the recurrence of endometriomas and pain and the success rate of postoperative pregnancy rate.

Material and Methods: This is a retrospective cohort study of 2558 operated patients with benign ovarian tumors at the Dpt. Obstet. and Gynec., University Hospital Kiel, Germany between 1995 and 2004, including 550 histologically verified ovarian endometriomas (21.5%). Demogra

Results: Multiple significant risk factors for recurrence were analyzed. While additional postoperative medical treatment led to higher spontaneous pregnancy rate (41.4% vs. 12.6%) and fertility rate with assisted reproduction (77.3% vs. 22.7%), worse results were shown in terms of recurrence-free rate (70.5% vs. 82.6%). Two cases of Endometriosis-associated malignancy were reported.

Discussion: There are many known risk factors for endometriomas and recurrence of pain such as previous surgery, adhesions, use of ovary-stimulating drugs, and advanced endometriosis stage. The impact of additional postoperative medical treatment is still controversial in the literature. Malignant degeneration is described to vary between 0.7 to 5.0%.

INTRA-ABDOMINAL SPACE AT DIFFERENT PRESSURES AND LEVEL OF BLOCK, CONSEQUENCES AND BENEFIT OF SUGAMMADEX

Innovation in Instrumentation and Surgical Techniques

Video

Olav Istre*, Pringborg Henrik

Aleris Hamlet hosp and university of southern Denm

Summary (4 lines): Sugammadex means the patients can be kept in deep neuromuscular blockade during the complete surgery time allowing the surgeons to have perfect working condition By reversing neuromuscular blockade one can avoid the associated risks caused by the block, furthermore the shortened operating and recovery time improves the patient’s quality of recovery and their discharge time. Significant reduction in pain score, including shoulder pain,

Introduction: Now we have the possibilities to keep the patients in deep neuromuscular blockade during the complete surgery time allowing the surgeons to have perfect working condition and the patient can be reversed exactly when we want.

Material and Methods: Pilot study of 15 patients for laparoscopic hysterectomy. We concluded that identical expansion of the abdomen is seen at 8 mmHg CO2 with deep neuromuscular blockade as at 12 mmHg CO2 without deep neuromuscular blockade.

Results: Intra-abdominal pressure of 8mmHg combined with deep neuromuscular blockage, gives the same surgical working conditions as a pressure of 12mmHg, without neuromuscular blocking. Measurement of the distance from the abdominal wall at the umbilicus to the promontorium and on our subjective evaluation.

Discussion: Shorter surgical time, Reduced Pain. Reduced Ventilation problems, Reduced Hemodynamic problems, Reduction in surgical complications, More workspace, less damage to other organs. Avoids herniation,

UTERINE SLIDING SIGN – A SIMPLE SONOGRAPHIC PREDICTOR FOR PRESENCE OF DIE OF THE RECTUM

Endometriosis: Diagnosis

Poster

Hudelist Gernot*, Stefan Staettner, Tammaa Ayman, Tinelli Andrea, Radmilla Sparic, Jörg Keckstein

Summary (4 lines): Sonographic demonstration of utero-rectal adhesions reflected by a positive uterine sliding sign is an easy at hand method for prediction of the presence of DIE involving the rectum. This could be a valuable “red flag sign” for triaging patients for tertiary referral centres and specialized clinics for detailed investigation.

Introduction: The aim of the study was to evaluate whether the presence of utero-rectal adhesions demonstrated by transvaginal sonography (TVS) could aid as a simple sonographic predictor for deep infiltrating endometriosis of the rectum in patients with symptoms suggestive of endometriosis.

Material and Methods: A prospective study was conducted in pelvic pain clinics including one-hundred and forty-two symptomatic women scheduled for laparoscopy due to symptoms suggestive of endometriosis. Patients were prospectively assessed via TVS prior to laparoscopy and radical resection of disease and histological confirmation was performed. Sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV), accuracy and positive and negative likelihood ratios (LR+ and LR-) were calculated.

Results: In total, 34 (29%) of patients exhibited deep infiltrating endometriosis (DIE) of the bowel. Sensitivity, specificity, PPV, NPV, accuracy, LR+ and LR- for a negative sliding sign as shown by TVS regarding the presence of DIE of the rectum was 85%, 96%, 91%, 94%, 93.1%, 23.6 and 0.15.

Discussion: Sonographic demonstration of utero-rectal adhesions reflected by a positive uterine sliding sign is an easy at hand method for prediction of the presence of DIE involving the rectum. This could be a valuable “red flag sign” for triaging patients for tertiary referral centres and specialized clinics for detailed investigation.

DIAGNOSTIC DELAY OF ENDOMETRIOSIS IN AUSTRIA AND GERMANY – CAUSES AND POSSIBLE CONSEQUENCES

Endometriosis: Diagnosis

Poster

Hudelist Gernot*, Almut Thomas, Christiane Niehues, Peter Oppelt, Dietmar Haas, Ayman Tammaa, Heinrich Salzer

Summary (4 lines): Diagnostic delay in Austria and Germany is considerable long and is influenced by several causative factors.

Introduction: Diagnostic delay of endometriosis is a problematic phenomenon which has been evaluated in several European countries and the US. The aim of the present study was to investigate the reasons and length of diagnostic delay of endometriosis in Austria and Germany.

Material and Methods: A questionnaire-based study was conducted in 171 patients with histologically confirmed endometriosis.

Results: The median interval from the first onset of symptoms to diagnosis was 10.42 (SD: 7.91) years. Seventy-four percent of patients received at least one false diagnosis. Patients with misdiagnosis and women whose mothers considered menstruation as a negative event had a significant negative impact on diagnostic delay.

Discussion: Measures such as training programs to enhance diagnostic skills and public awareness initiatives could possibly reduce diagnostic delay in Central European countries.

THE FIVE CRUCIAL STEPS TO SAFE LAPAROSCOPIC HYSTERECTOMY

Hysterectomy

Oral

Geraldo Gomes-da-silveira*

Santa Casa Hospital

Summary (4 lines): With the five crucial steps of technique, laparoscopy could be the approach of choice to hysterectomy, with advantages of vaginal and open surgery together.

Introduction: Hysterectomy is one of the most frequently performed surgical procedures among gynecologists. The standard approach, through an open incision, in despite of more invasive, is performed in more than 80% of cases around the world.

Material and Methods: The purpose of this paper is to show how the following five crucial steps allow a safe and standardized laparoscopic hysterectomy: 1. Placement and function ability of uterine manipulator 2. Broad ligament opening 3. Bladder dissection and cervical fascia exposure 4. Uterine vessels ligation 5. Vaginal opening.

Results: Laparoscopic route, in trained teams, is a safe surgery with power to avoid laparotomy in more them 90% of benign diseases indications of hysterectomy.

Discussion: The learning curve of laparoscopic hysterectomy is often far longer than anticipated, and, complications rate can be higher than in laparotomy in teams that do not have long-standing experience in advanced laparoscopic surgery.

ANALYSIS OF THE INDICATION OF TOTAL LAPAROSCOPIC HYSTERECTOMY WITH THE RESECTION OF DEEP INFILTRATING ENDOMETRIOSIS

Endometriosis: Surgery

Poster

Shinichiro Wada*, Fukushi Yoshiyuki, Fujino Takafumi, Sato Chikara

Teine Keijinkai Hospital

Summary (4 lines): Total laparoscopic hysterectomy with resection of deep infiltrating endometriosis is effective to the patient having tender induration around uterine cervix.

Introduction: Deep infiltrating endometriosis (DIE) is mainly located at uterosacral ligaments and recto-vaginal septum which are not resected at common hysterectomy. Therefore, it may cause endometriosis associated pain after hysterectomy for patients of DIE. On the other hand, the resection of DIE sometimes causes urination disorder. The aim of this study is to analyze clinical backgrounds and postoperative endometriosis associated pain of patients undergoing total laparoscopic hysterectomy (TLH) with or without resection of DIE.

Material and Methods: Postoperative endometriosis associated pain were examined more than three months later from the operation to 82 cases of endometriosis undergoing TLH conducted by one surgeon during January 2005 to June 2012. The DIE resection was not added to TLH before

Results: Regarding TLH without DIE resection, four of 13 patients (30.7%) having induration with tenderness around uterine cervix, and none of seven (0%) having induration without tenderness complained postoperative endometriosis associated pain. Furthermore, 12.5% of patients with tender induration undergoing TLH with DIE resection complained postoperative pain.

Discussion: TLH with DIE resection helps the patients having induration with tenderness around uterine cervix to get out of postoperative endometriosis associated pain, on the other hand, DIE resection is not necessary for those having induration without tenderness.

LAPAROSCOPIC SURGERY FOR WOMEN WITH BORDERLINE OVARIAN TUMORS DEPENDING ON THE AGE. CASE REPORTS

Oncology

Poster

Boris Goldmann*

Luedenscheid Hospital

Summary (4 lines): It will be described the experience of our department in diagnosing and managing of boderline ovarian tumors depending on the age of the patient.

Introduction: There are many patients with boderline ovarian tumors, who undergo often the surgical therapy per laparotomy. The laparoscopic management with the exact histological diagnosis allows to achieve the same or better results in comparison with the open procedure.

Material and Methods The complete laparoscopic program includes the inspection of the abdomen, peritoneal washing cytology, multiple peritoneal biopsies, tumorectomy, total hysterectomy, bilateral salpingoovarectomy, infracolic omentectomy and possibly appendectomy. Depending

Results: Recurrence free survival is following laparoscopic surgery in not fertility-preserving group.

Discussion: Laparoscopic accuracy, oncological safety and painless postoperative process: an alternative to laparotomy.

LAPAROSCOPIC MYOMECTOMY OF TWO LARGE PEDUNCULATED MYOMAS IN THE FIRST TRIMESTER OF PREGNANCY

Case reports

Video

Andrey Dubinin*, Ermolaeva Olga, Ignatiev Alexey

Medical Company IDK

Summary (4 lines): We performed laparoscopic myomectomy of large, multiple, pedunculated subserous myomas during the first half of pregnancy. Myomectomy was performed for avoiding torsion of myoma and spontaneous abortion.

Introduction: Uterine myomas are diagnosed in 1.6% to 4% of pregnancies. With the increasing age of obstetric patients, more cases are being encountered during pregnancy. The effect of myomas on pregnancy depends on their size and location. Indications for myomectomy during the pregnancy include a severe abdominal pain due to torsion of subserous myomas and an increasing size of myoma causing complications during the pregnancy. Myomectomy during the pregnancy has special technical features.

Material and Methods: Physical examination of 38 year-old primigravid woman showed huge mobile tumor located in the right upper region of abdomen. A sonographic scan showed the presence of 10 weeks intrauterine pregnancy and two subserous fibroids measuring 12 and 6 cm. Having used Hasson’s technic the first umbilical trocar was inserted. Pedicles of myomas were strangled with two surgical vicryl threads. Afterwards fibroids was cut off by scissors and removed by morcellation.

Results: The whole blood loss was 50 ml. The duration of surgery took 145 minutes in which 95 minutes was the time of morcellation. There were no intra- or post-operative complications and patient was discharged after five days. Now pregnancy is continued on term of 20-21 weeks of gestation.

Discussion: Laparoscopic myomectomy can be considered as a minimally invasive surgery with minimal blood loss during the pregnancy. Indications to the operation are an abdominal pain resulting of torsion myoma and prevention of complications during the pregnancy. The restriction for laparoscopic myomectomy is the diameter of myoma’s base.

ANALYSIS OF THE POSTSURGICAL ADHESION IN CASES OF THE SECONDARY OPERATION AFTER LAPAROSCOPIC MYOMECTOMY

Complications

Poster

Yukiio Suzuki*, Wada Shinichiro

Teine Keijinkai Hospital

Summary (4 lines): We considered the risk factor of post surgical adhesion after LM are more than 100ml of hemorrhage, more than three hours of operation time, and more than 200g of myoma weight.

Introduction: Postsurgical adhesion after laparoscopic myomectomy (LM) might be an issue on the infertility and the ileus. In addition, the second LM or hysterectomy is necessary because uterine myoma often recurs, therefore, the adhesion is also an issue on the recurrent operation. The aim of this study is to evaluate the risk factor of postsurgical adhesion after LM on the cases of the second LM or total laparoscopic hysterectomy (TLH).

Material and Methods: We retrospectively analyzed the adhesion at uterus and adnexa in 26 cases of the recurrence of uterine myoma, undergoing the second LM or TLH, performed after the initial LM among 1869 cases of LM from January 2005 to March 2013.

Results: The second LM was performed in 19 cases, and TLH in seven cases. In five cases (19.2%) the adhesions were already seen in the initial operation. In the second operation, the uterine adhesions were seen in 17 cases (65.4%).

Discussion: Analyzing the risk factor, in the cases of more than 100ml of the hemorrhage, of more than three hours of the operation time, and of more than 200g of the myoma weight, the adhesions were more frequently seen.

MINILAPAROSCOPIC HYSTERECTOMY - “STEPS, DIFICULTIES & ADVANTAGES”

Innovation in Instrumentation and Surgical Techniques

Video

Hélder Carvalho Ferreira*, Cubal Rosália, Sousa Rita, Braga Antonio, Tomé Pereira António

Centro Hospitalar do Porto - Universidade do Porto

Summary (4 lines): We present a video that illustrates minilaparoscopic hysterectomy procedure as a minimally invasive alternative to conventional laparoscopic hysterectomy with its difficulties, steps and benefits for the patients.

Introduction: Recent advances in instrumentation have improved the surgeons’ armamentarium with smaller caliber instruments, thus triggering the emergence minilaparoscopic surgery. The concept behind minilaparoscopy is that smaller instruments cause less abdominal wall trauma and thus reduce incision related morbidity and minimize pain and stress response to surgery. Many surgeons believe that the performance debt of miniaturized instruments severely limits the applicability of the technique, and many are unwilling to endure the difficulties of using finer instruments.

Material and Methods: We present, according to our recent experience, an educational video explaining the “steps, difficulties & advantages” of minilaparoscopic total hysterectomy with a new smaller size bipolar coagulator (ROBI®, Karl Storz).

Results: We found feasible and reproducible to perform total hysterectomy using smaller size instruments. The new bipolar instrument is, not only an efficient bipolar tool, but also a good dissector and grasping forceps.

Discussion: In spite of our short experience, we dare to say that minilaparoscopic total hysterectomy can be considered a minimally invasive alternative to conventional laparoscopic hysterectomy with potential benefits for our patients.

HOW TO DECREASE PAIN AFTER TOTAL LAPAROSCOPIC HYSTERECTOMY IN SAME DAY DISCHARGE: A PROSPECTIVE STUDY

Hysterectomy

Selected abstract Oral

Olivier Donnez*, Donnez Jacques, Mitchell John, Darii Natalia, Michaux Nathalie

CHU UCL Godinne Dinant

Summary (4 lines): We present an observational prospective study of 54 patients undergoing TLH in an ambulatory setting (group I) and 24 undergoing TLH with overnight hospitalization (group II) using the same protocol.

Introduction: Despite first total laparoscopic hysterectomy (TLH) being performed in 1989, the rate of abdominal hysterectomy still remains too high. We recently published results on complication rates after an adequate learning curve, showing that in experienced hands, TLH is the technique of choice for hysterectomy. Laparoscopic hysterectomy has proved to be feasible and safe in an outpatient setting. However, most studies are retrospective and little information is provided on pain scores, surgical technique, or postoperative evaluation.

Material and Methods The surgical technique, anesthesia protocol and postoperative care were all designed to reduce postoperative pain and improve postoperative conditions. Visual analog scale (VAS score) was used according to a previous study on TLH. Primary endpoints were e

Results: All patients from group I were able to be discharged after 4.92 hours. Four hours after TLH, all patients from both groups showed VAS ≤ 2 and remained stable until day 1. Moreover, 96.3% of patients were satisfied and would recommend one-day surgery to another.

Discussion: Four hours after TLH using our technique, patients presented with VAS scores oup I and II results are not statistically different, TLH with same-day discharge should be offered to selected patients.

LAPAROSCOPIC REPAIR OF POST-CESAREAN SECTION UTERINE SCAR DEFECTS DIAGNOSED IN NON-PREGNANT WOMEN

Innovation in Instrumentation and Surgical Techniques

Oral

Olivier Donnez*, Donnez Jacques, Marotta Maria-Laura, Darii Natalia, Michaux Nathalie

CHU UCL Godinne Dinant

Summary (4 lines): We describe the technique of laparoscopic CO2 laser repair of uterine scar defects after cesarean section and pregnancy outcomes in a series of 30 patients.

Introduction: The number of cesarean section deliveries performed worldwide has grown over recent decades. With defects due to cesarean section increasingly described, a rate as high as 61% was reported in women after 1 cesarean section, reaching 100% in those undergoing ≥3. Even if the cause of these defects remains unclear, it seems that there is an association between large defects and uterine rupture/dehiscence in subsequent pregnancy, spotting, dysmenorrhea and infertility.

Material and Methods: The surgical technique is described in a series of 30 patients. As the residual myometrium covering the scar appears to be the most appropriate discriminating factor, we identified patients with remaining myometrium of allowed to attempt pregnancy.

Results: On MRI, the median residual myometrium covering the dehiscence was 1.5±0.7mm before surgery and 10.1±1.3mm 3 months after surgery. All patients who had experienced pain, dysmenorrhea or intermenstrual bleeding were free of symptoms after surgery. Five uneventful pregnancies occurred, with subsequent cesarean section between 38 and 39 weeks.

Discussion: In case of residual myometrial thickness performed, with reproducible postoperative anatomical and functional outcomes. This laparoscopic technique enables further pregnancy with term delivery. However, we strongly recommend cesarean section at 38-39 weeks.

SUCCESSFUL TREATMENT OF CERVICAL INCOMPETENCE USING A MODIFIED LAPAROSCOPIC CERVICAL CERCLAGE TECHNIQUE: A COHORT STUDY

Innovation in Instrumentation and Surgical Techniques

Oral

Shu Zhong Yao*, Luo Lu, Chen Shuqin, Zhang Huan Xiao

The first affiliated hospital of Sun yat-sen uni.

Summary (4 lines): cervical incompetence is a main cause for second trimester pregnancy lose. Vaginal cerclage is a common used methods for treatment of cervical incompetence, but it has a high failure rate. Here we introduce a modified laparoscopic cervical cerclage procedure with high success rate compared with vaginal cerclage.

Introduction: The trans-vaginal cervical cerclage for treatment of cervical incompetence has been used for several decades. However, some of the patients may still have pregnancy lose because of dilation and laceration of cervix after vaginal cervical cerclage. Laparoscopic cervical cerclage was described in recent years with a satisfied results. The present study reports a modified laparoscopic cervical cerclage. Operative details and obstetric outcomes were compared with those obtained using traditional vaginal cerclage.

Material and Methods: Laparoscopic cervical cerclage(LCC) was performed using Mersilene tape and a modified surgical technique. Nineteen patients treated by LCC were prospectively monitored and the pregnany outcomes were compared to a control group of 25 patients treated by tr

Results: Of the 19 LCC patients, 15 (78.9%) became pregnant The fetal salvage rate was 92.3% (12/13) The mean gestational age in LCC group was 36.4 weeks,which was on average 17.4 weeks longer than their previous pregnancy length. This result was significantly higher than that obtained by TVC.

Discussion: This modified technique for laparoscopic cervical cerclage demonstrates good obstetric outcomes with low risk of adverse events, which may provide a reasonable alternative to achieve pregnancy success in patients with cervical incompetence.

NOVEL SURGICAL APPROACH FOR CESAREAN SCAR PREGNANCY: SUCCESSFUL TRANSVAGINAL HYSTEROTOMY IN 40 CASES

Innovation in Instrumentation and Surgical Techniques

Oral

Shu Zhong Yao*

The first affiliated hospital of Sun yat-sen uni.

Summary (4 lines): 40 women with cesarean scar pregnancy were treated with transvaginal hysterotomy. the advantage and operation methods of this novel procedure were intraduced in this article.

Introduction: cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy There is no standard and satisfactory therapeutic protocol established until now. With the concept of minimally invasive surgery, we designed and performed the first case of hysterotomy by transvaginal approach for the treatment of CSP in 2009. A preliminary report of six cases was published in 2011. Herein, we introduce the clinical results of 40 cases with CSP treated by transvaginal hysterotomy.

Material and Methods: 40 patients were included. The mean size of gestational sacs was 33.78mm, β-hCG levels was 47379.73IU/L. Operative time was 57.25 minutes. No complications were encounted. The mean hospitalization stay was 4.95 days. The serum β-hCG level declined to norm

Results: 40 patients were included. The mean size of gestational sacs was 33.78mm, β-hCG levels was 47379.73IU/L. Operative time was 57.25 minutes. No complications were encounted. The mean hospitalization stay was 4.95 days. The serum β-hCG level declined to normal range within 1 month in all the cases.

Discussion: Transvaginal hysterotomy with removal of ectopic pregnancy tissue and repair of uterine defect is a novel approach of managing CSPs, with reduced postoperative hospital stay, postoperative pain, minimum blood loss and cost. It is a safe and effective method for patient with CSPs.

LAPAROSCOPIC HYSTERECTOMY FOR THE LARGE UTERUS, INDICATIONS AND TECHNIQUE. A CASE REPORT AND A REVIEW

Hysterectomy

Poster

Amr Soliman*, El Mahdy Mohamed, Eid Noha, Abdelsalam Tawfeek, Alashqar Ussama, Meligy Haytham

University of Alexandria

Summary (4 lines): In a review of literature LAVH was advocated as the most convenient laparoscopic route to remove large uteri. We report a case of LAVH performed on a 920 gram uterus in reasonable operative time and acceptable blood loss.

Introduction: The size of the uterus is one of the important independent factors determining the success of the laparoscopic hysterectomy. Whether the uterus is laparoscopically morcellated, extracted through a minilaparotomy or extracted through the vagina, are all independent risk factors affecting operative time and amount of blood loss. Our aim is to report a case of LAVH for a 920 gm uterus and to review the literature regarding the important steps in the operative techniques.

Material and Methods: We present a case of ultrasonographically-confirmed huge fibroid uterus, reaching two finger breadths below the umbilicus, that was admitted for hysterectomy. She was 45 years old with history of four unremarkable normal deliveries. In preparation for the

Results: In our review of literature we found 4 trials studying the route of uterine removal according to uterine size. Two of them advocated the use of LAVH when performing laparoscopic hysterectomy for large uteri. Our patient went a LAVH that was performed in 119 minutes, with 134 mL blood loss.

Discussion: LAVH seems to be the most convenient way to perform a laparoscopic hysterectomy for a uterus larger than 500 gm, with lower operative time, lower blood loss and less conversion rate to laparotomie.

LESS MANAGEMENT OF HUGE OVARIAN CYST

Single Access Surgery

Video

Abdulaziz Alobaid*

King Fahad Medical City

Summary (4 lines): We present a video presentation of unilateral salpingoopherectomy of a 28 cm ovarian cyst, during the surgery 5 liters of serous fluid was aspirated from the cyst.

Introduction: Laparoscopic management of huge ovarian cysts has been described in previous case reports. Despite of this, most patients with huge ovarian cysts are managed by laparotomy. Single access surgery for such huge neoplasms might be even more challenging due to technical difficulties related to removal of the cyst and space constrains. Few case reports were published about LESS of huge cysts (up to 26 cm).

Material and Methods: We present a 34 years old patient who was referred with a huge pelvi-abdominal mass. Her exam revealed a huge mass that was reaching till the xiphi-sternum. The mass was mobile. The patient had normal tumor markers. She had ultrasound and CT scan. The clinical and radiological evaluation was in favor of a benign cyst. A 2.5 cm umbilical incision was made. The cyst was drained laparoscopically. 5 liters of serous fluid was aspirated.

Results: We performed unilateral salpingo-oopherectomy. There were no intraoperative complications and the blood loss was minimal. The patient was discharged home the next day in good condition. The histopathology report revealed a benign mucinous cystadenofibroma. She was seen in the clinic 4 weeks after the surgery and was doing well.

Discussion: We believe that huge cysts can be safely managed using LESS. There should be no size limit to LESS. Before aspiration of a huge cyst, the malignancy index should be very low. Proper patients selection and expertise are essential to perform these cases.

BARBED SUTURE AND ENTERO-VAGINAL FISTULA

Complications

Poster

Oumar Camara*, Sylvia Seyfarth, A Apostolov, Anne Kieselbach, Oumar Camara

Hufeland Klinikum GmbH

Summary (4 lines): entero-vaginal fistula due to a barbed suture can be successfull managed by Endo-GIA resection

Introduction: Barbed sutures are increasingly used in many fields in surgery. An unusual complication is an entero-vaginal fistula.

Material and Methods: We present a case report, a 46 years old woman with uterine fibroid, menstrual disorders and dysmenorrhea treated with a total laparoscopic hysterectomy.

Results: 3 days after the total laparoscopic procedure with a v-care manipulator, she was discharged without adverse signs. 4 weeks later we found an entero-vaginal fistula caused by the barbed suture. The complication was successful managed laparoscopically with Endo-GIA. The further follow-up was uneventfull.

Discussion: The closure of the vaginal cuff is, since the introduction of the barbed suture easier to perform. However some critical points should be mentioned to avoid complications in relation to the barbed suture itself.

VIDEO OF A NEW INTRAUTERINE ANCHORING TECHNIQUE FOR THE DELIVERY OF BIOACTIVE SUBSTANCES

Innovation in Instrumentation and Surgical Techniques

Oral

Dirk Wildemeersch*

GYNECOLOGICAL OUTPATIENT CLINIC AND IUD TRAINING C

Summary (4 lines): A novel technique for the anchoring of bioactive substances in the uterus was developed and tested for contraception and treatment of various gynecological conditions.

Introduction: None.

Material and Methods: None.

Results: None.

Discussion: None.

TUBAL FLUSHING EFFECT OF SELECTIVE CHROMOPERTUBATION AT OFFICE HYSTEROSCOPY

Diagnostic & Operative Office Hysteroscopy

Poster

Peter Darago*, Török Peter, Lampé Rudolf

University Of Debrecen Dept. of Obs.and Gyn.

Summary (4 lines): The aim of the study was to assess the tubal patency at office hysteroscopy.

Introduction: Tubal dysfunction is a leading factor in female infertility. Tubal flushing effect of Hysterosalpingography has been described by many studies. We aimed to evaluate the flushing effect of the outpatient method, selective chromopertubation via office hysteroscopy (OHSC-SPT).

Material and Methods 50 infertile patients (mean age: 32.4 ± 2.75) took part in the study. As the part of infertility work-up diagnostic office hysteroscopy was performed to evaluate uterine cavity. Second part of the procedure during selective chromopertubation via office hysteroscopy tubal patency was evaluated. Patients with at least one patent tube had a 30 months of follow-up, when we recorded their obstetrical events, or conceiving a pregnancy after sterile period.

Results: Out of the 50 cases in 30 at least one of the tube was patent and in 20 cases both tubes were blocked. Out of these 50 cases 6 (12%) spontaneous pregnancies and after IUI 3 (6%) pregnancies conceived, in the 6 months follow up period.

Discussion: The novel method of OHSC-SPT has tubal flushing effect that has been described in connection of hysterosalpingography before.

VAGINAL, ABDOMINAL, ROBOTIC LAPAROSCOPIC, AND LAPAROSCOPIC ASSISTED VAGINAL HYSTERECTOMY: STUDY ON CLINICAL OUTCOMES AND COST

Hysterectomy

Oral

Magdi Hanafi*

Saint Joseph's Hospital / Emory Healthcare System

Summary (4 lines): Retrospective comparative study of different methods of hysterectomy performed by the author in three years to evaluate which method of hysterectomy is best for the patient clinical outcome and cost.

Introduction: To compare the effect of total vaginal hysterectomy (TVH), abdominal hysterectomy (TAH), robotic laparoscopic hysterectomy (RLH), and laparoscopic assisted vaginal hysterectomy (LAVH) on length of hospital stay, operative time, post-operative outcomes (patient pain level, days of pain analgesics use, days until first bowel movement, days until self care, days until returning to work, weeks until first intercourse), and total hospital charges.

Material and Methods: Retrospective study for all consecutive hysterectomy cases performed by the author from 10/01/2009 to 07/31/2012. 174 patients were divided into four surgical groups: TVH, TAH, RLH, and LAVH. Patient records were used to determine patient demographics, length of hospital stay, operative time, estimated blood loss, and total hospital charges. Questionnaires for 113 patients were used to determine the patient post-operative outcomes.

Results: No significant differences were seen in patient demographics between surgical groups. Significant differences were seen for length of hospital stay, operative time, estimated blood loss, total hospital charges, and most post-operative outcomes (pain level, days of pain analgesics use, days until self care, and days until returning to work).

Discussion: Study findings reveal a significantly higher hospital stay in TAH versus all other methods. TAH & RLH had significantly higher total hospital charges versus LAVH & TVH. TAH had significantly higher estimated blood loss than RLH. TAH had higher levels of post operative pain than RLH, LAVH & TVH.

A CASE OF PRIMARY OVARIAN ECTOPIC PREGNANCY ON ENDOMETRIOSIS SITE

Case reports

Poster

OLARU Flavius*, Constantin Olaru, Viviana Narad, Dragos Erdelean, Izabella Diana Erdelean, Alina Corpade

County Hospital Timisoara Romania

Summary (4 lines): We report a case of a 28-year-old woman diagnosed with ovarian ectopic pregnancy on endometriosis site. β-human chorionic gonadotropin concentration was 4000 IU/ml. She presented at 47 days of amenorrhoea with a 2 day history of vaginal bleeding and lower abdominal discomfort. Diagnostic laparoscopy confirmed right ovarian ectopic pregnancy on endometriosis site. Histology confirmed a ruptured ovarian ectopic pregnancy associated with ovarian endometriosis. Ovarian ectopic pregnancy was managed laparoscopically.

Introduction: Spiegelberg described in 1878 four criteria for the diagnosis of ovarian pregnancy: the tube has to be normal, the gestational sac has to be anatomically located in the ovary, the ovary and the gestational sac have to be connected to the uterine ovarian ligament, and placental tissue has to be mixed with ovarian cortex. It commonly mimics tubal ectopic, ruptured corpus luteum and ovarian torsion. We present a case with clinical presentation of ovarian ectopic pregnancy.

Material and Methods: We report a case of a 28 -year-old woman diagnosed with ovarian ectopic pregnancy. She presented at 47 days of amenorrhoea with a 2 day history of vaginal bleeding and lower abdominal discomfort. β-hcG concentration was 4000 IU/ml. Ultrasound showed a right adnexal mass 4.0 × 3.8 × 5.5 cm with a 16 mm cystic area suggesting right ovarian ectopic pregnancy. Laparoscopy confirmed the diagnosis.

Results: The intraoperative finding of normal tubes bilaterally was surprising, and to confirm, tissue samples from the excised right hemorrhagic ovarian mass were sent for histopathological exam. The presence of trophoblastic activity in the ovarian tissue confirmed an ovarian pregnancy in accordance to the four Spiegelberg criteria.

Discussion: There are few reports about cases of ovarian pregnancies, the largest include 54 cases. There are two features that make this an unusual case; the relatively late gestation at which she presented and her mild presenting features.

SINGLE SITE LAPAROSCOPIC NERVE SPARING RADICAL HYSTERECTOMY USING CONVENTIONAL PORTS AND INSTRUMENTS

Single Access Surgery

Video

Puntambekar Shailesh*, Agarwal Joshi Geetanjali, Lawande Akhil, Puntambekar Seema, Desai Riddhi

Galaxy Care Laparoscopy Institute

Summary (4 lines): We applied the steps of our nerve sparing radical hysterectomy to do a nerve sparing radical hysterectomy with LESS using conventional ports.

Introduction: Advanced Minimally invasive gynaecological procedures have gained popularity nowadays. Surgeons are finding new ways to meet patient’s demands for better cosmetic results. Thus LESS (Laparoendoscopic single site surgery) has come in vogue. We report our first case of nerve sparing radical hysterectomy done by this technique.

Material and Methods: A 45 year old woman was referred to us with carcinoma of the cervix stage IA2. Biopsy report showed Invasive keratinizing Squamous cell carcinoma, Grade II. We applied the steps of our nerve sparing radical hysterectomy to do a nerve sparing radical hyste

Results: The oncological clearance was comparable to the routine laparoscopic radical hysterectomy. Complete recovery of bladder function was seen after removal of Foley's catheter on 2nd post-operative day.

Discussion: Nerve sparing laparoscopic radical hysterectomy is technically feasible. The oncological clearance, time taken and the functional results are comparable to the multiport variant.

SINGLE SITE LAPAROSCOPIC RADICAL HYSTERECTOMY USING CONVENTIONAL PORTS AND INSTRUMENTS

Hysterectomy

Video

Puntambekar Shailesh*, Desai Riddhi, Lawande Akhil, Agarwal Joshi Geetanjali, Puntambekar Seema

Galaxy Care Laparoscopy Institute

Summary (4 lines): LESS (Laparoendoscopic Single Site Surgery) is now being used in gynaecologic oncological procedures. We applied our expertise of LESS to perform a laparoscopic radical hysterectomy by LESS.

Introduction: Advanced Minimally invasive gynaecological procedure have gained popularity in the world. With advancement in technology the surgeons are finding new ways to meet patient’s demands for better cosmetic results. Thus LESS (Laparoendoscopic single site surgery) and NOTES (natural orifice trans endoscopic surgeries) have come in vogue. We applied our expertise of LESS to perform a laparoscopic radical hysterectomy by LESS.

Material and Methods: A 45 year, old woman, was referred to us as a patient of cancer of the cervix stage IA2. The biopsy report showed Invasive keratinizing Squamous cell carcinoma, Grade II. We duplicated the steps of our ‘Pune technique’ of laparoscopic radical hysterectomy

Results: The oncological clearance was comparable to the conventional laparoscopic radical hysterectomy. Time taken was 120 mins and blood loss was 50ml.

Discussion: Reduced port laparoscopic radical hysterectomy is technically feasible. The oncological clearance and the functional results are comparable to the multiport variant, with good cosmetic results.

LAPAROSCOPIC SACROCOLPOPEXY FOR THE TREATMENT OF THE APICAL PROLAPSE: OUTCOMES AND LONG TERM FOLLOW-UP

Urogynaecology

Poster

Claudia López *, DE LOS RIOS JOSE, CIFUENTES CAROLINA, CALLE GUSTAVO, ARANGO ADRIANA, Castañeda juan, Vasquez Ricardo , Almanza Luis

Clínica del Prado

Summary (4 lines): Assessment of the 6 year outcome of laparoscopic sacrocolpopexy

Introduction: The aim of this study was to evaluate the long-term subjective, anatomical and functional outcomes after laparoscopic sacrocolpopexy for pelvic organ prolapse.

Material and Methods: An observational study of women undergoing laparoscopic sacrocolpopexy between February 2006 and December 2012 was undertaken, at three centers in Medellín - Colombia. Pelvic organ support was assessed objectively using the pelvic organ prolapse quantification scale (POP-Q). Functional outcomes were assessed using a questionnaire of bowel, urinary, sexual and physical discomfort symptoms postoperatively. Also was assessed the overall satisfaction of surgery with a scale of one to ten.

Results: 24 women with a mean age of 63 years were included. Mean follow up was 34 months, all patients had stage 0 vault support with point C of POP-Q score averaging – 6.8 cm. Subjective improvements in symptoms were observed with significant reductions. satisfaction measured with visual scale averaged 9.1

Discussion: Laparoscopic sacrocolpopexy is a safe and effective surgical treatment for post-hysterectomy apical prolapse. It provides excellent apical support and good level of satisfaction, with overall improvement in prolapse symptoms.

THE IMPACT OF THE BODY MASS INDEX (BMI) ON LAPAROSCOPIC HYSTERECTOMY FOR BENIGN DISEASE

Hysterectomy

Poster

David Bardens*, Erich Solomayer, Sascha Baum, Achim Rody, Ingolf Juhasz-Böss

Saarland University Hospital

Summary (4 lines): This study deals with the influence of the BMI on laparoscopic hysterectomy and concludes that it is a safe and feasible method even in obese and morbidly obese patients.

Introduction: Excess of body weight has become a global epidemic. More and more of our patients are overweight or obese. The aim of this study was to investigate the influence of the Body Mass Index (BMI) on laparoscopic hysterectomy.

Material and Methods: We analyzed the medical records of 200 women who underwent laparoscopic hysterectomy for benign disease at the Saarland University Hospital and compared the weight groups in terms of pre-, intra- and postoperative findings and complications. All statistic tests were carried out by a professional statistician.

Results: Over half of the patients were overweight or obese. The operating times increased together with the BMI (p=0.017). Blood losses were very low. Only one laparoconversion had to be performed. The group of overweight women had the highest rate of complications and the group of obese women had the lowest.

Discussion: Laparoscopic hysterectomy is a safe and feasible method even in obese and morbidly obese patients. Overweight and obesity increase the time needed to perform laparoscopic hysterectomy but do not seem to relevantly influence the rate of major intra- or postoperative complications.

LAPAROSCOPIC HYSTERECTOMY FOR BENIGN DISEASE: SHOULD THE CERVIX BE LEFT IN SITU?

Hysterectomy

Poster

David Bardens*, Erich Solomayer, Sascha Baum, Julia Radosa, Achim Rody, Ingolf Juhasz-Böss

Saarland University Hospital

Summary (4 lines): The results of this retrospective observational study suggest that leaving the cervix in place when performing laparoscopic hysterectomy may reduce postoperative wound healing problems of the vaginal cuff.

Introduction: Even though hysterectomy is one of the most frequently performed surgical procedures in the world, there is still a debate about the removal of the cervix. In this study, we compared total laparoscopic hysterectomy (TLH) with laparoscopic supracervical hysterectomy (LASH) for benign disease in terms of pre-, intra- and postoperative findings and complications.

Material and Methods: We analyzed the medical records of 200 women who underwent either total laparoscopic hysterectomy (TLH) or laparoscopic supracervical hysterectomy (LASH) at the Saarland University Hospital. TLH was performed in 108 cases during the study period, 92 patients underwent LASH. We compared patient characteristics, operating time, blood loss, uterine weight, length of stay as well as intra- and postoperative complications.

Results: The time needed to perform TLH was significantly longer than the time needed for LASH (P=0.004). The blood losses did not significantly differ. Our laparoconversion rate was 0.5%. The rate of wound healing problems was significantly higher in the group of patients who underwent TLH (P=0.027).

Discussion: Both TLH and LASH are save operative procedures that can be performed with a minimal rate of intra- and postoperative complications. Nevertheless, one should be aware that leaving the cervix in situ significantly reduces the rate of wound healing problems of the vaginal cuff.

SENTINEL LYMPHONODECTOMY IN UTERINE CANCER

Oncology

Poster

Céline Hayo*, Erich Solomayer, David Bardens, Sascha Baum, Ingolf Juhasz-Böss

Saarland University Hospital

Summary (4 lines): The aim of this study was to establish the sentinel node biopsy in uterine cancer in a tertiary center.

Introduction: The use of sentinel node biopsies in uterine cancer is described by more and more study groups. The aim of our study group was to establish this method in our department and to analyze the safety and oncologic outcome of this method.

Material and Methods: The study included all patients who underwent a SNB in case of endometrial or cervical cancer. We will show patient characteristics, intraoperative findings such as detection rates and false negative rates.

Results: During the study period between September 2009 and February 2012 n=70 patients underwent SNB. Most of the patients got a combined injection of patentblue and Technetium. The intraoperative detection rate of SN was 83% (for the whole patient collective). Only one patient (1,4%) had a false negative SN.

Discussion:The SNB can be established with the same technical and oncological findings as described in the literature.

INTEREST OF THE THREE-DIMENSIONAL ULTRASOUND EVALUATION OF SUBURETHRAL TAPE AFTER TVT-O PROCEDURE

Imaging

Poster

Guillaume Legendre*, Levaillant Jean-Marc, Fernandez Hervé

Hopital Bicêtre - APHP

Summary (4 lines): 3D Ultrasound examination is very useful in the evaluation of the position of anti-incontinence tape. A sling too closer from the bladder neck is causes of overactive bladder.

Introduction: The aim of the study is to define the place of 3D-US in the post-operative evaluation of suburethral slings, especially in order to predict further complications.

Material and Methods: Prospective study of 32 consecutive cases of TVT-O procedures for stress urinary incontinence (SUI) from November 2010 to December 2011. A 3D pelvic floor examination was performed between 6 and 9 weeks after the TVT-O procedure. The tape position was det

Results: A 3D ultrasonography was available for each patient. For 30 patients (93.7 %) the tape seems to be well spread. The mean distance between the tape of the bladder neck was 13.1 mm (2.8-20). A short distance is significatively associated with an over-active bladder after such surgery. (p=0.002).

Discussion: A 3D ultrasonography was available for each patient. For 30 patients (93.7 %) the tape seems to be well spread. The 3D Ultrasound seems to be a good exam to evaluate the good positioning of the sling and to predict overactive bladder symptoms.

MICRORNA MIR-145 AS A POSSIBLE PATHOGENETIC MARKER IN ENDOMETRIOSIS

Endometriosis: Diagnosis

Poster

Sebastian Daniel Schaefer*, Adammek Marlene, Greve Burkhard, Kässens Nadja, Schüring Andreas, kiesel ludwig, Götte Martin

Summary (4 lines):Expression of microRNA-145 is dysregulated in endometriosis. The current study on endometriotic cells of laparoscopically confirmed endometriosis patients validates microRNA miR-145 as a functionally relevant marker.

Introduction: microRNAs are small noncoding RNAs which regulate gene expression at the posttranscriptional level. miR-145 has been shown to be misexpressed in endometriosis, suggesting an involvement in the pathogenesis of this disease. The objective of the present study was to identify and confirm target genes and proteins of miR-145 and to study the functional consequences of miR-145 dysregulation in vitro using an endometriotic cell line and primary eutopic and ectopic endometrial stroma cells.

Material and Methods:The human endometriotic cell line 12Z and primary eutopic and ectopic endometrial stroma cells were transfected with miRNA precursors and investigated for posttranscriptional regulation of predicted target genes and changes in cell behavior. Predicted ta

Results: miR-145 overexpression inhibited cell proliferation and induced down-regulation of FASCIN-1, SOX2, and MSI2. In 12Z cells miR-145 upregulation reduced Matrigel invasiveness and side population and aldehyde dehydrogenase-1 activity. JAM-A, FASCIN-1, and PAI-I down-regulation in 12Z cells were confirmed by Western blotting.

Discussion: miR-145 modulates endometriotic cell proliferation and invasiveness by targeting the expression of cell adhesion molecules, cytoskeletal elements and pluripotency factors. Ectopic expression of miR-145 may emerge as a novel future therapeutic concept in endometriosis.

INHALATORY ANALGESIA WITH NITROUS OXIDE VS OTHER ANALGESIC TECHNIQUES: PILOT STUDY

Diagnostic & Operative Office Hysteroscopy

Oral

Cristina del Valle Rubido*, Solano Juan Antonio, Juez Pedro, Marcos González Victoria, Heras Sedano Irene, Zapico Goñi Alvaro, Delgado Espeja Juan Jose

Hospital Universitario Príncipe de Asturias

Summary (4 lines): Analgesia with Nitrous Oxide(NO) seems very successful and could be widely used for hysteroscopic polipectomy, increasing the patient´s satisfaction and well-being during the procedure.

Introduction: This is a sequential study of 120 patiens from Area III of Madrid Community, diagnosed of endometrial polyps in gynecological office. Our aim is to demonstrate the decrease in pain and better tolerance to hysteroscopic polypectomy by using inhalatory analgesia with 50% equimolar mixture of NO and oxygen, comparing it to paracervical anesthesia and control group. Although this study clearly shows the advantages of NO, a wider randomized study is being developed to confirm these results.

Material and Methods: We have used a double-way 5.5mm hysteroscope with 0.9% saline solution (Karl-Storz- Bettochi Endoscope). Polipectomy was performed with Karl-Storz scissors or 5Fr Twizzle Electrode (Gynecare- Versapoint). NO was administered by "On-demand Flow": an administration device with a valve that regulates the flow according to the patient´s demand during inhalation, and stops it during exhalation.

Results: Pain perceived by patients was lower in the NO group with a median of 30 on VAS, and show no difference between the control and paracervical analgesia groups (median 50). Tolerance to pain, assessed by medical staff, was better in NO group, with statistically significant differences (p lower than 0.05)

Discussion: NO had a lower rate of adverse effects(AE), with statistically significant differences. The most common were nausea and dizziness. No severe AE took place. This study shows better results for NO in pain control during hysteroscopic polipectomy and lower rate of AE.

PROXIMAL OCCLUSION OF HYDROSALPINGES BY ESSURE ® BEFORE IN VITRO FERTILIZATION: A FRENCH SURVEY

Infertility and Reproductive Medicine

Oral

Guillaume Legendre*, Moulin Julie, Fernandez Hervé

Hopital Bicêtre - APHP

Summary (4 lines): Hysteroscopic placement of Essure® is a minimally invasive and efficient way to occlude hydrosalpinges before infertility care. These results assess the feasibility and safety of this procedure. Furthermore, live birth rate resulting is comparable to one’s expected in women without hydrosalpinges.

Introduction: Diseases of the fallopian tube, such as hydrosalpinx can severely reduce the chances of pregnancy from in vitro fertilization (IVF) . The aim of this study is to evaluate the feasibility and results in terms of live birth rate and complications of Essure® placement before IVF-ET (in vitro fertilization-embryo transfer) for infertile women with hydrosalpinges.

Material and Methods: A Nationwide survey resulting in investigating the cases of Essure® placement for hydrosalpinges between January 2005 and 2013 among french centers. Retrospective analysis of 43 cases of microinsert placement before IVF with clinical pregnancy and implant

Results: Fourty three infertile women were included. The procedure was successful in 92.8% (65 tubal proximal placement out of 70 pathological tubes) and the mean intrauterine coils was 1.61 (range 0 to 6). Clinical pregnancy and live birth rates per transfer were respectively 40.7% and 25.9%. Implantation rate was 29.3%.

Discussion:Hysteroscopic placement of Essure® is a minimally invasive and efficient way to occlude hydrosalpinges before infertility care. These results assess the feasibility and safety of this procedure. Furthermore, live birth rate resulting is comparable to one’s expected in women without hydrosalpinges. Additional trials are necessary to confirm our datas.

3D PERINEAL ULTRASOUND TO ASSESS TRANSVAGINAL MESH AFTER ANTERIOR VAGINAL WALL PROLAPSE SURGERY

Urogynaecology

Oral

Guillaume Legendre*, Levaillant Jean-Marc, Fernandez Hervé

Hopital Bicêtre - APHP

Summary (4 lines): 3D Ultrasound seems to be useful to evaluate the good positioning of the mesh and to predict further complications.

Introduction: The aim of this study is to define the place of 3D Perineal Ultrasound in the post-operative evaluation of prolapse meshes (Anterior Elevate System ; AMS).

Material and Methods: A prospective study of 43 consecutive cases of symptomatic stage 2 or greater cystocele repair from May 2010 to December 2012 and evaluated thanks to 3D ultrasound were evaluated. All cystocele repairs used polypropylene mesh. The 3D pelvic floor examina

Results: Clinical success rate was 95.3% . 3D ultrasound follow-up was available for each patient. A post-operative diminution of 42 % and 39 % of mesh dimensions respectively in height and in width occurred. Good spreading was noted in 88.4 %. Clinical findings were concordant with 3D US.

Discussion: 3D Ultrasound seems to be useful to evaluate the good positioning of the mesh and to predict further complications.

A NEW SURGICAL METHOD TO CURE URGE URINARY INCONTINENCE (UUI) IN WOMEN

Innovation in Instrumentation and Surgical Techniques

Oral

Wolfram Jäger*, Ludwig Sebastian, AbuDabbous Mohamed

University of Köln

Summary (4 lines): According to the results of experiments in rhesus monkeys we developed a surigcal method to replase the utero-sacral ligaments (USL). So far more than 800 patients were operated and a cure rate of 77% of patients with UUI was obtained.

Introduction: Urge Urinary Incontinence (UUI) was considered to be a neurologically induced disorder. We, however, suspected that the pathogenesis is largely influenced by the body position - upright or lying. In rhesus monkeys we observed the critical role of the USL for establishment of continence. We therefore developed an operative procedure to support/replace the USL in women suffering from UUI

Material and Methods: The USL in patients with UUI were usually histologically reduced to 15% of the composition of continent women. We replaced the USL by different alloplastic tapes using different lengths and different operational ways cesa and vasa

Results: So far more than 800 patients with UUI were operated with cesa or vasa. The overall cure rate was between 77% and 83% - sometimes in combination with a TOT. The follow-up revealed that the materials were of utmost importance for long-time success.

Discussion: UUI could not be cuired so far. Our experiments showed that it is the result of an anatomical change in the USL. cesa and vasa can cure UUI.

INEXPENSIVE AND VERSATILE ENDO TRAINER: THE DO IT YOURSELF WAY

Teaching & Training

Video

Ricardo Sousa-Santos*

Centro Hospitalar Entre Douro e Vouga

Summary (4 lines): The construction of an inexpensive, “do it yourself” laparoscopy training model is presented, that allows for versatile, autonomous training of surgeons.

Introduction: Laparoscopic surgery presents new challenges to an accomplished surgeon. Simulation enhances learning and perfecting of new skills before their use in live patients. However, training is often expensive if there is no free access to a skills laboratory. Buying a commercial training model is often prohibitively expensive for use at home.

Material and Methods: A plastic storage box was modified for multiple port simulation, with a pluggable light source, a high definition web camera and open source software for visualization, as well as custom pads that may be modified for specific training.

Results: 65 Euros worth of materials were bought, excluding laparoscopic instruments. The training box was built in a few hours, with some basic tools, present in many households. The resultant box includes inexpensive light and video sources and can be connected to almost any computer.

Discussion: An easy to make, versatile training model, may be used by beginners and accomplished surgeons alike, either to improve hand-eye coordination or to learn and perfect certain techniques, such as suturing. The investment is scarce and the result should encourage other colleagues to build and improve this training aid.

LAPAROSCOPYC SURGERY OF ADNEXAL MASS DURING PREGNANCY

Infertility and Reproductive Medicine

Poster

Alexander Popov*, Logutova Lidiya, Manannlkova Tatiana, Fedorov Anton, Ramazanov Murad, Machanskite Olga, Golovin Alexander

Moscow Regional Reserch Institute O\G

Summary (4 lines): adnexal cysts often become a reason of cesarean section. 276 patients who was undergoing surgical laparoscopy in 16-18 weeks of gestation

Introduction: adnexal cysts usually leads to pregnancy abnormalities, often become a reason of cesarean section. Typical removing technique of tumor for these patients is laparotomy. In some cases laparoscopycal acces is possible.

Material and Methods: 413 pregnant patients were divided on 3 groups: 1 group 276 patients LS in 16-18 weeks of gestation; 59 patients cesarean section with tumor removement; LS at 78 patients from 3 group on 5-9 day after delivery. Laparoscopy in pregnant patients have sev

Results: 263 patients group 1 were delivered, 3 patients are pregnant, 9 patients delivered by CS. In 2 case histologicaly ovarian cancer were found, Among patients with successful vaginal delivery we did not mention any complications such as cyst perforation, bleeding or distortion of ovaries.

Discussion: 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.

ENDOSCOPY IN DIAGNOSTICS AND TREATMENT OF INCOMPETENT UTERINE SCAR AFTER CESAREAN SECTION

Infertility and Reproductive Medicine

Poster

Alexander Popov*, Logutova Lidiya, Fedorov Anton, Chechneva Marina, Barto Ruslan, Krasnopolskaya Irina, Slobobiniyaouk Boris, Zemskov Yuri

Moscow Regional Reserch Institute O\G

Summary (4 lines): 101 patients with scar incompetency after cesarean section was treated lower segment reconstruction was done in 48 cases by laparotomy at 10-40 days. 40 times after conservative treatment surgery was done 18-24 months later at pregnancy planning stage. 26 patients were treated by laparotomy, 14 by laparoscopyс aproach.

Introduction: Cesarean Section rate In Moscow Regional Inst. O\G , 23.7% in 2008, 24.9% in 2009. In 2010 among 2177 deliveries after cesarean section was 203(9,3%) patients. In these group scar defect – niche formation was detected in 79 (38,9%) and become an indication for repeated cesarean section. Puerperal endometritis in our region detected in 3-4% cases after cesarean section and become a most common reason of this complication.

Material and Methods: from 2006 till 2012 101 patients with scar incompetency CS was treated. Indication were scar inconsistency with niche formation and puerperal endometritis. 61 patients were undergoing surgery at first 40 days after childbirth. 40 women were treated befo

Results: lower segment reconstruction was done in 48 cases by laparotomy at 10-40 days. Hysterectomy in 13 cases. 40 times reconstruction at pregnancy planning stage . 26 patients LT, 14 by LS aproach. Successful childbirth by CS in LT group was in 15 times, in LS group in 2 cases.

Discussion: The most often reason of uterine scar inconsistency after cesarean section is puerperal endometritis. Ultrasound investigation of scar condition with hysteroscopy allowed to identify patients who can be treated with uterus preservation in puerperal and delayed period by laparotomyc and laparoscopyc aproaches.

USE OF PROPHYLACTIC ANTIBIOTICS IN GYNAECOLOGICAL ENDOSCOPY IN THE UK. DO WE NEED A GUIDELINE?

Operative Risk Management

Poster

Vasileios Minas*, Gul Nahid, Rowlands David

Wirral University Teaching Hospital

Summary (4 lines): We conducted a survey which suggests significant variation in clinicians’ practice and potential overuse of prophylactic antibiotics in gynaecological endoscopy in the United Kingdom.

Introduction: Surgical site infection is a common post-operative complication that can result to increased morbidity, prolonged hospital stay and readmission. Pre-operative antibiotics may prevent such infections. Unnecessary prophylaxis however can be detrimental due to adverse reactions, emergence of resistant bacteria and additional costs. Endoscopic procedures are thought to carry a low risk of surgical site contamination and therefore antibiotics may not confer any additional benefit. Many European countries, including the UK, lack relevant guidelines.

Material and Methods: The survey was designed using the SurveyMonkey® website (www.surveymonkey.com) and emailed to the members of the British Society for Gynaecological Endoscopy (BSGE). The members were asked to select “yes”, “no”, “unsure” or “I do not perform this procedur

Results: Seventy nine BSGE members responded to our survey. There is significant variation in clinicians’ practice in intermediate level laparoscopy. One in 8 surgeons administers antibiotics for diagnostic laparoscopy, whereas 1 in10 do so for diagnostic hysteroscopy. Hospitals often lack such guidelines. A national guideline would be welcomed by most responders.

Discussion: Antibiotic prophylaxis is over-utilised in gynaecological endoscopy in the UK. Production of relevant national recommendations is likely to benefit both patients and hospitals and will provide coherence in clinical practice. These conclusions are likely to be also applicable to other European countries.

IDIOPATHIC BRACHIAL PLEXUS NEURITIS VS BRACHIAL PLEXUS INJURY FOLLOWING LAPAROSCOPY. CAN YOU SPOT THE DIFFERENCE?

Complications

Poster

Vasileios Minas*, Aust Thomas

Wirral University Teaching Hospital

Summary (4 lines): We report a case of idiopathic brachial plexus neuritis (IBN) following laparoscopic excision of endometriosis. The differential diagnosis between this non-position-related neuritis and brachial plexus injury is discussed.

Introduction: IBN was reported in 1948 by Parsonage and Turner and presents with shoulder girdle pain followed by profound weakness. The syndrome is of unknown aetiology and has been described as a potential post-operative complication. In gynaecology there exists a report of IBN following hysteroscopic surgery. In the post-operative patient the appearance of IBN symptoms may lead to misdiagnosis as they can be attributed to brachial plexus injury (BPI) due to peri-operative patient positioning.

Material and Methods: A 37-year-old woman underwent laparoscopic excision of endometriosis. The operation was performed in Trendelenburg position. The patient’s head was kept in a neutral position and her arms were placed straight by her side. She had an initially uneventful r

Results: Clinical examination revealed wasting and weakness of the infra-spinatus muscle i.e. likely isolated supra-scapular nerve palsy in keeping with IBN. Magnetic resonance imaging showed atrophy of supra-spinatus and infra-spinatus left shoulder muscles without evidence of nerve compression. Nerve conduction studies confirmed the diagnosis of IBN. Recovery was enhanced with physiotherapy.

Discussion: IBN may complicate laparoscopic gynaecological surgery. It can be transiently debilitating for the patient and distressing for the surgeon, with potential medico-legal implications if misdiagnosed as BPI. The diagnosis must be based on history, clinical examination, absence of evidence of nerve compression in MRI and confirmation by electromyographic studies.

LAPAROSCOPIC CERVICAL CERCLAGE IN PATIENT WITH RECURRENT PREGNANCY LOSS (CLINICAL CASE)

Case reports

Poster

Veresnyuk Nataliya*, Pyrohova Vira, Vernikovskyy Igor, Malaschynska Mariya

Lviv national medical university

Summary (4 lines): Cervical incompetence is the cause of 18 to 37% of the second trimester pregnancy losses. Abdominal cervical cerclage is quite appropriate procedure for women who have the history of previous failure of vaginal cerclage.

Introduction: The numerous methods are presently used for the surgical treatment of cervical incompetence. For many years the traditional treatment of this condition has been the transvaginal cervical cerclage. But this procedure is ineffective in the number of cases due to the technical difficulties of putting stitches on the uterine cervix, the development of the ascending infection etc. Here we describe our first case of the laparoscopic cervical cerclage in a patient with recurrent miscarriage.

Material and Methods: Case presentation. We have performed laparoscopic cervical cerclage using mersilene tape suture before pregnancy in order to treat cervical incompetence in 31-year-old woman who had four late abortions and the history of failure of the vaginal cerclage (t

Results: We performed a low transverse caesarean section after premature rupture of membranes and the insignificant vaginal bleeding (at 37.4 weeks). The weight of boy was 3200 g and the Apgar score was 7/8. We removed the tape because there was partial slipping of tissues of uterine isthmus past the tape.

Discussion: The abdominal procedure in contrast to vaginal cerclage is more difficult to perform and is more dangerous due to its potential complications (uterine rupture, haemorrhage, intrauterine fetal death etc). The patients who have undergone laparoscopic cervical cerclage require a careful supervision and need to be delivered by caesarean section.

CONCENTRATION OF VEGF, FGF IN SERUM AND PERITONEAL FLUID OF WOMEN WITH ENDOMETRIOSIS AND INFERTILITY

Endometriosis: Diagnosis

Oral

Krzysztof Gałczyński*, Gogacz Marek, Adamiak Aneta, Romanek-Piva Katarzyna, Rechberger Tomasz

Medical University of Lublin, Poland

Summary (4 lines): Concentrations of VEGF and FGF in serum and peritoneal fluid in patients with endometriosis or infertility didn`t differ between groups. Higher concentrations of these factors were observed in peritoneal fluid.

Introduction: Angiogenesis is a fundamental biological process regulated by a balance between pro- and antiangiogenic factors. Physiologically it occurs in the female reproductive system and during wound healing. The most important mediators of angiogenesis are VEGF and FGF. These factors are responsible for physiological and pathological angiogenesis. Establishing of a blood supply is crucial for the development of endometriotic changes. This process may also play an important role of unknown significance in patients with infertility.

Material and Methods: Levels of VEGF and FGF were measured by enzyme-linked immunosorbent assay in samples containing serum (S) and peritoneal fluid (PF) of 39 patients (19 with confirmed endometriosis and 20 with diagnosed idiopathic infertility) who underwent laparoscopy

Results: Endometriosis vs idiopathic infertility (pg/ml) (S) VEGF: 194,3 ± 390,6 vs 146,7 ± 263; p= 0,66 FGF: 10,5 ± 9,6 vs 10,1 ± 4,6; p= 0,89 (PF) VEGF: 242,08 ± 495 vs 139,53 ± 80,37; p= 0,37 FGF: 16,59 ± 18,53 vs 13,51 ± 14,05; p= 0,56

Discussion: VEGF and FGF are present in S and PF of both groups. Concentrations of these angiogenic factors were higher in PF in comparison with the S in both groups. The local synthesis of these angiogenic factors (PF) is probably higher than systemic (S)

LAPAROSCOPIC STRIPPING OF DIAPHRAGM AS A COMPONENT OF COMPLETE CYTOREDUCTIVE SURGERY IN ADVANCED OVARIAN CANCER

Oncology

Video

Yasuhiko Shiki*, Kim Yong-Kok

Osaka Rosai Hospital

Summary (4 lines): Using laparoscope, wide horizontal incision along costal margin is avoided and good visualization for operation is obtained. Shorter post operational hospital stay is achieved.

Introduction: To achieve complete cytoreductive surgery in advanced ovarian cancer, a thorough stripping of parietal peritoneum include diaphragm is needed. By using laparoscope, stripping of diaphragm can be achieved without wide horizontal incision along costal margin, and good visualization of surgical area can be obtained. Surgical techniques used in laparoscopic surgery, operational outcomes and complications were examined retrospectively.

Material and Methods: 11 consecutive patients of ovarian cancer stage 3, surgical intervention to whom accompanied with stripping of diaphragm, are included. Laparoscopic stripping was done in 10 cases. Laparotomy followed to complete cytoreductive surgery in 9 cases. Laparotomy was done in 1 case due to massive intraabdominal tumor and dissemination.

Results: Average CO2 inflation time was 182 minutes. Accidental thoracotomy occurred in 5 out of 11 cases, but managed safely by suturing defected area of diaphragm. Post operational hospital stay was 3 days in laparoscopic group, 12 days in conversion group, and 46 days in laparotomy group.

Discussion: Anatomical knowledge on the relation of diaphragm and thoracic cavity and the two ligaments attached to liver and its relation to hepatic vein and IVC are important in stripping diaphragm. Trouble shooting for accidental thoracotomy is also an essential part of this procedure.

LAPAROSCOPIC REMOVAL OF MISSING SURGICAL SWAB SIX MONTHS AFTER LAPAROTOMY

Complications

Video

MAKEDOS ANASTASIOS*, Pados George, Makedos Anastasios, Dimitrios Tsolakidis, Almaloglou Konstantinos, Tarlatzis Basil

1st Dept Obs&Gynae/ Aristotle University

Summary (4 lines): Video presentation of laparoscopic removal of a missing surgical swab, 3.5 years after laparotomy, in a 25 year old woman who had been operated for hydrosalpinx prior to IVF treatment.

Introduction: Missing swabs or gauges is not an extinct situation during laparotomy. The most common complication is intraperitoneal abscess and plastron of the foreign body with the bowels, as long as adhesions in the lower pelvis. The standard practice is to re-operate the patient by laparotomy and remove the swab. In the present video we will demonstrate the use of laparoscopy regardless of the size of the foreign body or the expected intraperitoneal adhesions.

Material and Methods: A 25 year old woman was operated in a private district hospital by laparotomy for right hydrosalpinx, prior to IVF treatment. The patient presented chronic pelvic pain for the following 3.5 years. A CT-scan was performed and the report was indicative of f

Results: Patient was discharged on the next day and on a follow-up she didn’t report chronic pelvic pain. The patient became pregnant at the second IVF trial.

Discussion: Laparoscopic surgery is a successful technique for removal of missing foreign bodies into the abdomen even after laparotomy. Keys to successful result are the competence of the surgeons and precise pre-operative evaluation of the size of the swab and the possible extend of the adhesions formed.

PARASITIC MYOMA POST SUPRACERVICAL LAPAROSCOPIC HYSTERECTOMY: A NEW AGE FOR IATROGENY CAUSED BY MORCELLATION?

Complications

Poster

Maurício Paulo Angelo Mieli*, Mattos Leandro Accardo, Grell Ana Maria Sampaio Moreira

Hospital Universitário - Universidade de São Paulo

Summary (4 lines): Parasitic myoma occurs spontaneously or as a consequence of surgical iatrogeny. Two patients developed parasitic myoma after videolaparoscopic supracervical hysterectomy, having the uterine body removed through morcellation.

Introduction: Parasitic myoma is defined as a myoma of extrauterine nourishing. It may occur spontaneously or as a consequence of surgical iatrogeny, after myomectomy or videolaparoscopic supracervical hysterectomy, due to remaining residues of uterine tissue fragments in the pelvic cavity after morcellation. After myomectomies or videolaparoscopic supracervical hysterectomies followed by uterine fragments removal from the pelvic cavity through morcellation, the search for residues or fragments of uterine tissue is mandatory, preventing the occurrence of parasitic myomas.

Material and Methods: Two patients were submitted to videolaparoscopic supracervical hysterectomy and uterine body removal through morcellation. The development site for the parasitic myomas was close to the cervix stump (case 1) and to the right round ligament (case 2). Both patients were submitted to videolaparoscopic surgery.

Results: The surgical findings were for both cases a solid mass with fibromuscular appearance. In Case 1, close to the uterine stump and in Case 2, close to the round right ligament stump. The surgical diagnosis was leiomyoma. Pathologic examination: leiomyoma for both cases.

Discussion: Parasitic myomas is divided in three categories: spontaneous development from pedunculated myomas; myomas with previous uterine surgical intervention using morcellation; and myomas with restriction uterine blood supply. Parasitic myoma remain as condition of rare occurrence. Iatrogenically caused parasitic myomas may be diagnosed with a higher frequency in the laparoscopic era.

SECONDARY INFERTILITY DUE TO INTRAUTERINE RETAINED FETAL BONE FRAGMENTS

Diagnostic & Operative Office Hysteroscopy

Poster

Julian Habibaj*, Bare Teuta, Kulenica Elisabeta, Lelcaj Mark, Murati Arben, Aliko Hysnie

University Hospital "Queen Geraldine"

Summary (4 lines): Retained fetal bones after a second trimester pregnancy were removed with a hysteroscope, in outpatient settings, using additional instruments, not designed for hysteroscopy.

Introduction: Intrauterine retention of fetal bones is a rare condition. The most common cause, among the reported cases, is a previous second trimester abortion. Transvaginal ultrasonography is important for an accurate diagnosis. Most patients complain of dysmenorrhea, dysfunctional uterine bleeding, pelvic pain, dyspareunia, vaginal discharge, or spontaneous passage of fetal bones. In this report, we describe a novel technique used in a rare case of secondary infertility due to prolonged retention of intrauterine bone after curettage.

Material and Methods: We introduced an alligator forceps inside the uterine cavity, in a parallel manner to the hysteroscope shaft. The alligator forceps were advanced slightly further than the hysteroscope shaft. With this technique, the ossified material was broken, and the

Results: A histopathological analysis confirmed that the structures contained bone fragments. Three months after the procedure, the patient was found to be free of pain or vaginal discharge. A repeated hysteroscopy showed a normal uterine cavity. The patient is pregnant one year from removal of body structures from intrauterine cavity.

Discussion: Intrauterine retention of fetal bone is a rare complication of abortion and can cause secondary infertility. In some cases, the removal of remnant bone may be performed in an outpatient setting during diagnostic hysteroscopy, using additional instruments not designed for hysteroscopy.

LAPAROSCOPIC EXCISION OF ENDOMETRIAL OSSIFICATION; AN EVOLVING CAUSE OF CHRONIC PELVIC PAIN

Case reports

Poster

Jong Min Lee*, Lee Kwang-Beom

Kyung Hee University Hospital at Gangdong

Summary (4 lines): A 27-year-old, gravida 2, para 1 woman with chronic pelvic pain that had lasted for 2 years. On MR finding, bony fragment and intramural uterine hematoma were observed. Laparoscopic mass removal and pathologic examination was performed. Nine months after laparoscopic management, subjective pain symptoms were significantly improved.

Introduction: Endometrial ossification is the formation of bone from an endometrial tissue inside the same individual, and has also been described as osseous metaplasia of the endometrium, ectopic intrauterine bone and heterotopic intrauterine bone formation. It is a rare occurence, with

Material and Methods: A diagnostic laparoscopy performed that revealed a 4 x 4 cm sized whitish solid mass. A laparoscopic mass removal and primary repair was performed in the operating room

Results: Histology of the solid tissue fragments was consistent with heterotopic bone formation. Nine month after the removal of the osseous tissue, she kept the improved state

Discussion: Endometrial ossification in women without abortive experience is very rare; most women presenting with this condition have recent history of abortion. Therefore, clinicians should consider the possibility of endometrial ossification as a differential diagnosis of chronic pelvic pain.

15 YEARS EXPERIENCE OF CLASSIC INTRAFASCIAL SUPRACERVICAL HYSTERECTOMY (CISH), A RETROSPECTIVE ANALYSIS OF 1,584 CASES

Hysterectomy

Poster

Jong Min Lee*, Lee Kwang-Beom

Kyung Hee University Hospital at Gangdong

Summary (4 lines): A retrospective analysis was conducted to determine the rate of intra- and perioperative complication of total 1,584 CISH operations. The total complication rate was 3.7%. The conversion rate to laparotomy was 0.44%. CISH is considered as a safe option of hysterectomy for benign disease with a low perioperative mobidity and high patient satisfaction.

Introduction: The main purpose of this study is to report and review our 15-years experience with classic intrafascial supracervical hysterectomy(CISH) focusing on our long-term experience and intraoperative and perioperative complications.

Material and Methods: CISH procedure is mainly consisted of preservation of uterosacral ligament and removal of endocervical canal. We performed a retrospective analysis of consecutive 1,584 CISH cases at Kyung Hee University Hospital, Seoul, Korea over a 15-year period from A

Results: In 1,584 patients undergoing CISH, mean operation time was 75.5 ± 31.4 min. The median age was 47 years (range, 29 to 78). The total complication rate was 3.7%. In seven cases, conversion to laparotomy was necessary due to intraoperative complications such as bowel injury, ureteral injury and bleeding.

Discussion: In this study, the rate of complications of CISH was very low. CISH is considered as a safe option of hysterectomy for benign disease with a low perioperative mobidity and high patient satisfaction.

THE EFFECTIVENESS OF LAPAROSCOPIC HO-YAG-LASER DRILLING IN WOMEN WITH INFERTILITY AND POLYCYSTIC OVARIES SYNDROME

Infertility and Reproductive Medicine

Poster

Tea Dzhibladze*, Ischenko Anton, Gorbenko Oksana, Agadjanyan Ella , Ischenko Anatoliy, Zuev Vladimir, Dzhibladze Tea

Moscow medical setchenov university

Summary (4 lines): Ho-Yag Laser was used in 36 patients with polycystic ovaries to get better results in hormone stimulations in IVF programs.

Introduction: Polycystic ovaries syndrome remains unsolved problem in gynecology. Polycystic lesions follow hormone disbalance and infertility. Laparoscopic Ho-Yag-laser drilling in ovaries suggest to be effective in hormonal stimulation of ovulation in IVF programs

Material and Methods: To evaluate laser drilling in ovaries in patients with polycystic syndrome and IVF programs.36 patients age of 32,6±1,4 years with primary infertility and polycystic ovaries syndrome and IVF. Lab investigations included biochemical, hormonal tests, sonography etc. Surgery was performed on 5-7 day of menstrual cycl.The number of apertures depended of square and volume of ovaries and was 8-12.

Results The follow up period included 6 months. The pregnancy rate was 71,4%, after 1st procedure 56% and 44% of women after the 2d. The androgene serum level decreased in 4,6% of patients (testosterone level

Discussion: Laser surgery in the treatment of polycystic ovaries could be an alternative for prehormone stimulation management. Results depends of apertures amount and number destroyed follicules.

HYSTEROSCOPIC MYOMECTOMY AS THE METHOD OF CHOICE FOR PATIENTS WITH LARGE SUBMUCOUS FIBROIDS AND INFERTILITY

Diagnostic & Operative Office Hysteroscopy

Poster

Oleksiy Aleksandrov*, Popova Lidija

Odessa National Medical University

Summary (4 lines): The study demonstrates high effectiveness of hysteroscopic myomectomy with absence of complications and good reproductive outcome for patients with large submucous fibroids and infertility

Introduction: Leiomyomas are the most common benign tumor found in women, as they affect 15-25% of women in the reproductive age group. Submucosal tumors, which derive from myometrial cells just below the endometrium, account for approximately 20% of fibroids. When we use hysteroscopic myomectomy for removing of large fibroids (>3-4cm) it can be controlled by laparoscopy. At the same time the endometrium should preferentially be in the early proliferative phase.

Material and Methods: There were 97 women (27-39 years olds) with large submucous fibroid (3,7-5 cm) observed. All patients had primary and secondary infertility caused by different factors (hormonal disorders, adhesions, male factors, idiopathic etc.). There was not prescribed any preoperative treatment with GnRH agonists. The mean term of infertility (2,6 ± 1,3 years). Hysteroscopic myomectomy was performed in all cases. Excisions usually began from the top of the fibroid, progressing in a uniform way towards the base, also in the case of a pedunculated fibroid. In 32 cases (the tumor size > 4,5 cm) this procedure was controlled by laparoscopy to prevent uterine perforation. The mean time of operation was 25±5,1 min.

Results: We did not reveal any complications after these operations. Two-step operations were performed in 19 cases where we could not remove whole fibroid tissue properly. Such women were operated repeatedly after 5 weeks. Thirty eight women have become pregnant during the next 2 years and they had deliveries through the natural passages with 9 women whom caesarean section was performed (indications included severe fetal hypoxia, dystocia and placental abruption).

Discussion: The results have proved high effectiveness of hysteroscopic myomectomy with pregnancy rate as well as the live birth rate in selected women. This method has to be more largely used for such category of patients. Diagnostic laparoscopy enables to avoid many possible complications and perform laparoscopic myomectomy if it is required.

LAPAROSCOPIC APPROACH TO TUBO-OVARIAN ABSCESSES

Case reports

Poster

Oleksiy Aleksandrov*, Shevchenko Olga, Anufriev Michael

Odessa National Medical University

Summary (4 lines): In this study laparoscopic approach to tubo-ovarian abscesses was evaluated. Laparoscopic surgery has significant advantage in terms of preserving hormonal and reproductive function. This approach is usually safe, efficacious, cost-effective and minimally invasive.

Introduction: Tubo-ovarian abscess and complex is a severe complication of PID which also can result in pyosalpinx and peritonitis. Findings indicate that TOA develops in up to 30% of women hospitalized for PID. The approach to TOA is still a highly debatable issue. The abscess cavity should be thoroughly irrigated and aspirated until all pus is completely removed. The most problematic cases are the antibiotics-resistant tubo-ovarian abscess.

Material and Methods: There were 126 women with TOA observed. The mean age was 28±7,1 years. A unilateral TOA was present in 116 patients (92%). All patients were operated using laparoscopic access. All patients were treated during 72 hours before operation using broad-spectrum antibiotics, infusion therapy (2-3 liters per day), anti-inflammatory drugs, immunomodulatory drugs, etc. The mean time of an operation was 35±13,5 min. We were focused on saving ovarian tissue for infertile and nulliparous women.

Results: There was performed lysis of pelvic adhesions, drainage and irrigation of the pelvic cavity with 5 liters of physiologic saline. Removing of a unilateral infectious complex and resection of ovary was done for 81 patients. There was not revealed any complications after using this strategy.

Discussion: Laparoscopic surgery which diminishes postoperative complications should be the first choice in the managing of TOA. However, it is a main priority to provide adequate preoperative treatment and postoperative rehabilitation.

PREOPERATIVE TREATMENT FOR PATIENTS WITH ENDOMETRIOSIS

Endometriosis: Surgery

Poster

Oleksiy Aleksandrov*, Tatjana Lunko

Odessa National Medical University

Summary (4 lines): This research shows high effectiveness of preoperative treatment by semisynthetic, steroidal progestogen - Dienogest for women with endometriosis and infertility. Dienogest is almost completely absorbed with high bioavailability after oral administration.

Introduction: Among women with pelvic pain, the prevalence of endometriosis ranges up to 21% and it is diagnosed in 17% of women with primary infertility. Progestins apply an antiproliferative effect by causing initial decidualisation of endometrial tissue followed by atrophy. They should be used as a first line for treatment of endometriosis because they are as effective in reducing AFS stages and pain as danazol or GnRH analogues and have a lower incidence of negative effects.

Material and Methods: There were 157 women (mean age 29,7±3,3) who had endometriosis associated with chronic pelvic pain and infertility (primary and secondary) more than from 12 to 18 months. All women were prescribed steroidal progestogen - Dienogest (2 mg per day) during 3-4 month before laparoscopy was performed. There was confirmed endometriosis: 1-2st-52%, 3st-37%, 4st-11%. The mean time of operation was (47±12 min) with peritoneumectomies ecsisions, coagulation and ovarian resections to be performed.

Results: We did not reveal any significant complications after such operations. There were 72(45,6%) women who get pregnant during 3-4 month after operation. Chronic pelvic pain significantly reduced among 104 (66%) patients with 53 who did not complain of it.

Discussion: The results have proved high effectiveness of preoperative treatment which has anti-adhesive, anti-inflammatory and anti-proliferative effects. This reduces operational time, improves quality of life and reproductive outcome. Despite this fact endometriosis is a chronic oestrogen-dependent disease so further hormonal treatment may be needed.

THE USE OF SYNTHETIC ENDOPROTESIS IN TREATMENT OF GENITAL PROLAPSE : OUR EXPERIENCE

Urogynaecology

Poster

Oleksiy Aleksandrov*, Beblo Vadim

Odessa National Medical University

Summary (4 lines): The study demonstrates high effectiveness of pelvic floor surgery using a non-absorbable mesh in selected patients.

Introduction: A wide variety of abdominal and vaginal surgical techniques is available for the treatment of pelvic organ prolapse indicating lack of consensus on the optimal strategy. The choice of the type of operation depends on multiple factors such as site and severity of prolapse, additional symptoms, etc. The results of prolapse repair with synthetic mesh are promising, with success rates ranging from 71-100%.

Material and Methods: There were operated 73 women between 2007 and 2011 aged (56 ± 17 years). Cystocele was diagnosed in 32 women, urethrocele with stress incontinence 11, enterocele 9, cervical elongation 7, combined pelvic prolapse 5, rectocele 3, total genital prolapse 6. Prolift® System was used in 27 cases. TVT™ Obturator System was inserted in 4 women with UroSling which was applied in 17 cases. Transvaginal sacrospinous colpopexy Gyneflex - 25 cases.

Results: The complications occurred in 12 cases including intraoperative ( haemorrhages and trauma of the bladder), early post-operative - acute ischuria and late post-operative including vaginal erosion, shrinking of endoprotesis and recidive of apical prolapse. We did not revealed any recidives of cystocele during the all period of observation.

Discussion: The results have proved high efficacy of synthetic endoprotesis in treatment of such category of patients. However, different factors should be considered (age, extragenital pathology, individual characteristics of anatomy and connective tissue, etc.) before the final decision on the use of synthetic endoprotesis is made.

THE VALUE OF LASER CONVERCIAL DIAGNOSTICS IN OFFICE HYSTEROSCOPY

Diagnostic & Operative Office Hysteroscopy

Poster

Tea Dzhibladze*, Zuev Vladimir , Aleksandrov Mikhail, Dzhibladze Tea, Ischenko Anatoliy, Bortsvadze Shorena, Khomeriki Tina, Brynin Dmitriy, Svidinskaya Evgenia

Moscow medical setchenov university

Summary (4 lines): Laser spectroscopy of endometrium via office hysteroscopy elevate quality of diagnostics uterine disorders and could be applied numerously being non invasive.

Introduction: The office hysteroscopy is well known method for diagnostics of intrauterine pathology. Biopsy or curettage and pathomorphology are the gold standard for the determination of the pathology. However, it is surgical intervention and may cause inflammation by itself.

Material and Methods: Laser spectroscopy (laser convention) of endometrium during office hysteroscopy showed to be an effective alternative noninvasive method for determination endometrial disorderes – endometritis, hyperplasia (typic or atypic) and carcinoma. This technique based on rhaman reflection and potentially shows microcirculation, oxygenation, proliferation activity, methabolism, receptors activity. 250 patients with infertility were investigated. In all patients endometritis was aproved hystologicaly. Laser spectroscopy was used for monitoring during the improvement of inflammation and perfect proliferation and secretion.

Results: Laser spectroscopy during office hysteroscopy showed to be effective noninvasive technique for determination of endometrial pathology and may be used for multiple monitoring during treatment.

Discussion: Could spectroscopy be used instead of pathomorphology or it is additional method? The best approach is use the technique in case monitoring with prior pathomorphologic approvement.

LAPAROSCOPIC SACROCOLPOPEXY AND VENTRAL MESH RECTOPEXY AFTER PREVIOUS VAGINAL MESH PROCEDURES

Urogynaecology

Video

Christian Phillips*, Onifade Damola

Hampshire Hospitals

Summary (4 lines):We present a video of laparoscopic sacrocolpopexy and Ventral mesh rectopexy in a patient referred to our unit with symptomatic vault eversion, obstructed defaecation and faecal incontinence after previous failed vaginal mesh

Introduction: The patient had previously had a vaginal hysterectomy with anterior colporraphy, a sacrospinous fixation and then an anterior and posterior vaginal mesh procedure for recurrent prolapse. On examination she had grade 3 vault eversion and rectal prolapse. MR-proctography demonstrated vault eversion along with rectal intussusception and a large recto-enterocoele.

Material and Methods: The patient had a laparoscopic ventral mesh rectopexy for her intussusception and recto-enterocoele and a laparoscopic sacrocolpopexy for the vault eversion. We demonstrate the use of independant tensioning of meshes for greater efficacy and reduced de novo dyspareunia.

Results: At 12 months the patient had resolution of her prolapse symptoms and no constipation or faecal incontinence. She had returned to normal sexual activity. All compartments were at point 0. PGI-I score was “Very much improved”. Review of 13 patients showed symptomatic improvement and significant change in prolapse scores.

Discussion: Laparaoscopic sacrocolpopexy and ventral mesh rectopexy is a safe and effective treatment for patients with prolapse following failed vaginal mesh procedures. There is a learning curve as demonstrated from our data.

SEPTATED HEMATOMETRA AFTER THERMABLATE TREATMENT: A CASE REPORT

Case reports

Poster

C van Seeters*, Koks C

Maxima Medical Centre

Summary (4 lines): We report a case of a septated hematometra 10 months after endometrial ablation.

Introduction: A 44-year old, nulliparous woman, presented with intermittent abdominal pain since three months. There were no other complaints like fever, vaginal discharge and there were no risk factors for a seksual transmitted disease. Her past medical history included an Essure sterilization two years before presentation and a Thermablate endometrial ablation 10 months before. Since the Thermablate treatment she hasn’t had any blood loss related to her menstruation.

Material and Methods: Transvaginal ultrasound showed hypo-echogenic structures in the uterine cavity with a transverse septum, no free abdominal fluid and normal ovaries. Both Essure devices were in situ, confirmed by an abdominal X-ray. An office hysteroscopy was performed, demonstrating an obliterated cervical canal, which was partly opened. After acquiring an entrance, only a small part of the uterine cavity could be reached. An ultrasound afterwards demonstrated two cavities, separated by a septum, suggesting hematometra or pyometra.

Results: Complementary blood tests showed slightly raised infection parameters. A hysteroscopy at the operation room was performed, showing an obliterated cervical canal. After opening, two cavities appeared filled with old blood. The transverse septum could be removed, leaving an open arcuated shaped cavity. Afterwards the woman didn’t experience any pelvic pain.

Discussion: The ablation-related inflammatory reaction causes scarring of tissue between the uterine walls. When there is persistent endometrium, this can cause hematometra. In this case the hematometra was not only caused by an obliterated cervix, but also by the formation of a septum, which divided the uterus in two compartments.

TOTAL LAPAROSCOPIC HYSTERECTOMY: IMPACT OF BODY MASS INDEX ON OUTCOMES

Hysterectomy

Poster

Cristina Nogueira-Silva*, Pereira Elisa, Barata Sónia, Alho Conceição, Osório Filipa, Calhaz-Jorge Carlos

Hospital of Braga

Summary (4 lines): This study demonstrates that total laparoscopic hysterectomy (TLH) is safe regardless the body mass index (BMI), although operating time is longer in obese women.

Introduction: Hysterectomy is one of the most common gynaecological procedures and several studies have demonstrated the multiple advantages of the laparoscopic approach. Obesity was initially considered to be a contraindication for laparoscopy. However, this historical perspective has been disputed. The aim of this study was to assess the effect of BMI on intra-operative parameters and complication rates of TLH.

Material and Methods: We conducted a retrospective observational study, based on a review of medical records of patients who underwent TLH in our department, between April 2009 and March 2013 (n=226). Patient characteristics (age, medical and surgical history), surgical characteristics (surgical indication, operating time, uterine weight, length of hospital stay), and intra and post-operative complications were analysed according to patients’ BMI subclasses [WHO criteria: normal (n=105), overweight (n=80) and obese (n=41)].

Results: Mean operating time was significantly longer in obese patients when compared to women with normal BMI (91.3 ± 37.7 vs. 73.2 ± 25.9 minutes; p=0.01). No significant differences were found amongst all groups in terms of uterine weight, post-operative hospital stay, haemoglobin variation, or major and minor complication rates.

Discussion: This study demonstrates that, in qualified hands, obesity increases only the time necessary to perform a TLH and not the intra or post-operative complication rates. Thus, in our experience TLH is safe, regardless of BMI.

LAPAROSCOPIC SHORTENING OF A SACROHYSTEROPEXY MESH

Tips & Tricks in Surgery

Video

Tom Smith Walker*, Byrne Dominic L

Royal Cornwall Hospital

Summary (4 lines): This video shows the shortening of a mesh used in a laparoscopic Sacrohysteropexy (LSP). It demonstrates that there are minimal adhesions and how easily the mesh can be removed.

Introduction: In 2010 a 72 year old woman underwent laparoscopic Sacrohysteropexy to correct her uterine prolapse. The procedure had recently been introduced to the hospital and the technique was still being perfected. Whilst improved, her symptoms of prolapse remained after surgery. The cause was the mesh being too long. She was offered a repeat operation to investigate the cause and hopefully shorten the mesh. However, it took her three years before she was content to proceed.

Material and Methods: The patient had a repeat laparoscopy, the LSP mesh was left too long. This video demonstrates the mesh being shortened and correcting the patient’s uterine prolapse. The mesh is dissected out, peritonium opened either side and the mesh is then separat

Results: At 3 month follow-up, the prolapse and its accompanying symptoms had gone and the uterus had been returned to its normal position. It also confirms that her recurrence of the prolapse was not due a ‘failure’ of the procedure but due to less good technique which has since changed.

Discussion: When repeating surgery where mesh has been used, a surgeons concern is the ability to re-operate on tissue that is scarred and anatomy distorted. This video demonstrates it is straight forward to identify and mobilise a mesh and that an LSP leaves minimal adhesions or distortion of the anatomy.

TOTAL LAPAROSCOPIC HYSTERECTOMY: RETROSPECTIVE ANALYSIS OF 262 CASES

Complications

Oral

Cristina Nogueira-Silva*, Santos-Ribeiro Samuel, Barata Sónia, Alho Conceição, Osório Filipa, Calhaz-Jorge Carlos

Hospital of Braga

Summary (4 lines): We describe our experience performing total laparoscopic hysterectomy (TLH). This study demonstrates that TLH is associated with low complication rates regardless of patient body mass index (BMI) and surgical history.

Introduction: Hysterectomy is one of the most common gynaecological procedures and may be performed either by vaginal approach, laparotomy or laparoscopy. Although TLH has multiple advantages, there have been conflicting reports on major complication rates. The aims of this study were to describe our experience performing TLH and to evaluate the complication rates.

Material and Methods: A retrospective observational study of all TLH performed in our department, by the same surgical team, between April 2009 and March 2013 (n=262), was conducted. Medical records were reviewed for patient characteristics (age, BMI, gynaecological, obstetric, medical and surgical history), surgical indication, operating time, uterine weight, post-operative haemoglobin variation, length of hospital stay and intra and postoperative complications.

Results: 42% of women had BMI >25 Kg/m2 and 49.2% had previous abdominopelvic surgery. Mean operating time (+SD) was 77.7±27.5 minutes. Average uterine weight was 241.0±168.4 g and average hospital stay was 1.49±0.9 days. Mean postoperative haemoglobin variation was -1.5±0.8g/dL. The major and minor complication rates were 1.5% and 11.5%, respectively.

Discussion: Thus, our series demonstrates that, in experienced hands, TLH is a safe procedure with low complications rates, regardless of patient BMI and surgical history.

REDUCING TROCAR MOVEMENT IN OPERATIVE LAPAROSCOPY THROUGH THE USE OF A FIXATOR

Innovation in Instrumentation and Surgical Techniques

Poster

Cezar Cristina*, Vasileios Vrentas (first Author), Cristina Cezar, Anja Herrmann, Patrick Diesfeld, Rudy Leon De Wilde

Summary (4 lines): A non-blinded, prospective study to evaluate the effects of utilizing a fixator to control mobility of trocars in operative laparoscopy.

Introduction: Trocar dislodgement is a common problem complicating laparoscopy. Trocar stabilization methods have been vigorously investigated in order to minimize this risk contributing thus in patients’ safety, but also in reducing procedural time and increasing surgeon’s satisfaction. The aim of this study was to evaluate trocar stability using a fixation device aimed at controlling trocar insertion depth but especially providing greater stability during laparoscopic procedures.

Material and Methods: 43 patients received laparoscopic interventions longer than 10 minutes. We used 5mm working trocars bearing a plain sleeve. The fixator device was attached to one of the two side trocars prior to insertion. In 18 patients an unsutured fixator was used (FX-US-subgroup). In 25 patients the device was sutured to the skin through specially suturing ports (FX-S-subgroup). Position of both trocars was evaluated at the start of the procedure and eventually every 10 minutes intraoperatively.

Results: FX-group showed significantly decreased trocar movement compared to NFX-group (0.02 0.6 cm vs. 0.84 4.4 cm). In the NFX-group, the trocar showed a tendency to slip into abdomen and in the FX-group to slip out. 11 of 43 ports (25.6%) were reinserted or readjusted.

Discussion: The use of fixator significantly reduces plain (smooth) sleeve trocar movement, prohibits a complete dislocation or slippage of the port, while suturing the device to the skin further minimizes trocar movement. The fixation device may lead to a shorter operation time and reduce problems associated with trocar slippage or dislocation.

Surgical Hysteroscopy

Video

Jaime Albornoz*, Fernandez Carlos, Fernandez Emilio

Clinica Las Condes

Summary (4 lines): Uterine Isthmocele is a sacular cavity secondary to cesarean-section scar defect. It can cause abnormal uterine bleeding and secondary infertility and can be managed easily by hysteroscopy.

Introduction: Uterine Isthmocele is a sacular cavity located at the anterior wall of the uterine isthmus. It is secondary to cesarean-section scar defect, and can be a cause of postmenstrual abnormal uterine bleeding and secondary infertility due to the presence of blood stained cervical mucus that affect sperm quality and fluid-reflux into the uterine cavity that impairs endometrial implantation. Diagnosis can be made with Transvaginal Ultrasound and Sonohysterography.

Material and Methods: We present a case of uterine isthmocele managed by hysteroscopy. Surgical strategy consists in the resection of the lower margin of the isthmocele, which lead to an increase in the diameter of the cervical canal.

Results: After removal of the lower border of the uterine isthmocele, we show a significant increase in the diameter of the cervical canal, thus facilitating blood drainage during the menstrual period.

Discussion: Hysteroscopic management of symptomatic uterine isthmocele is a minimally invasive procedure that can solve postmenstrual abnormal uterine bleeding and increase spontaneous conception rate in infertile patients.

PRESURGICAL LONG-TERM ADMINISTRATION OF LOW-DOSE SUSTAINED-RELEASE LEUPROLIDE ACETATE DOES NOT INCREASE RECURRENCE AFTER LAPAROSCOPIC MYOMECTOMY

Myomectomy

Selected abstract Oral

Jun Kumakiri*, Kitade Mari, Kikuchi Iwaho, takeda Satoru

Juntendo University Faculty of Medicine

Summary (4 lines): The presurgical long-term administration of low-dose leuprolide acetate (LA) is a useful therapeutic modality before laparoscopic myomectomy (LM) because of improving surgical outcomes, and dose not affected recurrence after LM.

Introduction: The administration of gonadotropin-releasing hormone (GnRH) agonists in expectation of the improvement of surgical outcomes through their effects to prevent the enlargement and reduce the size of uterine myoma during the presurgical waiting period. However, potential risk of recurrence after LM by the presurgical use was reported. We prepared a protocol for a prospective, randomized, controlled study to assess the effects of the long-term presurgical administration of low-dose LA on the postsurgical recurrence of LM.

Material and Methods: A prospective randomized study was conducted in 77 patients with uterine myoma (diameter ≤ 9 cm and number ≤ 5). Thirty-eight and 39 patients were randomly assigned to the LA and the control groups during a waiting period of 6 months before LM. The two g

Results: The cumulative recurrence rate at 24 months after LM in the LA and the control group was 34.2 % and 41%, respectively. There was no significant difference between the groups. Cox regression analysis revealed that the number of enucleated myoma was significantly associated with the recurrence (Hazard ratio, 1.4; P=0.009).

Discussion: In selected patients, our data suggested that the potential risk of unintentional residue of myoma during LM which was shrinked by presurgical administration of low-dose LA is low.

A SYSTEMATIC TECHNIQUE FOR LAPAROSCOPIC NERVE-SPARING RADICAL HYSTERECTOMY

Oncology

Video

JESUS MOLERO VILCHEZ*, Martínez Lamela Ester, Exposito Lucena Yolanda, Sobrino Mota Verónica, Prieto Alonso Jose Luis, Moro Martin Maria Teresa, Rejas Gutierrez Miguel

Hospital Universitario Infanta Leonor. Clinica Tocogyn

Summary (4 lines): To describe in video format the laparoscopic technique of pelvic lymphadenectomy and nerve-sparing radical abdominal hysterectomy Piver III for cervical cancers.

Introduction: In 15 patients laparoscopic pelvic lymphadenectomy and nerve-sparing radical hysterectomy Piver III was performed either simultaneously. Based upon frozen section results, node-negative women were treated by laparoscopic radical hysterectomy with two different nerve-sparing approaches (Nerve-sparing and nerve plane-sparing).

Material and Methods: In this video we describe the nerve-sparing radical hysterectomy. The dissection of the pelvic spaces and the pelvic lymphadenectomy are showed. The detailed autonomic nerve structures (the pelvic splanchnic nerves, the inferior hypogastric plexus and the visceral afferent and efferent nerves) were identified and separated by meticulous dissection during this procedure.

Results: Mean surgical time was 350 minutes. Mean loss of pre-postsurgical hemoglobin was 2,8 g/dl. None blood transfusion was necessary. Mean removed lymph pelvic nodes was 25 nodes (7-49). Mean postoperative hospital stay was 4,5 days. We report 3 complications: one bladder injury, one ureteral injury, and one ureteral delayed fissure.

Discussion: Laparoscopic nerve-sparing radical hysterectomy is a safe and effective technique for the management of early stage cervical cancer and avoids bladder dysfunction.

ANALYSIS OF 87 LAPAROSCOPIC PELVIC AND PARAAORTIC LYMPHADENECTOMIES DURING THE LAST 5 YEARS

Oncology

Poster

JESUS MOLERO VILCHEZ*, Martínez Lamela Ester, Moro Martin Maria Teresa, Casado Fariñas Isabel, Rejas Gutierrez Miguel, Gonzalez Paz Carmen, Prieto Alonso Jose Luis

Hospital Universitario Infanta Leonor. Clinica Tocogyn

Summary (4 lines): A descriptive retrospective study was made. Comparative analysis of the pelvic and paraaortic lymphadenectomy performed by laparoscopy or by laparotomy route perfomed between April 2008 and May 2013.

Introduction: We revised 181 procedures of pelvic and/or paraaortic lymphadenectomies to evaluate the feasibility and oncologic value of laparoscopic in comparation with laparotomic approach. In 87 patients laparoscopic lymphadenectomy was part of the following surgical procedures: laparoscopic hysterectomy in 64 patients with endometrial cancer, laparoscopic radical hysterectomy in 15 patients with cervical cancer, staging laparoscopy in 3 patients with advanced cervical cancer, 3 patients with early ovarian cancer and in 2 patients with uterine sarcoma.

Material and Methods: Mean age was 58,4 years. Comparative analysis between laparoscopic and laparotomic groups was: Mean body mass index was greater for laparoscopic group (30,7 vs 28 kg/m2, p=0,97). Operating time was greater for laparotomic group (316,8 vs 272,1 minutes, p=0,13). 2 patients from laparotomic group blood transfusion was necessary. Mean postoperative hospital stay was significantly greater for laparorotomic group (8,3 vs 3,5 days, p smaller to 0.01). The overall complication rate was 7,8%.

Results: Mean removed lymph nodes by laparoscopy was 18,5 pelvic nodes (6–49) and 11,2 paraaortic nodes (3-20). Mean removed nodes by laparoscopy was 16,4 nodes (5-49). In 94 cases lymphadenectomy was made by laparotomy. Mean removed nodes by laparotomy was 13,1 nodes (3-51) (p=0,01)

Discussion: By laparoscopic lymphadenectomy an adequate number of lymph nodes can be removed in an adequate time. In 21 cases pelvic nodes and 13 cases paraaortic nodes were positive. The complication rate is low and can be minimized by standardization of the procedure.

SUCCESSFUL LAPAROSCOPIC RESECTION OF 7MMS OVARIAN TERATOMA ASSOCIATED WITH ANTI-NMDAR ENCEPHALITIS. A CASE REPORT

Case reports

Poster

Masaru Hayashi*, Fukasawa Ichio, Motegi Emi

Teine Keijinkai Hospital

Summary (4 lines): A 18 year-old woman was diagnosed with anti-NMDAR encephalitis associated with 7mms ovarian teratoma. This teratoma was macroscopically normal, however we could completely resected the teratoma by laparoscopic surgery.

Introduction: Anti-NMDAR encephalitis is an immune-mediated encephalitis. It has been predominantly described in young women associated commonly with ovarian teratomas. It’s an encephalitis arising from N-methyl-D-asparate receptor (NMDAR) dysfunction in the cerebral limbic system, damaged by antibodies against NMDAR on the cell membrane of the nerve tissue in an ovarian teratoma. We report a case of anti-NMDAR encephalitis associated with 7 mms ovarian teratoma, completely resected by laparoscopic surgery with sparing some ovarian reserves.

Material and Methods: A 18-year-old woman without medical history showed headache and fever up for a few days, and suddenly presented personality changes and speech disabilities, requiring her admission to the department of neurology. After that, she also showed involuntary mo

Results: As the abdominal image diagnosis revealed the possibility of right ovarian teratoma that size was 5x7 mm, a laparoscopic operation was undergone. The macroscopic appearance didn’t show up any abnormalities, however we performed partially resection of the right ovary for sparing the ovarian reserve with reference of the image diagnosis.

Discussion: The 22x22 mms resected ovary contained an intact 5x7 mms cystic tumor. The pathological diagnosis was mature cystic teratoma with component of brain tissue. Anti-NMDAR-antibody proved positive in serum and cerebrospinal fluid. After the surgery, clinical findings and symptoms are gradually improving. From these results, her diagnosis was anti-NMDAR- encephalitis.

A RARE CASE OF PERSISTENT INTRAUTERINE MYOMA

Case reports

Poster

Rudolf Lampé*, Török Péter, Daragó Peter

University of Debrecen Medical and Health Science Center, Hungary

Summary (4 lines): We present a case of an intrauterine myoma which persisted for years due to the lack of operative hysteroscopy procedure and caused abnormal uterine bleeding.

Introduction: Nowadays hysteroscopy is assumed to be the gold standard for evaluating the uterine cavity. A 59 year old postmenopausal woman presented with abnormal uterine bleeding. Office hysteroscopy was performed and evinced an intrauterine polypoid structure with narrow peduncle. Operative hysteroscopy was offered for resection, but the patient refused it. Three years later she presented with the same complaints, however dilatation and curettage was performed three times in another institute with a negative histological result.

Material and Methods: In our institute the transvaginal ultrasound examination showed an intrauterine 15x25 mm large roundish structure and operative hysteroscopy was performed. During surgery a round shaped solid “floating” structure was found with no connection to the uterine wall. No other intrauterine pathologies were found.

Results: Histological result confirmed the diagnosis of leiomyoma. After the procedure symptoms of the patient were completely ceased.

Discussion: This case report underlies the importance of hysteroscopy in the treatment of postmenopausal abnormal uterine bleeding. Draws attention that dilatation and curettage in such cases can be ineffective.

STUDY THE CONSTRUCT VALIDITY FOR SCANTRAINER ULTRASOUND SIMULATOR

Teaching & Training

Oral

Amal Alsalamah*, Pugh Neil, Amso Nazar

Cardiff University

Summary (4 lines): Simulators may become a beneficial learning tool in terms of learning and assessing performance and skills away from practising on patients. However, although simulators are being promoted as a means of assessing subjects’ skills, little evidence exists to support that simulator performance correlates and reflects the actual subject’s ability/ performance. Thus, evaluating the construct validity of the simulator is required before it can be used for training.

Introduction: Aims / Objectives To evaluate the construct validity of the ScanTrainer ultrasound simulator. The hypothesis is that the performance of novice, intermediate and experienced practitioners in transvaginal ultrasound scan is different on a simulator.

Material and Methods: Thirty subjects recruited and divided into three groups according to their level of ultrasonographic experience. Participants asked to perform three different tutorials in gynaecological and early pregnancy modules on the simulator. The assessment of each tutorial is based on multiple ultrasound skills including normal (AvU), retroverted (RvU) uterus and early pregnancy (EP). All groups’ performances were assessed using a checklist of total of 21 skills (7 per tutorial).

Results: In 20 out of 21skills, there were significant differences between novices and experienced practitioners (p practitioners (pwever, in 3 gynaecology skills only, there were significant differences between experienced and intermediate practitioners (p

Discussion: ScanTrainer simulator has construct validity to distinguish between expert and novice participants. Ultrasound simulator can be used to discriminate among subjects with different ultrasound experience.

LAPAROSCOPIC APPROACH FOR SURGICAL TREATMENT OF THE ENDOMETRIAL CARCINOMA

Oncology

Poster

JESUS MOLERO VILCHEZ*, Martínez Lamela Ester, Sobrino Mota Veronica, Aroca Cruzado Ana, Lorente Ramos Rosa, Sancho Garcia Sonsoles, Lara Alvarez Miguel Angel

Hospital Universitario Infanta Leonor. Clinica Tocogyn

Summary (4 lines): To report surgical outcomes of endometrial carcinoma managed between April 2008 and May 2013. Comparative analysis the laparoscopic and laparotomic management for the endometrial carcinoma management.

Introduction: We have studied retrospectively 127 cases of endometrial neoplasias. Mean age was 65,7 years. The most frequent histological type was the endometrioid (84%). The histological types of high degree were 17 cases. 64,7% cases were diagnosed in early stages (stage IA and IB) and 58.2% was low degree. In 102 patients surgical management were made. In 65 patients the surgical intention was laparoscopic management, in 21.5% the intention was open management.

Material and Methods: In 49 cases pelvic lymphadenectomy and in 15 cases pelvic and paraaortic lymphadenectomy were made. Mean body mass index of women in the laparoscopic group was greater than the open group (32.4 vs 31,2 kg/m2). Mean operating times were 194 minutes for laparoscopy and 225 minutes for the open procedure (p=0,46). Mean postoperative hospital stay was significantly shorter for the laparoscopic group (2,7 vs 5 days, p smaller to 0.01).

Results: Mean removed pelvic nodes in the laparoscopic group (16,6 nodes, 6-32) was similar than that in the open group (16,9 nodes,7-29). Mean removed paraaortic nodes in the open group (17,8 nodes, 8-29) was greater than that in the laparoscopic group (10,6 nodes, 3-20)(p smaller to 0.01). Similar complications were reported in both groups.

Discussion:When pelvic nodes were positive, 60% cases the paraortic nodes were positive. In 10% of cases with positive paraaortic affectation, none pelvic nodes were positive (jump). The laparoscopic surgical staging for endometrial cancer has many advantages over the open approach, especially in obese women.

LAPAROSCOPIC EXTRACTION OF GOSSYPIBOMA

Complications

Video

Ester Martinez Lamela*, Molero Vilchez Jesus, Saez Cerezal Elisa , Casariego Pola Rosa , Hernandez Aguado Juan Jose , Aramendi Sanchez Teresa

Hospital infanta leonor

Summary (4 lines): The term gossypiboma denotes a cotton foreign body retained inside the patient during surgery. Laparoscopy is proved to be a minimally invasive and highly effective technique for these cases.

Introduction: Clinical presentation may be acute or sub-acute, and may follow months or even years after surgery. The symptoms are non-specific, such as pain, palpable mass and fever, and sometimes, patients remain asymptomatic. Once a gossypiboma is identified, it should be removed. This surgery may be very difficult, due to extensive adhesions and it is associated with high complication rates. We report a case removed by laparoscopic surgery, two years after the initial surgery.

Material and Methods An asymptomatic 66 -year-old woman with clinical history of vaginal hysterectomy. In a routine control visit, a heterogeneous mass was discovered in pelvis with the gynaecological ultrasound and suggesting a foreign body. Size of 76 x 63 cm. Abdominal X-Ray showed overlapping lineal images in pelvis, compatible with surgical material. Laparoscopic finding was a general inflammatory process in minor pelvis, fibrin deposition and adhesions between the omentum, small bowel loops and sigmoid rectum.

Results: Adhesiolysis with scissors or hydro dissection of adhesions was performed. Dissection of small bowel loops, sigma and rectum allows developing the recto-vaginal and retro-rectal spaces. We show the dissection of the capsulated structure which partially wrapped the right adnexal. Blunt opening of the pseudocapsule allows removing two surgical sponges.

Discussion: The procedure finish with haemostasia and a copious irrigation of the peritoneal cavity. Postoperative developed successfully. Laparoscopic is adequate approach for these cases, but this difficult procedure requires precise surgical skills

LAPAROSCOPIC URETEROLYSIS AND OMENTAL WRAPPING FOR URETERAL FIBROSIS AFTER RADICAL HYSTERECTOMY

Complications

Video

JESUS MOLERO VILCHEZ*, Martínez Lamela Ester, Vaquerizo Vaquerizo Myriam, Moro Martin Maria Teresa, Cambronero Santos Javier , Lorente Ramos Rosa , Exposito Lucena Yolanda

Hospital Universitario Infanta Leonor. Clinica Tocogyn.

Summary (4 lines): To show as video presentation the technique for ureterolysis and omental wrapping. A case report with ureteral obstruction after delayed fissure. Ureteral fibrosis by inflammatory process can cause severe complications.

Introduction: 38 year old patient diagnosed of cervical cancer. Laparoscopic pelvic lymphadenectomy and radical hysterectomy was made in December 2012. Three months later, patient refers lumbar and pelvic pain unresponsive medical management. Intravenous urography shows left ureteral widening until the distal third of ureter demonstrating no permeability of distal ureter. TC scan shows a tumour in left iliac soft parts of 3 x 2 cm. and left ureteral widening up to pelvic tumour.

Material and Methods Unilateral hydronefrosis managed initially with percutaneous nephrostomy with placement of double J catheter situated in the renal pelvis and bladder. Significant progression of symptoms was referred. Surgical decompression (ureterolysis) of the urinary tract by laparoscopy was made. After the encased ureters are manipulated, to prevent recurrent obstruction different techniques have been used: Ileon interposition; urethral intraperitonization or transposition of the ureters laterally, with interposition of retroperitoneal fat.

Results: We favour wrapping the ureter with omental fat fixed to psoas muscle and bladder. This serves as a barrier to prevent encasement by fibrous tissue, may promote revascularization of the ureters (the process devascularizes the ureters) and limite the possibility of an ureter extrinsic compression, with good functional results

Discussion: Laparoscopic ureterolysis and wrapping the ureters with omental fat can be performed with minimal morbidity. We keep the double J catheter some months later to provide durable success rates for relief of symptoms and obstruction.

LAPAROSCOPY IN OVARIAN CANCER

Oncology

Poster

Ester Martinez Lamela*, Molero Vilchez Jesus, Lopez Lopez Manuela, Expósito Lucena Yolanda, Martin Marino Almudena, Prieto Alonso Jose Luis

Hospital infanta leonor

Summary (4 lines): A series of 89 cases diagnosed of ovarian cancer (OC) treated between April 2008 and May 2013 is reviewed. A descriptive study about the value of laparoscopy is made

Introduction: We study the role of the laparoscopy in OC. The laparoscopic evaluation enables suspecting potentially respectable advanced stages for OC and it avoids suboptimal surgeries. In this series, 70 patients were diagnosed of OC and 19 cases were diagnosed of borderline ovarian tumors (BOT). Mean age was 57 year (18-90) for OC and 47,7 years (22-76) for BOT. 69 cases were surgical treated. Serous histological type was the most frequently observed

Material and Methods In 3 cases with initial stages OC and 8 patients diagnosed of BOT primary surgical staging by laparoscopy were selected. In OC Mean operating times were 411 minutes and postoperative hospital stay was 3 days. Mean removed nodes was 16.1 pelvic nodes and 9.5 paraaortic nodes. In BOT group the mean operating times was 87 minutes and postoperative hospital stay was 1 day.

Results: Previous laparoscopic was chosen potentially resectable for primary surgical staging procedure, 37 cases of OC by opened surgery and 13 cases for interval staging surgery. Complete or optimal surgery was performed in 43 cases (34 cases primary surgical staging and 9 cases interval staging surgery).

Discussion: The laparoscopic approach enables a correct evaluation of potential resectability for primary surgical staging in OC. Only in 7 cases suboptimal surgery was made (14%). Laparoscpy is safe in the BOT and the initial OC cancer management. In all of patients none immediate complications was reported.

PARAAORTIC LYMPHADENECTOMY BY LAPAROSCOPY VERSUS LAPAROTOMY APPROACH

Oncology

Poster

JESUS MOLERO VILCHEZ*, Martínez Lamela Ester, Saez Cerezal Elisa , Lagarejos Bernardo Sandra, Rivero Garcia Maria Teresa , Lara Alvarez Miguel Angel

Hospital Universitario Infanta Leonor. Clinica Tocogyn.

Summary (4 lines): A descriptive retrospective study was made. Comparative analysis of the paraaortic lymphadenectomy performed by laparoscopy or laparotomy route in 65 cases between April 2008 and May 2013 for gynecologic cancers

Introduction: Previous diagnoses were: 26 cases for endometrial cancer, 5 cases for cervical cancer and 34 cases for ovarian cancer. In all of cases, additional staging surgical processes were made. Mean age was 58,4 years. In 20 cases a transperitoneal and retroperitoneal laparoscopic lymphadenetomy was made. The global average of removed paraaortic nodes was 13.1 nodes (3-51). In 13 cases nodes were positive. Comparative analysis between laparoscopic and laparotomic groups was made.

Material and Methods Mean body mass index was greater for laparoscopic group (32,8 vs 28,3 kg/m2, p=0,10). Operating time was greater for laparoscopic group (360,3 vs 309,6 minutes, p=0,23). Mean blood loss was similar in both groups, but in only one patient from the laparotomic group blood transfusion was necessary (p=0,85). Mean postoperative hospital stay was greater for laparorotomic group (9,4 vs 3,1 days, p smaller to 0,01). In all of patients, none complication referred for the technique was reported.

Results: Mean removed nodes by laparoscopy was 11.2 nodes (3-20) in 2 cases were positive nodes. In 45 cases lymphadenectomy was made by laparotomy route, 11 cases were positive nodes. Mean removed nodes by laparotomy was 14 nodes (3-51) (p=0,41).

Discussion: The number of removed paraaortic nodes for pathologic study by laparoscopy and by laparotomy were similar. The paraaortic lymphadenectomy by laparocopy enables a correct staging.

SIMPLIFIED TECHNIQUE OF NERVE-SPARING RADICAL HYSTERECTOMY FOR INVASIVE CERVICAL CANCER

Innovation in Instrumentation and Surgical Techniques

Poster

JESUS MOLERO VILCHEZ*, Martínez Lamela Ester, Sobrino Mota Veronica, Exposito Lucena Yolanda, Moro Martin Maite, Prieto Alonso Jose Luis, Rejas Gutierrez Miguel

Hospital Universitario Infanta Leonor. Clinica Tocogyn.

Summary (4 lines): The objective is to simplify the complicated procedure of nerve-sparing radical hysterectomy for invasive cervical cancer. A retrospective study of 64 patients between April 2008 and May 2013.

Introduction: In 15 consecutive patients laparoscopic pelvic lymphadenectomy and radical hysterectomy was performed either simultaneously. Based upon frozen section results, 9 node-negative women with cervical cancer were treated by laparoscopic radical hysterectomy with two different nerve-sparing approaches. Nerve-sparing radical hysterectomy was performed in 5 patients. The nerve plane-sparing radical hysterectomy procedure was performed in 4 patients. The nerve plane (meso-ureter and lower bladder pillars) containing most of the autonomic nerve structures was integrally preserved.

Material and Methods Mean age was 50.7 years. Stage IB to IIA1 of cervical cancer. A comparative analysis in both groups was made. There were no significant differences between both groups regarding surgical parametres. The mean surgical duration in the nerve plane-sparing radical hysterectomy and nerve-sparing radical hysterectomy groups were similar (335±4 and 365±3 minutes respectively, p ns). None pathologically positive margins were reported in both groups.

Results: Overall complication rate was 18,7%: One bladder injury and one ureteral injury in the and nerve-sparing radical hysterectomy group, and one ureteral delayed fissure with ureteral fibrosis in the nerve plane-sparing radical hysterectomy group. Only one patient referred bladder dysfunction from nerve-sparing radical hysterectomy group.

Discussion: Nerve plane-sparing radical hysterectomy is characterized by integral preservation of the autonomic nerve plane. This procedure is a reproducible and simplified modification of nerve-sparing radical hysterectomy and it requires a comprehensive knowledge of the pelvic neuroanatomy.

PELVIC LYMPHADENECTOMY BY LAPAROSCOPY VERSUS LAPAROTOMY ROUTE

Oncology

Poster

Ester Martinez Lamela*, Molero Vilchez Jesus, Saez Cerezal elisa, Expósito Lucena Yolanda, aroca cruzado ana, Prieto Alonso Jose Luis

Hospital infanta leonor

Summary (4 lines): A retrospective study was made. Comparative analysis of the pelvic lymphadenectomy performed by laparoscopy or laparotomy route in 117 cases between April 2008 and May 2013 for gynecological cancer

Introduction: Previous indications were 30 cases for ovarian cancer, 68 cases for endometrial cancer and 19 cases for cervical cancer. In all of cases additional staging surgical processes were made. Mean age was 58,4 years. A transperitoneal laparoscopic boarding was made in 68 cases. Mean removed pelvic nodes was 16.4 nodes (5-49). In 21 cases pelvic nodes were positive: 6 cases for cervical cancer, 11 cases for endometrial cancer and 4 caes for ovarian cancer

Material and Methods Comparative analysis between laparoscopic and laparotomic groups was made. Mean body mass index was greater for laparoscopic group (30,2 vs 27,8 kg/m2, p=0,12). Mean operating time was greater for laparotomic group (323,5 vs 247,5 minutes, p=0,49). Mean blood loss was similar in both groups, but in one patient from laparotomic group blood transfusion was necessary. Mean postoperative hospital stay was significantly greater for laparotomic group (7,4 vs 3,7 days, p smaller to 0,01)

Results: Mean removed nodes by laparoscopy was 18.5 nodes (6-49). In 11 cases nodes were positive. In 49 cases the lymphadenectomy was made by laparotomy and 10 cases nodes were positive. Mean removed nodes by laparotomy was 13.4 nodes (5-29) (p smaller to 0,01)None complication referred for the technique was reported

Discussion: The postoperative hospital stay days and the number of removed pelvic nodes for pathologic study were significantly greater by laparoscopy than by laparotomy route. The pelvic lymphadenectomy by laparocopy enables a correct staging

SURGICAL OUTCOMES OF LAPAROSCOPIC RADICAL HYSTERECTOMY FOR CERVICAL CANCER IN THE LAST 5 YEARS

Oncology

Poster

Ester Martinez Lamela*, Molero Vilchez Jesus, Perez quintanilla Almudena, casado fariñas isabel, gonzalez paz carmen, Saez Cerezal Elisa , Expósito Lucena Yolanda

Hospital infanta leonor

Summary (4 lines): To describe and evaluate the laparoscopic technique of radical hysterectomy with pelvic lymphadenectomy in 64 patients with cervical cancer between April 2008 and May 2013.

Introduction: Retrospective study. Mean age was 50.7 years. The most common frequent histological type was the squamous carcinoma (75 %). Mean presentation age for cervical adenocarcinoma (21.6%) was 46.2 years. The frequent stages of presentation were the stage IB1 (9 cases). A preoperative CT scan of chest, abdomen and pelvis was negative for any visible disease. In 16 patients with stage IB to IIA1 cervical cancer, laparoscopic pelvic lymphadenectomy and radical hysterectomy was performed either simultaneously

Material and Methods Based upon frozen section results, 15 node-negative women were treated by laparoscopic radical hysterectomy. In 9 cases nerve sparing radical hysterectomy was made (Querleu-Morrow C1). Mean body mass index (BMI) was 22,4, kg/m2. Mean surgical time was 350 minutes. Mean loss pre-postsurgical hemoglobin was 2,8 g/dl. Mean postoperative hospital stay was 4,5 days. Mean removed lymph pelvic nodes was 25 (7-49 nodes).

Results: Overall complication rate was 18,7% (3 complications): one bladder injury (laparoscopic suture), one ureteral injury (immediate laparoscopic ureteral reimplantation), and one ureteral delayed fissure with ureteral fibrosis (laparoscopic ureterolysis). None blood transfusion was necessary.

Discussion: Total laparoscopic radical hysterectomy can be considered a safe and effective therapeutic procedure for the management of early stage cervical cancer with a low morbidity. All of patients without nerve sparing referred bladder dysfunction, only one with nerve-sparing radical hysterectomy technique

PROPHYLACTIC BILATERAL SALPINGECTOMY AT TOTAL LAPAROSCOPIC HYSTERECTOMY FOR BENIGN GYNAECOLOGICAL DISEASES

Hysterectomy

Poster

ELHAMI EBEID*, Byrne Dominic

NATIONAL HEALTH SERVICE ROYAL CORNWALL TRUST

Summary (4 lines): Bilateral Salpingectomy performed at laparoscopic hysterectomy for benign gynaecological diseases can be considered a standard practice given its practicality, low complication rate and the reduced risk of developing ovarian cancer.

Introduction: Evidence is compelling that serous cancers of the ovary and peritoneum may originate from the epithelium of the fallopian tubes. Thus, when hysterectomy is performed salpingectomy should be considered; to reduce the risk of future ovarian and tubal pathology. In addition, elective laparoscopic Salpingectomy presents a unique training model for junior surgeons learning surgical management of ectopic pregnancy

Material and Methods We offered prophylactic salpingectomy to all patients undergoing total laparoscopic hysterectomy (TLH). We will present three year data on: indication for surgery, body mass index, previous operations, pelvic adhesions, peri-operative complications, histopathology and grade of surgeon.

Results: All patients accepted prophylactic salpingectomy, and the procedure was successfully performed in all cases. Whilst prophylactic salpingectomy did slightly prolong operating time it did not increase the overall risks of peri-operative complications. There was no conversion to laparotomy.

Discussion: Prophylactic salpingectomy during laparoscopic hysterectomy is a practical and a safe procedure. It provides risk reduction for ovarian malignancy and future tubal pathologies. It is ideal training opportunity for junior doctors to improve surgical skills and understanding of the pelvic anatomy, in preparation for emergency laparoscopic salpingectomy for tubal pregnancy.

ROLE OF LAPAROSCOPIC LYMPHADENECTOMY IN THE MANAGEMENT OF CERVICAL CANCER

Oncology

Poster

ester martinez lamela*, Molero Vilchez Jesus, Expósito Lucena Yolanda, rodriguez gonzalez patricia, Rivera rodriguez Teresa, Rejas Gutierrez Miguel

Hospital infanta leonor

Summary (4 lines): To evaluate the feasibility and oncologic value of laparoscopic pelvic and paraaortic lymphadenectomy in the management of 64 patients with cervical cancer between April 2008 and May 2013.

Introduction: Retrospective study. Mean age was 50.7 years. In 18 patients laparoscopic pelvic and/or paraaortic lymphadenectomies was performed. The most common frequent histological type was the squamous carcinoma (75% cases). Lumboaortic lymphadenectomy was held in 3 cases to match fields of radiotherapy in a stage IIIA. In 15 patients laparoscopic pelvic lymphadenectomy and nerve-sparing radical hysterectomy Piver III was performed either simultaneously. Based upon frozen section results, node-negative women were treated by laparoscopic radical hysterectomy

Material and Methods Mean removed lymph pelvic nodes was 25 nodes (7-49). In 5 cases pelvis nodes were positive after routine pathologic examination. Mean body mass index (BMI) was 22,4 kg/m2. Mean surgical time was 350 minutes. Mean postoperative hospital stay was 4,5 days. Overall complication rate was 18,7% (3 complications): one bladder injury (laparoscopic suture), one ureteral injury (immediate laparosopic ureteral reimplantation), and one ureteral delayed fissure with ureteral fibrosis (laparoscopic ureterolysis).

Results: In 3 cases only laparoscopic extraperitoneal paraaortic lymphadenectomy was made. Mean BMI was 24,7 kg/m2. Operating time was 227 minutes. Mean postoperative hospital stay was 2 days. Mean lumboaortic nodes was 14.6 nodes (12-17). In one case paraaortic lymph nodes were positive. None complications was reported

Discussion: Laparoscopic lymphadenectomy provides crucial information for staging of cervical carcinoma. Pelvic node-positive women are generally considered for radiotherapy and/or chemotherapy. Knowledge of periaortic node positivity allows for individualization of the radiation field. Laparoscopic staging of cervical carcinoma is also useful when radical trachelectomy is planned

TOTAL LAPAROSCOPIC HYSTERECTOMY FOR ONCOLOGICAL INDICATIONS

Hysterectomy

Poster

ester martinez lamela*, Molero Vilchez Jesus, Martin Marino Almudena, Saez Cerezal Elisa , Perez quintanilla Almudena, Expósito Lucena Yolanda

Hospital infanta leonor

Summary (4 lines): Retrospective study of 89 patients underwent total laparoscopic hysterectomy (TLH) for oncological indications between April 2008 and May 2013. To report surgical outcomes.

Introduction: Mean age was 58,4 years. Preoperative diagnoses included 65 endometrial neoplasias with mean age 63,8 years, 15 cervical carcinoma with mean age 45,8 years, 3 cases of cervical dysplasia, 3 ovarian carcinoma with mean age 54,1 years. In all of cases additional staging surgical processes were made. Mean body mass index for all patients was 29,1 kg/m2, greater for endometrial cancer cases (32,4 kg/m2, in 6 cases greater than 35). Surgical outcomes were studied.

Material and Methods Mean operating time for all patients was 315,5 minutes. In patients with only hysterectomy was 106 minutes, but in patients for ovarian carcinoma staging was 411 minutes. Mean loss pre-postsurgical hemoglobin was 1,9 g/dl. In one patient blood transfusion was necessary (1,1%). Mean postoperative hospital stay was 3,4 days. Overall complication rate was 8.9%. Reoperation was required in 2,24%.

Results: The complications were: one vascular bleeding, one severe dysfunctional bowel obstruction, one incisional hernia), and five urologic complications (two bladder solved immediate laparoscopic suture; two ureteral injuries both treated with double J catheter, one with immediate ureteral reimplantation, and the other with delayed ureteral fissure and ureteral fibrosis (laparoscopic ureterolysis).

Discussion: TLH appears feasible and safe for oncological practice indications throughout the life span. Laparoscopic approach is a long operation but involves few blood losses, a short hospitalization, and few intraoperative and postoperative complications.

QUSUM: A NEW REGISTRY TOOL FOR MEASURING INDIVIDUAL PROFICIENCY IN LAPAROSCOPIC HYSTERECTOMY

Hysterectomy

Selected abstract Oral

Sara Driessen*, Twijnstra Andries, Blikkendaal Mathijs, Jansen Frank Willem

LUMC

Summary (4 lines): A web-based quality control tool in laparoscopic hysterectomy was developed and individual risk adjusted performance graphs with respect to peers is provided. By signalling derailing performance patient safety is enhanced.

Introduction: It has become important to measure outcomes in health care. However, because of patient and surgeon factors, the probability of favourable surgical outcomes varies considerably between patients. Currently, no valid tool is available which provides the surgeon with direct feedback on his/her surgical performance with case-mix correction. Additionally this can be of great value for the certification of advanced surgical skills, such as provided by the three competence levels in the ESGE Diplomat Program (GESEA).

Material and Methods A web-based application is introduced using observed-minus-expected plots. A dataset of 1.534 LH’s is used as benchmark. Per procedure, five significant predicting characteristics (uterus weight, BMI, number of previous abdominal surgeries, one/two surgeons, type of laparoscopic hysterectomy) and three primary outcomes (operative time, blood loss and complication) must be entered in a web-based format. Successful surgical outcome was determined as, operative time less than 120 minutes, blood loss less than 200 mL, and no complication.

Results: For each primary outcome, a risk-adjusted proficiency graph is shown. This provides the surgeon with direct individual feedback. Derailing performance will be noticed by an “out-of-control” signal after 20 procedures (odds ratio 2). Finally a hand-out is demonstrated to the surgeon to evaluate his/her performance, the team and the equipment.

Discussion: This unique application will instantly measure operative quality with correction for case-mix and identify suboptimal factors in surgical performance. This allows improvement of the surgical outcomes and enhancement of patient safety. In addition this tool can be implemented in the ESGE Diplomat Program for an ultimate analysis of quality measurement.

PREFERRED APPROACH TO HYSTERECTOMY IN VERY OBESE PATIENTS: A SYSTEMATIC REVIEW WITH CUMULATIVE ANALYSIS

Hysterectomy

Oral

Mathijs Blikkendaal*, Schepers Evy, Burggraaf Florianne, Twijnstra Andries, Jansen Frank Willem

Leiden University Medical Center

Summary (4 lines): Based on pooled results of available comparative studies, sufficient evidence is acquired to conclude that laparoscopy is the preferred approach to hysterectomy in very obese patients.

Introduction: The prevalence of obesity, and accordingly the incidence of endometrial cancer, has been increasing over the past decades. Although the preferred approach to hysterectomy in non-obese patients is well-known, this is still subject to debate with regard to the very obese, i.e. patients with a BMI ≥35 kg/m2. The objective of this systematic review with cumulative analysis was to determine the preferred surgical approach to hysterectomy in these patients.

Material and Methods The PubMed and EMBASE databases were systematically searched for studies on abdominal (AH), laparoscopic (LH) and vaginal hysterectomy (VH) in very obese patients. The studies that met the inclusion criteria were graded on the level of evidence and a predefined set of data was extracted. The included comparative studies were pooled in a cumulative analysis. The results were expressed as risk ratios (RR) for dichotomous outcomes and as mean difference (MD) for continuous outcomes.

Results: In total, 32 studies were included. Compared to LH, AH was associated with more wound dehiscences (RR 2.55, 95%-CI 1.69-3.84, p=.000), more wound infections (RR 4.27, 95%-CI 2.72-6.70, p=.000), and longer hospital admission (MD 2.7 days, 95%-CI 1.8-3.7, p=.000). VH was associated with similar advantages over AH.

Discussion: Compared to AH, LH is associated with lower postoperative morbidity and shorter hospital stay. In contrast to VH, LH is suitable in case of malignancy and it is less challenging to obtain adequate visualization. Due to these clinical advantages, LH should be the preferred approach in the very obese.

CONSENSUS ON THE DEFINITION OF CONVERSION: A DELPHI STUDY AMONG GENERAL SURGEONS, GYNECOLOGISTS, AND UROLOGISTS

Hysterectomy

Selected abstract Oral

Mathijs Blikkendaal*, Twijnstra Andries, Bemelman Willem, Jansen Frank Willem

Leiden University Medical Center

Summary (4 lines): By means of a Delphi study, multidisciplinary consensus on a uniform definition of conversion was achieved. This definition was preferred by most respondents and considered applicable in its current form.

Introduction: In laparoscopic surgery, conversion to laparotomy is associated with worse clinical outcomes, especially if the conversion is due to a complication. In this perspective, conversion rate could be an excellent tool to evaluate current practice. However, although apparently important, no commonly used definition exists. The aim of this study was to achieve multidisciplinary consensus on a uniform definition of conversion and to hypothesize to which extent conversion rate can act as a means of evaluation.

Material and Methods Based on definitions currently used in the literature, a web-based Delphi consensus study was conducted among members of all four Dutch endoscopic societies. The Rate of Agreement (RoA) was calculated; a RoA of >70% suggesting consensus. The Delphi process would be ceased if consensus on a definition was obtained.

Results: The survey was completed by 268 respondents (response rate 45.6%); 43% general surgeons, 49% gynecologists, and 8% urologists. Average laparoscopic experience was 12.5 years (SD±7.2). In the second Delphi round a RoA of 90% was achieved with a consensus definition that was compiled based on the results of round 1.

Discussion: After two Delphi rounds, consensus on a uniform multidisciplinary definition of conversion was achieved. An unambiguous interpretation will result in a more reliable clinical registration of conversion. Consequently, regarding laparoscopic hysterectomy, a conversion rate of less than 5% can be used as valid reference for comparison of daily clinical practice.

ENDOMETRIOSIS: A CONDITION THAT CAN BE AVOIDED SINCE ADOLESCENCE

Endometriosis: Diagnosis

Oral

Maurício Paulo Angelo Mieli*, Baracat Edmund Chada, Girão Manoel João Baptista Castello, Paolera Lucas Della, Tannuri Uenis

Hospital Universitário - Universidade de São Paulo

Summary (4 lines): Symptoms such as dysmenorrhea, acute or chronic pelvic pain after the menarche may suggest endometriosis. Early diagnosis allow welfare and relief of the symptoms, as well as mantainance of reproductive function.

Introduction: Any patient, after the menarche, presenting symptoms such as dysmenorrhea, acute or chronic pelvic pain may develop endometriosis in the future. The patient must be submitted to directed propaedeutics, such as serum CA-125 at the beginning of the menstrual cicle and pelvic perimenstrual ultrasonography. The sooner the treatment is started, the larger are the chances to avoid the progressing of the disease and it's complications.

Material and Methods The data concerning hospitalization and total value dispended due to endometriosis, from January 2003 to December 2012, were collected from the Ministry of Health - Hospital Information System (SIH/SUS) – Brazil.

Results: 158.072 people were hospitalized due to endometriosis. From this amount, 1216 girls from 0 to 19 years old were hospitalized for the disease. 75,2% of these girls were aged between 15 and 19 years old. The total value dispended by the SUS for all hospitalizations was of US$ 45,967,109.19.

Discussion: Early diagnosis and treatment allow welfare and relief of the symptoms, as well as mantainance of the reproductive function. In cases when genital malformations are diagnosed, there is a possibility of coexistent endometriosis.

AN INTERNAL RETRACTOR FOR THE MANAGEMENT OF THE VESICOUTERINE LIGAMENT DURING LAPAROSCOPIC RADICAL HYSTERECTOMY

Tips & Tricks in Surgery

Video

Eiji Kobayashi*, Kimura Tadashi

Osaka University

Summary (4 lines): Ureteral injury is a serious complication during laparoscopic radical hysterectomy. We report a novel method to prevent such ureteral injury using an internal retractor (Endograb).

Introduction: To prevent serious ureteral injury during a radical hysterectomy, we propose that one of the most important procedures is for the management of the vesicouterine ligament. However, to date, there have been no reports regarding an effective method for avoiding ureteral injury during the laparoscopic radical hysterectomy.

Material and Methods To dissect of vesicouterine ligament safely, we isolate the ureter and wrap the ureter up in the vessel tape. Then we use internal retractor (Endograb) and pulled up the vessel tape to caudal lateral direction near the pubic bone. Then we can mobilize the ureter caudal direction without using the forceps. We used this method in 5 cases of LRH.

Results: We are able to gain a good surgical view using this internal retractor, without crowding the view with forceps. As a result, we prevented ureteral injury in all five cases.

Discussion: We have previously been forced to use forceps during the laparoscopy to dislocate the ureter to a caudal-lateral position during the management of the vesicouterine ligament. We can avoid the ‘fighting the sword’ and still dislocate the ureter safety by using an Endograb retractor.

HYSTEROSCOPIC MORCELLATOR SYSTEMS: A RANDOMIZED TRIAL COMPARING RESECTION TIME OF POLYP-LIKE TISSUE IN VITRO

Surgical Hysteroscopy

Poster

Sema Saglam-Kara*, Saglam-Kara Sema, Hamerlynck Tjalina W.O., van Vliet Huib A.A.M., Schoot Benedictus C.

Catharina Hospital Eindhoven

Summary (4 lines): In vitro comparison of different hysteroscopic morcellator systems shows that the blade with the smallest cutting window has the longest resection time of one surrogate polyp of five grams.

Introduction: Hysteroscopic morcellation (HM) is a safe, fast and effective more recent technique for removal of intrauterine pathology such as endometrial polyps and submucous myomas. Nowadays, three HM brands are marketed (TRUCLEAR, Myosure and intra-uterine BIGATTI Shaver). The aim of this study is to compare the resection time (RT) of polyp-like tissue of two HM brands, TRUCLEAR (Smith & Nephew, USA) and Myosure (Hologic, USA).

Material and Methods Forty-two fragments of umbilical cord (UC), as surrogate for polyps, were randomly allocated to four types of HM systems. All fragments weighed equal and were fixed in a water filled jar. Resection of the UC was performed using the TRUCLEAR 4.0 Rotary morcellator (TRM) and the TRUCLEAR 2.9 INCISOR Plus blade (TIP) with the TRUCLEAR 8.0 System, and the Myosure Classic (MC) and the Myosure Lite (ML) blade with the Myosure 6.25 Tissue Removal Device.

Results: When removing one UC, TIP was slower than TR, MC and ML. When removing three consecutive UC with one blade, the RT of the third UC was longer than the RT of the first UC in case of MC and ML, but not in case of TR and TIP.

Discussion: Comparison of RT shows that the blade with the smallest window (TIP) is slowest for removal of one surrogate polyp of five grams. RT of MC and ML increase after removal of greater amounts of polyp-like fragments, which was not the case for TR and TIP.

ASHERMAN’S DISEASE TREATMENT IN THE NETHERLANDS; THE EFFECT OF CENTRALIZATION, 2006-2011

Surgical Hysteroscopy

Oral

Mark Hans Emanuel*, Hanstede Miriam, Van der Meij Eva

Spaarne Ziekenhuis/Dept Ob&Gyn Hoofddorp

Summary (4 lines): In the Netherlands advanced hysteroscopic procedures like adhesiolysis in patients with Asherman’s disease is centralized. This seems to have a proven positive effect on surgical outcome

Introduction: The objective of this study was to provide descriptive statistics on hysteroscopic adhesiolysis in patients with Asherman’s disease in the Netherlands after centralisation and to compare these statistics with those reported in the literature.

Material and Methods A retrospective cohort study in a large university affiliated training hospital that serves as a National Reference Center for the treatment of Asherman’s disease This study is based on an analysis of the a five year retrospective database of all women

Results: In 94.4% of patients with M. Asherman who underwent surgery, a normal uterine cavity was restored in 1 to 3 attempts. After surgery 89.0% of the patients had a normal menstrual bleeding pattern. Overall these success rates are higher than those reported in the literature

Discussion: The surgical outcome of advanced hysteroscopic procedures like adhesiolysis in patients with Asherman’s disease is higher after centralisation than reported in the literature.

PATIENT OUTCOME MEASUREMENT TOOL, USEFULL OR USELESS

Complications

Oral

Peggy Geomini*

Maxima Medical Center

Summary (4 lines): Registration of outcomes of laparoscopic procedures using the Patient Outcome Measurement Tool (POMT) improves quality of health care through transparency and increases cost-efficacy.

Introduction: To reduce health care costs it is important to have knowledge about the results of medical treatment. By being transparent about the results of medical treatment, docters and hospitals are triggered to become better.Consequently best practices can be defined and implemented. A proper registartion of health care quality should focus on results of treatment, patient characteristics and indicators which implicate whether procedures are performed in accordance with guidlines.

Material and Methods In the Netherlands we started a webbased registration system Patient Outcome Measurement Tool, POMT) for endoscopic procedures (level III-IV), focussing on laparoscopic hysterectomy. All patients who have a Laparoscopic Hysterectomy, a vaginal hysterect

Results: Registration started in january 2012. Up untill now 1026 laparoscopic procedures are registered. In our department the complication rate appeared to be 5% (minor and major complications), comparable to the national complication rate. Correction for case load has not been accomplished yet but will be performed in very near future.

Discussion: POMT facilitates registration of quality of our laparoscopic procedures. Transparency within healthcare providers stimulates surgeons to improve their results.

INITIAL EXPERIENCE WITH MINITOUCH GLOBAL ENDOMETRIAL ABLATION IN AN AMBULATORY SETTING WITHOUT ANAESTHESIA

Innovation in Instrumentation and Surgical Techniques

Oral

Benedictus Tas*, Van Herendael Bruno, Weyers Steven

ZNA Stuivenberg

Summary (4 lines): Retrospective analysis of 20 cases of the Minitouch procedure to study the feasibility of performing the procedure in an ambulatory setting without anaesthesia.

Introduction: A simple GEA procedure that can be performed in an ambulatory setting is beneficial to the patient and to the healthcare system. We describe our initial experience with the minitouch procedure at two sites.

Material and Methods All 20 procedures were successfully completed by solo operators in an ambulatory setting. Mechanical or hormonal pretreatment or menstrual cycle timing was not employed. Each woman was prescribed 400mg oral Ibuprofen, to be taken one hour preoperatively.

Results: The patients tolerated the procedure without anesthesia (mean VAS score 4.8), and could leave immediately post-procedure. Cervical dilation was not needed. No patients reported post-procedure pain or other complications. Reports at 2 to 18 months follow-up indicate 80% amenorrhea and 10% hypomenorrhea. Two patients underwent hysterectomy, adenomyosis was found.

Discussion: Minitouch Global Endometrial Ablation procedure can be performed in an ambulatory setting. The outcomes are comparable to similar procedures.

TECHNIQUES OF LAPAROSCOPIC LUMBOAORTIC LYMPHADENECTOMY IN GYNAECOLOGICAL CANCER

Oncology

Poster

Alvaro Zapico*, Guzman Maria, Couso Aldina , Valenzuela Pedro, Fuentes Pedro, Garcia Pineda Virginia, Rodriguez Garnica Dolores, Heron Soraya

Príncipe de Asturias Hospital. Alcalá University.

Summary (4 lines): Transabdominal and retroperitoneal laparoscopic lumboaortic lymphadenectomies are feasible procedures.Choosing one or the other will depend on surgical team preferences and patient conditions

Introduction: Laparoscopic Lumboaortic lymphadenectomy (LLL) may be performed either by a transabdominal (TLLL) approach or by a retroperitoneal (RLLL) access. Surgical team preferences and patient conditions should be considered to use one of both procedures. In high BMI retroperitoneal approach seems to be easier to be performed. In this case, tolerance to tremdelemburg, neumoperitoneun and bowel mobilization are the greatest pitfalls to complete the procedure

Material and Methods From june 2009 to may 2013, LLLwas performed in 20 cervical, 12 endometrial and 10 ovarian cancers. Advanced cervical cancer was routinally schedulled for RLL. When ovarian and endometrial cancer, type of LLL was decided upon patients conditions.

Results: No intraoperative complications were seen. Postoperative complications consisted of anemia (2 in RLL and 3 in TLL ) and fever (1 in TLL). Neither blood transfusion nor hospital readmission were needed. Nodes collected were RLLL 9,76+1,1(2-28) vs TLLL 7,29+1,1(2-18)NS and hospital stay was 2,92+0,3(1-8)vs3,05+0,2(2-5)NS

Discussion: Laparoscopic lumboaortic lymphadenectomy has become an standardized procedure in oncological staging of gynecological cancers. However, preferences over a transabdomnal or a retroperitoneal approach are not clearly defined. Option for one of both technique will depend on surgical team preferences and patients conditions, BMI and anethesic tolerance to neumoperitoneum and trendelemburg

LAPAROSCOPIC ONCOLOGICAL SURGERY TRAINING: A NEW STRATEGY

Teaching & Training

Poster

LORENA GONZALEZ GEA*, Santacruz Martin Belen, Perez Martinez Ingrid, Martinez Campo Daniel, Garbayo Sesma Paloma, Brik Maia, Cristobal Martin Ignacio

TORREJON HOSPITAL

Summary (4 lines): We present a training method of oncological gynecological surgery for achieving a faster and safe learning curve, providing comfort to the patients.

Introduction: Although there are training programs for development of oncological gynaecological skills, the day-to-day theatre activity is more challenging. Surgeons need extensive practice to learn the correct techniques. Even though the development of fellowship programs provide professional skills, it is not enough to face the responsibility as a main surgeon. We present the start-up of a young professional team and how they carried out laparoscopic surgery in gynecologic oncology.

Material and Methods In 2011, a new community public hospital was set up in Madrid. Although there was a vast expertise in laparoscopic surgery, there was a lack of experience in oncological gynecological surgery as main surgeon. After a detailed economical and quality analysis, hospital´s management arranged senior oncological laparoscopic surgeons to assist and train its oncological surgeon, only during the procedure, instead of referring patients to specialized hospitals. The postoperative period was managed by the hospital´s medical team.

Results: From October 2011 to May 2013, 24 patients (14 endometrial and 10 cervical cancer) were operated by laparoscopy. Senior surgeon trained his colleagues in 3 paraaortic lymph node dissection procedure and in 2 radical histerectomy. The rest of the surgeries has been performed by the hospital team. No major complications.

Discussion: Learning curve period was short and safe. This method is more comfortable than and as safe as performed in specialized hospitals. At the moment, this training strategy is applied to other surgical procedures as laparoscopic colposacropexia or vaginoplasty.

COMPARISON OF COMPLICATIONS BETWEEN OPEN ABDOMINAL AND LAPAROSCOPIC SACROCOLPOPEXY FOR THE TREATMENT OF VAULT PROLAPSE

Complications

Poster

Anne Lotte Coolen*, M.Y. Bongers, van Oudheusden A.M.J. , van Eijndhoven H.W.F., Mol B.W.

Maxima Medical Centre

Summary (4 lines): Laparoscopic sacrocolpopexy is a safer treatment for vault prolapse compared to abdominal sacrocolpopexy because it is related to less procedure related morbidity concerning less blood loss, hospitalstay and severe complications.

Introduction: A variety of surgical procedures to correct vaginal vault prolapse have been reported. Sacrocolpopexy is a generally applied treatment for vault prolapse which can be performed laparoscopically or by laparotomy. Laparoscopic sacrocolpopexy was first reported in 1994 and has potential advantages in terms of reduced morbidity, shorter hospital stay and convalescence. Previous studies have shown less morbidity in favor of the laparoscopic method, but prospective comparisons are lacking, specifically to evaluate differences in complication rates.

Material and Methods Between October 2007 and December 2012, we performed a multi-center prospective cohort study in 2 university and 4 teaching hospitals in the Netherlands. We included patients with symptomatic post hysterectomy vaginal vault prolapse requiring surgical treatment, who either had abdominal or laparoscopic sacrocolpopexy. We studied surgery related morbidity, which was divided in pre-, peri- and postoperative characteristics. Eighty-five patients were included, of whom 42 had open abdominal and 43 laparoscopic sacrocolpopexy.

Results: In the laparoscopic sacrocolpopexy group blood loss and hospital stay was significantly less compared to the abdominal group. The overall complication rate was not significant different. However there was a significant difference in favor of the laparoscopic group in peri- and post-operative complications requiring complementary treatment or extended admittance.

Discussion: To evaluate in a RCT complications of open and laparoscopic sacrocolpopexy powered on complicationsrates, very large studies are needed. However, many studies were done comparing abdominal versus laparoscopic hysterectomy which showed a significantly higher complicationrate in the laparoscopic group. Fortunately we found less complications in the laparoscopic sacrocolpopexy group.

WHAT INVESTIGATION AND MANAGMENT ARE REQUIRED FOR THE LOST COIL? CASE REPORT

Case reports

Poster

Milica Perovic*, Khairunnisa Syeda, Ahmed Hasib

Medway Maritime Hospital

Summary (4 lines): Women who presents with a history of a “lost” IUD and abdominal pain/discomfort, the surgeon should have a high index of suspicion and obtain radiological studies and managed patient laparoscopically for removal of the coil

Introduction: Uterine perforation is a serious problem which can happen during intrauterine device (IUD) insertion and is common among women with “lost” IUD’s. This can cause severe morbidity and mortality and should be carefully managed. The recommended treatment is removal of the perforating IUD. This can usually be managed laparosocopically unless bowel perforation or other severe sepsis is present.

Material and Methods The patient of this case report had IUD inserted 13 years ago, and subsequently become pregnant resulting in vaginal delivery.Thereafter is had vaginal hysterectomy with pelvic floor repair and Tension Free Vaginal Tape (TVT). The IUD was incidentally fo

Results: It is important that the possibility of uterine perforation should be considered in anyone who has had a diagnosis of an missing IUD

Discussion: In any women who presents with a history of a “lost” IUD and abdominal pain/discomfort, the surgeon should have a high index of suspicion and obtain plain abdominal-pelvic X-ray films. It is prudent to specifically question women about history of IUD. We should aim to remove the lost coli laparoscopically.

COMPARISON OF OUTPATIENT ABLATION TECHNIQUES: FIVE YEAR FOLLOW-UP OF A RANDOMISED CONTROLLED TRIAL

Diagnostic & Operative Office Hysteroscopy

Oral

Paul Smith*, Clark Justin, Malick Sadia

Birmingham Women's Hospital

Summary (4 lines): At 5 years follow-up Thermachoice ablation was equivalent to Novosure ablation in the treatment of menorrhagia

Introduction: We have previously reported that Novosure was significantly quicker and achieved a greater degree of endometrial destruction than Thermachoice. At 6 months follow-up amenorrhoea rates were higher in the Novosure group, but not statistically significant (39% compared with 21%, RR 1.9 [95% CI 0.9-4.3], P=0.1). The objective was to assess the amenorrhoea rates, hysterectomy rates and quality of life 5 years after ablation with either Novosure or Thermachoice.

Material and Methods A single-blinded randomised controlled trial was performed in a large teaching hospital in the UK. Women with menorrhagia were treated with either Novosure or Thermachoice ablation techniques with local anaesthetic in the outpatient setting.

Results: At five years of follow-up the response rate was 69.1%. The amenorrhoea rates were 48.4% in the Thermachoice group and 56.0% in the Novosure group (RR 1.17 [95% CI 0.7-2.1], P=0.6). There were four women in the Thermachoice group and three women in the Novosure group that had hysterectomies.

Discussion: Outpatient endometrial ablation has been shown to be both safe and feasible. The Novosure ablation technique is quicker than Thermachoice ablation, but there was no significant difference in pain or acceptability. At 5 years follow-up both techniques were equivalent in treating women with menorrhagia.

LAPAROSCOPIC TREATMENT AND STAGING OF PRIMARY OVARIAN CANCER: OUR EXPERIENCE

Oncology

Poster

Cristina del Valle Rubido*, Valenzuela Ruiz Pedro Luis, Couso Gonzalez Aldina, Fernández Muñoz Laura, Nebreda Calvo Lucia, Rodriguez Garnica Maria Dolores, Solano Calvo Antonio

Hospital Universitario Príncipe de Asturias

Summary (4 lines): We performed 22 laparoscopic surgeries on patients diagnosed of primary ovarian cancer. Most of them in early stage and the results of all of them were considered complete surgery.

Introduction: Due to the low incidence of primary ovarian cancer, there are not enough clinical trials that support that the laparoscopic approach is as safer and adequate as the gold standard one (via laparotomy) for the treatment of ovarian cancer. We reckon that laparoscopic comprehensive surgical staging is an acceptable treatment option for those cases of early stage disease.

Material and Methods During the last six years we carried out 22 laparoscopic surgeries on primary ovarian cancer. The average age of that sort of women was 50 years old (range 30-79). The mean size of the tumour was 104,68 mm (from 28 - 300). In twelve of them, the diagnosis

Results: Most of the diagnoses were stage-1 of FIGO classification, except 3 patients. In all cases we carried out complete surgery, including peritoneal washing, hysterectomy, bilateral salpingo-oophorectomy, omentectomy and appendectomy. In those cases of infiltrating epithelial histologic type we added pelvic and paraaortic lymphadenectomy. Currently, all patients are alive and disease-free.

Discussion: In conclusion, our results suggest that endoscopic technique is an adequate way to perform the standard treatment for ovarian cancer. Although, the majority of our patients were in early stage, we reckon that the use of chemotherapy before surgery in advanced stage could turn them into operating cases via laparoscopy.

PROSPECTIVE COMPARATIVE STUDY OF VAGINAL SACROSPINOUS FIXATION VERSUS LAPAROSCOPIC SACROPEXY FOR WOMEN WITH UTERINE/VAULT PROLAPSE

Urogynaecology

Poster

Phatak Madhura*, Wael Agur, Kung Roger, Hair Mario, Rae David, Agur Wael

Summary (4 lines): At 3 months after surgery, vaginal and laparoscopic approaches have comparable subjective and objective outcomes. The laparoscopic approach took longer time and the vaginal one was associated with pelvic pain.

Introduction: Although vaginal sacrospinous fixation is considered by some to be less invasive than the laparoscopic counterpart, it has been associated with chronic pelvic pain and higher failure rates. In a recent systematic review, laparoscopic sacropexy has been shown to produce a better outcome but may take a longer time to perform. We compared the short-term patient-reported and objective outcomes of the two procedures as well as the time taken to perform in theatre.

Material and Methods Data was collected prospectively for 61 women between 2009-2012, where 32 underwent vaginal sacrospinous fixation and 29 underwent the laparoscopic approach using prolene mesh. Preoperative and 3-month postoperative outcomes were compared between groups using International Consultation on Incontinence Questionnaire–Vaginal Symptoms module (ICIQ-VS) and Pelvic Organ Prolapse Quantification (POP-Q) scores. Time was recorded from knife-to-skin to last closure stitch. The non-parametric Mann-Whitney test was used for statistical analysis due to small sample sizes.

Results: There was no significant difference between the two procedures in the degree of improvement in ICIQ-VS (p=0.91) or POP-Q (p=0.21) scores. Two patients (6%) in the vaginal group developed chronic pelvic pain requiring subsequent stitch removal. The laparoscopic approach took, on average, 64 minutes more to perform (95%CI, 26.0-102.3).

Discussion: The patient-reported and objective success rate is similar for the two procedures. The 6% rate of chronic pain (vaginal approach) is important for counselling. The longer time for laparoscopic procedures may be related to initial learning curve and to choosing the abdominal approach for women with complex and recurrent prolapse.

INTRODUCTION OF HYSTEROSCOPIC STERILISATION IN A UK NHS DISTRICT GENERAL HOSPITAL

Diagnostic & Operative Office Hysteroscopy

Poster

Alam Ash*, Alam M, Steele G, Chong Daphne

Summary (4 lines): To review the implementation and initial outcomes of hysteroscopic sterilisation, introduced as first line method of tubal ligation in an office setting in an NHS district general hospital

Introduction: Permanent methods of female contraception have evolved significantly over the past two decades. With guidance from the National Institute for Health and Clinical Excellence (NICE) in 2009, hysteroscopic sterilisation by tubal cannulation and placement of intrafallopian tubes is now accepted as a safe and minimally invasive method of achieving reliable pregnancy prevention.

Material and Methods From July 2012, outpatient hysteroscopic sterilisation was introduced in the gynaecology unit at Arrowe Park Hospital, Wirral, UK. A prospective data collection was undertaken on patients undergoing the elective procedure over 10 months. Patients were followed-up on a standard 3-month protocol with radiological imaging to confirm tubal occlusion.

Results: 28 patients underwent hysteroscopic sterilisation. In 86% cases, the procedure was completed with no immediate complications. This was abandoned in 14% due to difficult ostia cannulation. Tubal occlusion was confirmed by ultrasound and hysterosalpingogram in 82% and 18% respectively. Single case of chronic post –procedure pain occurred requiring bilateral salpingectomy.

Discussion: Hysteroscopic sterilisation can be safely and reliably implemented in an office setting in a UK NHS district general hospital as first line method of tubal ligation. The minimally invasive procedure can be expected to have a high post-implementation completion rate of 86%, aiding in patient counseling and business plans formulation.

LAPAROSCOPIC HYSTERECTOMY IN CASE OF UTERI WEIGHING > 1 KILOGRAM: A SERIES OF 65 CASES

Hysterectomy

Oral

Jvan Casarin*, Uccella Stefano, Cromi Antonella, Podestà Alluvion Carolina, Candeloro Ilario, Gisone Baldo, Ghezzi Fabio

University of Insubria, Del Ponte Hospital, Varese

Summary (4 lines): Based on our current knowledge, we here report the largest published series of laparoscopic hysterectomy performed in women with uterus weight >1000 grams.

Introduction: Some case reports or limited case series describe laparoscopic hysterectomy as a possible and feasible procedure even in women with very large uteri. Despite this, in the every-day routine practice, almost worldwide the treatment of choice when the uterine fundus approaches the umbilicus is open abdominal hysterectomy. Aim of this study has been to report the perioperative outcomes of laparoscopic hysterectomy for uteri weighing >1 kilogram in our experience.

Material and Methods In the period between 10/2000 and 04/2013, 65 women had laparoscopic hysterectomy for a uterus weighing >1 kilogram. All procedures were performed with the same technique. First a Rumi manipulator with Koh colpotomizer was inserted transvaginally. A 5mm-o

Results: Median uterine weight was 1170 (range, 1000–2860) grams. Operative time was 145 (55-360) minutes. Estimated blood loss was 200 (range 10–1000) milliliters. Three (4.6%) conversions to open surgery were needed. There were neither intra-operative complication nor blood transfusions. Two (3.1%) post-operative complications were observed.

Discussion: Our data show that, in a referral center with extensive background in endoscopic techniques, laparoscopic hysterectomy can be feasible even in the presence of an extremely enlarged uterus (i.e. weight > 1 kilogram), with a very high probability (>95%) of completing the procedure without conversion to open abdominal surgery.

HYSTEROSCOPIC ANAESTHESIA IN OFFICE HYSTEROSCOPY

Diagnostic & Operative Office Hysteroscopy

Poster

Patrícia Di Martino*, Vinagre Cláudia, Mairos João

Hospital das Forças Armadas

Summary (4 lines): The objective of this poster is to present a new method of local anaesthesia performed during Office Hysteroscopy, named Hysteroscopic Anaesthesia (HA), and evaluate its efficacy.

Introduction: Office Hysteroscopy is a diagnostic and operative technique performed predominantly without anaesthesia. However, sometimes pain during procedure may limit access to the uterine cavity or intervention closure. Authors describe a method of local anaesthesia, that uses an endoscopic needle, allowing injection of anaesthetics in specific points according to patients needs. The use of this needle doesn’t imply procedure interruption or speculum use. In Portugal there are no descriptions of use of this method in Gynecology.

Material and Methods Retrospective study between 19 of May of 2010 and 13 of March of 2013 in which 74 office hysteroscopies were performed under local anaesthesia, using this endoscopic needle. After hysteroscopy, an inquiry, using a 0-10 scale, was given to the patients to access the level of pain felt during the procedure, before and after HA administration.

Results: Out of 74 patients, 20 were excluded because the inquiry wasn’t complete, in 2 patients the access to uterine cavity wasn´t possible and 4 patients didn’t allow intervention closure due to severe pain. In the remainder 48, intensity of pain was clearly inferior after HA administration (3,83 vs 6,13).

Discussion: The use of this needle allows local anaesthesia under hysteroscopic visualization of cervix, uterine cavity or uterosacral ligaments, without the disconfort associated with procedure interruption and speculum use. This form of anaesthesia appears effective, allowing closure of the procedure in 91,2% of the cases with significant reduction of pain.

EXCISION OF INTRACAVITARY MASSES IN OFFICE HYSTEROSCOPY - DOES SIZE MATTER?

Diagnostic & Operative Office Hysteroscopy

Poster

Di Martino Patrícia *, Cardoso Edite, Mairos João, Rodrigues Milene

Hospital das Forças Armadas

Summary (4 lines): The objective of this poster is to access if size is a determinant factor in operative Office Hysteroscopy (OH) success.

Introduction: Operative Office Hysteroscopy is a developing technique in modern gynaecology, allowing masses extraction in an office setting, predominantly performed without anaesthesia. Factors such pain and mass characteristics may limit operative procedure closure. Authors intent to demonstrate that size of masses, itself, is not a determinant factor in operative office hysteroscopy success.

Material and Methods Retrospective study between January 2010 and December 2012 (230 operative office hysteroscopies). After hysteroscopy an anonymous survey was made to all patients, using a 0-10 scale, to access pain intensity felt and desire of general anaesthesia. Patients were divided, accordingly to masses size, in tree groups: masses smaller than 2 cm; masses between 2 and 5 cm and masses of 5 cm and larger. Data analysis was performed with SPSS version 20 with α 0,05.

Results: Pain level was inferior to score 5 in 73.1% of patients. Only 10% expressed desire of general anaesthesia. There was no correlation between size of mass removed and pain reported. 38 patients underwent OH, with removal of masses 5 cm and larger. One patient was sent to the operating room.

Discussion: Office Hysteroscopy is an effective technique to treat intrauterine pathology. Mass dimension is not related to pain intensity or anaesthesia desire. Removal of masses larger than 5 cm is practicable in office hysteroscopy. Only 7.4% of patients was send to the operating room.

LAPAROSCOPIC SUPRACERVICAL HYSTERECTOMY VERSUS VAGINAL, ABDOMINAL AND LAPAROSCOPIC ASSISTED VAGINAL HYSTERECTOMY. DURATION, COST AND MORBIDITY

Hysterectomy

Poster

Milica Perovic*, Khan Naila, Ahmed Hasib, Hany Wisa

Medway Maritime Hospital

Summary (4 lines): A comparison between the four different techniques of Hysterectomy in terms of operating time, hospital stay, morbidity and total financial cost at Medway Foundation Trust, UK during the year 2012.

Introduction: Laparoscopic approach for hysterectomy is generally believed to be associated with less morbidity, hospital stay and therefore less total cost compared to abdominal and vaginal approaches. Aiming to examine this statement relative to the current practice at Medway Foundation Trust, UK, we analysed all hysterectomies performed during the year 2012 to identify the safest and most cost effective approach. Morbidity was defined as need for blood transfusion, intra-operative visceral injury, venous thromboembolism and readmission.

Material and Methods Retrospective analysis of 214 women who had Hysterectomy for different indications between January and December 2012 at Medway Foundation Trust. 65 had Laparoscopic assisted vaginal hysterectomy, 21 Laparoscopic supracervical hysterectomies, 53 abdominal and 75 vaginal approaches. The duration of the procedure, morbidity and number of nights in hospital were compared. The data was obtained from Galaxy data base system, Electronic discharge notes. Costs were obtained from theatre managers.

Results: Laparoscopic approach was similar to abdominal route in duration but morbidity was significantly lower (5% versus 22%), and shorter hospital stay. Total cost was considerably higher for Laparoscopic approach versus abdominal. Vaginal hysterectomy was associated with comparable morbidity to the laparoscopic approach (6%), and least cost compared to all approaches.

Discussion: Laparoscopic hysterectomy has the highest cost but least morbidity and hospital stay. It is more expensive initially, but quicker recovery and return to work makes it most cost effective. Vaginal hysterectomy costs least and similar to laparoscopic approach in morbidity making it cost effective if laparoscopic technique is not available.

VAGINOPLASTY FOR RELAXED VAGINA

Innovation in Instrumentation and Surgical Techniques

Oral

Vishwa Prakash*, Garg neeta

Safdarjung hospital and VMMC

Summary (4 lines): There is a group of women who have relaxed vagina and request its tightening.We have developed new technique for vaginoplasty for such patients with good results

Introduction: relaxed vagina in women results in loss of sexual pleasure. In literature the technique decribed is excision of mucosa in V fashion and tighten it,We have developed the etchnique of tightening by creating rugae and tightening of muscles

Material and Methods We have done the technique in 93 women over a period of six years .Only those women were included who had relaxed vagina but not having any cysto or rectocele .We have raised the flap from posterior vaginal wall , created rugae and tightened the muscles

Results: We got excellent results.Patients felt tightness but no dyspareunia which was main complication in traditional V excision of mucosa

Discussion: By creating rugae and tightening the muscles the originality of vagina is restored which is aim in any reconstruction

MINI DERMAL SLING FOR MANAGEMENT OF STRESS INCONTINENCE

Innovation in Instrumentation and Surgical Techniques

Poster

Vishwa Prakash*

Safdarjung hospital and VMMC

Summary (4 lines): Stress incontinence is very common in women.Different meshes are being used in TVT TVT -O but all are falling in disrepute.We have used autogenous dermal sling with good results in 15 patients

Introduction: Stress incontinence is common in women.Usual techniques are TVT and TVT -O but extrusion rate is high,We believe that autogenous material is better option as extrusion rate and complications are negligiblw

Material and Methods We have used minidermal sling in 15 patients suffering from stress incontinence .The dermal sling was crated from thigh and applied just behind urethra ..The tesnion was adjusted the next day when patient was asked to cough

Results: We have found good results in 13 patients .In two pateints retightening was to be done

Discussion: Autogenous material is always better tan meshes.Described procedure were technically complicated .So we simplified the sling procedure just like TVT or TVT O and think that it is viable alternative to TVT and TVT -O

INTRAOPERATIVE CYTOLOGY DURING LAPAROSCOPIC SURGERY OF UTERINE CARCINOMA

Oncology

Poster

Anika Gittler*, Sascha Baum, Zoltan Takacs, Erich Franz Solomayer, Ingolf Juhasz-Böss

Unikilikum Homburg/Saar

Summary (4 lines): The objective of this study was to determine if laparoscopic surgery of uterine cancer can lead to an intraperitoneal tumor cell dissemination. In 21 patients no conversion of cytology could be detected, proofing that laparoscopic surgery is a safe option of oncologic therapy.

Introduction: The laparoscopic treatment of uterine cancer is an oncologically safe treatment option in early stage carcinoma. However, there still is no information whether laparoscopic surgery can lead to an intraperitoneal tumor cell dissemination. The aim of our study was to investigate the peritoneal cytology at the beginning and at the end of laparoscopic operations.

Material and Methods A prospective study of intraperitoneal cytology at the beginning and at the end of laparoscopic surgery of patients suffering from cervical and endometrial cancer with stage I and II grade cancer.

Results: A first evaluation of the data of 21 patients is available. At the beginning of the operation only one patient showed a positive cytology. None of the patients had tumor cell dissemination during surgery. All patients were free of recurrence at the time of data analysis.

Discussion: During laparoscopic surgery of earlier stages of cervical Cancer and endometrial cancer no conversion of cytology can be detected, which proves that laparoscopic surgery is a safe option of oncologic therapy.

EXCISION OF INTRACAVITARY MASSES IN OFFICE HYSTEROSCOPY - DOES SIZE MATTER?

Diagnostic & Operative Office Hysteroscopy

Poster

Milene Rodrigues*, Cardoso Edite, Patricia Serafim, Mairos João

Hospital Garcia de Orta

Summary (4 lines): The objective of this poster is to access if size is a determinant factor in Office Chirurgic Hysteroscopy sucess.

Introduction: Office Chirurgic Hysteroscopy is a developing technic in modern gynaecology, allowing masses extraction in an office setting, predominantly performed without anaesthesia. Factors such as pain and mass characteristics may limit chirugic procedure closure. Authors intent to demonstrate that size of masses, itself, is not a determinant factor in chirurgic office hysteroscopy sucess.

Material and Methods Retrospective study between January 2010 and December 2012 (230 Office Chirurgic hysteroscopies). After hysteroscopy an anonymous survey was made to all patients, using a 0-10 scale, to access pain intensity felt and desire of general anaesthesia. Patients were divided, accordingly to masses lenght, in tree groups:masses inferior to 2 cm;masses between 2 and 5 cm and masses of 5 cm and more. Data analysis was preformed with SPSS version 20 with α 0,05.

Results: Pain level was inferior to score 5 in 73.1% of patients. Only 10% expressed desire of general anaesthesia. There was no correlation between size of mass removed and pain reported by patients. 38 hysteroscopy was performed in patients with masses ≥5cm and only one was sent to the operating room.

Discussion: Chirurgic Office Hysteroscopy is an excellent technic to treat intra-uterine pathology. Mass lenght size is not related to the intensity of pain, or with anaesthesia desire. Removal of masses longer than 5 cm is practicable in office hysteroscopy. Only 7.4% of the patients was send to the operating room.

COMPLETE LAPAROSCOPIC SURGICAL MANAGEMENT OF EARLY STAGE OVARIAN CANCER COMPARED TO STANDARD LAPAROTOMY SURGICAL MANAGEMENT

Oncology

Poster

Borut Kobal*, Cvjetičanin Branko, Brabič Matija, Meglič Leon, Jakimovska Marina

University medical centre ljubljana

Summary (4 lines): The resuts of complete laparoscopic staging of early ovarian cancer (EOC) compared with those obtained with standard surgical staging via laparotomy are presented.

Introduction: Early stage ovarian cancer (EOC) represents a rare condition and is usually diagnosed through laparoscopic management of suspect adnexal masses. Standard management is to convert to laparotomy for comprehensive staging. Feasibility and safety to conduct the comprehensive laparoscopic staging for EOC has already been reported. In our series we analyze demographic, clinical, surgical, fertility outcome and recurrence data in patients having complete laparotomic or laparoscopic staging for EOC in the period 2009 – 2012.

Material and Methods 28 patients had complete surgical staging for EOC. Retrospective analysis of clinical, histopathologic, surgical, reproductive and oncological data regarding adjuvant treatment, recurrence and overall survival was performed between the three subgroups: Group A (13 patients) staging by laparotomy, Group B (8 patients) conversion from laparoscopy and complete staging or restaging with laparotomy and group C (7 patients) complete laparoscopic staging or restaging of EOC. Median (range) follow up was 22 (4-51) months.

Results: Patients differed in demographic and clinical data. Hystotypes, grade, stage were normally distributed with no differences in staging procedures. 53% of patients in group A received chemotherapy compared to 62% and 71% in groups B and C. No disease related death, one recurrence and two deliveries were reported.

Discussion: Our results contribute to feasibility and safety of comprehensive laparoscopic staging in EOC, to those already reported. Volume of the tumor presented the main indication for laparotomy or conversion to it in our otherwise homogenous study population. Nevertheless, laparoscopic staging should be performed by experienced laparoscopic surgeon.

THE EFFECT OF 10% OF N2O UPON ADHESION FORMATION IN LAPAROSCOPIC AND OPEN SURGERY

Innovation in Instrumentation and Surgical Techniques

Both Oral or Poster

roberta corona*, binda maria mercedes, Koninckx Philippe

UZ Brussel, Centre for Reproductive Medicine Free

Summary (4 lines): Adhesion formation at surgical sites is enhanced by factors from the entire peritoneal cavity driven by acute inflammation.

Introduction: N2O, has advantages over CO2 for the pneumoperitoneum (PP) since lower irritative effect, less postoperative pain and less metabolic side effects. N2O is a safe gas given the high solubility in water and diffusion in the lungs similar to CO2. N2O however has an explosion risks at concentrations higher than 29%, and thus was not used.

Material and Methods In our laparoscopic mouse model and in a mouse model for open surgery the effect of N2O in different concentrations upon pneumoperitoneum and surgical gas environment enhanced adhesion formation was investigated.

Results: In open surgery, adhesions decreased with concentration of N2O in humidified CO2 with a maximal effect adding 10% of N2O (P= 0.0006). In laparoscopic surgery, dose response curves demonstrated that the addition of 5%,10%,25%,50%,100% of N2O to the CO2 PP strongly decreased the proportion of adhesions in all groups (P=0,0001).

Discussion: N2O from concentrations of 5% onwards is the most effective prevention of adhesion formation both during laparoscopic surgery and in open surgery. N2O in concentration of 5 to 10% is safe since N2O is highly soluble in water as CO2 is, while the explosion risk does not exist below 30%

SURGICAL TACTICS IN TOTAL LAPAROSCOPIC HYSTERECTOMY FOR VOLUMINOUS UTERINE FIBROIDS

Tips & Tricks in Surgery

Poster

Dorin Grigoras*, Mazilu Octavian, Rednic Robert, Bacila Mihai , Pirtea Laurentiu

UMF Victor Babes Timisoara

Summary (4 lines): Many times voluminous uterine fibroids enable low mobility and difficult access when performing conventional operatory steps.

Introduction: Voluminous uterine fibroids represent a challenge requiring beside technical abilities from a surgeon with experience in laparoscopy some technical and tactical surgical details for restricting intraoperatory bleeding, decreasing the duration of intervention and facilitate the evacuation of the entire fibroid. This desiderates are acquired by associating the abdominal step with the morcellating and the vaginal step to minimaise the uterine tumor.

Material and Methods Situations: -cases with multiple intramural,subserous nodules with fundic localisation and variable dimensions until 10 cm in which we used the technique of multiple myomectomy then extracting each nodule by morcelating and then performing TLH. -cases w

Results: TLH for voluminous uterine fibroids weighting 500 to 800 grams (our experience is under 50 cases of TLH) raised problems of surgical technique and we had to find individual intraoperatory solutions . The surgical techniques described in materials and method allowed us to reduce the operatory time also facilitating the extraction.

Discussion: Reducing the volume of the tumor by laparoscopic technique directly raises the importance of this type of surgery eliminating the difficulties of performing the vaginal step. Reducing the volume of the tumor we can perform total laparoscopic hysterectomy in better anatomical conditions avoiding complications related to nearby lesions or hemorrhagic complications.

A COMPARISON OF ROUTES OF HYSTERECTOMY IN A DISTRICT GENERAL HOSPITAL IN THE UNITED KINGDOM

Hysterectomy

Poster

Navneet Kaur*, Bambang Katerina, Mohiyiddeen Gaadha, George Suku

Stepping Hill Hospital

Summary (4 lines): This retrospective case note review aims to add to the current body of literature on operative outcomes of patients following different operative routes for hysterectomy.

Introduction: Hysterectomy is one of the most frequently performed gynaecological procedures and the proportion of laparoscopic hysterectomies performed is increasing. Although laparoscopic routes are thought to be superior in terms of length of hospital stay and recovery, they require highly skilled surgeons and longer operating times. It is still important therefore to report data on operative outcomes to inform future techniques of choice.

Material and Methods This is a retrospective case review of 87 patients undergoing total laparoscopic hysterectomy (TLH), laparoscopic assisted vaginal hysterectomy (LAVH), total abdominal hysterectomy (TAH) or vaginal hysterectomy (VH) over a period of one year in a district general hospital in the UK. A number of clinical outcomes were collected including demographics, length of procedure, estimated blood loss, length of stay and details of intra- and post-operative complications. The data was analysed using Graphpad Prism 6.

Results: The commonest indication for hysterectomy was dysfunctional uterine bleeding accounting for 38% (n=33) of operations then malignancy (22% n=19). VH had shorter operating times and estimated blood loss was significantly lower in women having a TLH. Complications occurring in the LAVH and TLH groups consisted of bladder and vascular injury.

Discussion: There are clear advantages to using laparoscopic techniques especially TLH for hysterectomy. These include reduced blood loss and shorter hospital stay. Interestingly, TLH had significantly lower incidence of blood loss than the alternative routes including LAVH. Complications occurred mainly with the laparoscopic routes and in most cases this required re-admission.

STUDY OF ENDOMETRIAL RECEPTIVITY THROUGH OPTICAL PROPERTIES OF TISSUE AND VESSELS CHARACTERISTICS

Imaging

Poster

Fani Gkrozou*, Kavvadias Vasileios , Stefos Theodoros, Balas Costas, Paschopoulos Minas

University Hospital of Ioannina

Summary (4 lines): This study took place in university Hospital of Ioannina by applying hyperspectral hysteroscopy such as to identify the hyperspectral map of implantation window.

Introduction: Receptivity of the endometrium has as an important role in the implantation of the blastocyst as the quality of the ovule. The implantation window is from the 20th to 22nd day of menstrual cycle. The purpose of this study is to create a new protocol of diagnostic approach, which can provide an easy, direct and intimate way to the gynecologist to gather better information on the quality of the endometrial cavity and the endometrial receptivity

Material and Methods 20 women participated in this study, 10 of them already had at least one delivery while the rest had infertility problems. All women had diagnostic hyperspectral hysteroscopy on the 20th to 22nd day of menstrual cycle, known as implantation window. This technique is used for the first time at the University Hospital of Ioannina and aims to quantify morphological characteristics of the endometrium and its structural changes. Endometrial biopsies were taken at the same time

Results: Hyperspectral hysteroscopy resulted to a hyperspectral map. All fertile women and 3 infertile had a map of normal endometrium, according to the histological result. From infertile women 7 had the hyperspectral map of endometritis, a fact that was certified by histology

Discussion: The goal of the final comparison of these results is to identify and quantify information about the implantation window. During this women had two different types of endometrial characteristics. More studies are necessary to further classify a personalized implantation window for each woman by applying hyperspectral hysteroscopy

ENDOMETRIAL STROMAL SARCOMA MIMICKING SUBMUCOUS LEIOMYOMA: A CASE REPORT

Case reports

Poster

Sinem Sudolmus*, Koroglu Nadiye, Bakar Rabia Zehra, Sarıoglu Elif Aslı, Dansuk Ramazan

Bemialem Vakif University

Summary (4 lines): A case of endometrial stromal sarcoma presenting like a submucous leiomyoma is reported.

Introduction: Uterine sarcomas are rare neoplasms comprising 4–9% of all malignant uterine neoplasms. Among those ESS is an uncommon entity of uterine malignancy, accounting for 6–20% of all uterine sarcomas.

Material and Methods A 42 year old woman presented with menorrhagia. Ultrasound evaluation revealed an intrauterine lesion 37 mm in diameter with heterogeneous appearance. Although preoperative endometrial biopsy result was consistent with endometrial polyp, hysteroscopy was performed with an indication of submucous leiomyoma due to the ultrasonographic imaging of the lesion. Myoma was completely resected and material was sent to pathology for histological confirmation. Final pathological diagnosis was ESS.

Results: Staging laparotomy was performed and FIGO stage of the patient was stage I. Accordingly, no adjuvant therapy was administered and patient has been followed up for 2 years. No recurrence has been observed.

Discussion: Endometrial stromal sarcomas usually grow into myometrium, however, they may involve endometrium and present as an intrauterine pathology. Nonetheless, it may be impossible to diagnose it with certainty on hysteroscopy alone. Histopathological diagnosis is a must in all intrauterine lesions.

ENDOMETRIOSIS-ASSOCIATED INFERTILITY: PREGNANCY OUTCOME DURING 12 MONTHS AFTER LAPAROSCOPY IN DIFFERENT STAGES OF ENDOMETRIOSIS

Infertility and Reproductive Medicine

Poster

Deniss Sõritsa*, Saare Merli, Laisk-Podar Triin, Padrik Lee, Kadastik Ülle, Sõritsa Andrei, Soplepmann Pille, Matt Kadri, Karro Helle, Salumets Andres

Tartu University Women`s Clinic

Summary (4 lines): Eighty two (76.6%) of conceived patients became pregnant within 12 months after laparoscopy (54 patients in Group 1 and 28 patients in Group II).

Introduction: Endometriosis-associated infertility is scantily treatable and treatment mainly consists of surgical and medical approaches, or combinations of them. Surgical treatment alone or in combination with gonadotropin-releasing hormone (GnRH) treatment remains the most effective treatment for patients with endometriosis after several unsuccessful in vitro fertilisation (IVF) treatments. The objective of this study was to evaluate the pregnancy outcome during 12 months after laparoscopy in patients with different stages of endometriosis.

Material and Methods This retrospective study (2005-2009) was carried out on 181 infertile patients from private infertility center, Elite Clinic. All patients underwent curative laparoscopic surgery with or without postoperative treatment using GnRH agonists. For statistical analysis patients were divided into two groups according to severity of endometriosis (ASRM criteria): Group 1 (stage I-II) 121 and Group 2 (stage III-IV) 60 patients.

Results: The general pregnancy rate in study groups was 66.3% (66.9% in Group I and 65.0% patients in Group II). Sixty five (79.3%) patients received GnRH treatment. Sixty eight (82.9%) patients conceived on the first IVF attempt or spontaneously. Seventy patients (85.4%) had a delivery.

Discussion: No statistically significant differences in pregnancy outcome were found between patients with various stages of endometriosis. Pregnancy in patients with infertility for more that 6 years is generally achieved within 12 months after laparoscopy and either spontaneously or on the first IVF attempt.

CURRENT USE OF SURGICAL SIMULATORS IN GYNECOLOGY ACROSS FRENCH ACADEMIC SCHOOLS : A NATIONAL SURVEY

Teaching & Training

Poster

Patrice Crochet*, Aggarwal Rajesh, Marcelli Maxime, Agostini Aubert

Hopital La Conception

Summary (4 lines): This survey shows that a majority of French gynecologic residents have already a limited experience on simulators. There is a strong agreement about the use of these tools for training.

Introduction: Simulation is a promising method to enhance surgical education in gynecology. The use of simulation tools is left to local initiative in France, and varies highly depending on the centers. The purpose of this study was to provide baseline information on the current use of surgical simulators in gynecology across French academic surgical schools.

Material and Methods Two questionnaires were created, one specifically for gynecologic residents and one for professors. These questionnaires were sent by email to 998 residents and to 120 professors. Main issues included the type of simulators used and the kind of use made f

Results: 258 residents (26%) and 29 professors (24%) answered the questionnaire. 65% of residents had experienced simulators. Laparoscopic pelvic-trainers (84%) and sessions on alive pigs (63%) were most commonly used. Residents and professors believed the simulators useful for training. Professors were less enthusiastic regarding the use of simulation for certification (2,55/5).

Discussion: Simulators are already experienced by a majority of residents. However, the use of these educational tools varies among surgical schools and remains occasional for the majority of residents. There is a strong agreement among both professors and residents that surgical skills laboratories should be a component of gynecologic residency training.

CAESAREAN SCAR PREGNANCIES: A MODERN CHALLENGE IN GYNAECOLOGY

Case reports

Poster

Becky Liu*, Buddha Lavanya, Waters Natasha

Worthing Hospital, Western Sussex NHS Trust

Summary (4 lines): Caesarean scar pregnancies (CSP) have become increasingly prevalent due to the recent rise in Caesarean section (CS) rates. We present a case of a CSP and its challenges in management.

Itroduction: CS rates have risen significantly in the recent decades, leading to Obstetric dilemmas, and a range of Gynaecological disorders ranging from abnormal bleeding to CSP. To date, there is no consensus on the optimal management of such complications. We present a 32 year old lady with two previous CS, who presented at seven weeks into her third pregnancy with pain and bleeding. Ultrasound scan confirmed a live ectopic pregnancy in her CS scar.

Material and Methods Potassium chloride was injected into the gestation sac via Hysteroscopy, followed by intramuscular Methotrexate. The pregnancy continued to progress. Hysteroscopic resection of the pregnancy under direct laparoscopic vision was then planned. After dissecting the uterovesical fold, the majority of the gestation sac was protruding through the lower segment scar, and at Hysteroscopy, only a small section of it was visualised. Therefore the resection was abandoned due to the risk of torrential bleeding.

Results: Successful laparoscopic resection of the pregnancy would have preserved her fertility, but may predispose her to significant haemorrhage, conversion to laparotomy, and future CSP. As the patient has completed her family, we felt that the safest option was to proceed with a laparoscopic hysterectomy.

Discussion: Caesarean scar pregnancy is a rare form of ectopic pregnancy, with no current preferred mode of treatment. Early diagnosis is crucial, and treatment options should be tailored towards each individual. The benefits of fertility preservation should be weighed against the risk of performing a complicated procedure with possible long-term implications.

MINI-LAPAROSCOPIC SINGLE UMBILICAL INCISION TOTAL HYSTERECTOMY: A SCARLESS WAY TO REMOVE THE UTERUS

Innovation in Instrumentation and Surgical Techniques

Poster

Stefano Uccella*, Casarin Jvan, Cromi Antonella, Rossi Thomas, Sturla Davide, Carollo Simona , Ghezzi Fabio

University of Insubria, Del Ponte Hospital, Varese

Summary (4 lines): To the best of our knowledge this is the first description of a series of minilaparoscopic single umbilical incision total hysterectomy using two 3mm-umbilical accesses and no further skin incisions.

Introduction: The quasi-utopic whish of enthusiastic supporters of minimally-invasive surgery is to perform scarless operations. Single-site laparoendoscopic surgery (SILS) has used the umbilicus to perform a vast variety of gynaecological procedures. One of the downsides of SILS is that this technique can leave a non-cosmetic result in the woman’s umbilicus. Aim of the present study has been to present our preliminary experience of total minilaparoscopic hysterectomy using only two 3mm-trocars inserted through the umbilicus.

Material and Methods Five nulliparous women (BMIperated for benign conditions were selected for the present study. A Rumi manipulator with a Kho colpotomizer cup was inserted in all cases to expose uterine supportive structures. Two 3mm-trocars were inserted through a singl

Results: Median operative time was 40 (range 35-55) minutes. Blood loss was negligible. No conversion to conventional laparoscopy or laparotomy and no intra or post-operative complications occurred. Post-operative pain 8 hours post-operatively was 0 (range: 0-4) using a VAS score. Hospital stay was less than 24h for all patients.

Discussion: Our preliminary experience with minilaparoscopic single umbilical incision total hysterectomy shows that, in the hands of an experienced minimally-invasive surgeon, this operation is feasible in selected women. Further research is needed to prove the real feasibility and the possible (if any) advantages of this procedure.

ENDOMETRIOSIS OF THE RECTOVAGINAL SEPTUM PRESENTING WITH SEVERE VAGINAL BLEEDING, CAUSING HYPOVOLAEMIC SHOCK

Endometriosis: Diagnosis

Video

Laura Reddin*, Smith-Walker Tom, Byrne Dominic

Royal Cornwall Hospital Trust

Summary (4 lines): A 31 year old woman presented with hypovolaemic shock following acute vaginal haemorrhage. Examination revealed extensive endometriosis in the posterior fornix. Vaginal endometriosis presenting with acute haemorrhage is currently unreported.

Introduction: Vaginal endometriosis often presents with pelvic pain, dyspareunia and dyschezia, but rarely with vaginal bleeding. We present a 31 year old woman with hypovolaemic shock following an acute vaginal bleed of approximately 1500ml. She was previously fit and well, with no gynaecology history and a negative pregnancy test. Her haemoglobin dropped from 125 g/l to 76 g/l. She had a long history of dysmenorrhoea, dyspareunia and post-coital bleeding which she thought to be normal.

Material and Methods The initial priority was resuscitation followed by investigation to exclude malignancy. She was resuscitated with intravenous fluids, a blood transfusion and then given intravenous iron. A speculum examination confirmed a bleeding lesion behind the cervix, so a colposcopy was performed to exclude a cervical or vaginal tumour. Vaginal endometriosis was diagnosed and she was treated with GnRH down-regulation to prevent further bleeding before a planned diagnostic laparoscopy.

Results: Detailed examination revealed several blood filled cysts in the posterior fornix, some of which were actively bleeding. The cervix was normal. At diagnostic laparoscopy a large nodule of endometriosis was present in the rectovaginal septum extending through to the vagina, along with left uterosacral ligament and left pelvic sidewall endometriosis.

Discussion: Endometriosis of the rectovaginal septum is often deep infiltrating disease from the pelvis and usually presents with pain, dyspareunia and dyschezia. Dysmenorrhoea may be associated, but there are no reports of primary presentation by severe vaginal haemorrhage. A video will be shown of the acute presentation, diagnostic laparoscopy and treatment.

LAPAROSCOPY FOR APPARENT EARLY-STAGE OVARIAN CANCER: A SERIES OF 24 PATIENTS WITH MINIMUM 3-YEAR FOLLOW-UP

Oncology

Poster

Stefano Uccella*, Casarin Jvan, Cromi Antonella, Rossi Thomas, Sturla Davide, Carollo Simona , Ghezzi Fabio

University of Insubria, Del Ponte Hospital, Varese

Summary (4 lines): Outcomes of laparoscopic treatment for early-stage ovarian cancer (EOC) are a matter of debate. We here report our experience of laparoscopic staging of apparent EOC.

Introduction: Laparoscopy has become an increasingly common approach for the treatment of gynecologic malignancies. Different studies published in the last years suggest that minimally-invasive approach is a feasible alternative to traditional open surgery also for apparent EOC. However there is scant information about long-term oncologic outcomes.

Material and Methods Twenty-six consecutive women with macroscopically EOC who were operated at least 3 years before study and who had complete follow-up information were enrolled. They all received a complete laparoscopic staging, including peritoneal washing, random biopsie

Results: Nine (33.3%) patients were upstaged, four (14.8%) had FSS and 3 pregnancies occurred in 2 women. Twenty-three (85%) patients received adjuvant chemotherapy. Three (11%) recurrences were observed and one (3.7%) patient died of disease. Disease-free and overall survival were 89% and 96.3%, respectively after a median follow-up of 69 months.

Discussion: Our study suggests that laparoscopic treatment of EOC has very encouraging long-term oncologic outcomes. Further studies are needed to support this preliminary evidence.

TWO-MILLIMETERS OPERATIVE MICROLAPAROSCOPIC SALPIGO-OOPHORECTOMY: A CASE SERIES OF 5 PROCEDURES

Innovation in Instrumentation and Surgical Techniques

Poster

Jvan Casarin*, Uccella Stefano, Cromi Antonella, Podestà Alluvion Carolina, Candeloro Ilario, Ghezzi Fabio

University of Insubria, Del Ponte Hospital, Varese

Summary (4 lines): Operations using exclusively 2-mm instruments have been reserved by gynecologic surgeons only to diagnostic purposes. We present a series of consecutive salpingo-oophorectomies entirely performed microlaparoscopically.

Introduction: Since 1993 several studies about microlaparoscopy have been published; however, none of these regarded gynecologic operative procedures using only 2-mm extraumbilical ports. The advantages correlated to needlescopic surgery include faster return to every-day activities, more comfortable postoperative recovery and satisfactory aesthetic outcomes with possibly better results compared to the traditional laparoscopy. The aim of this paper is to show data about the first series of 2mm-laparoscopic salpingo-oophorectomy.

Material and Methods Five consecutive women with molecular diagnosis of BRCA1-2 were enrolled. A 3-mm trocar was introduced intra-umbilically. A right and left suprapubic 2-mm ancillary trocars were inserted under vision. For right adnexectomy, a 2-mm scope and grasper were

Results: Median operative time was 35 minutes (range 30-50). Neither conversion to conventional laparoscopy nor open surgery were needed. No intra-operative complications occurred. Estimated blood-loss was less than 10cc for each procedure. No post-operative complications were reported 1 month after surgery. All patients were discharged the same day of surgery.

Discussion: Our first experience with 2-mm operative laparoscopy appears encouraging. However, we believe that this technique should be reserved to skilled laparoscopic surgeon.

LAPAROSCOPIC COLPOSUSPENSION

Urogynaecology

Oral

Schmidt Ernst-Heinrich*, Cristina Cezar, Vivian Frank, Anja Herrmann, Rudy Leon De Wilde

Pius Hospital Oldenburg

Summary (4 lines): The aim of the prospective study is to determine the safety and efficacy of the laparoscopic colposuspension in the treatment of urinary stress incontinence.

Introduction: The principle of abdominal colposuspension, first initiated in 1961, has been used for many years as "gold standard" technique in the treatment of the urinary stress incontinence. The laparoscopic colposuspension, first reported in 1991, was accepted in the medical world due to its lower postoperative morbidity and shorter hospital stay. The purpose of the study is to put forward our own experience in the domain of laparoscopic colposuspension in the treatment of urinary stress incontinence.

Material and Methods We conducted a prospective single arm observational study between April 1993 and April 2000. The patients included in this biggest study ever, suffered of urinary stress incontinence or mixed incontinence; we used the laparoscopic colposuspension for the treatment of the disorder. The cure rate was evaluated objectively based on personal examination and subjectively, using an Incontinence Questionnaire, filled by the patients postoperatively.

Results: Out of 312 patients, 7,2% had preoperatively a USI I, 23,1% a USI II and 69,7% a USI III. The cure rates achieved in our study were 62,5% for the recurrent urinary incontinence and 86,4% for the primary incontinence. The overall complication rate was 11,5% of the 312 patients.

Discussion: The laparoscopic colposuspension remains a valuable primary or alternative operative technique in primary and recurrent urinary stress incontinence. It is standardized, can be successfully used in combination with other surgical procedures, has an acceptable morbidity and excellent long-term outcomes.

FACTORS AFFECTING DURATION OF OVARIAN CYSTECTOMY BY LAPAROENDOSCOPIC SINGLE-SITE SURGERY (LESS)

Single Access Surgery

Poster

MARCELLI MAXIME*, Sabine Poizac, Patrice Crochet, Nicolas Menager, Marc Gamerre, Aubert Agostini

Hôpital la conception; marseille

Summary (4 lines): to evaluate factors affecting duration of ovarian cystectomy procedure by LESS.

Introduction: Feasibility of LESS for ovarian cystectomy is today validated but there a lack of data concerning factors affecting duration of procedure.

Material and Methods From June 2010 to September 2012, 49 patients who required ovarian cystectomy by LESS were included in this study. All procedures were performed by 5 surgeons in the department of Obstetrics and Gynecology, La Conception Hospital, Marseille, France.

Results: 54 cystectomies were performed.No statistical correlation was found between size of cyst or BMI and duration of procedure. Mean duration of procedure for endometrioma was significantly higher than duration for other cyst. Rate of procedure with duration higher than 60 minutes was significantly higher in the endometrioma group .

Discussion: In our series, histologic type of cyst was the only factor affecting duration of procedure whereas size of cyst and BMI didn’t influence duration of procedure . These results are interesting for a better selection for LESS in patients requiring laparoscopic ovarian cystectomy.

POST-OBSTETRIC SEVERE PERINEAL INJURIES. WHAT LONG TERM IMPACT ON WOMEN’S QUALITY OF LIFE ?

Urogynaecology

Oral

Georges BADER*, Marion SAMIE, Anne Cécile PIZZOFERRATO, Arnaud FAUCONNIER

POISSY UNIVERSITY HOSPITAL

Summary (4 lines): The aim of the study is to evaluate the pelvic floor disorders and their long-term consequences on the quality of life of women exposed to complex post-obstetrical perineal injuries.

Introduction: Despite the big evolution of obstetric practices, the incidence of severe post-obstetrical perineal tears varies from 0.6 to 20% with a rate of anal incontinence in the medium term neighboring 11.5%. Even though the risk factors of these injuries are well known, symptoms and impact on quality of life for women at long term have been poorly studied.

Material and Methods Prospective, single center case-control study comparing two groups of 204 primiparas who delivered vaginally between January 1st 2005 and December 31st 2010. Validated self questionnaires of quality of life (QOL) and symptoms were used.

Results: The overall response rate was 47.4% (92/194). The mean follow up was 39 months. Only the rate of anal incontinence to liquid stool was significantly higher in anal sphincter injury group (p = 0.05). With regard to the overall QOL, scores were comparable in both groups with a satisfactory QOL.

Discussion: Perineal post obstetrical consequences (AI, UI, pain, sexuality) were found in both groups. Only AI for liquid stool was significantly higher after grade III and IV perineal tears. However, overall QOL was satisfactory in both groups (EQ-5D). Scores of pain, dyspareunia and UI were also statistically equivalent.

HYSTEROSCOPIC CONFIRMATION OF ENDOMETRIAL POLYPS

Diagnostic & Operative Office Hysteroscopy

Poster

Nadiye Köroğlu*, Sudolmus Sinem, Bakar Rabia Zehra, sarıoğlu elif aslı , dansuk ramazan

Bezmialem Vakif University

Summary (4 lines): Retrospective analysis of 94 patients hysteroscopically operated for endometrial polyps in a tertiary center.

Introduction: Endometrial polyps are the most frequently encountered endometrial pathology in women who present with irregular vaginal bleeding. Hysteroscopy is the gold standard in treatment of this pathology because it is relatively safe and minimally invasive, allowing “see and treat “ option.

Material and Methods Patients who underwent hysteroscopy between June 2011 and April 2013 in our institution were analyzed retrospectively. 94 patients who had polyps in their final diagnosis were enrolled to evaluate the malignant potential of their lesions. Median age was 43±10,6, ranging 24-77 years. 27,7% of patients were postmenopausal and 22,3% of patients were asymptomatic and polyps were detected incidentally during ultrasonography. 75,6% had abnormal uterine bleeding including intermenstrual bleeding, postmenopausal bleeding, and menorrhagia.

Results: Histopathological results revealed solely polyps in 84%, polyps with hyperplasia without atypia in 14,9%, and adenocarcinoma in polyp in one. The size of polyps were >1cm in 79 %. Malignancy was observed in a polyp with a 5 cm diameter. 41,2% of polyps were located posteriorly and 20,2% were fundal.

Discussion: Although hysteroscopy has a high sensitivity to detect intrauterine pathologies, endometrial biopsy should follow the procedure in order to discriminate premalignant or malignant lesions.

ROBOTER ASSISTED THREE-DIMENSIONAL LAPAROSCOPIC GYNAECOLOGIC SURGERY – INITIAL EXPERIENCE AT THE UNIVERSITY MEDICAL CENTRE MANNHEIM

Innovation in Instrumentation and Surgical Techniques

Poster

Amadeus Hornemann*, Benjamin Tuschy, Sebastian Berlit, Marc Sütterlin

University Hospital Mannheim, Germany

Summary (4 lines): We present our initial experience with a roboter assisted camera system enabling three-dimensional full HD visualisation. The system was used for a wide range of gynaecologic laparoscopic surgery.

Introduction: Laparoscopic surgery evolved from a diagnostic to a treatment tool for nearly every benign as well as malign gynaecologic disease. Three-dimensional visualisation with a stable image in challenging and time-consuming surgeries can be helpful.

Material and Methods More than 100 laparoscopic surgeries such as myomectomy, total / supracervical laparoscopic hysterectomy, colposacropexy, adhesiolysis, radical hysterectomy, lymphonodectomy e.g. were performed with the Einstein Vision® system. In a prospective investiga

Results: Operations were performed with active camera holder, three-dimensional visualisation and without additional medical assistance. Even lymphadenectomy was possible in this setting with only two incisions. For patients in the LASH group, duration of surgery and blood loss was less compared to the control collective. No conversation to laparotomy was necessary.

Discussion: The combination of an active camera holder and three-dimensional visualisation can shorten the duration of surgery, reduce the number of incisions and can be performed successfully without medical assistance. We thus believe that these novel devices are advantageous in laparoscopic surgery.

THE PREDICTIVE VALUE OF ENDOMETRIOSIS RELATED INFORMATION ON THE INTERNET

Endometriosis: Diagnosis

Poster

Mihai Gherghe*, Hawthorn Robert, Young David, Hardwick Christopher

Southern General Hospital

Summary (4 lines): We searched the internet for websites providing medical information on endometriosis. This information was rated against published guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG).

Introduction: Thirty one websites were identified as containing written medical information on endometriosis by using three most popular search engines (google.com, google.co.uk, bing.com). “Silberg” and “Health on the net” (HON) recommendations were used to assess the predictability of up to date medical content.

Material and Methods Websites were searched using a single search term, “endometriosis” and rated by three independent data collectors against a scoring system of 16 relevant statements derived from the RCOG guidelines. Each website was then scored once against “Silberg” and

Results: Websites scored poorly against the RCOG guidelines (median score, 5/16). There was good agreement between the 3 raters (W=0.806, P0.262 and rho(“Silberg”) 0.259; 0.352; 0.348.

Discussion: The websites did not provide key information and consequently scored poorly against the RCOG guidelines. HON or “Silberg” scores did not predict the RCOG scores for any of the raters . Internet based medical information should be clearly written and in accordance with the latest evidence based studies.

LEVONORGESTREL IUD VERSUS ENDOMETRIAL ABLATION IN THE TREATMENT OF HEAVY MENSTRUAL BLEEDING; DISCRETE CHOICE EXPERIMENT

Innovation in Instrumentation and Surgical Techniques

Oral

Malou Herman*, Claassen N.J.J.S., Bongers M.Y., van den Wijngaard L, van Wely M.

Maxima Medical Centre

Summary (4 lines): We are presently exploring patients’ preferences in a discrete choice experiment (DCE) and present the preliminary outcomes of this study.

Introduction: Patients’ preferences are important determinants in clinical decision-making for women who seek treatment for heavy menstrual bleeding. Understanding their considerations in their decision-making can contribute to further improvement in patient counselling. We are presently exploring patients’ preferences in a discrete choice experiment (DCE) and present the preliminary outcomes of this study.

Material and Methods This study is ongoing and will include 140 women. Women were asked to choose between hypothetical screening profiles characterised by the following treatment attributes: (1) procedure performed by gynaecologist or general practitioner, (2) reversibility, (3) dysmenorrhoea, (4) irregular bleeding, (5) hormones, (6) use of contraception, (7) repeating procedure after five years. The relative importance of attributes and trade-offs patients were willing to make were analysed using a probit regression model.

Results: Data of 85 women were analysed at the time of writing. All attributes were of significant importance. Respondents had a preference for least side-effects and preferred treatment by a gynaecologist. Not requiring a repeat procedure after five years was considered the most important attribute. A subgroup analysis will follow.

Discussion: Our study provides insight into the relative weight patients place on characteristics of two different treatment options for heavy menstrual bleeding, the levonorgestrel IUD and endometrial ablation, and the trade-offs they make.

LAPAROSCOPIC MANAGEMENT OF BIG UNRUPTURED INTERSTITIAL PREGNANCY

Tips & Tricks in Surgery

Video

Oudai Ali*, Irfan Ibrahim, Yeates Liz

North Devon District Hospital

Summary (4 lines): 24year female had Ultrasound confirmed ectopic with BHCG> than 17600iu.Laparoscopy indicated large unruptured interstitial ectopic which was treated by salpingectomy and suturing of uterine defect.She made full recovery.

Introduction: Interstitial pregnancy is diagnosed when gestational swelling is found lateral to the insertion of the round ligament.it accounts for up 3% of ectopic pregnancies. It presents with rupture in 20-50%. Most gynaecologists initially treat interstitial pregnancy with multidose medical therapy resorting to surgical therapy if there is any deterioration in clinical status.Increasingly the problem is treated upfront laparoscopically with various approachs like injecting vasoactive agents, prior suturing to reduce bleeding.This requires advanced skills

Material and Methods This lady had standard 4 ports laparoscopy with 5mm zero scope, 12mm port suprapubically and 5mm ports in each iliac fossa.Adhesions between the right tube and appendix were freed and proceeded to salpingectomy using bipolar/monopolar energy up to the ectopic sac.Then a direct dissection of the sac from the uterine body by bipolar/monopolar energy encountering some bleeding.Eventually sac was dissected away and the defect sutured laparoscopically using vicryl.

Results: This operation took 120 minutes with good postoperative recovery.Drain was removed next day and she was discharged on day two. Histology confirmed ectopic tissue with salpingitis isthmitica nodosa.She was seen later in two weeks and made good full return to normal function.

Discussion: This video demonstrates the direct approach to treat interstitial unruptured ectopic laparoscopically. This was done with simple energy source and laparoscopic suturing acheiving good hemostasis.There was no attempt at catheterising the uterine cavity, or injecting methotrexate or vassopressin.Also the sac was not opened and minimally handled.

LAPAROSCOPIC HYSTERECTOMY IN THE OBESE PATIENT, FEASIBLE OR NOT?

Hysterectomy

Oral

Patty van der Heijden*, Heijmans Fransje, Bongers Marlies, Coppus Sjors , Geomini Peggy

Maxima Medical Center

Summary (4 lines): We conducted a retrospective analysis to identify differences in patient characteristics for successful laparoscopic hysterectomy versus the conversion group.

Introduction: Hysterectomy is a very common gynecological procedure. Laparoscopic hysterectomy (LH) is known to offer benefits to women requiring total hysterectomy for benign indications compared to total abdominal hysterectomy (TAH), particularly regarding minor complications, blood loss, and hospital stay. Although obese women benefit most from laparoscopic surgery, they are also at risk for conversion to laparotomy, which is known to bring extensive higher risks for complications.

Material and Methods Patients planned for LH between January 2007 and December 2011 were included in this retrospective study. Patient characteristics, operation data, complications, and number of conversions were analyzed. The reasons for conversions were noted. All data were retrieved from patient records. Complications were registered according to standard Dutch guidelines.

Results: 393 patients were included. Conversion rate was 7.1%. There was a significant higher Body Mass Index in the conversion group versus the successful LH group, 30.0 versus 26,8kg/m2 (OR 1.11 ). Also uterus weight was higher in the conversion group: 505 grams (conversion) versus 259 grams (successful LH) (OR 1.04).

Discussion: Obese patients planned for laparoscopic hysterectomy run a risk for conversion to laparotomy. However,especially obese patients benefit from a laparoscopic procedure. Pour visibility because of limited possibility of Trendelenburg position and (other) anesthesiologic problems are main reasons for conversion, teamwork with the anesthetic team is of utmost importance.

HYSTERECTOMY FOR BENIGNE UTERINE PATHOLOGIES WHICH FACTORS INFLUENCE POSTOPERATIVE PATIENTS`SATISFACTION?

Hysterectomy

Poster

Christina Kastl*, Radosa JC

Uniklinik Homburg

Summary (4 lines): Decision making in hysterectomy for benigne uterine pathologies is a complex process. In this study we evaluated the effect of factors which are part of patients` determination process on postoperative outcome and patients` satisfaction.

Introduction: We evaluated the long term results and patients` satisfaction after hysterectomy for benigne uterine pathologies. Aim of this study was to identify preoperative factors which influence the postoperative outcome and patients`satisfaction

Material and Methods Between 2010 and 2012 a total of 532 patients underwent hysterectomy with unilateral or without adnexectomy for benigne uterine pathologies at the department of gyneacology & obstetrics university of homburg. Patients were contacted in 2012 and asked to co

Results: Patients who took the decision for surgery themselves seemed to be significantly(por surgery to others. Patients who felt certain about their decision were more satisfied (p

Discussion: Factors which influence preoperative decision making have an impact on postoperative outcome and patients `satisfaction. Therefore extensive preoperative counseling of patients and adequate time of decision making are important factors, which should be considered in the preoperative work up.

REPRODUCTIVE OUTCOME FOLLOWING MYOMECTOMY FOR INTRAMURAL OR SUBSEROUS MYOMA IN INFERTILE PATIENTS

Infertility and Reproductive Medicine

Oral

Sylvie Gordts*, Puttemans Patrick, Gordts Stephan, Campo Rudi, Valkenburg Marion

Leuven Institute for Fertility and Embryology

Summary (4 lines): This study indicates that myomectomy can be an option, also in patients with unexplained infertility, with reasonable reproductive outcome and no major obstetrical side effects.

Introduction: Intramural and subserous myomas are often diagnosed in infertile patients. Their relation to the patient’s reproductive outcome is still not clear. Whether myomectomy is going to improve reproductive outcome or not is also a matter of debate. This study evaluates the reproductive outcome of infertile women after myomectomy.

Material and Methods This is a retrospective analysis of 94 myomectomies performed in a unit of reproductive medicine for intramural and/or subserous myomas in a subfertility population. Reproductive outcome was evaluated. Sixty-four myomectomies were performed laparoscopically. Conversion to laparotomy was necessary in 4 cases. In 26 patients laparotomy was planned because of multiple myomas. In most cases both intramural and subserous myomas were removed. Only in 7 cases myomectomy was performed for purely subserous myomas.

Results: Pregnancy rate was 58%. Natural conception was achieved in 26% of pregnancies, 74% occurred following ART. In 57% of deliveries a C-section was preferred. No uterine rupture was noted. Unexplained infertility was the initial diagnosis in 45% of these couples. In this group, the pregnancy rate following myomectomy was 48%.

Discussion: This study does not allow us to conclude that myomectomy improves reproductive outcome; only a randomised controlled trial can come to that kind of conclusion. This study indicates that myomectomy can be an option, also in patients with unexplained infertility, with reasonable reproductive outcome and no major obstetrical side effects.

REPRODUCTIVE OUTCOME AFTER HYSTEROSCOPIC TREATMENT OF ASHERMAN SYNDROME

Surgical Hysteroscopy

Poster

Yassir Ait Benkaddour*, Ilham Yassine, Hanane Dhibou, Abderrahim Aboufallah, Hamid Asmouki, Abderraouf Soummani

University hospital of Marrakesh, Cadi Ayyad unive

Summary (4 lines): We report a study of 45 patients with Asherman syndrome treated by hysteroscopy in the. Despite good anatomical results, pregnancy rates are still to be improved.

Introduction: Asherman’s syndrome is defined by the presence of intrauterine adhesions, obliterating partially or completely the uterine cavity. Infertility and amenorrhea are the major clinical manifestations. Diagnostic and therapeutic management of Asherman’s syndrome has been dramatically modified by the introduction of hysteroscopy. Despite good anatomical results by hysteroscopic approach, pregnancy rates are still to be improved.

Material and Methods We report a retrospective study of 45 patients with Asherman syndrome treated by hysteroscopy in the department of gynecology of the university hospital of Marrakesh between January 2009 and December 2012.

Results: Twelve patients required two procedures and 3 required 3 procedures. Excellent anatomical results were achieved in 30 patients, satisfactory results in 10 patients and in 3 patients the procedure had failed. A normal menstrual flow has been achieved in 20 patients. Thirteen pregnancies were achieved with pregnancy rate of 38.2%.

Discussion: Asherman syndrome remains one of the most challenging conditions for the reproductive surgeon. The gold standard treatment is hysteroscopic lysis. The main cause of non optimal reproductive results is decreased endometrial receptivity due to endometrial damage. Future advances are directed to reduce recurrence and improve endometrial regeneration after surgery.

LAPARODOME PERSONAL LAPAROSCOPIC TRAINER

Teaching & Training

Poster

Oudai Ali*, Merchant Irfan

North Devon District Hospital

Summary (4 lines): This is a dome like trainer with realistic dimentions, six ports and exercise pad.This was appraised through an audit tool after some basic exercises at the BSGE ASM in Brighton,UK 2013.

Introduction: Laparoscopic training improves safety and efficiency.Simulation is an integral part in acquiring new skills and maintaining performance at many levels. Most of the realistic simulators are available at a high cost with high maintenance required and usually are not easily accessed. This is a transparent dome shaped trainer designed for personal use and easy to accommodate in an office space with minimal maintenance.It could connect to any screen to be functional offering flexibility.

Material and Methods This was presented to the BSGE annual scientific meeting in Brighton 2013.It was evaluated on simple tasks including manipulating a thread and making knot. A form was filled by the participant with scoring 1(very poor) to 5 (excellent) in some areas and yes or no answers in other areas.

Results: 13/20 were advanced laparoscopist and the rest were intermediate level.Only 5/20 have their own trainers and 9/15 intened to acquire one.Majority scored the dome trainer 3(good) or more in; video quality (16/20), lighting (17/20), simplicity (19/20), overall simulation (19/20),eye-hand coordination (18/20), developing skills (17/20),and maintaining skills(20/20).

Discussion: This trainer offers a simple dynamic approach for training at many levels.It helps acquiring, developing and maintaining laparoscopic skills, particualrly suturing.It has low maintenance costs and connects to any screen easily.It is also realistic with actual dimentions but occupys small space.It is versatile with many exercises.

PELVIC PAIN AFTER TRANSCERVICAL TUBAL OCCLUSION: A CASE REPORT

Case reports

Poster

Simon Marta*, Ubeda Alicia, Cusido Maria Teresa

Hospital

Summary (4 lines): Transcervical tubal occlusion (TTO) with the Essure® procedure causes tubal obstruction by a fibrosis of the intratubal canal through dacron fibers. Placement must be a standardized process and control is currently authorized in the FDA and EEC with a simple pelvic x-ray of pelvis within three months.

Introduction: 47 year-old patient with a spontaneous miscarriage, vaginal delivery in 1990 and TTO 2008. After an unexpected pregnancy in 2010, she underwent an uneventful laparoscopic bilateral tubal binding (BTB). In October 2010, she complained of a two years chronic pain.

Material and Methods Ultrasound showed the absence of the intramural portion of the device. She was suggested to undergo a diagnostic laparoscopy. During surgery both devices were found to be subserous at the level of both uterine cornual regions. They were both easily remove

Results: Chronic pelvic involves up to 15% of women, being 20% of gynecologic origin (endometriosis and pelvic adhesions). TTO is a good office method of definitive contraception, well tolerated, safe and effective

Discussion: Any kind of difficulty or adverse event during insertion, or pelvic pain after the procedure should be sent to a hysterosalpingography to discard unadverted expulsion, and to ensure correct placement and tubal obstruction.

USEFULNESS OF THE ULTRASONOGRAPHIC OVARIAN TUMORS MORPHOLOGICAL INDEX IN PREDICTION OF THE LAPAROSCOPY CONVERSION

Imaging

Oral

Rafal Moszynski*, Szubert Sebastian, Szpurek Dariusz, Sajdak Stefan

Division of Gynecological Surgery

Summary (4 lines): Morphological index assessment and CA125 serum level may help in prediction the risk of conversion laparoscopy to open surgery in management of adnexal masses because the differences are statistically significant.

Introduction: Laparoscopy is a gold standard in treatment of ovarian tumors, but in some cases surgical procedure has to be completed in open surgery. The aim of our study was the evaluation of ultrasonographic morphological index and CA125 serum level usefulness as tests in prediction the conversion of laparoscopy to open surgery in management of ovarian tumors.

Material and Methods In this cohort study 192 women diagnosed with adnexal masses were qualified for laparoscopy. They were examined preoperatively with morphological index SM proposed and used in our department summarizing seven ultrasonographic features of ovarian tumor. CA125 level was also assessed. Within the analyzed group 20 (10.4%) laparoscopies were converted for open surgery. Statistical analysis was performed using Statistica for Windows v. 6.1.

Results: The value of morphological index was significantly higher in patients with conversion – median 9 (2-15) versus 4 (0-14). CA125 serum level was also significantly higher in patients with conversion median 81.6 IU/ml (4.2-329.6) versus 29.3 (3.2-126.3). There were no statistically significant differences in patients age, tumor volume and BMI.

Discussion: All malignant tumors (n=5) were diagnosed in group of patients with conversion Ultrasonographic assessment of adnexal masses based on morphological index may help in prediction of the risk of conversion laparoscopy to laparotomy. These tumors were more complex in ultrasonographic examination and also CA125 level was higher.

SEPTOPLASTY OF A COMPLETE UTERINE SEPTUM, CERVICAL AND VAGINAL SEPTUM

Diagnostic & Operative Office Hysteroscopy

Video

Simon Marta*, Ubeda Alicia

Hospital

Summary (4 lines): Complete uterine septum, including cervix and vagina is a rare pathology with major problems of infertility, with easy handling hysteroscopic.

Introduction: Many of the complete septums including vagina go unnoticed, therefore it is very important to make a good clinical examination of the patient.

Material and Methods The septoplasty is a safe minimally invasive outpatient surgery with excellent obstetrics results. We no consider necessary to respect the cervical septum. After two month of the intervention, it is important to do a diagnostic histerocopy.

Results: Results

Discussion: In conclution the hysteroscopy is a useful tool in the whole management of resortive uterine pathologies. In this video we want to present our technique for a complete septoplaty via histerocopy.

LAPAROSCOPIC ABDOMINAL CERCLAGE - SUNRISE TECHNIQUE

Innovation in Instrumentation and Surgical Techniques

Video

Sandesh Kade*, Rehman Hafeez

Sunrise hospital

Summary (4 lines): technical difficulties make laparoscopic abdominal cerclage operation a challenge. but it is a surgery with lots of good results. our sunrise technique makes it simple , easy and easy to learn technique

Introduction: Cervical insufficiency complicates 0.1 to 1 % of all pregnancies with very high reoccurrence rate. Traditionally this was treated with vaginal approach but failed in 13% of cases. Benson and Durfee advocated abdominal cervical cerclage at internal os with very high success rate. Last decade the shift has been from laparotomy to laparoscopic approach. . This video demonstrates the innovative steps to make this surgery easy , safe , effective and reproducible.

Material and Methods this is a video of laparoscopic abdominal cerclage in pregnant state 10 weeks. uterus pulled up by holding round ligament. bladder peritoneum opened up to push bladder down and expose uterine complex . open posterior leaf of broad ligament . pass mersele

Results: innovation of opening the broad ligament gives many advantages 1. the entry and exit point of needle can be seen at the same time . 2window can be used to retract uterus and bring merselene tape in anterior compartment. 3 exact placement of tape at the level of internal os .

Discussion: sunrise technique of laparoscopic abdominal cerclage is safe, easy , effective , and reproducible method .broad ligament window is the key innovative step in this technique

COMPARISON OF LAPAROSCOPIC, VAGINAL AND ABDOMINAL HYSTERECTOMY

Hysterectomy

Poster

Milica Perovic*, Khairunisha Syeda, Pop Lucian , Wisa Hany, Ahmed Hasib

Medway Maritime Hospital

Summary (4 lines): The LSCH is the safest procedure with the shortest hospital stay followed by TLH, which require longest operative time.

Introduction: The aim of this study was to assess the intra operative and post operative outcomes for laparoscopic supra cervical hysterectomy (LSCH) total laparoscopic hysterectomy (TLH), laparoscopic assisted vaginal hysterectomy (LVH) vaginal hysterectomy (VH) and total abdominal hysterectomy (TAH), performed for benign pathology. All procedures were done by single surgeon.

Material and Methods Between 2007 and 2012, 183 hysterectomies were analysed. 47 patients had LAVH, 32 had TLH, 24 had LSCH, 56 had VH and 22 TAH. Data obtained from patients’ notes, including age, weight, parity, length of surgery, blood loss, hospital stay and complication

Results: TAH had shortest operative time but longest hospital stay and higest blood loss. There were no complications in LSCH, while TLH had 3.1%, VH 6.9% and LAVH 12.8% complications. TAH had highest complication rate of 22.7%.

Discussion: In our hands LSCH is the safest procedure with the shortest hospital stay followed by TLH, which require longest operative time. TAH appear to be procedure with most complication and the highest blood loss.

EFFECT OF HYSTERECTOMY ON POSTOPERATIVE SEXUALITY AND QUALITY OF LIFE

Hysterectomycim

Oral

Christina Kastl*, Radosa JC, Solomayer EF, Baum S, Mavrova R, Radosa MP, Radosa CG

Uniklinik Homburg

Summary (4 lines): 150.000 hysterectomies per year are conducted in Germany. Most patients are between 40 and 50 years at time of surgery and sexually active. Therefore the impact of hysterectomy on postoperative sexuality is an important issue for these patients. We evaluated the effect of hysterectomy on postoperative sexuality and quality of life.

Introduction: Between 2010 and 2012 a total of 157 patients underwent hysterectomy with unilateral or without adnexectomy for benigne uterine pathologies. Patients were contacted in 2012 and asked to complete a self-assessment survey that evaluated quality of life and postoperative sexuality.

Material and Methods Patients’ quality of life and sexual function improved after surgery. There were no significant differences between this improvement comparing different techniques of hysterectomy.

Results: This study shows that patients who suffer from benigne uterin pathologies profite from hysterectomy regarding quality of life and sexual function. Which surgical technique is used seems to play a minor role.

Discussion: Hysterectomy is common and safe treatment for benign uterine pathologies. Most patients are about 45 years at time of operation, the impact of this procedure on sexuality and quality of life is an important issue.

ARNOLD CHIARI I MALFORMATION IN LAPAROSCOPY: A CASE REPORT

Case reports

Poster

Brenda Sohn*, Artin Ternamian

St. Joseph's Health Centre, University of Toronto

Summary (4 lines): We present a case where an apparently healthy individual underwent an otherwise uneventful endoscopic procedure and suffered an unexpected and serious complication as a result of the dynamics between pneumoperitoneum, Trendelenburg position, elevated intracranial pressure (ICP) and an incidental unrecognized finding of Chiari Malformation Type I (CMI).

Introduction: Not applicable.

Material and Methods Not applicable.

Results: Not applicable.

Discussion: Not applicable.

ROBOTIC STAGING WITH BARIATRIC SURGERY IN MORBIDLY OBESE ENDOMETRIAL CANCER PATIENTS

Robotics

Poster

Jiheum Paek*

Ajou University Hospital

Summary (4 lines): Robotic staging with bariatric surgery is feasible in morbidly obese endometrial cancer patients.

Introduction: Overweight and obesity have been consistently associated with endometrial cancer. However, substantial weight loss has been demonstrated to reduce the risk of endometrial cancer. We introduce three marked obese patients with endometrial cancer who underwent robotic staging with bariatric surgery.

Material and Methods Firstly, robotic sleeve gastrectomy was performed. The stomach was resected to 5 cm proximal to the pylorus and omental resection from stomach G.C wall was done to the proximal upto the 1 cm distal of angle of His. With H-bond #2-0, continuous inbagination suture was done along resection line. The procedure for surgical staging included paraaortic and pelvic lymphadenectomy, total hysterectomy. After hysterectomy, resected specimens were removed through the vagina.

Results: The operating time was 368, 380, and 385 mins, respectively. The postoperative hospital stay was 6 days. There was no operation-related complication. The body weight (BMI) of patients was 100 (39.1), 120 (41.5), and 105 (40.5) kg. They lost about 30 kg in the space of a few months.

Discussion: Bariatric surgery induced improvement of underlying metabolic disease as well as body weight loss. Robotic staging operation with bariatric surgery is feasible in morbidly obese endometrial cancer patients.

HYSTEROSCOPIC MYOMECTOMY WITH THE INTEGRATED BIGATTI SHAVER VERSUS BIPOLAR RESECTOSCOPE: A RETROSPECTIVE COMPARATIVE STUDY

Surgical Hysteroscopy

Selected abstract Oral

Giuseppe Bigatti*, Franchetti Sara, Rosales Miguel, Baglioni Andrea, Bianchi Stefano

Ospedale San Giuseppe

Summary (4 lines): At present, the surgical use of the IBS® seems to be superior to the conventional resectoscope, as we have been able to remove all types of submucosal myomas, including G2 ones, in a very precise way, without any thermal injury of the surrounding healthy endometrium.

Introduction: The IBS® Integrated Bigatti Shaver improves visualization during the procedure, as tissue chips are removed at the same time as resection with no need for coagulation or cutting current. Moreover, the use of normal saline and a very fast learning curve reduce several problems of conventional resectoscopy, such as fluid overload, water intoxication and uterine perforation.

Material and Methods This is a retrospective and comparative study using our personal surgical data collected over a three-year period, from June 2009 to June 2012.The study population involves 76 patients mean aged 47,3 ± 10,1 (43,7; 50,9), who have undergone an IBS®-performed myomectomy and have been included in Group A, versus 51 women®, mean aged 48,04 ± 11,4 (44,8; 51,3), who have undergone a Versapoint®-performed myomectomy and have been included in Group B.

Results: II look procedures have statistically significantly been less frequent in the IBS® Group (Group A - n.7, 9,2%) than in the Versapoint® Group (Group B - n.15, 29,4%; p = 0.0067).With the IBS®, we have been able to treat 93,5% Ø ≤ 3cm sized myomas in a single step procedure.

Discussion: We believe that this new technique will replace the use of the resectoscope in the next future. A lot of work still has to be done in order to improve on this new device that already proves to be a valid alternative to the Versapoint® in this study.

LAPAROSCOPIC PROMONTO HYSTEROPEXY AND PARAVAGINAL REPAIR FOR GRADE 3 GENITAL PROLAPSE

Urogynaecology

Poster

Laurentiu Pirtea*, Dorin Grigoras, Mihai Bacila

Umf Victor Babes Timisoara

Summary (4 lines): It is presented the case of a 33 years old female with grade 3 genital prolapse and associated sclerodermia. Laparoscopic promonto hysteropexy and paravaginal repair were performed. Results were good in terms of pelvic floor statics and function.

Introduction: Genital prolapse is rare finding in young patients that wish to preserve fertility. Still a surgical option that conserves the uterus must be offered to those patients. The laparoscopic hysteropexy with paravaginal repair restores all 3 levels of vaginal support and offers the advantage of preserving the fertility.

Material and Methods It is presented the case of a 33 years old female with grade 3 genital prolapse and associated sclerodermia. Laparoscopic promonto hysteropexy and paravaginal repair were performed. Pictures of the key steps of the surgery and images of pelvic floor stati

Results: Laparoscopic hysteropexy and paravaginal repair seem to be a good option for patients with genital prolapse that wish to conserve their uterus.

Discussion: Removal of uterus is no longer considered to be mandatory in the treatment of genital prolapse. Transvaginal mesh augmentation and sacrospinous fixation also showed good result. Related complications such as dyspareunia and mesh erosion could limit the use of transvaginal mesh in young and sexually active patients.

THE CORRELATION OF HYSTEROSCOPIC AND PATHOLOGIC FINDINGS IN CASES OF RETAINED PRODUCTS OF CONCEPTION

Surgical Hysteroscopy

Oral

Noam Smorgick*, Vaknin Zvi , Barel Oshri, Halperin Reuvit, Pansky Moty

Assaf Harofe Medical Center

Summary (4 lines): Specific hysterosopic findings are correlated with confirmed pregnancy rests on pathology.

Introduction: Retained products of conception (RPOC) may occur after vaginal or cesarean delivery and after pregnancy termination by medication or by curettage. Hysteroscopy has become the gold standard for diagnosis of RPOC. Nevertheless, not all cases of RPOC diagnosed on hysteroscopy are found to contain pregnancy rests on pathologic examination. The purpose of this study is to examine the correlation between hysteroscopic and pathologic findings in different cases of RPOC.

Material and Methods 48 women diagnosed with suspected RPOC on hysteroscopy from 11/2012 to 5/2013 were prospectively followed. The hysteroscopic findings were recorded and compared to the pathology results, classified as pregnancy rests (i.e. positive pathology) or as decidu

Results: The rates of positive pathology after term delivery, medical termination of pregnancy and surgical termination of pregnancy were 14/23 (52.2%), 9/11 (81.8%) and 7/14 (50%), respectively (p=.08). Positive pathology was correlated with hysteroscopic findings of villi structure after delivery and with polypiod structure after medical termination (sensitivity=100%, specificity=55.6%).

Discussion: False positive diagnosis of RPOC by hysteroscopy is not uncommon. The hysterosocpic appearance of villi structure after term delivery and of polypoid structure after medical termination of pregnancy is correlated with pregnancy rests on pathology.

ENDOMETRIAL THICKNESS AND POSTMENOPAUSAL BLEEDING: ESTABLISHING A THRESHOLD FOR FURTHER INVESTIGATION

Imaging

Poster

Mark Roberts*, Choudhary Meenakshi, Johnson Sarah

Newcastle upon Tyne Hospitals

Summary (4 lines): A large study of post-test risk of endometrial cancer following ultrasound investigation of PMB. A 4mm threshold avoids the needs for biopsy in 51% but recurrent bleeding warrants further investigation

Introduction: Endometrial cancer is the most common gynaecological cancer in the UK. Most present with post-menopausal bleeding (PMB), a common symptom but biopsy (Pipelle, LA hysteroscopy) can be painful and can still miss some cancers. Different evidence-based guidelines indicate a range of ET thresholds for further investigation of PMB, 3-5 mm. Lack of agreement is due to limited data

Material and Methods Prospective study of PMB in 1062 consecutive women over 45 years of age, menopause at least 12mths. Primary investigation was TVS. Pipelle sampling or LA hysteroscopy for ET 4mm or greater. Cancers identified from histology and cancer register within 12mnths. Pre-Test and:Post-Test Risk calculated. Aims: 1. To determine the optimum threshold value of ET for endometrial sampling 2. To investigate the adequacy of endometrial Pipelle sampling based on determined ET.

Results: ET less-than 4mm in 545(51%) women. 29% biopsies were unsatisfactory due to insufficient endometrium, most with ET less-than 6mm. Pre-test risk 5.3% (56 cancers), post-test risk by ET was 0.0%(3mm), 0.7%(4mm). 1.1%(5mm), 1.2%(6mm), 1.6%(10mm). The correlation of ET and cancer was (P less-than 000.1, OR 1.14 (95%CI:1.09-1.25)

Discussion: The study has been used to set a threshold for endometrial biopsy at ≥4mm. Approximately 50% of patients avoid biopsy with a risk of undetected cancer of 0.7%. These patients are given written information that the post test risk of cancer is very low but to re-attend if bleeding continues.

VAGINALLY-ASSISTED LAPAROSCOPIC SACROHYSTERO/COLPOPEXY (VALS) FOR WOMEN WITH UTERINE/VAULT PROLAPSE: 1-YEAR FOLLOW-UP OF A PILOT STUDY

Innovation in Instrumentation and Surgical Techniques

Oral

Phatak Madhura*, Wael Agur, Kung Roger, Hair Mario, Rae David

Summary (4 lines): VALS appears to be safe and effective minimally-invasive procedure with encouraging short-term patient-reported and anatomical outcomes. Average operative time was 112 min and mesh erosion noted in 1 patient (12%).

Introduction: Laparoscopic sacrocolpopexy has been shown to combine the benefit of a gold standard with those of a minimally-invasive technique. However, it requires a high experience and is time-consuming. Vaginally-assisted laparoscopic hystero/colpopexy (VALS) is a relatively-new technique aiming at reducing the requirement of extensive laparoscopic manipulation and suturing. We assessed the patient-reported and objective outcomes of VALS at 12 months for women with symptomatic uterine/vault prolapse. All uteri were preserved.

Material and Methods Data was collected prospectively for the first 8 women on the learning curve, Jan-March 2012, where 6 had Stage II-III uterine and 2 had stage II-III vault prolapse. Pre- and 12-month postoperative patient-reported and objective outcomes were compared using the scores of vaginal symptoms module of the International Consultation on Incontinence Questionnaire (ICIQ-VS) and the Pelvic Organ Prolapse Quantification (POP-Q). Assessors were blinded.

Results: The average age was 61.0 years and BMI was 28.6 kg/m2. There was a significant improvement in ICIQ-VS (p=0.02) and POP-Q (p=0.04) scores. Average operative time was 112 min. There were no significant intra-operative complications. Mesh erosion (1cm at introitus) was noted in 1 patient (12%) 3 months postoperatively.

Discussion: The patient-reported and objective success rate of VALS is maintained at 12 months. The rate of mesh exposure may be higher compared to an exclusively-laparoscopic procedure. The long operative time is related to initial learning curve.

PATENT URACHUS ABSCESS

Case reports

Video

Andreas Stavroulis*, Cutner Alfred

University College London Hospitals NHS Trust

Summary (4 lines): This video shows laparoscopic surgery to a 15 year old virgo intacta girl with congenital adrenal hyperplasia.

Introduction: She presented with recurrent lower abdominal pain not related to her periods having had a diagnostic laparoscopy at a different hospital showing bilateral hydrosalpinges.

Material and Methods The laparoscopy showed extensive pelvic adhesions and infection. Both Fallopian tubes were excessively distorted and full of pus (bilateral large pyosalpinges). There was an inflammatory pus-filled mass attached to the anterior abdominal wall and was invo

Results: After adhesiolysis, the mass is freed and the bladder is opened to remove inflammed urachus. The bladder is then repaired. Methylyne blue dye is used to demarcate the bladder at the beginning and exclude leakage after the repair. The inflammatory mass is excised and bilateral salpingectomy is perfomed.

Discussion: Peritoneal lavage was done and a drain was left in the pelvis. She reveived antibiotics and made a good recovery. Her catheter was removed 3 weeks later and a cystogram confirmed no urine leak. The histology showed chronic omental inflammation, pyosalpinges and xanthogranulomatous inflammation of the urachus and the tubes.

LAPAROSCOPIC SACROCOLPOPEXY FOR POSTHYSTERECTOMY PROLAPSE: OUR EXPERIENCE

Urogynaecology

Poster

Ferreira Hélder*, Cubal Rosália, Tomé Pereira António, Guimarães Serafim

Centro Hospitalar do Porto - Universidade do Porto

Summary (4 lines): This retrospective descriptive analysis of our initial experience demonstrates that laparoscopic sacralcolpopexy may be the procedure of choice for post-hysterectomy vaginal prolapses in patients who wish to maintain a functioning vagina.

Introduction: We wish to describe our initial experience of laparoscopic sacral colpopexy in our tertiary university hospital

Material and Methods Ten patients with recurrent prolapse of the vagina apex (stage III–IV) after previous hysterectomy underwent laparoscopic sacralcolpopexy with Gynemesh (Ethicon) used as the graft material. We analyzed the period between September 2011 to May 2013. 7 pati

Results: Median age was 62 years (range 37–78 years), and median BMI was 26 (range 24–28). Intraoperative and postoperative complications didn’t occur. The median hospital stay were 2 days (range 1–3 days). Postoperative recovery has been uneventful. Objective cure is 100%. No cases of graft exposure or recurrence till now.

Discussion: Our experience is recent and short, but our results are comparable with the majority of the literature publications. Laparoscopic sacral colpopexy is a safe and effective procedure.

ANATOMY IN DIAGNOSTIC GYNECOLOGIC LAPAROSCOPY - AN EDUCATIONAL FILM

Teaching & Training

Video

Robert Oehler*, Ueli Hermann, Michael Mueller, Bernhard Fellmann, Kirsten Stähler, Sara Imboden

Centre hospitalier Bienne

Summary (4 lines): An educational video for students and young residents showing the basic intraabdominal anatomy as seen in laparoscopy.

Introduction: As surgical assistant and as surgeon, good anatomical knowledge in gynecologic laparoscopy is a prerequisite for efficient communication and a successful course of surgery. Compared to the usual depiction found in anatomy books, the variable viewing angle of the laparoscope results in unfamiliar perspectives of known anatomical structures.

Material and Methods The most commonly found anatomical structures in laparoscopy were defined. Video recordings during diagnostic laparoscopies with planned camera pans were produced. Relevant sequences were edited and the anatomical structures were marked and labeled using software.

Results: An educational film was created, visualizing the laparoscopic anatomy of the parietal and visceral peritoneum in laparoscopy. Two versions of the film were produced, one version with marks and labels of the structures, for study purposes, the other version without labels, to review the anatomical knowledge.

Discussion: Prior to first assisting a laparoscopy, an educational film of this nature enables the viewer to acquire basic knowledge in laparoscopic anatomy.

VIDEO SELECTION: ADVANTAGES OF THE IBS® INTEGRATED BIGATTI SHAVER IN ACTION

Innovation in Instrumentation and Surgical Techniques

Video

Giuseppe Bigatti*, Iemmello Roberta, Pollino Silvia, Santirocco Maddalena, Bianchi Stefano, Miguel Rosales

Ospedale San Giuseppe

Summary (4 lines): 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 . 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.

Introduction: The IBS® Integrated Bigatti Shaver improves visualization during the procedure, as tissue chips are removed at the same time as resection with no need for coagulation or cutting current. Moreover, the use of normal saline and a very fast learning curve reduce several problems of conventional resectoscopy, such as fluid overload, water intoxication and uterine perforation.

Material and Methods At present we have performed more than 320 cases including all kinds of operative hysteroscopic procedures such as polyps and submucosal myomas resection, septum resection and endometrial ablation according to ESGE classification.

Results: 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.

Discussion: This video selection offers an overview of all the clinical and technical advantages of the IBS® . No heating inside the uterine cavity, the tubal ostia are not damaged , the healthy endometrium is respected very low bleeding during the procedure are reported.

ACCESSORY CAVITATED UTERINE MASS (ACUM)

Case reports

Oral

Andreas Stavroulis*, Cutner Alfred, Creighton Sarah

University College London Hospitals NHS Trust

Summary (4 lines): ACUM could be caused by duplication and persistence of ductal Müllerian tissue in a critical area at the attachment level of the round ligament, possibly related to a gubernaculum dysfunction. It should be differentiated from true cavitated adenomyomas and cavitated rudimentary uterine horns

Introduction: Surgical treatment to ACUM has been described (laparotomy, laparoscopy, robotic). We present a symptomatic ACUM case treated with laparoscopic excision.

Material and Methods The patient was seen pre and postoperatively. Her symptoms were assessed.

Results: She made an uneventful recovery and was cured. A video of the surgery will be shown.

Discussion: Symptomatic ACUM can be treated laparoscopically by a skilled surgeon. This is another case of this new type of Müllerian anomaly.

TOTAL MINILAPAROSCOPIC HYSTERECTOMY - “STEPS, DIFICULTIES & ADVANTAGES”

Innovation in Instrumentation and Surgical Techniques

Video

Ferreira Hélder*, Sousa Rita , Costa Braga António, Tomé Pereira António

Centro Hospitalar do Porto - Universidade do Porto

Summary (4 lines): We present a video that ilustrates minilaparoscopic hysterectomy procedure as a minimally invasive alternative to conventional laparoscopic hysterectomy with its difficulties, steps and benefits for the patients.

Introduction: Recent advances in instrumentation have improved the surgeons’ armamentarium with smaller caliber instruments, thus triggering the emergence minilaparoscopic surgery. The concept behind minilaparoscopy is that smaller instruments cause less abdominal wall trauma and thus reduce incision related morbidity and minimize pain and stress response to surgery. Many surgeons believe that the performance debt of miniaturized instruments severely limits the applicability of the technique, and many are unwilling to endure the difficulties of using finer instruments.

Material and Methods We present, according to our recent experience, an educational video explaining the “steps, difficulties & advantages” of minilaparoscopic total hysterectomy with a new smaller size bipolar coagulator (ROBI®, Karl Storz).

Results: We found feasible and reproducible to perform total hysterectomy using smaller size instruments. The new bipolar instrument is, not only an efficient bipolar tool, but also a good dissector and grasping forceps.

Discussion: In spite of our short experience, we dare to say that minilaparoscopic total hysterectomy can be considered a minimally invasive alternative to conventional laparoscopic hysterectomy with potential benefits for our patients.

MEASURES TO INCREASE SUCCESS RATE OF OUTPATIENT HYSTEROSCOPY PROCEDURES

Diagnostic & Operative Office Hysteroscopy

Poster

Sameena Kausar*

Royal Berkshire hospital

Summary (4 lines): 60% patients were discharged after first visit. We recommend pre-op cervical preparation and oral analgesia, to make it successful. Preferred as first choice by patients and doctors, 94% would recommend it friends for its low complication rate (5%).

Introduction: Aim was to audit the new outpatient hysteroscopy services that was started in November 2009 at Royal Berkshire hospital, in UK. Objectives were to make sure referrals were appropriate and met with clinic referral criteria. To compare our results with previous studies regarding use of local anaesthesia for procedure, detection rate of hyperplasia and endometrial cancer, complication rates, lastly, number of patients who needed further hysteroscopy under GA.

Material and Methods Retrospective audit from 2009-2013 on 420 patients. Computerised proforma used to collect data. Analysed on excel sheet. Patient satisfaction survey through questionnaires. Standards used: Local hospital guidelines for referrals. 70% should be discharged at the first visit. Less reliable in diagnosing hyperplasia, hence biopsy must be taken. Detection rate of structural lesions in pre-menopausal women is 65-80% with 90% positive predictive value(PPV). Whereas in menopausal patients it has a 100% negative predictive value and 97% PPV.

Results: OPH services were used for diagnostic (45%) and therapeutic (51%) purposes. Most referrals were for DUB (65%), PMB (22%) and suspected cancer (4%). 3% of referrals were inappropriate. 56% of endometrial polyps and 75% of impacted coils were removed at first visit. Detection of hyperplasia and endometrial cancer was 3%.

Discussion: 60% of patients who didn’t have pre-op cervical preparation had difficulty with dilation. On comparing patients who were given pre-op analgesia versus no analgesia, 37% vs11% had no pain. No significant difference in pain score- mild discomfort (89% vs 86%) and moderate-severe (11%vs 14%)

DETECTION OF LYMPHATIC LEAKAGE WITH NEAR INFRARED FLUORESCENCE AND INDOCYANINE GREEN

Innovation in Instrumentation and Surgical Techniques

Poster

Sara Imboden*, Mélina Buchwalder, Wolfgang Schöll, Michel Mueller

Department of Obstetrics and Gynecology, Universit

Summary (4 lines): In this case report a lymphatic leakage after lymphadenectomy was detected with near infrared fluorescence and indocyanin green (ICG) and could so be treated successfully

Introduction: Near infrared fluorescence with ICG is being used for sentinel lymph node techniques in many gynaecological cancers. Also ICG lymphoscintigraphy is applied for detection of lymphatic drainage complications for example in surgery for lymphatic venous anastomosis. For detection of the lower limb lymph node radioactive isotopes have been used to detect the first lymph nodes after the inguinal canal with injection of Tc99 in the foot.

Material and Methods In a 46 year old patient a laparoscopy was performed due to a vaginal vault dehiscence after radical hysterectomy and pelvic lymphadenectomy for cervical cancer. She had lymphatic leakage first vaginal, then the vaginal vault healed but the lymphocele per

Results: Intraoperativ 3ml ICG was injected in the first interdigital room in each foot. With the near infrared fluorescence optic lymphatic leakage was detected at the height of the circumflex vein, closed with a PDS 5-0 suture and sealed with TachoSil. Postoperative no lymphocele or lymphedema was observed.

Discussion: Lymphatic leakage in the pelvis can be detected using near infrared fluorescence and ICG. With this a new, easy technique is given to help treat complications after lymphadenectomy.

LAPAROSCOPIC TREATMENT OF UTERINE RETROVERSION ASSOCIATED WITH PELVIC PAIN: OUR EXPERIENCE

Case reports

Poster

Ferreira Hélder*, Costa Braga António, Pereira António

Centro Hospitalar do Porto - Universidade do Porto

Summary (4 lines): We describe our short experience with laparoscopic anterior ligamentopexy for pelvic pain associated with retroverted uterus

Introduction: Chronic pelvic pain and dyspareunia are important health problems in women of reproductive age. There are many potential causes of chronic pelvic pain and dyspareunia. It is suggested that the correction of uterine retroversion and retroflexion using a simple uterine suspension effectively relieves pelvic pain in women with no identified pelvic disease.

Material and Methods We found the association of chronic pelvic pain, retroverted uterus, pain relief with ventral decubitus and no other obvious etiologies for pelvic pain in 5 patients. Intraoperative correction by pulling ventrally on the round ligaments was first done. Th

Results: Pre operative and post operative pain scores are assessed by visual analogous scale. Type and postoperative duration of use of pain killers are also noted. Fertility data and subsequent surgeries for other abdominal pathologies are collected. Results are still ongoing.

Discussion: Our short experience shows good results for pain control after laparoscopic anterior ligamentopexy. Since pelvic pain associated with uterine retroversion is still a challenging and controversial pathology to diagnose and treat, randomized controlled study are mandatory.

EFFECTIVENESS OF HYSTEROSCOPIC REMOVAL OF SUBMUCOSAL FIBROIDS IN WOMEN WITH MENORRHAGIA

Surgical Hysteroscopy

Poster

Steffi van Wessel*, Tjalina Hamerlynck, Steven Weyers

Ghent University Hospital

Summary (4 lines): Hysteroscopic removal of submucosal fibroids, if necessary combined with additional hormonal treatment, is a highly effective alternative to hysterectomy in women presenting with menorrhagia.

Introduction: One out of four fibroids will become clinical apparent. Due to their location, submucosal fibroids may cause menorrhagia. While the burden of menorrhagia can be quite high, hysterectomy is frequently performed as it is 100% effective in treating menorrhagia. A hysterectomy remains a major intervention, therefore minimally invasive, more conservative, alternatives, in particular hysteroscopic removal, are recommended.

Material and Methods We performed a retrospective chart review of women up to 45 years old who underwent hysteroscopic removal of submucosal fibroids because of menorrhagia between January 2001 and January 2012 at the Ghent University Hospital, Belgium. A questionnaire was sent to 63 eligible patients and 22 (35%) of them responded. Effectiveness was evaluated by both patient satisfaction and the need to perform hysterectomy within the first year after myomectomy. Moreover, additional treatments were taken into consideration.

Results: The satisfaction rate was 91%. Nine women (41%) received additional hormonal treatment and no hysterectomies were performed within one year postmyomectomy. Finally, 3 women (14%) underwent repeat myomectomy and 2 women (9%) underwent hysterectomy, both after an average of 5 years due to recurrence of fibroids and menorrhagia.

Discussion: Hysteroscopic removal of submucosal fibroids in women with menorrhagia is an effective alternative to hysterectomy. Symptoms can be alleviated quickly with a high patient satisfaction. Since new fibroids may develop, additional conservative treatment may increase success rates, or else repeat myomectomy can be performed.

HYSTEROSCOPY FINDINGS AND ITS CORRELATION WITH LATENT ENDOMETRIAL TUBERCULOSIS IN INFERTILITY

Infertility and Reproductive Medicine

Oral

SUBRAT KUMAR MOHAKUL*, B.V RADHA KULMARI

Rashtriya Ispat Nigam Limited(Visakha Steel General Hospital),Vishakhapatnam

Summary (4 lines): Endometrial tuberculosis is one of the important causes of long standing infertility. Early diagnosis by hysteroscopy supplemented by TB-PCR and effective chemotherapy will help in reversing the reproductive capability.

Introduction: Tuberculosis plays a major role in infertility. It is the commonest symptom of genital tuberculosis in women. GENITO-URINARY TUBERCULOSIS is always secondary to Tuberculosis elsewhere in the body (lungs). Long latent period between healed primary and appearance of genital tuberculosis makes it difficult to suspect. In India 5—18% of females attending infertility clinics are diagnosed to be suffering from Genital tuberculosis, in contrast to the western countries where it is 1% or less

Material and Methods ) Patients with more than 2 years of unexplained infertility, previous failed infertility treatment, history of unexplained abortion or ectopic pregnancy were included. Total no. of 105 cases was studied. All cases were subjected to hysteroscopy and endometrial TB PCR testing. In TB PCR+ve cases complete course of ATT (-RIFAMPICIN +ISONIAZID+ ETHAMBUTOL +PYRAZINAMIDE) was given. Hysteroscopic features were compared in PCR positive and negative cases. Treatment results in terms of pregnancy outcome were recorded.

Results: Ostial and periostial fibrosis was associated with positive PCR in 43.75% and intrauterine fibrosis was associated with positive PCR in 48.48% of cases. Irregular cavity was associated with 66.67% of positive TB-PCR. 39% of TB PCR positive cases conceived with anti tubercular treatment only.

Discussion: Latent tuberculous endometritis is one of the most intractable causes of infertility. Early diagnosis by hysteroscopy supplemented by TB-PCR will prevent the development of genital tuberculosis and reverse the reproductive capability. A large scale study is recommended to establish the role of endometrial tuberculosis in infertility in developing countries

THE IMPACT OF TYPE OF MYOMECTOMY ON REPRODUCTIVE OUTCOME

Infertility and Reproductive Medicine

Oral

Steffi van Wessel*, Tjalina Hamerlynck, Steven Weyers, Michel Degueldre, Jan Bosteels

Ghent University Hospital

Summary (4 lines): Whether removal of submucosal fibroids improves fertility is unclear. Using strict criteria, we could not demonstrate an impact of type of myomectomy on clinical pregnancy rate or time to pregnancy.

Introduction: The extent to which fibroids have an impact on fertility remains controversial. It is assumed that this effect mainly depends on the type of fibroid. Despite the consensus of a detrimental effect of submucosal fibroids, their removal has not sufficiently proven effective. The influence of intramural fibroids is less clear; meta-analysis limited to studies that used highly accurate methods to exclude cavitary involvement suggests no effect. Subserosal fibroids appear to have no effect on fertility.

Material and Methods We performed a retrospective study at two university hospitals in Belgium. Women up to 38 years who underwent a fertility-related myomectomy between 2001 and 2012 were selected using strict criteria for fibroid classification and other infertility factors. Eligible women were sent an additional questionnaire. We studied clinical pregnancy rate and time to pregnancy comparing women who underwent hysteroscopic removal of submucosal fibroids to women who underwent laparoscopic/laparotomic removal of intramural and/or subserosal fibroids.

Results: In total 74 women were eligible, of whom 17 consented. We found a non-significant difference in clinical pregnancy rate at one year after myomectomy of 25% and 62% in case and control group, respectively. Moreover, a significant influence of type of myomectomy on time to pregnancy could not be demonstrated.

Discussion: Due to strict inclusion- and exclusion criteria our study was underpowered, which can explain why we found no significant impact of the type of myomectomy on fertility. We do believe this new perspective, comparing the different types of myomectomy, will aid future research on this subject.

FETAL DEATH AT 23 WEEKS AND UTERINE RUPTURE IN LABOR INDUCTION FOLLOWING HYSTEROSCOPIC METROPLASTY

Case reports

Poster

Ricardo Sousa-Santos*, Rodrigues Cátia, Ferreira Carolina, Nogueira Rosete, Silva José, Teles Teresa Paula

Centro Hospitalar Entre Douro e Vouga

Summary (4 lines): We report a case of a woman with a uterine rupture at 23 weeks following labor induction for fetal death. She had undergone metroplasty for a septate uterus 14 months earlier.

Introduction: Congenital abnormalities of the uterus have long been recognized as a cause of obstetric problems. Although corrective surgery in selected cases is often safe, complications may arise, immediately or in the future. We report a case of a healthy 28-year-old woman, presenting in our institution at 23w with fetal death. She had a history of an incidentally diagnosed septate uterus, corrected hysteroscopically and complicated by a small uterine fundal perforation, 14 months earlier.

Material and Methods Induction of labor was initiated with misoprostol and continued with sulprostone after 24h. The patient grew ill, with signs of peritoneal irritation, and uterine rupture was suspected on ultrasound and confirmed with computed tomography.

Results: At laparotomy an intact amniotic sac was found in the abdominal cavity, with a contracted empty uterus ruptured in the fundus, which was sutured. The patient recovered uneventfully after stabilization. The anatomopathological exam of the 605g fetus and placenta, almost bipartite, hinted abruptio placentae as the cause of the demise.

Discussion: The uterine scar tissue following perforation during may have been the cause of the abnormal placentation, abruption and subsequent uterine rupture during prostaglandin stimulation. These events led to a serious life threatening complication. The uterus was salvageable, but the reproductive future of the patient is, still, compromised.

ARE PATIENTS WITH MULTIPLE REPEAT TRANSCERVICAL RESECTION OF UTERINE FIBROIDS AT HIGH RISK OF COMPLICATIONS?

Complications

Video

Alexander Frick*, Hoo Will, Hamoda Haitham, Narvekar Nitish

King's College Hospital

Summary (4 lines): We present two videos of transcervical resection of fibroids following previous incomplete resections which resulted in two separate, significant complications - one a cardiac arrest and the other massive blood loss.

Introduction: Both cases initially presented with subfertility and had undergone two previous incomplete resections each for the same fibroid in the last 12-18 months. The first was a 41 year old woman with a 70% submucous 41X40x30 fibroid and the other a 38-year old with a 80% submucous 45x41x40mm fibroid.

Material and Methods Both cases, the fibroids were resected with a 10 mm operative bipolar resectoscope and saline distension medium. 1st case halted due to intra-operative cardiac arrest after 30 minutes and received 3-4 cycles of CPR before regaining cardiac output. 95% of the fibroid had been resected and the fluid deficit was 900mls. 2nd case halted 40 minutes into the procedure due to one litre blood loss. 3 fibroids were resected completely and fluid deficit was 800mls.

Results: 1st patient- Investigations - normal echocardiogram; normal cardiac catheterisation studies; no pulmonary thromboembolism. Differential diagnosis was air embolism. She was discharged home following two days on the intensive care unit. 2nd patient- haemoglobin dropped to 6.9 and was transfused two units before being discharged home within 24 hours of surgery.

Discussion: Both cases suffered from unexpected significant complications that resulted in unplanned admission and additional care. We propose that rapid regrowth of fibroids following incomplete resection may involve abnormal neovascularisation which can result in complications at the time of repeat surgery.

LAPAROSCOPY APPROACH OF ADNEXAL MASSES – A 5 YEAR RETROSPECTIVE STUDY

Teaching & Training

Poster

Ana Cristina Nércio*, Correia Andre

Hospital Dona Estefania - CHLC

Summary (4 lines): A 5 year retrospective study of women undergoing laparoscopy for adnexal mass was done. The adnexal masses are more frequent in the reproductive age group, and most are benign.

Introduction: The adnexal masses are a common gynecologic problem. The incidence ranges between 3 to 8% occurring in female of all ages. The adnexal masses can be accidentally discovered during routine examinations or may present with symptoms. Surgery is performed when the mass is symptomatic, whenever malignancy is suspected or there are other risks associated with the mass. Laparoscopy approach has several advantages over laparotomy, being increasingly used.

Material and Methods A 5 year retrospective study from 2008 to 2012 of women undergoing laparoscopy for adnexal mass was done (N: 225). The data were collected from hospital records and patients files, descriptively. We analysed the hystologic findings and correlated them wit

Results: The majority of women undergoing laparoscopy for an adnexal mass (67,5%) belong to the reproductive age group. There were no malignancies in this group, most were epithelial tumors (57%) followed by non-epithelial tumors. In peri/postmenopausal women group there were 4,8% malignancies, correlated with elevated tumor markers and suspicious ultrasound characteristics.

Discussion: The histologic findings were consistent with the results of large population studies, with the exception of the reproductive age group with a higher incidence of endometrial cysts and the absence of malignant masses. The correlation between ultrasound and serum markers showed to increase the diagnostic accuracy of malignancy.

VALIDATION OF TWO RATING SCALES USED FOR LAPAROSCOPIC SUPRACERVICAL HYSTERECTOMY (LSH)

Teaching & Training

Oral

Jeanne Mette Goderstad*, Lieng Marit, Fosse Erik

Oslo University Hospital

Summary (4 lines): Assessment of surgical competence is essential for feedback in surgical training. We validate two rating scales used for laparoscopic supracervical hysterectomy (LSH)

Introduction: To improve surgical education we need assessment tools to evaluate surgical competence. We want a rating scale useful in a training module for laparoscopic supracervical hysterectomy. We compare validity of two rating scales for surgical skills, The Global Assessment of Laparoscopic Skills (GOALS) and Competence Assessment Tool (CAT) for LSH. GOALS is for laparoscopy in general, established and evaluated in former studies. We made a procedure spesific rating scale, the CAT for LSH.

Material and Methods This is a prospective cohort, observer blinded study. Gynecologists and gynecological trainees with different surgical experience are included. They perform a LSH.The operation is video recorded and evaluated by two observers who use GOALS and LSH-CAT. A pilot study of 10 videos was conducted. Based on the results we need to include 37 videos to achieve a power of 80% and a level of significance of 0,05. We have so far includes 34 videos.

Results: Will be presented.

Discussion: Will be presented

THE ROLE OF ENDOMETRIAL SAMPLING WITH PIPELLE

Diagnostic & Operative Office Hysteroscopy

Poster

Ana Vanessa Santos*, Lopez Berta, Lopes Catarina, Mettelo José, Canelas Luís, Ribeirinho Ana Luísa, Romão Fátima

Hospital Fernando Fonseca

Summary (4 lines): In this study the authors reviewed the cases submitted to hysteroscopy in which endometrial sampling with Pipelle® was performed previously, at the Garcia de Orta hospital, during 2012.

Introduction: Office-based endometrial sampling provides a minimally invasive option for diagnoses of endometrial cancer, hyperplasia and other endometrial pathology. A frequent indication to perform these techniques is abnormal uterine bleeding. The goal of this study was to analyze the histology and the hysteroscopic alterations found in women submitted to hysteroscopy who had previously had endometrial sampling with Pipelle®.

Material and Methods Retrospective analysis of the cases submitted to hysteroscopy in which endometrial sampling with Pipelle® was performed previously, at the Garcia de Orta hospital, during 2012, by consulting clinical records and diagnostic exams. The authors analyzed ag

Results: There were 61 cases of hysteroscopy with previous endometrial sampling with Pipelle®. The endometrial sampling with Pipelle® was compatible with endometrioide adenocarcinoma in one case and the hysteroscopic findings were suspicious of dysplasia in 5 cases. The biopsy performed during hysteroscopy revealed 2 cases of endometrioide adenocarcinoma.

Discussion: In the 2 cases of endometrioide adenocarcinoma the hysteroscopic findings were compatible with dysplasia. The endometrial sampling with Pipelle® agreed with the hysteroscopy biopsy of endometrioide adenocarcinoma in one situation, and in the other case it revealed hyperplasia without atypia.

OVARIAN DRILLING BY TRANSVAGINAL LAPAROSCOPY USING TWO DIFFERENT ENERGY SOURCES

Innovation in Instrumentation and Surgical Techniques

Video

Sylvie Gordts*, Puttemans Patrick, Gordts Stephan, Campo Rudi, Valkenburg Marion

Leuven Institute for Fertility and Embryology

Summary (4 lines): Ovarian capsule drilling for clomiphene resistant polycystic ovary syndrome by transvaginal laparoscopy using either bipolar energy or a diode laser.

Introduction: Ovarian drilling for polycystic ovary syndrome is a treatment option for clomiphene citrate resistant patients. Transvaginal laparoscopy allows for an easy and less invasive exploration for fertility patients. This technique can also be used for small interventions such as ovarian drilling for clomifene resistant patients. In this video two different energy sources are used via transvaginal laparoscopy. Previous studies of ovarian drilling by transvaginal access have shown as good results as conventional laparoscopic access.

Material and Methods The video shows an ovarian drilling using bipolar cutting and coagulation in one side and using a diode laser in the other ovary. In the bipolar technique first a short burst of cutting energy is used to perforate the ovarian cortex, followed by 5” of coagulation, heating the underlying stroma. The needle has a length of 8 mm and a diameter of 200μ.

Results: Both techniques are feasible using the single access route of transvaginal laparoscopy. No complications occurred. The transvaginal access permits to perform an ovarian drilling in a significantly less invasive way than conventional laparoscopy, i.e. with a destruction/vaporization of ovarian cortex that is only a fraction compared with the laparoscopic route.

Discussion: Ovarian drilling of polycystic ovaries by transvaginal laparoscopy using bipolar or laser energy is minimally invasive, safe and easy.

HIGH BILATERAL CERVICOSACROPEXY FOR THE CORRECTION OF PELVIC ORGAN PROLAPSE IN SINGLE INSCISION TECHNIQUE

Urogynaecology

Poster

Joerg Neymeyer*, Sarah Weinberger, Kurt Miller

Medical University Charitè, Department of Urology

Summary (4 lines): Using a partially resorbable mesh sling for high medial bilateral fixation nearly the sacrouterine ligaments successfully correct the vaginal vault prolapse. This technique may prevent vaginal erosions, reduce dyspareunia and reduces mean operating time and costs. Further vaginal interventions are still feasible and may present a treatment option for young or multimorbid patients. The MRI suitable mesh enables surgeons to gain further data on the outcome of mesh grafts in vaginal vault prolapse repair.

Introduction: For the correction of ventral and central vaginal vault prolapse tension free, partially resorbable mri-visible mesh sling were generated. The aim was to partially reconstitute the statical function of the pelvic floor with the sling nearly at the sacrouterine ligaments via the generation of kollagen fibers and the iron coated mesh sling was used to allow postoperative MRI-imaging.

Material and Methods 64 patients with vaginal vaults prolapse or apical descent - POP-Q, Grade 2-3 were treated by implantation of the sling (Seratex PA) using a single incision technique and the reusable suturing device called RSD-Ney in “W-Techninqe”. In 9 cases we used the

Results: After 210 days the scar tissue of the resorbable mesh part began to resolve, which was documented using elastography. MRI imaging was able to visualize the exact anatomic position of the mesh graft. Correction of the vault prolapse remained in all patients at 9 months end point.

Discussion: Using a partially resorbable mesh sling for high medial bilateral fixation nearly the sacrouterine ligaments successfully correct the vaginal vault prolapse. The MRI suitable mesh enables surgeons to gain further data on the outcome of mesh grafts in vaginal vault prolapse repair.

MECHANICAL REMOVAL OF ENDOMETRIAL POLYPS IN OUTPATIENT SETTINGS

Diagnostic & Operative Office Hysteroscopy

Poster

Julian Habibaj*, Bare Teuta, Aliko Hysnie, Hoxha Odeta, Murati Arben

University Hospital "Queen Geraldine"

Summary (4 lines): We analyzed hysteroscopic removal of 116 endometrial polyps in 102 patients referred to our clinic.

Introduction: Polyps were most frequently removed in an inpatient setting, under general anesthesia. We present our experience with hysteroscopic polypectomy by scissors in outpatient settings.

Material and Methods We retrospectively studied 116 polyectomies performed in 102 patients in outpatient settings. All the procedures were performed by vaginoscopic approach with e 5.5 mm hysteroscop. Saline solution was the distention media. The polypectomy was performed by

Results: The mean time of procedure was 8 minutes. There was no complication except a vago-vagal reaction. Only 9 patients needed a light sedation.

Discussion: Hysteroscopic polypectomy performed in an outpatient setting by scissors without anesthesia is an effective and a well-tolerated procedure.

A NEW SURGICAL-ULTRASOUND SCORING SYSTEM TO MAP PELVIC DEEP INFILTRATING ENDOMETRIOSIS AND PREDICTING SURGICAL DIFFICULTIES

Endometriosis: Surgery

Oral

Errico Zupi *, Mario Malzoni, Lucia Lazzeri, Alessandra Di Giovanni, Gabriele Centini , Felice Petraglia, Caterina Exacoustos

Department of Molecular and Developmental Medicine

Summary (4 lines): Prospective study to evaluate the extension of pelvic DIE with a new scoring system by TVS and during laparoscopy

Introduction: A new scoring system, referred to as “Endometriosis Surgical-Ultrasonographic Score System” (ESUSS) was developed to assess the extent of deep endometriosis(DIE).The aim of this study was validate ESUSS by surgical/ histological control and to correlate the score to surgical difficulties.

Material and Methods With ESUSS we assess the extent of DIE by measuring the size and depth of the lesions at the various pelvic locations first with ultrasound and later at laparoscopy. Each site has its own numerical score assigned. The correlations between the different localizations was recorded. The involvement of bowel was described, distinguishing between cranial rectum and caudal rectum and correlated to the need or not to perform a segmental resection.

Results: Posterior DIE alone was found at surgery in 135 patients (88%), anterior DIE in 2 patient(1%), posterior and anterior DIE in 17 patients (11%). The numerical score assigned to each site depends on the surgical technical difficulty. High total score correspond to wide disease extension, requiring high surgical expertise.

Discussion: This new ultrasound/surgically driven scoring system is accurate in mapping the extent of DIE and may be useful for preoperative planning and intraoperative management of symptomatic patients with DIE.

THREE DIMENSIONAL ULTRASOUND FEATURES OF UTERINE JUNCTIONAL ZONE IN PATIENTS WITH OVARIAN OR DEEP ENDOMETRIOSIS

Endometriosis: Diagnosis

Oral

Errico Zupi *, Catherine Exacoustos, Claudia Tosti, Lucia Lazzeri, Valeria Romeo, Mara Di Felicenatonio, Felice Petraglia

Department of Molecular and Developmental Medicine

Summary (4 lines): JZ features appeared similar in patients with OMAs and those without endometriosis, whereas they are statistically different if correlated to patients with DIE.

Introduction: The aim of this study was to assess three-dimensional (3D) transvaginal sonography (TVS) detectable alterations of the uterine junctional zone (JZ) in patients with only endometriomas (OMAs) or with only deep endometriosis (DIE) and to compare these findings to those without pelvic endometriosis

Material and Methods Prospective analysis of JZ 3D TVS features in secretive phase of the cycle in patients with TVS sign of pelvic endometriosis, never treated surgically. 80 patients (ages 23-35yrs) with OMAs or DIE at TVS . Patients with both OMAs and DIE or >35yrs or with previous pelvic surgery were excluded. A control group of 20 patients without endometriosis at TVS and confirmed by laparoscopy and histology was assessed.

Results: 38 patients had only OMAs and 42 only DIE at TVS. The maximum thickness of JZ (JZ max) in patients with DIE was significantly greater than in patients with OMAs and those without endometriosis (6.5±1.9 vs 4.7±1.0mm vs 4.8±1.0mm).

Discussion: JZ thickness and its alterations are different in patients with DIE compared to those with OMAs and without endometriosis. Since these JZ ultrasound features are mostly associated with adenomyosis, a correlation between DIE and JZ hyperplasia and adenomyosis could be hypothesized.

PELVIC RETROPERITONEAL EPIDERMOID CYST TREATED WITH LAPAROSCOPIC RESECTION WITHOUT ADDITIONAL PERINEAL APPROACH

Case reports

Video

Ornella Sizzi*, Rossetti Alfonso, Manganaro Lucia, Saldari Matteo, Mercuri Massimo

Nuova Villa Claudia Hospital

Summary (4 lines): First laparoscopic approach for resection of a pelvic retroperitoneal and presacral tumor

Introduction: We report a detailed description of the laparoscopic procedure performed in a 32-year-old woman to remove a mass, detected on US and MRI, closely adherent to the left sacrospinous ligament and compressing the rectum. The histopathological exam confirmed the suspect of a rare case of pelvic retroperitoneal epidermoid cyst.

Material and Methods Laparoscopic examination of the peritoneal cavity was negative.Considering the MRI , we performed a thorougher inspection of the vagina and rectum. We found a softness and increased thickness of the left pubococcygeal and puborectalis muscle. The left ureter was mobilized and the peritoneum was incised between the left uterosacral ligament and the rectum. Through a sharp and blunt dissection the underneath connective and fat tissue was removed and the visualization of the cyst was possible.

Results: The mass appeared to be tenaciously adherent to the pelvic floor muscles and to the rectum . We proceeded with an accurate dissection of the lesion and with its progressive isolation.The histological exam made a diagnosis of epidermoid cyst.

Discussion: Experience with MIS to resection of these tumors is limited. Although a few cases of laparoscopic excision of a pararectal cyst have been reported , this is the first case describing a successful laparoscopic enucleation of a pelvic retroperitoneal epidermoid cyst without a combined perineal approach.

FEASIBILITY OF ELECTROHYSTEROGRAPHY FOR UTERINE PERISTALSIS MEASUREMENT IN NON-PREGNANT UTERI

Imaging

Poster

Benedictus Schoot*, Nienke Kuijsters, Willem Methorst, Madeleine Kortenhorst, Matteo Santini, Chiara Rabotti, Massimo Mischi

Catharina Hospital

Summary (4 lines): Electrohysterography (EHG) could be a suitable option to measure uterine peristalsis, enabling the long-term measurement of pre- and post-treatment effect of interventions in fertility patients.

Introduction: Uterine peristalsis in a non-pregnant uterus has proven to play a role in fertility. Uterine pathology can interfere with uterine peristalsis and subsequently hamper fertility. Currently used measurement tools, such as trans-vaginal ultrasound (TV-US), are time-consuming and inter-observer variability is of concern. In this study, we evaluated the feasibility of a new method based on trans-vaginal electrohysterography (TV-EHG) for the measurement of peristalsis in non-pregnant uteri.

Material and Methods We carried out a study in a Dutch peripheral hospital. We included five women (aged 27-37 years) with a natural and regular menstrual cycle. TV-EHG and TV-US measurements were performed simultaneously during the active (peri-ovulatory) and non-active (mid-luteal) phases of the menstrual cycle. Contractions were annotated by two experts after visual inspection of the recorded TV-US image sequences. A new method was used to automatically and independently detect contractions in the TV-EHG signal.

Results: The frequency of contractions, in number of contractions per minute, derived by the two methods was evaluated. We found a Pearson correlation coefficient ρ of 0,68 (p-value

Discussion: This feasibility study suggests that TV-EHG is able to measure the frequency of uterine peristalsis reliably, showing correlation with TV-US. Future studies will focus on an extended validation of the method and see if EHG can be of aid in measuring pre- and post-treatment effect of interventions in fertility patients.

METHYLATION OF 5MDC IN LYMPHOCYTES AND ENDOMETRIAL TISSUE IN PATIENTS WITH DIAGNOSED ENDOMETRIAL ADENOCARCINOMA

Oncology

Poster

Krzysztof Gałczyński*, Adamiak-Godlewska Aneta , Gogacz Marek, Postawski Krzysztof

Medical University of Lublin, Poland

Summary (4 lines): The aim of the study was to check if there are changes in the total DNA methylation of peripheral blood lymphocytes in healthy and with endometrial cancer patients.

Introduction: DNA methylation is an epigenetic mark that plays significant role in control mechanism, especially in cancerogenesis. Lymphocytes take part in the defence mechanism against cancers. The number of natural killer cells significantly decreases in noninvasive uterine carcinomas, whereas in grade 3 tumours their quantity is very high. The aim of the study was to check if there are any changes in the total DNA methylation of peripheral blood lymphocytes in patients with endometrial adenocarcinoma.

Material and Methods Peripheral blood lymphocytes were isolated from venous blood of hormonally non-treated, healthy patients (10), and with endometrial cancer(21). Lymphocytes DNA isolation has been performed using Qiagen RNA:DNA kit, uterine cancer tissues–using conventional phenol-chloroform method. The radioactivity of the labeled spots of 5-methyldeoxycytidylic acid(pm5dC) and deoxycytidylic acid(pdC) was measured by the same person twice in a three days intervals either by bio-imaging analyzer and/or by Cerenkov counting and expressed as a ratio: (m5dC/m5dC+C) x100%.

Results: The average 5methyldeoxycitidine levels measured in lymphocytes in endometrial cancer group was (3,58+/-0,07). There were no statistically significant differences between 5mdC levels in lymphocytes(3,58+/-0,07) and adenocarcinoma tissue(3,32 +/-0,09) of the cancerous patients(p

Discussion: Our investigations revealed that 5mdC levels measured in peripheral blood lymphocytes and in endometrial tissue in healthy and diagnosed with endometrial cancer patients were not statistically significant. However our results may suggest that in overall DNA methylation can to be a result of cancerogenous transformation. Further investigation is required.

VISUALIZATION OF MESH WITH FERRO PARTICLES AFTER COLPOSACROPEXY WITH USE OF MRI

Imaging

Oral

Joerg Neymeyer*, Joerg Neymeyer, Christian Scheurig-Muenkler, Hannes Cash, Kurt Miller

Medical University Charitè, Department of Urology

Summary (4 lines): For the first time visualization of the anatomic localisation of mesh at the promontory is made possible by the use of iron coated mesh grafts. Post operative follow up of mesh Fixation are now possible.

Introduction: To visualize the postoperative position of the mesh graft after sacropexy with use of MRI. Until now MRI vizualisation was not possible and transvaginal ultrasound was only capable of showing the distal part of the mesh.

Material and Methods After permforming LASH and sacropexy with an iron coated mesh, postoperative follow up 4 weeks after surgery consisted of a clinical examination with transvaginal ultrasound, elastography, MRI and ultrasound-Fusion with MRI.

Results: MRI imaging was able to visualize the exact anatomic position of the mesh graft. The ultrastructure of the mesh was visible in all cases. Ultrasound was only capable to vizualize the mesh at the cervical stump. Elastography demonstrated the postoperative incorporation of the mesh.

Discussion: For the first time visualization of the anatomic localisation of mesh at the promontory is made possible by the use of iron coated mesh grafts.

ENDOLUMINAL TREATMENT OF URETERIC VAGINAL FISTULAE WITH AN POLYMERIC STENT - A CASE REPORT

Complications

Poster

Joerg Neymeyer*, Essa Adawi, Hannes Cash, Kurt Miller

Medical University Charitè, Department of Urology

Summary (4 lines): Ureterovaginal fistulas are rare but relatively frequent complication of pelvic surgery. The treatment of uretero-vaginal fistulas with an Polymeric Stent (Allium®) is a new non open surgical procedure for the closure of the uretero-vaginal fistula.

Introduction: Ureterovaginal fistulas are rare but relatively frequent complication of pelvic surgery. Abdominal hysterectomy is responsible the most for the ureteral injuries. In the past most ureterovaginal fistulas have been repaired by ureteroneocystostomy or end-to-end anastomosis. Now endourological techniques with D-J or M-J implantations are successful in treating ureterovaginal fistulas and ureteral stricture does not appear to be a common complication.

Material and Methods We report a case of 61-years-old woman who, during the late postoperative period of a total laparoscopic hysterectomy, presented with incontinence with episodic flank pain, recurrent UTI compatible with Uretero-Vaginal fistula in the left side. This was initially treated with JJ-stent and Folly-catheter for one month with neither improvement of the symptoms nor closure of the fistula. As an alternative therapy we replaced the JJ-stent with an Polymeric Stent (Allium®).

Results: One month after the intervention the patient dose not report any incontinence during the day or the night. The flank pain has disappeared completely. An intravenous urography showed a spontaneous healing and resolution of the uretero-vaginal fistula.

Discussion: Patients, who have failed the endourological treatment with JJ or MJ stents, have The option be treated with polymeric stents. In our case, the polymeric stent did not only guarantee normal urine flow, but also maintained steady pressure over the fistula, which lead to tissue ingrowth and increased healing process.

THE MAP FOR SURGERY OF PATIENTS WITH ENDOMETRIOSIS

Complications

Oral

Ricardo Lasmar*, Lasmar Bernardo

Federal Fluminense University

Summary (4 lines): To evaluate a representative diagram (MAP) of all endometriosis sites before surgery to help the procedure and to define the best team to do it.

Introduction: The diagram is a graphic representation of all sites of endometriosis. It should be filled at the time of surgery indication, namely with all the propaedeutics completed and the surgeon having already identified the locations affected by the disease.

Material and Methods To demonstrate the application and practicality of the MAP with the locations of endometriosis in laparoscopic surgery for patients with endometriosis in university hospital and in private clinics.

Results: The MAP with only one page, in which all endometriosis sites graphically and precisely was represented, led to a better discussion of case selection and surgical team, with shorter operative time and leaving no disease previously known.

Discussion: The surgeon with the diagram at the time of surgery, has a special tool that concentrates all the details of the case. This MAP can be checked at any time in surgery and may guide the surgical team, even in the absence of medical records.

ADVANCED CERVICAL CANCER. LAPAROSCOPIC VERSUS CT SCAN STAGING

Oncology

Poster

Alvaro Zapico*, Couso Aldina, Valenzuela Pedro, Fuentes Pedro , del Valle Cristina, Marcos Victoria , Heras Irene, Heron Soraya

Príncipe de Asturias Hospital. Alcalá University.

Summary (4 lines): Aortic nodes Laparoscopic evaluation seems to be mandatory to set the need of extended radiotherapy treatment

Introduction: FIGO stage more than IB1 is treated with chemotherapy and radiotherapy. If there is metastatic para-aortic nodal disease, radiotherapy is extended to cover this area. Due to increased morbidity, ideally extended-field radiotherapy is given only when para-aortic nodal disease is confirmed. Therefore, accurate assessment of the extent of the disease is very important for planning the most appropriate treatment.

Material and Methods From 06/2011 t0 06/2013, 20 patients with advanced cervical cancer were scheduled for laparoscopic staging to set the need of extended radiotherapy field. Transperitoneal approach was used in 4 cases and retroperitoneal in the remaining 16 patients. In all cases, CT scan has been performed for clinical-radiological staging. Aortic lymphnodes metastasis were seen in 5 (25 %) patients. Ct scan aortic nodes assessment is studied

Results: CT scan aortic nodes assessment had 40 % Sensibility and of 88% specificity. Positive predictive value was 50 % and negative predictive value was 84,2 %. There were 2 false positive and 3 false negative cases

Discussion: Aortic nodal status is mandatory to set in the need of extended radiotheray fields. Ct scan findings are not enough to stablish whether extended field is necessary. Surgical staging may solve this problem. Otherwise, 50% of patients will be overtreated and 15% cases will not received the apropiate extended radiotherapy

PRE-HYSTERECTOMY ASSESSMENT OF IMMEDIATE TUBAL OCCLUSION WITH THE NEXT GENERATION ESSURE INSERT (ESS505)

Innovation in Instrumentation and Surgical Techniques

Oral

John Thiel*, Rattray Darrien

University of Saskatchewan

Summary (4 lines): This study evaluated the rate of hysteroscopic tubal occlusion for the current ESS305 insert with the new ESS505 one hour after placement and at 30, 60 and 90 days.

Introduction: The current ESS305 insert occludes the fallopian tube by PET-fiber-initiated tissue ingrowth and requires 90 days to complete. A confirmation test is required, by either ultrasound, pelvic x-ray or hysterosalpingogram. To provide immediate contraception, a polymer hydrogel seal was placed on the distal end of the new ESS505 insert resulting in occlusion of the tube within one hour post-placement. The mechanism of long-term occlusion remains the same as the previous device.

Material and Methods Non-randomized prospective cohort trial (Canadian Task Force classification II-1) completed at the Regina General Hospital. Women (N=31) scheduled to undergo laparoscopic hysterectomy underwent ESS305 (left tube) and ESS505 (right tube) placement 30, 60 and 90 days prior to hysterectomy. Ultrasonongraphy confirmation of placement was completed on the day of placement. Hysterosalpingogram confirmation was completed one hour post-placement and on the day of hysterectomy 30, 60 and 90 days later.

Results: Twenty nine patients completed the study (exclusions, n=2). Acute ESS505 occlusion occurred in 97% (28/29) of tubes and at hysterectomy 100% (29/29) of tubes were completely occluded. Acute ESS305 occlusion occurred in 10% of tubes and at hysterectomy 100% of tubes were completely occluded.

Discussion: Essure 505 was successful at causing tubal occlusion within one hour post-placement as well as at 30, 60 and 90 days later. These finding suggest next generation Essure 505 will provide immediate and long term tubal occlusion.

TRANSVAGINAL MYOMECTOMY

Myomectomy

Video

Vladimir Durasov*

Samara City Clinic 5

Summary (4 lines): Transvaginal myomectomy is one of organpreserving surgical method for patients with uterine myomas. Surgery is performed via vaginal approach. Utery is reconstructed manually. 264 transvaginal myomectomies were performed by one surgeon. In 231 cases laparoscopic assistance was performed, 33 surgery were done only through vagina. Transvaginal myomectomy is safe and feasible for nulliparous women.

Introduction: More than 30% of women at reproductive age have uterine myomas. In case symptomatic myomas myomectomy is surgery of choice. Usually surgery is performed via laparotomy or laparoscopy. Transvaginal myomectomy is an alternative technique. This surgery is carried out on everted utery through vaginal route according to the principals of Natural Orifice Surgery.

Material and Methods 264 surgeries were performed between January 2002 and May 2013. Through anterior or posterior vaginal incision utery was delivered into vagina. Myomas were removed and uterine wall was repaired layer-by-layer by conventional suturing. After this uterus was placed back in abdominal cavity, colpotomy wound was sutured. In 231 cases laparoscopic control was used. Also 33 surgeries were performed exclusively through vagina. In 44 cases harpoon system was used for facilitate the delivery of utery.

Results: The average patients` age was 35.4 years old. The mean size of a dominant myoma was 6.5 cm (2 -12cm). In average it took 91.5 minutes (3 – 215 min). 138 patients (52%) were nulliparous. There were no cases of hysterectomy . There were no complications or blood transfusions either.

Discussion: A vaginal approach to myomectomy seems to be a real alternative to abdominal and laparoscopic myomectomy. It combines all the advantages of both laparotomy (manual suturing in several layers and inspection of myometrium for searching small myomas) and laparoscopy (good cosmetic results and reducing adhesions formation).

IATROGENIC UTERINE PERFORATION AND BOWEL PENETRATION WITH HOHL MANIPULATOR: A CASE REPORT

Complications

Poster

Ali Akdemir*, Cırpan Teksin

Ege University School Of Medicine, Department of O

Summary (4 lines): The use of uterine manipulator is a key factor for improving laparoscopic hysterectomy. The proper use of Hohl manipulator is very crucial to avoid uterine perforation and even bowel penetration.

Introduction: Adequate exposure is a vital factor in total laparoscopic surgery, and uterine manipulators have long been used in achieving that. Hohl uterine manipulator has been considered the one of the safe and feasible manipulator, in the literature. Beside adequate exposure, it is associated with lower intraoperative complications. However, we report a case of iatrogenic uterine rupture with Hohl manipulator which also caused bowel penetration.

Material and Methods 52-year-old lady with endometrial hyperplasia was scheduled to total laparoscopic hysterectomy. Before the intraabdominal entrance, Hohl uterine manipulator was introduced into uterine cavity without strain.

Results: During the laparoscopic exploration of pelvis, it was realized that the tip of the Hohl manipulator perforated the posterior uterine fundus and penetrated the bowel. Thereafter, laparotomy was required and penetration site of the bowel was primarily repaired by colorectal surgeon. The patient was discharged on the eighth postoperative day.

Discussion: Although Hohl uterine manipulator can facilitate the laparoscopic hysterectomy procedure, it can cause uterine perforation and even bowel penetration.

LAPAROENDOSCOPIC SINGLE-SITE SURGERY (LESS) FOR ADNEXAL TUMORS: INITIAL EXPERIENCE

Single Access Surgery

Oral

Abdulaziz Alobaid*, AlAkeel Faisal

King Fahad Medical City

Summary (4 lines): We present our initial experience with 17 Patients who had LESS for adnexal tumors that include large ovarian cysts (up to 30 cm in diameter).

Introduction: The benefits of LESS when compared to conventional laparoscopy include better cosmetic results and possibly less pain and reducing the potential morbidity from using multiple ports. We present our experience with 17 Patients who had LESS for adnexal tumors that include large ovarian cysts (up to 30 cm in diameter). The objective is to assess the feasibility, safety and operative outcome for the management of adnexal masses by LESS.

Material and Methods We performed a retrospective chart review of patients who underwent LESS at our hospital. We analyzed the patient’s age, body mass index (BMI), tumor maximum diameter as measured by ultrasound, operative time, estimated blood loss and the histopathology result. The procedures were done through a 2.5 cm umbilical incision using the open technique. The operation was then done similar to procedures performed using the conventional technique. The specimens were retrieved through the umbilical incision.

Results: All patients had benign ovarian cysts except for one that had a stage 1A1 granulosa cell tumor. The median BMI was 28.3 (21.9-39.5). The median tumor size was 14 cm (5-30). The median surgery time was 76 minutes (51-113) and the mean drop in hemoglobin was 0.55 gm/dl (0-1.5).

Discussion: We believe that LESS may be a safe and feasible alternative to conventional laparoscopy for patients with adnexal tumors and provides a great cosmetic benefit. The short-term operative outcome evaluated by the operative time and blood loss was satisfactory, however, long-term outcomes like hernia formation could not be evaluated.

FREQUENCY OF UTERINE PERFORATION DURING DIAGNOSTIC AND OPERATIVE HYSTEROSCOPY.

Complications

Poster

Ewa Milnerowicz-Nabzdyk*, Zimmer Mariusz

Wroclaw Medical University

Summary (4 lines): Diagnostic hysteroscopy had no perforation complication when minimally invasive methods of introducing 2.7 mm optics into the uterine cavity were used. Operative hysteroscopy had the smallest rate of uterine perforation complication when a diagnostic hysteroscopy was performed prior to the operative procedure.

Introduction: Objectives: aim of the study was to analyze the frequency of uterine perforations as a complication during diagnostics and operative hysteroscopy. 5023 diagnostic office and 1063 operative hysteroscopies were performed by the Obstetrics and Gynecology Department of Wroclaw Medical University in 2007-2013.

Material and Methods 520 office hysteroscopies have been performed with 2.7 mm optics, without hegars, tire-balles or local anesthesia. In the remaining 4503 office hysteroscopies - 3 mm optics and local anaesthesia were used. The highest tolerance of the procedure was noted in cases of thin 2.7 mm optics without cervical manipulation. The operative procedures were performed with bipolar electrodes - loop and spring - and 3 and 5 mm optics.

Results: Uterine perforation was the only serious complication of hysteroscopies performed in our department between 2007-2013. 10 perforation took place during operative procedures: 2 in 267 myomectomies, 6 in 744 polypectomies and 2 in 42 septal resections. 5 perforation - during diagnostics procedures.

Discussion: 6 of operative and 3 of diagnostic perforations occurred during cervix dilation with hegars. In diagnostics with 2.7 mm optics with minimally invasive method no perforation was observed. When the diagnostic hysteroscopies prior to operative hysteroscopies were used, halving of the occurrence of uterine perforation during operative procedures were observed.

THE LEARNING CURVE OF 30º CAMERA NAVIGATION SKILLS ON A NEW BOX TRAINER FOR HYSTEROSCOPY

Teaching & Training

Oral

Juliënne Janse*, Tolman Christine, Veersema Sebastiaan, Broekmans Frank, Schreuder Henk

Sint Antonius Ziekenhuis Nieuwegein

Summary (4 lines): This study investigated the learning curve of hysteroscopic 30° camera navigation on a new box trainer. The results indicate a good training capacity by significant improvements of participant skills.

Introduction: Despite the upcoming use of hysteroscopy and increased applicability during last decades, little work has been done regarding the development of hysteroscopic training models. Camera navigation is often perceived to be easy, but it is far from an innate ability, especially when an angled hysteroscope is used. Recently, the HYSTT box trainer has been developed under auspices of the European Academy of Gynaecological Surgery, and aims at practicing camera navigation skills with a 30° hysteroscope.

Material and Methods This prospective study enrolled thirty novices (medical students) and ten experts (gynaecologists, more than 100 diagnostic hysteroscopies). Participants performed nine repetitions of a 30° exercise on the HYSTT. Novices returned after two weeks and performed a second series. Procedure time and the clinical parameter Global Rating Scale provided measurements. Two-way repeated-measures analysis of variance was used to analyse curves. Effect size was calculated to express the practical significance (more than 0.50 indicates large learning effect).

Results: For both parameters, significant improvements were found in novice performance within nine repetitions. Moderate to large learning effects were established (p-value less than .05; effect size 0.44–0.71). Retention of skills and prolonged learning curves were observed in the second series. Novices approached expert level but did not reach it.

Discussion: The learning curve established of hysteroscopic 30° camera navigation skills on the HYSTT box trainer, indicates a good training capacity and provides the first step towards recommended implementation into a training curriculum. One or more training sessions substantially improve the speed of acquiring 30° camera navigation skills on the HYSTT.

ELECTROMECHANICAL MORCELLATION IN LAPAROSCOPIC HYSTERECTOMY: QUANTIFICATION AND EFFICIENCY

Hysterectomy

Oral

Ewout Arkenbout*, Sara Driessen, Andreas Thurkow, Frank Willem Jansen

Delft University of Technology

Summary (4 lines): A time-action analysis of morcellation during hysterectomies is provided to give insight into morcellation efficiency and the time-division of the morcellation phases, allowing for improved pre-operative planning.

Introduction: Morcellation entails the minimally invasive removal of large amounts of tissue. Current morcellators are based on the relatively inefficient cyclical process of grasping, cutting and depositing tissue, and are generally associated with a large degree of tissue spread throughout the abdomen. In order to identify the major issues with current morcellation practice, a better understanding of the time required for all morcellation steps, as well as quantification of the degree of tissue scatter, is needed.

Material and Methods Experienced surgeons from two hospitals recorded intra-operative morcellation data during 65 operations. Additionally, time-action analyses of video material of 23, out of the 65, procedures was performed. The number of tissue strips and degree of tissue scatter was noted, and the time spend in the various morcellation phases quantified (including the post-morcellation clean-up phase which entails the visual inspection and irrigation of the abdominal cavity).

Results: Total morcellation time was 22,1±18,4min, which was 12,6%±8,6% of the procedure time. Morcellation and clean-up time are correlated with increasing tissue mass removal (r=0.76, p0.001 and r=.81, p0.001 respectively). Time-action-analysis shows that tissue-manipulation, tissue-cutting, depositing-time and cleaning-time is 30%, 15%, 15% and 40% respectively of the morcellation and cleaning time.

Discussion: As the majority of the time spent morcellating is lost in tissue manipulation and post-morcellation cleaning it is apparent that morcellating remains relatively inefficient. Tissue scattering causes increasing time-loss, yet is an inherent problem in the current peeling morcellators. Hence a morcellator redesign, focussing on tissue scatter prevention, is required.

SENTYNEL LYMPH NODE BIOPSY AND ENDOMETRIAL CANCER

Oncology

Poster

Alvaro Zapico*, Valenzuela Pedro, Couso Aldina , Heras Irene, Marcos Victoria, del Valle Crsitina , Fuentes Pedro, Heron Soraya

Príncipe de Asturias Hospital. Alcalá University.

Summary (4 lines): Sentynel lymph node biopsy could be an alternative to standard lymphadenectomy in low and medium risk endometrial cancer

Introduction: The prognosis of endometrial cancer (EC) is generally favorable, while lymph node status remains the most important prognostic factor. Sentinel lymph node mapping (SLNM) could help to find women where adjuvant therapy could be omitted.

Material and Methods From 09/2010 to 06/2013 SLNM was used in 39 patients. In 18 cases, single isosulfan blue dye mapping was done while in the remaining 21 patients a double Tc99 and isosulfan dye was performed. In all cases, SLN was followed by lymphadenectomy. No differences between groups were achieved according to age, BMI or total number of lymphadenectomy nodes collected. Obturator fossa (52%) and Interiliacs (32%) and common iliac (16%) were the finding location

Results: Double mapping allowed a higher detection rate (90.5%vs77.8%,p 3,08vs2,01. False negative rate was 3,7 %.

Discussion: SLNM in endometrial cancer is a promissing procedure. However due to the low rate of node metastasis a great number of cases is needed for validation

INGUINO-FEMORAL ENDOSCOPIC LYMPHADENECTOMY FOR VULVAR CANCER

Oncology

Video

Alvaro Zapico*, Couso Aldina, Valenzuela Pedro, Fuentes Pedro, Marcos Victoria, Heras Irene, del Valle Cristina, Heron Soraya

Príncipe de Asturias Hospital. Alcalá University.

Summary (4 lines): Inguino-femoral lymphadenectomy may be an alternative procedure to classic surgical approach

Introduction: Inguino-femoral lymphnodes metastasis remains the main prognosis data in vulvar cancer. Radical vulvectomy or three incision technique for vulvectomy and inguinal lymphadenectomy has been the standard approach. SLNB may avoid inguinal lymphadenectomy. Finally, inguinofemoral endoscopic lymphademnectomy has been reported as an alternative to conventional surgery

Material and Methods 82 years old female with a 4 cm central vulvar cancer was scheduled for SLNB and vulvectomy. SLN mapping was achieved in left groin but no migration was obtained on the contralateral side.

Results: Leftside SLNB was performed followed by right side inguinofemoral lymphadenectomy. One SLN and 9 right side nodes final pathology was benign. Postoperative follow up was uneventfull

Discussion: Inguinofemoral endoscopic lymphadenectomy may be an alternative to classic surgical approach

OUTPATIENT TRANSVAGINAL HYDROLAPAROSCOPY IN THE NETHERLANDS

Infertility and Reproductive Medicine

Selected abstract Oral

Mianne van Kessel*, Coenders-Tros Rachel, Oosterhuis Jur, Kuchenbecker Walter, Koks Carolien, Mol Ben Willem

Isala Klinieken Zwolle

Summary (4 lines): THL is a safe method of tubal patency testing, tolerated well by patients and has a high concordance with laparoscopy with a positive predictive value of 84%.

Introduction: Transvaginal hydrolaparoscopy (THL) is a novel method for tubal patency testing in women with infertility. It was first described by Gordts in 1998. The technique uses the transvaginal route, giving access to the pouch of Douglas by culdocentesis. It has proven to be a safe procedure with a learning curve of 50 procedures. Prospective studies comparing THL with diagnostic laparoscopy demonstrated high sensitivity and specificity values.

Material and Methods In four hospitals in the Netherlands, THL is performed as a first line investigation for tubal patency testing in couples with primary or secondary subfertility of more than one year. Our study population consists of 1141 subfertile women in which THL was performed between January 2000 and December 2011. In two hospitals women were asked to rate pain, acceptability (on a visual analogue scale (VAS)) rating from 0 to 10) and recommendation of the technique.

Results: Successful access to the pouch of Douglas was achieved in 1086 (95.0%) patients. Complications were seen in 24 patients (2.1%). The VAS for pain was 4.2, acceptability 1.5 and recommendation 1.2. THL showed abnormalities in 298 patients (28.5%). Laparoscopy was performed in 70 patients and showed similar findings in 84%.

Discussion: THL is a safe and accurate method of tubal patency testing, and is well tolerated by patients when performed in an outpatient department using local anaesthesia. The positive predictive value is high, implicating that when THL is abnormal, diagnostic laparoscopy rarely gives new insights.

SINGLE İNCISION LAPAROSCOPIC HYSTERECTOMY WITH GELPOINT

Hysterectomy

Video

Mert GOL*, Karas Çiğdem

Izmir University Faculty Of Medicine

Summary (4 lines): Although LESS surgery has some advantages compared to conventional laparoscopy, it is a more difficult technique especially in manipulating the instruments. To solve this problem Gelpoint trocar may be an option.

Introduction: A - 44 years old gravida 2 para 1 woman with complex endometrial hyperplasia underwent total laparoscopic hysterectomy using Gel Point.

Material and Methods A - 3 cm incision is performed through the umbiliculus to insert the Gelpoint trocar. Ligasure vessel sealing device and Harmonic scalpel are used to complete the operation

Results: Total duration of the operation was 55 minutes with a 30 cc intraoperative bleeding. There was no intra and postoperative complications. The patient discharged on the next postoperative day.

Discussion: Gelpoint trocar seems to be a good option for LESS surgery to ease the movements of instruments.

HYSTEROSCOPIC REMOVAL SUBMUCOSAL MYOMAS TYPE II WITH MORCELLATOR MYOSURE

Surgical Hysteroscopy

Poster

Dimitris Mathiopoulos*,

REA MATERNITY HOSPITAL

Summary (4 lines): : The Hysteroscopic Morcellator MyoSure has been gaining popularity. The use of this device has been evaluated. In this study presented the new procedure MyoSure Lite and MyoSure XL for type II submucosal myomas.

Introduction: The submucosal fibroids type II never removal and described with the use of Morcellator. In this study we used all the types of MyoSure Morcellator for three different cases and evaluated

Material and Methods : Three women with submucosal myomas type II treated with MyoSure Morcellator standard, Lite and MyoSure XL. Evaluated the operating time, fluid loss, the results of the procedure and feasibility.

Results: The use of MyoSure Morcellator in three cases are acceptable, useful and well tolerated. The results are perfect and completely removed the fibroid. The power and speed of XL, decreased the operating time and fluid loss and is better for biggest myomas too.

Discussion: The new types of MyoSure Morcellator are effective and acceptable for fibroidectomy in type II submucosal myomas.

FIRST SERIES OF 50 CASES OF LAPAROSCOPIC BOWEL RESECTION FOR COLORECTAL ENDOMETRIOSIS IN HUNGARY

Endometriosis: Surgery

Poster

Attila Bokor*, Lukovich Péter, Brubel Réka, Rigó János

Semmelweis University

Summary (4 lines): With the present study we aimed to evaluate the outcome of the first consecutive series of radical laparoscopic resection of bowel endometriosis in Hungary.

Introduction: 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.

Material and Methods Between 10/07/2009 and 01/12/2012 at the 1st. Dept.of OB/GYN, Semmelweis University, Budapest a series of 50 multidisciplinary CO2-laser laparoscopic bowel resection was performed for colorectal DIE. A prospective database was established for all elective patients undergoing laparoscopic colorectal surgery by one surgical team. The main outcome measures assessed were operative duration, conversion rate, incidence of early complications, length of hospital stay, morbidity and mortality.

Results: Operative time (min, median, range) was: 210 (95-580). Non-colorectal DIE (number, %): 15(30), Laparoconversion (number, %): 3(6) Hospital stay (days, median, range): 6(3-10). Early major postoperative complications (number, %) Total: 4(8)

Discussion: 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.

INTEREST IN THE USE OF GLUE IN LAPAROSCOPIC SACROCOLPOPEXY. A COMPARATIVE STUDY ABOUT 32 CASES

Urogynaecology

Selected abstract Oral

Georges BADER*, Claire WILLECOCQ, Anne Cécile PIZZOFERRATO, Alain SAAB, Arnaud FAUCONNIER

POISSY UNIVERSITY HOSPITAL

Summary (4 lines): Laparoscopic sacrocolpopexy (LSCP) is the reference technique for the repair of pelvic organ prolapse (POP). This complex surgical technique requires special skills and mastering of laparoscopic sutures, which makes it poorly accessible to young surgeons

Introduction: To study the impact of the use of glue instead of some laparoscopic sutures, on the operative time, the morbidity, and the short term anatomical and functional results

Material and Methods A prospective, comparative, unicentric study (done at Poissy-St-Germain-en-Laye University Hospital) including 32 patients who underwent a LSCP by an experienced surgeon. The fixation of prostheses was made either exclusively by sutures (Group 1, January-December 2012), or by associating sutures (on traction sites) and biological glue (Group 2, January-March 2013). Group 1 patients were retrospectively selected after pairing on the following criteria: number of prostheses and associated surgey (supracervical hysterectomy, suburethral tape).

Results: Characteristics of both groups were comparable. The mean operative time (173.1 [G1] vs 178.7 [G2] minutes, p = 0. 64) and the mean hospital stay (3.31 [G1] vs 3.94 [G2] days, p = 0. 08) were identical. Anatomical and functionnal results, the mean satisfaction rate and morbidity were also similar.

Discussion: In our study, the use of the glue in the LSCP did not significantly reduce the operative time. Beside the simplification of surgey, the use of glue for the adhesion of prostheses in addition to sutures has shown its safety and efficacy compared to the conventional technique (sutures exclusively).

LAPAROSCOPIC CERVICAL CERCLAGE – REPRODUCTIVE OUTCOMES (EARLY RESULTS).

Infertility and Reproductive Medicine

Poster

Alexander Popov*, Krasnopolsky Vladislav, Fedorov Anton, Tumanova Valentina, Kapustina Marina, Krasnopolskaya Kseniya, Chechneva Marina

Moscow Regional Reserch Institute O\G

Summary (4 lines): During last years amount of patients who are planning pregnancy after cervix amputation or radical abdominaltrahelectomy progressively increasing. For progression of pregnancy laparoscopic cerclage is mandatory. For the last 25 month we perform 20 laparoscopyc procedures. 3 patient are successfully delivered at 36-38 weeks of gestation. One patient on early stages of pregnancy.

Introduction: During last years amount of patients who are planning pregnancy after surgery of cervical cancer progressively increasing. Except patients after cervix amputation, radical abdominal trachelectomy or vaginal trachelectomy with laparoscopyc lymphadenectomy cervical cerclage application is necessary for patients with miscarriages of pregnancy. For progression of pregnancy in this group laparoscopic cerclage is mandatory.

Material and Methods For the last 25 month we perform 20 laparoscopyc procedures. 7 patients were after radical abdominal trachelectomy, 10 patients after cervix amputation, 3 patients with noncarrying of pregnancy. 19 patients were undergoing laparoscopic approach, in one case laparotomyc surgery was done with simultaneously myomectomy. We use Mesh type 3 protesis 10-15mm wide for this procedures, with suturing fixation to the cervix.

Results: 2 patients have spontaneously pregnancy, 2 patient achieve pregnancy by IVF. 3 patients with miscarriages of previous pregnancy on 16-18 weeks were delivered on 36-38 weeks by cesarean section. One patient is on the early stages of pregnancy.

Discussion: laparoscopyc cervical cerclage with Mesh application on a pregnancy planning stage create conditions for successful carrying of a pregnancy among patients with high risk of pregnancy miscarriages.

TRANEXAMIC ACID + MISOPROSTOL FOR REDUCING BLOOD LOSS IN LAPAROSCOPIC MYOMECTOMY

Myomectomy

Poster

Jay Mehta*, Gilvaz Sareena

Jubilee Mission Hospital

Summary (4 lines): Though a combination of tranexamic acid and vaginal misoprotol isn’t as effective as vasopressin to reduce bleeding, it is very safe and may be an alternative where vasopressin is contraindicated.

Introduction: About 30-50% women with myomas warrant treatment for symptomatic relief. Laparoscopic Myomectomy is an option for the ones who wish to preserve fertility. Several options have been considered for reducing blood loss during myomectomy. Intralesional vasopressin remains the agent of choice, however, it requires stringent intra-operative monitoring considering its side-effects. Other agents like Oxytocin, Misoprostol, Uterine Ligation have been tried but not found as effective.

Material and Methods Patients undergoing laparoscopic myomectomy for predominantly intramural myomas (4-10cm size) were included and divided into two groups by simple randomization. Group I– Intralesional dilute vasopressin (20units in 100ml saline) infiltration. Group II- 400μg of vaginal misoprostol 1 hour prior to surgery + bolus i.v. tranexamic acid 10mg/kg 15 min prior to surgery + continuous infusion of 1mg/kg/h dissolved in 1 L of saline during surgery. Direct blood loss was estimated from suction collection and subtraction.

Results: 44 patients matching criteria were randomised, 22 in each group. Mean blood loss in Group I (85.4ml) was significantly less as against Group II (115.7ml). Mean Myoma Size was similar for both groups (6.46 x 6.61cm vs 6.24 x 5.81cm). Difference in pre-post operative hematocrit not significant (3.1 vs 3.87)

Discussion: Individual studies have found the efficacy of Tranexamic Acid (Cagler et.al) and Misoprostol (Celik et.al) as against a placebo in reducing blood loss. Using the same rationale, we tried to combine the protocol and compare it with Vasopressin. In our study no major intra-operative complication was reported with this combination.

LAPAROSCOPIC COPOSUSPENTION IN A REDUCED ACCESS

Single Access Surgery

Video

Guenter Karl Noé*

KKH Dormagen Obst. Gynecology

Summary (4 lines): In the video we show how simple operations can be carried out without special instruments and expensive access systems. From this we have developed the Colposuspention with only two entries.

Introduction: The single port laparoscopy is used since approx. 1998. Within the last 10 years various applications have been described. The cosmetic advantage could be proved for certain. Whether a medical advantage is reached, remains to be discussed. Primarily the high costs make use difficult in many countries. The partly necessary special instruments also aggravate use. Less scars after an operation is a wish expressed increasingly. We have therefore reduced the usage of trocars.

Material and Methods We show a tubal sterilization and an ovarectomy as a SILS (umbilicus) procedure without a special port system or special instruments. The next step is a laparoscopic super cervical hysterectomy with one additional 5mm port. The main operation is a complete retro peritoneal performed colposuspention. A 5 mm port is inserted 5 mm above the symphesis in the midline. Optic and an additional 5 mm port are inserted in the umbilicus.

Results: By using the umbilical access for the morcelation and additional 5mm optics the LASH is performable even for 500g uterus. The colposuspention can be carried out in 30-60 minutes.

Discussion: Routine surgery in gynaecology is more and more performed laparoscopically. The costs for a laparoscopic operation are considerably higher than at standard interventions. To not generate any more costs, we get by without the use of expensive instruments or ports. The described method arrives under the patients very well.

CATAMENIAL PNEUMOTHORAX- A RARE GYNECOLOGICAL DISEASE?

Case reports

Poster

Jaroslav Klat*, Simetka Ondrej, Mittak Marcel

University Hospital Ostrava

Summary (4 lines): Thoracic endometriosis should be suspected in all women with spontaneous pneumothorax during menstruation, even in the abscence of symptoms associated with pelvic endometriosis. Surgical identification and confirmation should ideally be performed during menstruation to reduce the risk of misdiagnosis. The optimal treatment involves the radical thoracic surgery with combination of hormonal therapy.

Introduction: The catamenial pneumotorax is an entity of spontaneous, recurring pneumothorax in women. The relationship with menstruation bleeding defines the catamenial character. It has been associated with thoracic endometriosis. Nearly half of the patients with thoracic endometriosis have pelvic endometriosis too.

Material and Methods 36 years old nulligravida with history of recurring spontaneous pneumothorax presented to our department. The thoracoscopy in common team of thoracic surgeon and gynecologist was carried out. Small endometrial implants were detected, partially excised and histology confirmed thoracic endometriosis. The hormone contraception was prescribed as adjuvant treatment. Two months later she presented with another recurrence of spontaneous pneumothorax. Therefore a thoracoscopic total pleurodesis was carried out.

Results: During the 24 months follow-up she had no recurrence of pneumothorax.

Discussion: Thoracic endometriosis is still an under diagnosed disease in population of women undergoing surgery for spontaneous pneumothorax. Tratment of catamenial pneumothorax involved surgery and hormonal treatment.

RESECTOSCOPIC ROLLERBALL ENDOMETRIAL ABLATION AND CONCOMITANT LEVONORGESTREL-RELEASING INTRAUTERINE SYSTEM IN WOMEN WITH ABNORMAL UTERINE BLEEDING

Surgical Hysteroscopy

Oral

Brenda Sohn*, Vilos George, Ternamian Artin, Vilos Angelos, Abu-Rafea Basim

St. Joseph's Health Centre, University of Toronto

Summary (4 lines): Objective: To determine clinical outcomes of women with abnormal uterine bleeding (AUB) following treatment with resectoscopic rollerball endometrial ablation alone versus rollerball ablation combined with levonorgestrel intrauterine device (LNG-IUS).

Introduction: Abnormal uterine bleeding (AUB) is a very common gynecologic concern. Contemporary practice offers endometrial ablation techniques or levonorgestrel intrauterine system (LNG-IUS), as options for AUB when traditional medical therapy fails. Both therapies have been shown to be equally effective. The objective of this study is to determine clinical outcomes when both are combined.

Material and Methods Design: Pilot comparative clinical study (Canadian Task Force Classification II-I) from 2008-2012. Setting: University-affiliated teaching hospital. Patients: Fifty women (ages 37-43) with AUB of benign pathology and normal intrauterine cavity were treated with either rollerball endometrial ablation alone (n=25) or with a combination of rollerball ablation and LNG-IUS insertion immediately after ablation (n=25).

Results: At a median follow-up of 2 years (range 1-3), amenorrhea and re-intervention rates were 28% vs. 92% (ply. There were no perioperative complications.

Discussion: Conclusion: The combination of resectoscopic rollerball endometrial ablation and LNG-IUS significantly improved clinical outcomes in women with AUB as determined by amenorrhea and patient satisfaction rates.

LONG TERM FOLLOW-UP OF LAPAROSCOPIC SACROCOLPOPEXY– A GOOD SOLUTION FOR THE MESH CRISIS

Urogynaecology

Poster

Dimitri Sarlos*, Kots LaVonne , Ryu Gloria, Schaer Gabriel

Kantonsspital Aarau

Summary (4 lines): This study presents the long term results of laparoscopic sacrocolpopexy as standard treatment for pelvic organ prolapse regarding anatomical results, recurrences and quality of life.

Introduction: This study shows long term results of laparoscopic sacrocolpopexy. To evaluate this minimal invasive treatment of pelvic organ prolapse we conducted a prospective study enrolling 101 patients from 2003 to 2007. The 12 months follow-up established that laparoscopic sacrocolpopexy is safe, with excellent anatomical results and low recurrence rates. To obtain reliable results over a longer time we examined these patients regarding postoperative history, objective anatomical results and quality of life 5 years after surgery.

Material and Methods Long term results were assessed through gynaecological examination including POP-Q and quality of life assessment using validated questionnaires. 68 patients received a clinical follow-up exam. 17 Patients were assessed by questionnaires only.

Results: Six recurrences in the anterior, four in the posterior and one in the apical compartment occurred 5 years postoperatively, with an 83.8% objective cure rate. Two mesh protrusions into the bladder and no vaginal mesh erosion occurred. Preoperative quality of life index improved from 5.6 to 9.1 respectively 8.3 postoperatively.

Discussion: Laparoscopic sacrocolpopexy has demonstrated excellent anatomical and functional long-term results. After widespread concern about vaginal mesh augmentation laparoscopic sacrocolpopexy should be considered as favourable treatment option for patients with pelvic organ prolapse.

HERLYN WERNER WUNDERLICH SYNDROME - A DIAGNOSTIC DILEMMA

Case reports

Poster

Nageshu Shailaja*, Krishna Kirtan, Linge Gowda Krishna, Bhat Shyamasundar, Kulkarni Namrata, Shivaraju Pradeep

PESIMSR, Kuppam

Summary (4 lines): A 15 yr old girl presented with lower abdominal pain for three months. Detailed evaluation revealed Herlyn Werner Wunderlich syndrome. She underwent laparoscopic right salpingectomy and vaginoplasty following drainage of haematocolpos.

Introduction: Herlyn-Werner-Wunderlich (HWW) syndrome is a rare congenital anomaly of the urogenital tract involving Müllerian ducts and Wolffian structures, and it is characterized by the triad of didelphys uterus, obstructed hemivagina and ipsilateral renal agenesis. The incidence is approximately 1/2,000 to 1/28,000, and it is accompanied by unilateral renal agenesis in 43% of cases.

Material and Methods A 15yr old girl presented with lower abdominal pain for last three months two years after attaining menarche. She had normal and regular cycles every month. MRI imaging showed a uterine-vaginal anomaly consisting of didelphys uterus and double vagina, one of which was obstructed, consequently there was accumulation of fluid exhibiting hematometra, right hematosalpinx.,enormously enlarged the right obstructed vagina and the absent right kidney.

Results: Intra operative findings were uterus didelphys, right sided transverse vaginal septum, hematocolpos, haemotometra and hematosalpinx. Right sided laparoscopic salpingectomy ,excision of transverse vaginal septum and drainage of haematocolpos followed by vaginoplasty was done.

Discussion: Delay in diagnosis has been attributed to regular menstruation in the context of incomplete vaginal outlet obstruction. The diagnosis should be suspected in cases with pelvic pain and a pelvic mass with ipsilateral renal agenesis. Management of these cases consists mainly of vaginoplasty with excision of the vaginal septum.

THE USE OF LAPAROSCOPY IN PELVIC EXENTERATION

Oncology

Poster

Dirk Michael Forner*, Heike Creutz

Sana Klinikum Remscheid

Summary (4 lines): Under certain conditions parts of a pelvic exenteration (PE) may be done by laparoscopy, thus reducing the morbidity

Introduction: The role of laparoscopy in gynaecologic oncology is increasing continuously. Surgery for cervical or endometrial carcinoma is regularly done by laparoscopy, in advanced cases it is used for surgical staging. PE is the most extensive gynaecologic operation with considerable perioperative morbidity. On the cases of two patients with advanced vaginal carcinomas (VCA) invading neighbouring organs we show to what extend laparoscopy can reduce the patients morbidity.

Material and Methods On the example of two cases of vaginal carcinoma we show the laparoscopic possibilities in the context of an anterior and posterior exenteration. In the first case, the carcinoma is located in the lower half of the vagina and infiltrates the anus, in the second case the carcinoma originates from the upper vaginal half and invades the bladder over a large area.

Results: In exenterative surgery, too, lymphadenectomy, radical hysterectomy and parametriectomy, rectal and bladder resection may be done by laparoscopy. The resected tissues are removed through the vagina. Postoperative recovery was uneventful, the patient was up much quicker and hospital stay was shorter than after an equivalent conventional surgery.

Discussion: Laparoscopy is able to reduce the patients morbidity after pelvic exenteration. It should only be used when the minimal invasive procedure will be as radical as by a conventional approach. In vaginal carcinoma large part of the procedure is done vaginally, so a laparoscopic assistance seemed appropriate.

COMPLICATIONS AND LONG-TERM RESULTS AFTER LAPAROSCOPY FOR STAGE ENDOMETRIAL CANCER

Oncology

Poster

Ester Martinez Lamela*, Molero Vilchez Jesus, sobrino mota veronica, gonzalez paz carmen, Expósito Lucena Yolanda, Rivera rodriguez Teresa

Hospital infanta leonor

Summary (4 lines): We compared the complications after total laparoscopic hysterectomy (LPS) and abdominal hysterectomy with lymphadenectomy (LPM) for stage endometrial cancer and to study the long-term results

Introduction: In this series, 87 women had undergone laparoscopic (65 cases) or abdominal (22 cases) hysterectomy with bilateral salpingo-oophorectomy and pelvic (49 cases) or pelvic and paraaortic (15 cases) lymphadenectomy. The mean age and body mass index were similar in both groups. Two urologic complications, one epigastric artery injury and one blood transfusion were reported in LPS group. In two patients from LPM group vascular bleeding was observed and blood transfusion was necessary

Material and Methods Also we described the postoperative complications and its treatment. One patient had an abdominal-vaginal fissure and another one had an incisional hernia in trocar place were reported in LPS group. In LPM group one fibrosis ureteral retroperitoneal, one incisional laparotomic hernia and retroperitoneal haematoma were described. Reintervetion was required in 3,4%. Overall complication rate was 8,7%. The difference in surgical complications between groups was no statistically significant (p = 0.70).

Results: With a median follow-up of 25,8 months for LPS group and 17.9 months for LPM group, there were no significant differences between the two groups in 2-year estimated recurrence-free survival rates (98,1% vs. 85.7% respectively, p=0,14); as well as similar 2-year overall survival rates (95,7% vs. 92,9%, p=0,68).

Discussion: The low intraoperative and postoperative complications rate, observed in the LPS group, highlights the feasibility and safety of this surgical approach. Our analysis showed no difference with respect to recurrence or survival between both groups. The laparoscopic approach may be considered for endometrial malignancy which typically occurs in obese women.

QUESTIONING THE UPPER LIMIT OF 2500 ML OF NACL INTRAVASATION DURING HYSTEROSCOPIC SURGERY

Surgical Hysteroscopy

Oral

Paul van Kesteren*, Rademaker Bart, Overdijk Lucilla, de Haan Peter

OLVG hospital

Summary (4 lines): Gas emboli frequently occur during hysteroscopic surgery, and may cause deterioration of cardiovascular function and even collaps, especially if intravasation exceeds 1000 ml of NaCl. We advice to terminate the procedure as soon as signs of gas embolism occur on parameters of cardiovascular function

Introduction: Based on a consensus meeting the AAGL stated that the upper limit of NaCl intravasation during hysteroscopic surgery should be 2500 ml. One of our patients encountered a cardiovascular collaps likely due to gas embolism during transcervical resection of a fibroid while the NaCl intravasation was within the upper limit of 2500 ml.

Material and Methods Because of the worrisome finding of a patient with cardiovasular collaps during TCRM with less than 2500 ml NaCl intravasation, we performed a retrospective study and a RCT to elucidate the occurrence of gas emboli during hysteroscopic surgery and its effect on clinical parameters of cardiovascular function

Results: It appears that gas emboli frequently occur during hysteroscopic surgery, and the quantitiy rises concomitantly with the increase of intravasation of distension fluid. This was associated with a deterioration of cardiovascular function during surgery, in particular when intravasation exceeded 1000 ml.

Discussion: We advice that if intravasation is more than 1000 ml, the procedure should be terminated as soon as any sign of gas embolism occurs on parameters of cardiovascular function such as ST-segment depression on electrocardiogram, increase in end-tidal CO2, and decrease of saturation or blood pressure

TOTAL LAPAROSCOPIC HYSTERECTOMY: A SMALL DISTRICT GENERAL HOSPITAL (DGH) EXPERIENCE

Hysterectomy

Poster

Raphael Laiyemo*, Porter Stephen, Awad Mohamed

Airedale General Hospital

Summary (4 lines): Total laparoscopic hysterectomy is a feasible and safe procedure for the experienced laparoscopic surgeon at DGH level. It should be the preferred option if the vaginal route is contra-indicated or technically not feasible.

Introduction: Laparoscopic Hysterectomy should be the operative route of choice when considering hysterectomy if vaginal route is contra-indicated. Vaginal Hysterectomy should be 1st choice if technically feasible; however if contra-indicated then laparoscopic route should be the next option as the morbi-mortality rate approaches that of vaginal hysterectomy compared to open abdominal route This abstract is a review of the outcomes of total Laparoscopic hysterectomy performed in our department.

Material and Methods Retrospective study of TLH from March 2006 – February 2012, performed by the same operating team.100 cases of total laparoscopic hysterectomy were analysed in terms of operating time, uterine weight, estimated blood loss, hospital stay, rate of complications and laparo-conversion rate. 79 cases were for benign conditions and 21 for stage 1 endometrial cancer. 95 cases had Laparoscopic intracorporeal vault suturing. We use a 4 port technique,harmonic scalpel,Pelosi uterine manipulator and McCartney tube for pneumoperitoneum.

Results: Mean age was 47.56 yrs (SD 13.08), Uterine weight - 112.3 grams (SD 89.95g), Hospital stay- 1.92 days (SD 0.75days), Estimated blood loss -101.16mls (SD55.35mls). Mean surgery time was 76.40 min (SD 23.0). 3/100 cases had cystotomy that was repaired intracorporeally.1/100 case of laparo-conversion.No major visceral or vascular injuries.

Discussion: The benefits of Laparoscopic hysterectomy to patients approaches that of vaginal hysterectomy as they have similar morbimortality rates.Our study shows that total laparoscopic hysterectomy has low complication rates and this even more significant in obese women and should be the operation of choice if vaginal hysterectomy is contraindicated.

ATTITUDE OF GYNECOLOGISTS TOWARDS OVARIAN HEMOSTASIS IN LAPAROSCOPIC SURGERY OF BENIGN CYSTS

Complications

Oral

Sleiman Zaki*, kesrouani Assaad, Elie Attieh

Université Saint Joseph

Summary (4 lines): The type, the size of cysts and the hilar bleeding affect the decision of the gynecologists to shift faster from bipolar cauterization to suture, in order to ensure complete hemostasis

Introduction: Hemostasis in laparoscopic surgery of ovarian cysts is performed either by bipolar cauterization or by suturing the ovary. Sutures give more postoperative adhesions and bipolar cauterization reduces more the follicular count. No evident recommendations are found in literature, because there are no sufficient arguments to disadvantage one of the two techniques over the other. The aim of the study is to describe factors that might incite the gynecologists to favor one of the two methods.

Material and Methods Thirty gynecologists were asked about their attitude towards hemostasis during laparoscopic surgery of ovarian cysts. Factors that might influence this attitude and described in this study are: experience to perform intracorporeal knots, cyst size, cyst type, adverse effects of the hemostasis technique, and hilar bleeding. The attitude of the surgeons was evaluated by 2 criteria: The duration and the number of inefficient bipolar cauterization trials before shifting to suturing in order to accomplish hemostasis.

Results: Adverse effects and experience in suturing are not correlated with the duration and the number of inefficient bipolar cauterization. Gynecologists shift faster to suturing during surgery of endometriomas (6vs 12 attempts ) p=0.004,larger cysts (8min vs 12 min), p= 0.035 and face to hilar bleeding (5 vs 11 min), p=0.002.

Discussion: Independently of the adverse effects of the technique, even less experienced gynecologists in laparoscopic suturing will attempt this method, especially in the surgery of endometriomas , larger cysts and face to hilar bleeding. This is probably due to the larger stripping area and difficult access to the site of bleeding.

LAPAROSCOPIC NERVE-SPARING SEGMENTAL ANTERIOR RECTAL RESECTION FOR ENDOMETRIOSIS

Endometriosis: Surgery

Video

James English*, Clark Jeremy, Sandwell Jo, Moth Philippa

Brighton & Sussex University Hospitals

Summary (4 lines): This video demonstrates a routine and reproducible approach in terms of nerve-sparing rectal resection.

Introduction: Problems with rectal and bladder function are common following radical bowel surgery for endometriosis. Consequently, every effort should be made routinely to preserve the pelvic nerves in the course of dissection. This is best done by adopting a standardized approach in which the nerves are dissected out prior to the performance of any excisional surgery.

Material and Methods The reflection of the sigmoid is taken down to optimise visualisation of the pelvis. Next, the peritoneum is opened between the rectum and left ureter revealing the superior hypogastric plexus and hypogastric nerve running along the axis of the deep branch of the internal iliac artery. The sacral ventral rami and the pelvic splanchnics may be approached by division of the sacral hypogastric fascia. Only those nerves attached to the resectable rectum need be divided

Results: A standardised approach may be adopted when dealing with severe lower pelvic rectal disease in order to achieve a genuinely nerve-sparing approach to rectal resection for severe endometriosis

Discussion: This video demonstrates the dissection of the hypogastic plexuses and conservation of nerves despite their involvement in the endometriotic nodule. This approach is entirely feasible with low pelvic endometriosis and offers a technique for the routine conservation of pelvic neural function.

URETERAL TRANSECTION DURING TOTAL LAPAROSCOPIC HYSTERECTOMY, WHAT ARE YOU UP TO? - A CASE REPORT

Innovation in Instrumentation and Surgical Techniques

Video

Kwang-Beom Lee*, Chung Han

Gachon University Gil Medical Center

Summary (4 lines): We describe a successful management of ureteral transection with simultaneous laparoscopic intravesical non-refluxing ureteroneocystostomy combined with a posas hitch and cystoscopy-assisted submucosal tunneling.

Introduction: In 2006, laparoscopic nonrefluxing ureteral reimplantation with a psoas hitch using a submucosal tunneling technique combined with cystoscopy was described in detail and performed by our urologic surgical team; it was then modified and developed by other urologists. Recently, our gynecologic surgical team tried it with help of our urologic surgical team.

Material and Methods A 50-year-old female who had abdominal distention and pain after total laparoscopic hysterectomy at a local clinic was referred to our hospital. After cystoscopy, retrograde ureteropyelograpy, intravenous pyelography and computed tomograpy, lower ureteral transection was suggested. We performed laparoscopic intravesical ureteral reimplantation with a psoas hitch using submucosal tunneling after a submucosal injection of normal saline was provided under cystoscopy.

Results: The anesthesia time was 190minutes. The estimated blood loss was less 100mL. The hospital stays were 3 days. There were no immediate postoperative complications. Follow-up voiding cystourethrography and intravenous urography demonstrated normal compliance and function of the kidney and ureter with no vesicoureteral reflux.

Discussion: Simultaneous laparoscopic intravesical non-refluxing ureteroneocystostomy with a psoas hitch for ureteral injury is a safe and feasible procedure

PREGNANCY OUTCOMES WITH IN SITU MICRO-INSERTS

Diagnostic & Operative Office Hysteroscopy

Oral

Sebastiaan Veersema*, Hans Brölmann, Mijatovic Velja, Dreyer Kim

St Antonius Hospital

Summary (4 lines): De-identified data were collected on 50 pregnancies in 43 patients in the Netherlands who became pregnant with one or two Essure® micro-inserts in situ. The results of this case series report supports the conclusion of the earlier reports that it is unlikely that the presence of the Essure® micro-inserts interferes with implantation and the developing amniotic sac and fetus.

Introduction: A theoretical concern for all women who want to become pregnant or who have an unintended pregnancy after the Essure® procedure, is the trailing micro-insert coils in the uterine cavity and their possible effects on pregnancy. In theory, the micro-inserts could cause similar tissue effects as an Intra Uterine Device and consequent myometrial contractions or rupture of membranes could be considered a possible cause of premature birth as the literature shows an increased risk of preterm delivery and chorioamnionitis with the use of intra-uterine copper devices.

Material and Methods All 136 gynecologists in the Netherlands who perform Essure® sterilization were asked by e-mail in December 2010 about either intended (IVF-ET) or unintended pregnancies in patients following the Essure® procedure. After a positive reply a questionnaire was sent to collect data about the patient’s history, the Essure® procedure and obstetrical outcomes.

Results: The outcomes of 50 pregnancies in women with one or two micro-inserts in situ were evaluated. Seventeen unintended pregnancies ended by elective termination or miscarriage. Eight unintended pregnancies and eighteen intended pregnancies resulted in the birth of a full-term healthy baby; seven were delivered by Cesarean-section (C-section). Two women delivered prematurely by C-section, (singleton after 34+1 weeks, twins after 35+3 weeks). All babies are healthy and without any congenital anomalies. There were two stillbirths after 20 weeks which were unrelated to the presence of the micro-inserts.

Discussion: To our knowledge this is the largest study published to date about the outcomes of pregnancies after hysteroscopic tubal occlusion with Essure® micro-inserts. The results of this case series report supports the conclusion of the earlier reports that it is unlikely that the presence of the Essure® micro-inserts interferes with implantation and the developing amniotic sac and fetus.

LAPAROSCOPIC TERATOMA CYSTECTOMY IN A 15 WEEKS PREGNANT

Case reports

Video

Diana Almeida*, Barbosa Antonio, Pinelo Sueli, Serra Helena, Felgueira Eduarda, Tavares Angelina

Centro Hospitalar Vila Nova Gaia

Summary (4 lines): We recorded a successfully laparoscopic teratoma cystectomy in a 15 weeks pregnant woman, in order to produce video material to further discussion and learning.

Introduction: A young 28 years old patient, with history of bilateral teratoma removal by laparoscopy at 23 years old, came to us pregnant for the first time. She was diagnosed with a right ovary mass, suggestive of teratoma, at the time of her first trimester sonography. The mass had 78mm of larger diameter. Given the high risk of adnexial torsion, she was submitted to a laparoscopic cystectomy at 15 weeks and 2 days.

Material and Methods The laparoscopic access of a pregnant abdomen must take into account the enlarged uterus. Thence, the access was made through Palmer point, once created a pneumoperitoneum with veress needle, always with low pressure. Once the abdomen was accessed, security conditions were created to introducing new access points. An umbilical and a right inguinal trocars were placed and the cystectomy took place. At this point, the intervention was recorded from the screen, using a cell phone.

Results: The mass was removed using an endobag, through the umbilical access point, that was extended in about 2 centimeters. The result was a video showing a large teratoma cystectomy in the presence of a pregnant uterus, maintaining a low abdomen pressure

Discussion: Laparoscopic interventions in pregnant women are fairly rare. Even rarer, when the goal is to remove a large ovarian mass. We successfully performed this intervention, in order to produce video material that can be used review the obstacles and safety measures of laparoscopy in pregnant women.

TO LYSE OR NOT TO LYSE? RESULTS A RANDOMIZED CONTROLLED TRIAL OF ADHESIOLYSIS VERSUS DIAGNOSTIC LAPAROSCOPY IN WOMEN WITH CHRONIC PELVIC PAIN

Endometriosis: Surgery

Oral

Ying Cheong*, Reading Isobel, Sadek Khaled, Ledger William, T.C. Li

University of Southampton

Summary (4 lines): There is evidence that laparoscopic adhesiolysis of adhesions in women presenting with chronic pelvic pain improves pain and quality of life.

Introduction: Pelvic adhesions are found in up to 50% of women with CPP during investigative surgeries and adhesiolysis is often performed as part of their management although the casual or casual association of adhesions, and the clinical benefit of adhesiolysis in the context of CPP is still unclear. This study aims to test the hypothesis that laparoscopic adhesiolysis leads to significant pain relief and improvement in quality of life (QoL) in patients with chronic pelvic pain (CPP) and adhesions.

Material and Methods This was a double blind RCT randomising patients to laparoscopic adhesiolysis or diagnostic laparoscopy. It was conducted over 4 years in 2 hospitals in the UK. Women were assessed at 0,3 and 6 months for Visual analogue scale scores (VAS) and QoL measures (SF-12 and EHP-30). Randomisation was computer generated with allocation concealment.

Results: A total of 92 participants were recruited; 42 qualified to be randomized. In women who underwent adhesiolysis, at 6 months there was a significant improvement in VAS scores (-17.5 (-36.0 - -5.0) (-1.5 (-15.0 – 4.5; p=0.048); SF-12 scores physical component score (25.0 (18.8 – 43.8)) (6.3 (-6.3 – 18.8); p=0.021), SF-12 emotional component score 32.5 (4.4 – 48.8) -5 (-21.3 – 15.0); p

Discussion: This study stopped before recruitment could reached the statistically powered sample size of n=100. Despite this, the significant improvement in the outcome measures in VAS scores, SF-12 and EHP-30 scores were achieved in its present form. In selected population of women presenting to the gynecological clinic with chronic pelvic pain, adhesiolysis in those who had adhesions is of benefit in terms of improvement of their quality of life.

SINGLE SITE ADVANCED GYNAECOLOGICAL SURGERY BY CONVENTIONAL DEVICES

Tips & Tricks in Surgery

Video

Alvaro Zapico*, Couso Aldina, Fuentes Pedro, valenzuela Pedro, Garcia Pineda Virginia, Rodriguez Garnica Dolores , del Valle Cristobal, Heron Soraya

Príncipe de Asturias Hospital. Alcalá University.

Summary (4 lines): Conventional devices may be used as a single access approach in a great number of gynecological procedures

Introduction: Single site surgery has become an increasing procedure in gynaecological surgery. Specific devices had been worldwide designed to improve single port technique, however some gynecological procedures may be done using conventional devices through a single access

Material and Methods Video presentation of some gynaecological procedures that includes benign and oncological cases.

Results: Single access could be successfully used in endometrial cancer, great ovarian cyst , sentinel node byopsy and omentectomy. Paraortic lymphadenectomy could be performed combining single access plus vaginal scope and two ancillary 5 mm trocar

Discussion: When specific single port devices are not available, some advanced gynaecological single site procedures may be done using conventional equipment

ROBOTIC-ASSISTED LAPAROSCOPIC HYSTERECTOMY AND TOTAL LAPAROSCOPIC HYSTERECTOMY: A COMPARISON OF SURGICAL OUTCOMES

Robotics

Oral

Paul Dijkhuizen*

Rijnstate Hospital Arnhem

Summary (4 lines): Robotic-assisted laparoscopic hysterectomy in the learning curve compared to conventional total laparoscopic hysterectomy (TLH) was comparable for operative and postoperative outcomes.

Introduction: To compare the surgical outcomes of robotic-assisted laparoscopic hysterectomy and conventional total laparoscopic hysterectomy (TLH).

Material and Methods Ninety-four consecutive patients; the last 47 total laparoscopic hysterectomy and the first 47 robotic assisted laparoscopic hysterectomy patients were compared for operative and postoperative outcomes.

Results: No significant differences in skin-to-skin OR time, uterine weight, number of conversions, the number of intra- and postoperative comlications, the length of hospital stay and the number of readmissions. However, the OR in-out time was longer in the Robotic group. Furthermore, significantly less bloodloss in the Robotic group.

Discussion: In the learning curve of robotic-assisted laparoscopic hysterectomy no major differences were found in surgical outcomes compared to conventional TLH.

LARGE PARASITIC MYOMA ARISING AFTER LAPAROSCOPIC MYOMECTOMY: A CASE REPORT

Case reports

Video

Magdalena Karadza*, Barisic Dubravko, Pavicic Baldani Dinka, Skrgatic Lana

University Hospital Center, Zagerb, Croatia

Summary (4 lines): We present a case of a large parasitic myoma interspersed with endometrial cysts arising six years after laparoscopic myomectomy with electric tissue morcellation.

Introduction: The incidence of iatrogenic parasitic myomas associated with the laparoscopic use of electric tissue morcellation is increasing. Morcellation remnants may implant and grow around the peritoneal cavity captivating blood supply from adjacent structure. We report a case of an unusual manifestation of a large parasitic myoma interspersed with endometrial cysts arising six years after laparoscopic myomectomy.

Material and Methods A 40-year-old nulliparous women underwent laparoscopic myomectomy with electric tissue morcellation for subserous myoma with no intraoperative or postoperative complications. Six years later she presented with large pelvic mass and abdominal discomfort. On physical exam a firm mobile mass about 8 cm in diameter was found in the left pelvis and just above the uterus. Pelvic ultrasound demonstrated a cystic mass (5x2x2.5cm) with ultrasound appearance similar to observed in the case of endometriomas.

Results: Laparoscopy was preformed and a large clustered vascularised mass firmly attached to uterine fundus and rectum was found and excised. Cross-section of the tumor revealed multiple cystic cavities filled with altered blood. Hystologically tumor was composed of smooth muscle cells and multiple cavities covered with endometrial stroma and endometrial epithelium.

Discussion: All tissue pieces that are morcellated should be diligently removed and irrigated. Implantation and regrowth of morcellated remnants may result with formation of bizarre appearing tumors. Therefore, a parasitic myoma must be included in the differential diagnosis if a solid tumor is found succeeding the use of electric tissue morcellation.

PRE-OPERATIVE USE OF GNRH ANALOGUES BEFORE HYSTEROSCOPIC RESECTION OF SUBMUCOUS FIBROID: SYSTEMATIC REVIEW AND META-ANALYSIS

Surgical Hysteroscopy

Poster

Theodoros Kalampokas*, Bhattacharya Siladitya, Kamath Mohan

University of Aberdeen

Summary (4 lines): A systematic review and meta-analysis of the literature examining preoperative GnRH-analogue administration in women undergoing hysteroscopic resection of fibroids does not support routine use of GnRH analogues prior to hysteroscopy.

Introduction: GnRH analogues are commonly used pre operatively before hysteroscopic myomectomy in order to make surgery easier and safer. However, they are expensive,have potential side effects and lack a robust evidence base to support this practice. We undertook a systematic review of the literature to determine whether, in women with submucous fibroids, preoperative GnRH analogues were more effective than placebo/no treatment in terms of symptom relief, complications and ease of surgery.

Material and Methods A comprehensive electronic literature search was performed usingMEDLINE, EMBASE, Cochrane Library (1970 - June 2012) . The outcomes were patient reported relief of symptoms , complete resection of the fibroid , operative time and complications. Meta-analysis was performed where appropriate. Two trials including 86 women were identified. Aggregation of data was possible for completion of surgery, operating time and fluid deficit but not for symptom relief which was assesses differently in the two trials.

Results: The Relative risk for completion of surgery and mean differences (95% Confidence Intervals) for operating time and fluid deficit were [ 0.94, ( 0.68 to 1.31); - 5.34 min, (- 7.55 min to -3.12min) and -176.2ml, (- 281.05ml to - 71.5ml)] respectively. Symptom relief was comparable in both arms.

Discussion: Data from two small trials suggest that GnRHa may improve some outcomes but there is insufficient evidence to support their routine use prior to hysteroscopic resection of submucous fibroids. More randomised trials are needed to inform definitive conclusions.

REPRODUCTIVE OUTCOMES AFTER COMBINED TREATMENT OF INFILTRATIVE ENDOMETRIOSIS

Endometriosis: Diagnosis

Oral

Alexander Popov*, Popov Alex, Chanturia Teona, Slobodyanyuk Boris, Manannikova Tatiana, Ramazanov Murad, Fedorov Anton, Machanskite Olga, Abramyan Karina, Tyurina Svetlana, Koval Alexey

Moscow Regional Reserch Institute O\G

Summary (4 lines):

Introduction: More that 50% of women with deep infiltrating endometriosis (DIE) are Infertile. An appropriate treatment (conservative or surgical), use of assisted reproductive technologies (ART) can increase a pregnancy rate (PR) as well.

Material and Methods From January 2009 to December 2012 51 patients were operated laparoscopically with histological confirmation of DIE (infiltration of endometrial tissue more than 5 mm with muscle involvement (vagina, rectum, bladder or ureter). After that 35 operated women were observed. Ten of them (28%) were excluded from the study because they did not plan pregnancy. However, the diagnosis of infertility was found in 25 (100%) patients. There were 22 (88%) patients with primary infertility and 3 (12%) cases with the secondary. The duration of infertility was 23±7 months. The mean age was 30 (22-38) years. Besides removing endometrioid nodules (100%), simultaneous procedures were as follows: unilateral removal of endometrioma in 5 patients (20%), bilateral endometrioma removal in 8 (32%), full-thickness excision of the bladder wall (2 patients, 8%). Excision of the posterior vaginal wall was performed in 2 (8%) patients. Ureterolysis was done in 21 cases (84%), 8% of which required J-J stent due to skeletonization during the mobilization of nodules in parametrum. The mean size of endometriomas was 45±27 mm. There were no postoperative complications. Hormone therapy was applied in 15 patients (60%) In the postoperative period, among them GnRH agonist was taken in 7 cases (28%), Dienogest in 5 women (20%), the OC in 3 patients (12%). It’s important that 4 (16%) patients were operated before due to endometriosis. One patient underwent surgery 10 months later, because of relapse of rectosigmoid endometriosis which required a bowel resection laparoscopically.

Results: The mean follow-up was 23 months. Spontaneous pregnancy occurred in 6 patients (24%), all of these patients had delivery, in 5 cases (20%) - vaginal delivery, in one case (4%) - CS. In 4 (16%) of the women the conception achieved by IVF, all women had vaginal delivery without complications. Also, in 5 patients (20%) there were unsuccessful IVF (1 or 2 attempts). Thus, PR in our study was 40%. There was no case of abortion. There were no pregnancies in patients with reoperation due to endometriosis.

Discussion: Development of infertility in DIE is multifactorial: pelvic adhesions, decrease of ovarian reserve, and the poor quality of oocytes in case of involvement of the ovaries (52% in our study). We believe that changes in eutopic endometrium, which registered in cases of several adenomyosis in patients with DIE are overestimated, since there was no pregnancy loss and the rate of successful IVF procedures is satisfactory. However we should take in consideration that a control group without treatment is not present and the number of cases are too small. More extensive multi-center studies are needed.

CONSERVATIVE LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY IN CAESAREAN SECTION SCAR TIPS AND TRICKS

Infertility and Reproductive Medicine

Oral

Jean-Bernard Dubuisson*

HFR Fribourg - Hôpital cantonal, Fribourg, Switzerland

Summary (4 lines): A case report of ectopic pregnancy in a previous cesarean scar treated successfully laparoscopically with complete excision of scar and trophoblast. Tips, tricks to avoid failures are discussed.

Introduction: The occurrence of an ectopic pregnancy implantation within a previous caesarean section scar is a rare complication, with an incidence reported to be up to 6.1%. Treatments remain controversal. Methotrexate is followed by frequent failures. Curettage may fail because of intense trophoblastic invasion of the myometrium and scar with risk of uterine perforation. It is the reason why surgery may be chosen. Laparoscopy gives the opportunity to remove the pregnancy and repair the damaged scar

Material and Methods We report a case of ectopic pregnancy implantation in the scar in a 24-year-old patient with a history of a previous cesarean section. It was diagnosed initially as a non evolutive intrauterine pregnancy treated at 10 weeks by a curettage. The postoperative course was complicated by continuous bleeding. Three weeks later, ultrasound diagnosed the ectopic implantation with a trophoblastic retention (48, 28, 27 mm).

Results: The laparoscopic treatment consisted of excision of the uterine scar and ablation of the trophoblastic retention. For the repair we did 2 layers of separate absorbable sutures associated with reperitonealization. Four months after, an echography confirmed the quality of the scar with a thickness of 41 mm.

Discussion: Cesarean scar pregnancy may be complicated with rupture and haemorrhage. We report one case interesting because of the initial wrong diagnosis, and failure of curettage. Laparoscopy consisted of performing the resection of the damaged scar, the removal of trophoblast into a bag and the extraction through the scar before repair.

LAPARSCOPIC ABDOMINAL CERCLAGE AT 12 WEEKS GESTATION

Case reports

Video

Paul van Kesteren*

OLVG hospital

Summary (4 lines): We performed a laparoscopic abdominal cerclage at 12 weeks gestation in a women with recurrent immature deliveries.

Introduction: Abdominal cerclage to prevent immature birth has a high success rate of more than 90%. The abdominal cerclage is preferably performed by laparotomy. We demonstrate that laparoscopic abdominal cerclage early in pregnancy is feasible

Material and Methods We performed a laparoscopic abdominal cerclage in a 32 year old female at 12 weeks gestation who had 3 previous immature deliveries; two at 20 and 16 weeks, and one at 18 weeks after vaginal cerclage. After bladder dissection from the cervix, a mercilene band with straightened needle was inserted at the anterior side of the cervix, median from the left and right ascending branch of the uterine artery, and the knot was tightened at the posterior side. During the procedure, transvaginal ultrasound was used to guide the needle through the cervix, and to lift the cervix and uterus when needed. The procedure was without complications, there was only minimal blood loss.

Results: The postoperative period was uneventful, she was discharged from the hospital the day after surgery. The procedure was performed recently, and up to now, the pregnancy is developing without any further complications.

Discussion: Abdominal cerclage during pregnancy to prevent immature deliveries, is preferably performed by laparotomy. However, early in pregnancy it is feasible to performed it laparoscopically.

LAPAROSCOPIC TREATMENT OF BORDERLINE OVARIAN TUMORS

Oncology

Poster

María Dolores Rodríguez Garnica*, Menéndez Fuster Jose Manuel, González Hinojosa Jerónimo, Zapico Goñi Álvaro, Delgado Espeja Juan Jose, Solano Calvo Juan Antonio

Hospital Universitario Príncipe de Asturias

Summary (4 lines):

Introduction: Borderline ovarian tumors are a heterogeneous group of lesions which are defined histologically by atypical epithelial proliferation without stromal invasion. The aim of this study is to review the clinical characteristics of women with borderline ovarian tumors operated by laparoscopic.

Material and Methods In between 1992 and 2012, it have been operated by laparoscopic approach, in the Prince of Asturias University Hospital, 1321 patients with adnexal masses. Tumors with solids or complex in the ultrasound previous the surgery and those who had suspected findings in the surgery , it was sent to intraoperatory study. Occurred in 60 cases (4.5%) and its dissection, excision and removal of the piece was protected by endoscopic bags.

Results: In 18 patients the final result was a borderline tumor. The 66.7% were premenopausal (12) and 22.22% had elevated CA 125 (4). The adnexal tumors average diameter was 86.67 ± 10.98 (38-200) mm. At 44.4% of cases malignancy in the preoperative study (8) was suspected. At 33.33% of cases (6), the suspicion was by surgical findings. At 22.22% (4 cases) intraoperative study was not carried out. They were detected as borderline later and reoperated.

Discussion: All precautionary measures have to be taken during the surgery. Despite of previous ultrasound and surgical findings, they are always patients with delayed diagnosis.

COLPOSACROPEXY BY LAPAROSCOPIC APPROACH AS TREATMENT OF VAGINAL VAULT PROLAPSE

Urogynaecology

Poster

María Dolores Rodríguez Garnica*, González Hinojosa Jerónimo, Menéndez Fuster Jose Manuel, Zapico Goñi Álvaro, Sendra Ramos Rebeca, Fernández Muñoz Laura, Delgado Espeja Juan Jose

Hospital Universitario Príncipe de Asturias

Summary (4 lines): We reviewed 10 patients treated by colposacropexy of recurrence of symptomatic genital prolapses (2011-2012) . As risk factors we high light: multiparity, fetal weights greater than 3500 grams, BMI over 25 and previous vaginal hysterectomy (100%).

Introduction: Introduce that technique of reconstruction of the pelvic floor, its indications and our initial results.

Material and Methods We executed a retrospective study in 10 patients with recurrence of vaginal vault prolapse between 2011 and 2012. We analyzed risk factors, mean surgical time, average stay and postoperative evolution. The indication was the recurrence of symptomatic genital prolapses. We carried out a preoperatory urodinamic study for all the patients. The surgery was performed by laparoscopic approach and we did not associated any incontinence technique.

Results: The mean operative duration is 3 hours 35 minutes and 5 hours (no intraoperative complications). In the immediate postoperative period we did not found complication. One patient was readmitted at 7 days for vaginal vault abscess. The average stay was 3 days. During the the follow-up (12.3 months (6-18), in any cases we have observed prolapse recurrence.

Discussion: Colposacropexy by laparoscopic with meshes solves vaginal vault prolapse appeared after a hysterectomy or uterine prolapse, permanently.

HYSTERECTOMY IS AN EFFICIENT METHOD OF MODERN OPERATIVE GYNECOLOGY

Hysterectomy

Poster

Daria Simrok-Starcheva*, Iulia Zheltonozka, Vasily Simrok

Lugansk state medical university

Summary (4 lines): 78 woman underwent hysterectomy by the BiClamp ERBE in COAG – mode. The data received give evidence of clinical social-economic feasibility and advantages of this operative method.

Introduction: In modern operative gynecology using conventional tools spend much time to provide hemostasis. Modern technologies of tissue separation with adequate hemostasis is highly relevant and encourages for the active introduction of physical methods of dissection and coagulation in daily practice. Therefore, the aim of our research was to evaluate the efficacy of coagulation as bloodless method of crossing the anatomical structures during the laparotomic hysterectomy

Material and Methods 78 patients (experimental group I) had a hysterectomy by using BiClamp ( ERBE) in a special COAG-mode for intersection of the anatomical structures at all stages of hysterectomy. The control group II included 72 women were operated in the same conditions, but when the hysterectomy was applied to them crossing the anatomical structures of the classic conventional method using clamps, the intersection by acute and suturing of the stump

Results: The duration of operation in the I group was 37±11 minutes in the control group 45±12.The bleeding was observed in 2 patients of the main group and 6 patients of the comparison group. In the I group the blood loss was 110±25 ml in the control group 180±30 ml.

Discussion: Using bloodless technique of coagulation by BiClamp for intersection anatomical structures during the laparotomic hysterectomy has a low traumatic effect on patient’s organism by reducing the risk of intra-and postoperative complications resulting in high clinical effectiveness of this method. All this confirms the clinical-social practicability

LAPAROSCOPIC PROPHYLACTIC ISTHMORRHAPHY: PRECONCEPTIONAL CERVICOISTHMIC CERCLAGE

Innovation in Instrumentation and Surgical Techniques

Poster

STERGIOS TZITZIMIKAS*, Chastamouratidis Charalampos, Fragkos Marios , Karavida Aikaterini

Bioclinic

Summary (4 lines): Cervical insufficiency is a major complication of pregnancy, which is associated with adverse obstetrical and perinatal outcomes. We propose that laparoscopy should replace laparotomy when an abdominal cerclage is needed.

Introduction: The traditional treatment for cervical insufficiency is the placement of a suture around the cervix vaginally (cerclage). However in patients with an extremely short cervix or in whom a vaginal cerclage has previous failed, the abdominal approach offers an alternative. Benefits of laparoscopic pregestational placement are related to decreased uterine size, decreased uterine blood flow, absence of fetal risks, and the advantages of an elective procedure over an emotionally charged urgent procedure.

Material and Methods A 39-year old patient with a history of a previous failed transvaginal cerclage and a premature delivery at 25weeks with adverse neonatal outcome. Laparoscopic prophylactic isthmorraphy was carried out at the late follicular phase using Polyester Fiber Tape placed at the level of the internal os, medial to the uterine arteries. The ends of the tape were anchored to the lower uterine segment.

Results: An uneventful laparoscopic prophylactic isthmorraphy was performed. The technique presented seems easy to perform and teach with minimal instrumentation needed. Finally an ultrasound examination confirmed the correct placement of the cerclage. Ultrasound guidance could improve accuracy of needle placement, thus reducing potential injuries.

Discussion: Laparoscopic preconceptional isthmorraphy is a feasible and efficient technique, with minimal maternal morbidity, can be used in subsequent pregnancies and can be offered as an outpatient procedure. Where the vaginal cerclage is not technically feasible, the laparoscopic approach is an effective option, with the additional known benefits of this technology.

ANALYSIS OF SURVIVAL AFTER LAPAROSCOPY IN WOMEN WITH ENDOMETRIAL CARCINOMA

Oncology

Poster

JESUS MOLERO VILCHEZ*, Martínez Lamela Ester, Sancho Garcia Sonsoles, Exposito Lucena Yolanda , Gonzalez Paz Carmen, Martin Merino Almudena , Lara Alvarez Miguel Angel

Hospital Universitario Infanta Leonor. Clinica Tocogyn.

Summary (4 lines): The aim of the study was to study the long-term results of laparoscopic surgery in patients with endometrial cancer and to analyze the factors that affect such survival.

Introduction: Laparoscopic approach in the surgical treatment of endometrial cancer has gained wider acceptance by gynecologic surgeons. A retrospective review of 86 women diagnosed of endometrial carcinoma was performed. 63 women treated with laparoscopy were compared with 23 patients treated with laparotomy with regard to surgical procedure, treatment, surgical stage, histology, tumor grade, and recurrence-free and overall survival. Factors affecting survival were evaluated using multivariate analysis and survival curves were constructed using Kaplan-Meier analyses.

Material and Methods Both groups were similar with regard to age, parity, menopausal status, lymphadenectomy, surgical stage, tumor grade, histology, and postoperative radiation therapy. Women who underwent laparoscopy and those who underwent laparotomy had similar 2-year and 5-year estimated recurrence-free survival rates (98,1% vs. 85.7% and 87,2% vs. 42,9%, respectively), (Long Rank test p=0,14); as well as similar 2-year and 5-year overall survival rates (95,7% vs. 92,9% and 93% vs. 92%, respectively) (Long Rank test p=0,68).

Results: There was no apparent difference with regard to the sites of recurrence between both groups. In univariate and multivariate analyses, surgical stage (p smaller to 0,05), age, (p smaller to 0,01), pelvic or/and paraaortic lymph nodes affectation (p smaller to 0,05) were found to have a significant effect on survival.

Discussion: Although longer follow-up is needed, the survival of women with endometrial carcinoma does not appear to be worsened by laparoscopy. Surgical stage and lymph nodes affectation were found to significantly affect survival regardless of the surgical approach used.

OPERATIVE LAPAROSCOPY IN INFERTILE PATIENTS WITH PCOS, METABOLIC SYNDROME WITH PCOS AND OBESITY WITH PCOS

Infertility and Reproductive Medicine

Poster

Mariana Panevska -Gareva*

University Hospital

Summary (4 lines): Many investigations in the last years demonstrated the relationships between hypesinsulinemia in the etiopathogenesis of Polycystic ovary syndrome /PCOS/. We investigated the effect of Metformin/Siofor administration in patients with high insulin resistance and PCOS. Ovarian drilling is an effective second line treatment for infertile patients with PCOS. To perform laparoscopy in women with the metabolic syndrome /MS/ and PCOS or women with the obesity and PCOS was very difficult because of visceral obesity /waist circumference > 80 cm/.

Introduction: Our aid was to evaluate the effect of Metformin/Siofor administration and ovarian drilling in infertile patients with MS and obesity

Material and Methods We studied prospectively 113 women for 5 years period /2008-2012/ in Department of sterility and endocrinology at UH “Maichin dom”, Sofia. All women had well documented clinical, biochemical and ultrasound diagnosis of PCOS. They were divided in three groups: first group - 70 women with PCOS; second group - 26 women had basic characteristic of MS and PCOS; third group - 17 women had obesity and PCOS. We treated second and third group with Metformin/Siofor for 6 months and women were advised to follow a diet. When body weight was lower we performed laparoscopy and drilling of ovaries.

Results: The number of pregnancies after drilling of ovaries and treatment with Metformin/Siofor is 45 /39.85%/. In the second group there are 4 pregnancies /15.38%/. In the third group there are 7 pregnancies /41.1%/. Conclusion: Treatment with Metformin/Siofor and diet lead to reduction of body weight. Analysis of the result after drilling of ovaries and treatment show a decrees of absolute values of body mass index, WHR, IRI, testosterone, LH LH/FSH ratio.

Discussion:

SENTINEL LYMPHADENECTOMY WITH ICG FLUORESCINE

Innovation in Instrumentation and Surgical Techniques

Video

Sara Imboden*, Wolfgang Schöll, Robert Oehler, Mélina Buchwalder, Susanne Lanz, Michel Mueller

Department of Obstetrics and Gynecology, Universit

Summary (4 lines): Sentinel node detection with ICG Fluorescine in the pelvis is demonstrated in a video, showing good detection rates and a safe profile.

Introduction: The Sentinel technology is increasingly being used in various malignancies such as breast cancer, melanoma, vulvar and cervical cancer. As markers mostly radioactive isotopes (Technetium99) and / or patent blue are used, baring a large effort for the patients or a poorer detection rate of only about 80% respectively. With new laparoscopic optics fluorescent markers such as ICG, which is known to have a good safety profile, can be visualized with near infrared light.

Material and Methods The ICG Fluorescine technique is demonstrated step by step in this video. In patients with cervical or endometrial cancer 10ml ICG-PULSION © was injected cervical and with the fluorescein optics (Storz) a lymphatic mapping performed. After opening the peritoneum, the sentinel lymph nodes were located in the pelvis or in the upper abdomen and excised for histological examination. The technology and the localization of the sentinel lymph node in the pelvis is demonstrated.

Results: The ICG fluorescein technique could be applied in all patients when indicated. No allergic reactions were observed from the ICG. In 97% of the patients at least one sentinel node was detected and in 77% cases bilateral.

Discussion: The ICG fluorescence technique is a new, promising technique for detecting the local spread of gynecological tumors in the pelvis with low complication rates.

LAPAROSCOPY ON HEMATOMETRA IN HEMI-UTERUS WITH NON-COMMUNICATING RUDIMENTARY CAVITY ACCORDING ESGE CLASSIFICATION: U4AC0V0

Case reports

Video

Keck Alexander*, Yves Garnier, Jenni Preuss

Klinikum Osnabrück

Summary (4 lines): In this video, a laparoscopic drainage of a hematometra based on cryptomenorrhoea in a hemi-uterus with non-communicating rudimentary left cavity (ESGE classification: U4a C0 V0) is shown.

Introduction: A 17-year-old woman presented with severe abdominal pain. Her menarche took place several months ago with regular bleedings. A transvaginal scan revealed a 17 cm tumor filled with a blood-like, echo-dense liquid in the uterus position. The cervix could not be reached due to the secondary elongated vagina.

Material and Methods A laparoscopy was performed to explore the uterine conditions. It revealed a hemi-uterus with a non-communicating rudimentary left cavity filled up to an enormous size. An anterior uterotomy was executed on the left horn, and 600 mL of menstruational blood were released. After closing the uterotomy the vagina was examined by hysteroscopy, and only one cervix was found. The cervical channel lead into the right horn, and a regular fallopian tube was found.

Results: The absence of blood or stiches in the right horn proofed the theory of a hemi-uterus with a non-communicating rudimentary left cavity (ESGE classification: U4a C0 V0).

Discussion: The patient had regular menstruation through the right horn. A cryptomenorrhoea developed in the rudimentary left cavity causing a hematometra of 17 cm length. Drainage seems to be a good method to solve the problem in the acute situation. After informed consent, a resection of the left cavity is planned.

COMPLICATIONS OF GYNAECOLOGIC LAPAROSCOPY: 1990-2012 EXPERIENCE

Complications

Poster

Virginia García Pineda*, García Pineda Virginia, Rodríguez Garnica María Dolores , de Valle Corredor Cristóbal, Zapico Goñi Álvaro, Marcos González Victoria , Fuentes Castro Pedro

Principe de Asturias Hospital

Summary (4 lines): We study the intraoperative and postoperative complications rate of laparoscopic surgery, while considering the specialist learning curve and the introduction of complex laparoscopic procedures in oncological pathology.

Introduction: It is estimated that the overall complication rate ranges from 0.2-10.3%, with a frequency of complications in minor laparoscopic procedures ranging from 0.06-7% and in major laparoscopic operations ranging from 0.6-18%. We study laparoscopic major and minor complications considering the influence of the rapid adoption of the laparoscopic surgery, the increasing complexity of the surgical procedures (oncological pathology) and the learning curve of the specialist.

Material and Methods This is a retrospective study in 2224 patients operated by laparoscopic approach from 1990 to 2012. We divided the sample between oncological cases (n=353): endometrial, cervical, ovarian and breast cancer, and non-oncological cases (n=1871): ectopic pregnancy, fibroids, ovarian cyst and endometriosis. We study intraoperative complications considering the events on learning curve in the last 22 years, conversion to laparotomy and postoperative complications in both groups. Data analysis has been performed by SPSS 15.0 version.

Results: The overall intraoperative complications rate is 8,72% (n=194) being in oncological cases 17,20% (n=61) and in non oncological cases 7,10% (n=133). In oncological group the rate of major complications is 5,66% (n=20) and in non oncological group is 0,85% (n=17), being the most prevalent bladder injury.

Discussion: In our study the rate of major and minor complications as well as the rate of conversion to laparotomy are higher in oncological group and are influenced by the incorporation of new complex procedures, due to the complexity of the surgery and the learning curve of the specialist.

EFFICACY AND PATIENT SATISFACTION WITH ESSURE HYSTEROSCOPIC STERILISATION

Diagnostic & Operative Office Hysteroscopy

Poster

Maja Rosic*, Zegura Branka

General Hospital Ptuj

Summary (4 lines): Essure is a female sterilisation procedure. The rate of successful placement of Essure microinserts is very high, as is the efficacy of Essure as contraception.

Introduction: Essure is a permanent, non-surgical transcervical sterilization procedure for women. 3 months after the procedure a confirmation test is performed to evaluate tubal occlusion or microinsert location. During this period the tubal lumen is occluded by benign tissue ingrowth stimulated by the microinsert. Since 2007, 169 procedures have been performed in University Medical Centre Maribor. The objective of our study was to evaluate the efficacy, satisfaction, and complications of the procedure.

Material and Methods 38 consecutive patients were included in prospective study. All procedures were performed between August 2012 and March 2013 by the same experienced hysteroscopist in an outpatient setting. Transvaginal 2D ultrasound was performed 3 months after the procedure to asses the microinsert position. HyFoSy was performed in the same setting in 5 cases and HSG was performed once in a total of 6 cases with indeterminate position of microinserts. Questionnaires were filled by hysteroscopist and patients.

Results: Essure microinsert was successfully placed in 73 of 75 Fallopian tubes in 37 patients (97,3%). Transvaginal ultrasound demonstrated a correct placement of 67 microinserts (67/73, 91,8%). Tubal occlusion was confirmed in all 6 cases with indeterminate position of microinserts. The overall patient satisfactory rate was 9,92 on a 10-point scale.

Discussion: Essure is a method for permanent female contraception that is well tolerated, has a very high rate of success and patient satisfaction, and a low rate of complications. In cases of indeterminate position of microinserts on transvaginal ultrasound, HyFoSy could be an alternative to HSG.

NEW TRENDS OF HYSTERECTOMY DURING LAST 10 YEARS

Hysterectomy

Oral

Igor Gladchuk*, Zaporozhan Valeriy, Rozhkovskaya Natalia, Marichereda Valeria, Petrovskiy Yuriy, Gerasyutenko Irina

Odessa National Medical University

Summary (4 lines): Proportion of hysterectomy approaches used and their preference changed a lot during the last 10 years. It should be considered during conducting research related to analysis of hysterectomy outcomes.

Introduction: Hysterectomy remains one of the most frequently performed surgery in gynecological practice. There are three types of approaches in modern operative gynecology that are being used for performing hysterectomies: vaginal, abdominal and laparoscopic.

Material and Methods This retrospective study analyses a tendency in preferences of type of hysterectomies performed during last 10 years in the same hospital. We analyzed number and type of hysterectomies, which were performed in 2002 (182 cases), 2007 (245 cases) and 2012 (319 cases). All hysterectomies were performed for benign diseases. We excluded cases of invasive cancer and hysterectomy during pregnancy or delivery.

Results: We observed overall hysterectomies number increase by 1.75 times during last 10 years. Mean age was 45.5+3.5 years (range: 36 to 65 years). Mean parity was 2.1 (0-3). Near 20% of the patients had previously undergone pelvic surgery. The rate of complications was near 1 % (bladder, ureter injury, haematomas).

Discussion: Wide usage vaginal approach (with or without laparoscopic assistance), resulted in limited use of the abdominal approach during last 10 years. We prefer laparoscopically assisted hysterectomy for patients with previous pelvic surgery to minimize surgical trauma. We observed tendency to increasing of laparoscopic supracervical hysterectomies (LSH), in young women.

NEW TECHNOLOGIES IN THE SURGICAL TREATMENT OF DEEP INFILTRATING AND SUPERFICIAL PERITONEAL ENDOMETRIOSIS

Endometriosis: Surgery

¨Poster

Igor Gladchuk*, Rozhkovskaya Natalia, Volyanskaya Alla, Kozhakov Vitaliy, Maslenko Maria

Odessa National Medical University

Summary (4 lines): Presented work indicates a pathogenic rationale and feasibility of application of new energy in the radical surgical treatment of advanced severe endometriosis in young women interested in the preservation of reproductive function.

Introduction: Surgery for deep infiltrating endometriosis treatment (DIE) remain very actual topic. Chronic pelvic pain syndrome, dyspareunia, dyschesia, nodular infiltration of pararectal fat, intestinal lesions wich lead to stenosis require radical treatment. Radical operations lead to traumatization and postcoagulative peritoneal necrosis that aggravate postoperative period and leads to adhesions, intestinal paresis. Improvement of surgical treatment with help of new types of energy could possibly reduce these negative consequences and will lead to better reproductive results.

Material and Methods We compared results of treatment in 50 paired patients with DIE which composed two groups. All patients were in reproductive age (21-44 years old) and menstruating. First group (25 patients) undergone radical peritoneoectomy with using of ultrasound scalpel (Söring) and cold plasma (Söring).In second group (25 patients) traditional electrosurgical surgery was performed.

Results: Patients in first group had fewer complications, lower intestinal paresis incidence, hyperthermia and pain severity, less need for analgesics administration. Postoperative drainage was remover on second day in group 1 and on 3-4 day in group 2. Hospital stay was 2.2±0.2 and 4.5±0.5 days for group 1 and 2 respectively.

Discussion: Combination of ultrasonic scalpel and cold plasma in surgical treatment of the nodular DIE and superficial peritoneal endometriosis can minimizes surgical trauma and charring, improves postoperative period duration, decreases risk of postoperative adhesions and reduce hospital stay.

DIGITAL OPERATING ROOM WITH VIDEO OVER IP

Innovation in Instrumentation and Surgical Techniques

Oral

Philippe Koninckx*

Gruppo Italo Belga

Summary (4 lines): The lack of solid data emphasizes the importance of validation of new developments, such as DOR with video over IP, integrating the calculating power of the computer room.

Introduction: Endoscopic surgery is technically more challenging than anticipated considering its slow implementation. We therefore reviewed whether the digital operating room with artificial intelligence and integration of devices and information would be helpful in training, in improving quality and safety of endoscopic surgery, or in reducing costs.

Material and Methods Systematic review

Results: Little evidence could be found to support the numerous claims made. Dedicated operating theatres with a minimum of cables, with separate screens for the surgeon and the assistant, with the possibility to display stored images together with data from devices is claimed to facilitate organization of the OR, to facilitate surgery and to reduce fatigue and complications. Although this seems obvious by widespread clinical experience data are not available. Absence of delay in visualization is important for surgery although not documented.

Discussion: Visualization of structures by fluorescence is emerging technology as used for bladder cancer and blood flow. Similarly algorithms enhancing vascularization might be useful for diagnosis of endometriosis. What is lacking is real time integration of surgical images, i.e. enhanced reality. Live surgery is important for teaching and learning, although not demonstrated. Video registration is a great tool for teaching and for debriefing. Video registration of entire interventions is claimed to be useful since review of the surgery would facilitate diagnosis and treatment of complications. Video registration also is claimed to be useful medico legally to demonstrate that surgery was done carefully. Also the usefulness of 3D remains a claim.

FEASIBILITY OF MINIMALLY INVASIVE LAPAROSCOPIC CYSTECTOMY FOR BENIGN OVARIAN CYST DURING PREGNANCY

Innovation in Instrumentation and Surgical Techniques

Video

Ozaki Rie*, Kumakiri Jun , Kitade Mari, Takeda Satoru

Juntendo university of shool

Summary (4 lines): The minimally invasive surgery for a benign ovarian cyst, modified with multiport laparoscopically assisted extracorporeal cystectomy, is feasible for pregnant patients with benign ovarian cysts.

Introduction: The incidence of adnexal masses during pregnancy is 1:8000–20,000 live births, according to several studies. The removal of the ovarian cyst during first trimester is recommended for preventing complications during gestation, and laparoscopic surgery was commonly performed as the surgical management. Recently, reduced port surgery has been introduced for benign gynecological conditions. In the presentation, we demonstrate a new minimally invasive laparoscopic procedure for the pregnant patients with benign ovarian cysts.

Material and Methods A multiport device with capacity for up to three laparoscopic instruments was attached to a wound retractor inserted into a suprapubic 2.5-cm incision. After pneumoperitoneum, the abdominal cavity was accessed using a 10-mm rigid laparoscope with an adjustable 0° – 120° field of view. A double-balloon catheter was inserted via the multiport device into the ovarian cyst and their fluid contents were aspirated. The affected ovary was extracted to the extracorporeal space for ovarian cystectomy.

Results: The procedure was performed in 3 pregnant patients with ovarian teratoma. Conversion to multiport conventional laparoscopy was not required. The mean surgical duration and total blood loss were 94 min and 55 mL, respectively. The postoperative course was uneventful, and no fetal and maternal complication was diagnosed during further pregnancy.

Discussion: We considered that the new procedure is safe as well as the conventional procedure. The advantage of the multiport device and the adjustable laparoscope ensured the minimally invasive laparoscopic surgery for pregnant woman with ovarian cyst. A randomized, prospective study is needed to confirm the value of the new procedure.

SURVIVAL OF ENDOMETRIAL CARCINOMA IN OUR COMMUNITY: REVIEW FROM 1996 TO 2012

Oncology

Poster

María Dolores Rodríguez Garnica*, García Pineda Virginia, De Valle Corredor Cristóbal, Zapico Goñi Álvaro, Fernández Muñoz Laura, Menéndez Fuster Jose Manuel

Hospital Universitario Príncipe de Asturias

Summary (4 lines): We reviewed 324 patients with endometrial carcinoma in our hospital. Overall survival rate: 86.6% (median of 140,08 ± 3,90 (132,42-147,75) months). Disease free survival rate: 92.9% (median of 151,4 ± 3,29 (144,9-157,8 ) months).

Introduction: We analyzed the overall survival in endometrial carcinoma in our community according to the stage, histological type, surgical approach and the BMI.

Material and Methods We executed a descriptive and retrospective study in 324 patients with endometrial carcinoma in the Príncipe de Asturias University Hospital, Alcalá de Henares, Madrid, between 1996 and 2012. We divided patients according to: The histological type: 87.3% with endometrioid adenocarcinoma (283), overall survival rate of 94.3%. 12.7% with non endometrioid carcinoma (41),overall survival rate of 82.9% (p=0.004). Clinical stages: early stage (266), overall survival rate of 96.2%. Advanced stages (58), overall survival rate of 77.6%.

Results: Poorer survival in: In the laparotomy group (22.8%.74) overall survival rate of 75.7% (laparoscopic group (72.8% 236) overall survival rate 91.1%) (p=0.002). In the group of patients with a BMI higher than 35 kg/m² (24.7% 80), overall survival rate of 78.8% .Overall survival rate with death due to endometrial cancer was 87.5% (p=0.023)

Discussion: Patients treated for endometrial cancer in our community had a good prognosis but those in which surgical approach was performed by laparotomy and those with higher BMI had lower survival.

ENDOMETRIAL CANCER REVIEW IN OUR COMMUNITY HOSPITAL: FROM 1996 TO 2012

Oncology

Poster

María Dolores Rodríguez Garnica*, García Pineda Virginia, De Valle Corredor Cristóbal, Zapico Goñi Álvaro, Menéndez Fuster Jose Manuel, Martínez Gómez Elena

Hospital Universitario Príncipe de Asturias

Summary (4 lines): We reviewed 324 patients with endometrial carcinoma. Early stage: 82.1% (266) Advanced stages: 17.9% (58) 87.3% endometrioid adenocarcinoma (283). Surgery: 77.1% (250) hysterectomy, bilateral salpingo-oophorectomy, lymphadenectomy. Mean number of lymph nodes: 8,13 ± 0,358 (2-29).4.3% positive (14).

Introduction: We reviewed our case-serie of endometrial cancer. Our surgical protocol is: by laparoscopic approach we carry out a hysterectomy and bilateral salpingo-oophorectomy. Uterus is sent to intraoperative study.If we have a stage Ia G1 G2 a pelvic lymphadenectomy is not performed. In case of Ib G1 G2 a pelvic lymphadenectomy is performed with intraoperative study . If they are positive a para-aortic lymphadenectomy is performed. In cases with G3 a para-aortic lymphadenectomy is always performed

Material and Methods We executed a descriptive and retrospective study in 324 patients with endometrial carcinoma in the Príncipe de Asturias University Hospital, Alcalá de Henares, Madrid, between 1996 and 2012.

Results: Surgical approach: laparoscopy 72.8% (236).Laparotomy 22.8% (74). Intraoperative complication: higher in the laparoscopic group (16.5% 39 versus 10.8% 8) (p=0.232) (anesthesic problems) Conversion to laparotomy: 8.5% (21). Severe adherencial syndrome: 8.5% (22) of laparoscopic. Overall survival rate: 86.6%.

Discussion: The laparoscopic surgical treatment should be considered today as the first option.

SUCCESSFUL DELIVERY AFTER HYSTEROSCOPIC METROPLASTY FOR T SHAPED UTERUS: THREE CASES REPORT AND LITERATURE REVIEW

Surgical Hysteroscopy

Selected abstract Oral

Enlan Xia*

Hysteroscopic Center, Fuxing Hospital, Capital Medical University

Summary (4 lines): Hysteroscopic metroplasty is the practical and effective methods to treat T shaped uterus women without other infertility factors. this surgery should be performed by experienced doctors.

Introduction: To investigate the effectiveness and feasibility of T shaped uterus metroplasty. To Introduce the formation reason, impact on fertility and treatment strategies of T shaped uterus.

Material and Methods Hysteroscopic metroplasty was performed by making careful incisions or resection of the excess muscle tissue located on the uterus wall to widen the cavity and to obtain a triangular shaped cavity for 3 cases.

Results: Three cases metroplasty performed smoothly and no complication. Two months later hysteroscopic second look shown no adhesion. They got term delivery by CS at 1 year and 5 months, 1 year and 7months, 1 year and 9 months after surgery separately, one girl 3300g and two boys 3450g、4000g.

Discussion: For T shaped uterus women without other infertility factors, hysteroscopy uterine cavity expansion metroplasty is practical and effective. Due to cutting too deep have uterine perforation and uterine rupture during pregnancy may in the future, lack of cutting short of capacity, this surgery should be performed by experienced doctors.

AQUADISSECTION FOR MYOMECTOMY

Innovation in Instrumentation and Surgical Techniques

Video

Rajesh Modi*

Akola Endoscopy Centre

Summary (4 lines): Saline is injected in the myometrium and the blood in the myometrial tissue is replaced by saline. Thus when myometrium is cut only saline oozes out, almost no bleeding occurs and the field is further cleared by the saline which oozes out.

Introduction: Aquadissection is using a large quantity of saline injected in the myometrium to seperate the fibroid from the myometrium. The saline also replaces the blood in the myometrium, thereby reducing the blood loss when the myometrium is opened. Inj. Vasopressin is diluted with this large quantity of saline. Vasopressin holds the saline in place for 40 - 45 min. This helps to keep the field clear and it is easier to get the correct plane.

Material and Methods For a myomectomy of fibroid of about 8 cms size, 40U of vasopressin is diluted in 400ml of Normal Saline. This is injected in the myometrium. Incision is taken on the uterus with a scissors (no energy source is required). As the uterus is cut, instead of bleeding, saline leakage takes place. The separation of the fibroid is easier due to the dissection by the saline. Myometrium is sutured by barbed suture material.

Results: Aquadissection technique for myomectomy is effective in markedly reducing blood loss during surgery. It reduces the time taken for myomectomy. It shortens the recovery time. It also ensures better wound healing post-operatively. The use of barbed sutures decreases the total time taken for myometrial defect closure.

Discussion: As no energy source is used for cutting or coagulation, no dead or scarred tissue is left behind. Thus there is better tissue healing, better scar integrity and less chances of scar dehiscence.

ASSOCIATION BETWEEN UTERINE REPAIR AT LAPAROSCOPIC MYOMECTOMY AND POSTOPERATIVE ADHESIONS

Myomectomy

Video

Ayako Masuda*, Jun Kumakiri, Mari Kitade, Rie Ozaki

Juntendo University School of Medicine

Summary (4 lines): Our findings indicated that uterine repair at laparoscopic myomectomy (LM) was closely associated with adhesion formation. Appropriate uterine repair seems mandatory to avoid adhesions formation after LM.

Introduction: The wound status generated by enucleation and suturing during LM might influence the postoperative adhesion formation regardless of the use of adhesion preventing agents, because several investigators have reported that potential wound adhesions are related to the characteristics of the myomas. We investigated the incidence of adhesions at sites of uterine myomectomy at second-look laparoscopy (SLL) in order to determine whether the uterine repair at LM influenced postoperative adhesion formation.

Material and Methods: A total of 108 patients who underwent SLL after LM were retrospectively analyzed. Absorbable cellulose adhesion preventions were used for uterine repair at LM in all women. The influence of the uterine status immediately after uterine repair at LM (number, length and location of wounds, as well as wound appearance classified as virtually normal, swollen or protruding) on adhesion formation were evaluated.

Results: Forty-eight (16.2%) adhesions among 296 wounds were identified. A protruding wound was significantly associated with the adhesion (odds ratio, 2.53; p = 0.02). The number of enucleated subserosal myomas and the diameter of largest myoma were significantly associated with the wound protrusion, which was a critical factor influencing adhesion.

Discussion: The wound protrusion caused difficulties in achieving smooth wounds owing to redundant serosa after removing large myomas and multiple subserosal myomas. Appropriate trimming and placing several single knots to bury redundant tissue may help to decrease the degree of wound protrusion.

OUTPATIENT DIAGNOSTICS OF ENDOMETRIAL POLYPS

Imaging

Oral

Haykuhi Aghajanyan*

Moscow Sechenov Medical Academy

Summary (4 lines): The aim of this study is to estimate diagnostic accuracy of combined and isolated use of transvaginal ultrasound, saline infusion sonohysterography and diagnostic hysteroscopy in outpatient diagnostics of endometrial polyps.

Introduction: This is a blind prospective study of random 66 women of reproductive and postmenopausal periods, planned for operative hysteroscopy and D&C for pathological uterine bleeding (n30), abnormal pelvic ultrasound (n29) and cervical polyps (n7). The intrauterine pathology detected in 75,8% (n50) patients, in 12% (n8) - revealed more than one pathology. The final diagnoses: submucous myoma 18,2% (n12), uterine anomaly 3% (n2), sinechia 4,5% (n3), hyperplasia 13,6% (n9), polyp 45,5% (n30) and adenocarcinoma 7,6% (n5).

Material and Methods: The examination of patients conducted in outpatient and inpatient stages. The first stage consists of Pipelle (n64) and transvaginal ultrasound (n66), saline infusion sonohysteroscopy with Goldstein catheter (n55), diagnostic hysteroscopy (n64) and combined diagnostic hysteroscopy with saline infusion sonohysteroscopy (n64). The second stage - operative hysteroscopy and D&C (n66). The results of 89% operative hysteroscopy and D&C and 11% hysterectomies accepted as final diagnoses. All the technologies were used blindly - by 5 different gynecologists.

Results: No statistically significant difference between diagnostic hysteroscopy and saline sonohysteroscopy found. In seven per cent of cases polyps were erroneously interpreted as submucous myomas of 0 type at both transvaginal ultrasound and saline sonohysteroscopy. The histiologic conclusion in these cases were fibrous-glandular-muscular polyps.

Discussion: There is a category of polyps (histlogically, fibrous-glandular-muscular polyp) which look isoechogenic, like 0 type submucous myoma on transvaginal ultrasound and saline sonohysteroscopy, because of its muscular component. We suppose that a carefull attention to the integrity of the myometrial-endometrial border may help to distinguish fibrous-glandular-muscular polyps from submucous myomas.

SEVERE URETERAL ENDOMETRIOSIS: PRELIMINARY REPORT OF 30 CASES WITH HYDRONEPHROSIS

Endometriosis: Surgery

Selected abstract Oral

Marco Puga*, Alves Joao, Fernandez Rodrigo , Redondo Cristina, Wattiez Arnaud

Clinica Alemana

Summary (4 lines): Severe ureteral endometriosis is associated to risk of kidney function loss, ureteral resection and major complications. To achieve satisfactory outcomes its management should be done in specialized groups.

Introduction: The main risk of these patients is the loss of the kidney function that can be asymptomatic in 50% of them. In some cases, even after a thorough ureterolysis, the ureter remains stenotic due to intrinsic disease and surgeon is compelled to perform the resection and anastomosis. The objective is to describe perioperative management, complications and outcomes of severe ureteric endometriosis.

Material and Methods: Retrospective, descriptive study of thirty consecutive patients who underwent laparoscopic surgery for hydronephrosis due to ureteral endometriosis (HUE) at the Department of Obstetrics and Gynecology, Strasbourg Hospitals; between June 2004 and June 2013. Data were collected from medical records and telephone interview.

Results: Two patients had non-functioning kidneys. Left ureteral lesions were more common (76.9%). Conversion was not necessary. Ureterolysis was performed in 10 patients (33.3%) and segmental resection-anastomosis in twenty (66,7%). All patients had improvement in pain symptoms. There were no intraoperative complications, but five major postoperative complications in four patients (13%).

Discussion: HUE is a complex subset of patients presenting with a high possibility of ureteral resection and not negligible amount of complications. When managed in specialized team the outcomes are satisfactory, consequently it’s critical to diagnose this condition preoperatively in order to offer the best standards of care and safety.

LAPAROSCOPIC MANAGEMENT OF INFECTED MESH USED IN PROLAPSE SURGERY

Case reports

Video

Joao Alves*, Botchorishvili Revaz, Wattiez Arnaud, Rabischong Benoit, Ramilo Irina, Pouly Jean Luc, Mage Gerard , Canis Michel

IRCAD EITS Strasbourg

Summary (4 lines): We present a case report of a patient with prolapse surgery with mesh placement 14 years ago with four surgeries after due to complications, namely erosion and abscess.

Introduction: The prevalence of pelvic organ prolapse (POP) appears to be increasing, with mesh still widely used in both vaginal and abdominal surgery in POP treatment. Mesh-related complications are nowadays one of the major concerns mainly due to FDA recomendations, after several publications assessing mesh-related morbidity.

Material and Methods: We describe a case of a 51-year-old woman that in 1999 had a total laparoscopic hysterectomy with adnexectomy, Burch colposuspension, and a posterior compartment defect correction with a mesh. Patient had another 4 surgeries several years later: 1-Post-operative haematoma with laparoscopic approach; 2-mesh erosion with partial removal by vaginal route; 3- mesh abscess with laparoscopic removal of mesh; and, 4-mesh abscess recurrence with complete laparoscopic removal of remaining mesh.

Results: Mesh used in POP corrections have long-term complications being the most common the erosion of synthetic material (5-19%). Risk factors are: concurrent hysterectomy, vaginal cuff hematoma, diabetes, use of polyester mesh and, use of multifilament polyester tread. Mesh related abscess can follow erosions especially in patients presenting several risk factors.

Discussion: When exposition of the mesh appears, the treatment options are mainly two: if no infection is present then conservative treatment is prescribed; if suspected infection, removal of mesh is aimed, but they are not easy to perform completely and sometimes more than one surgery is required.

THIRD TRIMESTER OOPHOROPEXY FOR MATERNAL OVARIAN TORSION

Innovation in Instrumentation and Surgical Techniques

Video

Valerie Jennings*, Shepherd Jessica

University of Illinois

Summary (4 lines): We present a case of maternal ovarian torsion in the third trimester that was treated laparoscopically with detorsion and oophoropexy.

Introduction: Maternal ovarian torsion is a rare event with the majority presenting in the first or second trimester. The minimally invasive approach to ovarian torsion provides the advantages of shorter hospital stay, decreased morbidity, and earlier return to normal activity. Third trimester laparoscopy adds the technical difficulty of a gravid uterus and viable pregnancy. The risks of potential injury to the uterus, decreased uterine blood flow, or absorption of carbon dioxide further complicate the gynecologic emergency.

Material and Methods: A 38 year old woman at 32 weeks gestation and history of left ovarian torsion in presented with complaints of left lower quadrant pain. The patient was taken to the operating room with concern for recurrent torsion. A 8mm laparoscope was placed in the left upper quadrant and 2-5mm accessory ports were placed in the left side. The ovary was detorsed and oophoropexy was performed. Monitoring of the fetus performed during the case was reassuring.

Results: The operative time was 42 minutes, estimated blood loss was minimal, and fetal heart tracing was category I during the procedure. There were no intraoperative complications. The patient was discharged after 48 hours and there were no postoperative complications. There were no late complications or readmissions.

Discussion: Maternal ovarian torsion in the third trimester is a rare event that can be treated laparoscopically with detorsion and oophoropexy, thus preserving the maternal ovary and providing quick recovery.

CONVERTING SACROCOLPOPEXY/SACROHYSTEROPEXY FROM OPEN TO LAPAROSCOPIC - A SURGICAL COLLABORATION IN NON-TEACHING HOSPITALS

Teaching & Training

Poster

Tracy Jackson*, Fishwick Kathryn, Jackson Tracy

Harrogate NHS Foundation Trust

Summary (4 lines): A training collaboration was developed between consultant surgeons in order to convert open to laparoscopic sacrocolpopexy and sacrohysteropexy. The aim was to enable women to have the proven benefits of laparoscopic surgery.

Introduction: Laparoscopic sacrocolpopexy and sacrohysteropexy are technically difficult and advanced surgical procedures. In the absence of easily accessible training programs, the collaborators felt that by combining their individual skills they would be in a position to convert from open to laparoscopic surgery in a way that was both safe and efficient. As senior surgeons, the collaborators brought a variety of specific skills which were beneficial for the patients and provided support for the team.

Material and Methods: Three internationally renowned laparoscopic urogynaecologists provided observational and hands on training and support. The collaborators worked in different Trusts but obtained honorary contracts to enable them to work in both sites. Type 1 polypropylene mesh was inserted with a standard technique in all cases. The surgeons were a urogynaecologist, a gynaecological endoscopist and a colorectal surgeon. Antibiotic prophylaxis was given in all cases. All suitable cases were offered the laparoscopic approach from November 2010.

Results: From November 2010 - 13 laparoscopic sacrohysteropexies and 29 sacrocolpopexies performed. 2 planned conversions due to dense adhesions,1 unplanned conversion due to rectal injury. 2 patients have required TOT for USI (colpopexy) and 2 patients have required vaginal repair (hysteropexy). POP-Q analysis shows good anatomical correction in all other cases.

Discussion: To date the collaboration has been successful with equivalent anatomical results to open surgery and low complication rates. LOS has reduced as anticipated. Postoperative analgesia requirements are reduced with a positive effect on bowel function and a more rapid return to normal activity. This has been a positive experience.

OFFICE VERSUS INPATIENT POLYPECTOMY FOR THE TREATMENT OF ABNORMAL UTERINE BLEEDING: THE OPT NON-INFERIORITY RCT

Diagnostic & Operative Office Hysteroscopy

Oral

Natalie Cooper*, Middleton Lee, Smith Paul, Daniels Jane, Clark and The OPT trial collaborative group Justin

Birmingham Women's Hospital

Summary (4 lines): The OPT trial randomised women with endometrial polyps associated with abnormal bleeding to office versus inpatient polypectomy. There was no significant difference between the groups when symptom alleviation was assessed.

Introduction: Uterine polyps are a common cause of abnormal bleeding and previously were removed by blind curettage. Miniaturisation of hysteroscopes has made polypectomy feasible in the office setting, yet evidence of equivalent effectiveness is limited. To investigate this we examined a group of women with abnormal uterine bleeding who were found to have uterine polyps at diagnostic hysteroscopy. Inpatient polypectomy under general anesthetic was compared to office polypectomy in a pragmatic randomised, non-inferiority trial.

Material and Methods: Five-hundred and seven women from 31 UK hospitals were randomised to office or in-patient polypectomy. The primary outcome was a successful treatment at six months, determined by the women’s assessment of her bleeding, with a pre-specified non-inferiority margin of 25%. Secondary outcomes included generic (EQ-5D) and disease specific (Menorrhagia Multi-Attribute Scale) quality of life measures, bleeding response on a Likert scale, visual analogue scale (VAS) bleeding scores, procedure acceptability and surgical re-intervention/failure rates.

Results: 73% of women who underwent office polypectomy reported successful treatment compared with 80% who had inpatient polypectomy (Intention-to-treat RR: 0.91, p=0.09; Per-protocol RR: 0.92, p=0.13). Incomplete polyp removal was slightly higher (19% versus 7%). Acceptability was 98% in both groups There were no statistical differences in EQ-5D, MMAS or VAS.

Discussion: When treating women with abnormal uterine bleeding caused by hysteroscopically diagnosed uterine polyps, office polypectomy was found to be non-inferior to in-patient polypectomy at six months, Women found the procedure acceptable but failure rates were slightly higher.

PELVIC INFLAMMATORY DISEASE – AN ATYPICAL PRESENTATION

Case reports

Poster

Elisa Pereira*, Nogueira-Silva Cristina, Barata Sónia, Alho Conceição, Osório Filipa

CHLN

Summary (4 lines): A woman with thirty-six years old, with a history of pavimentocelular invasive carcinoma underwent a total hysterectomy with pelvic lymphadenectomy and preservation attachments one year ago, was admitted in our hospital with syntoms sugestive of pelvic inflammatory disease.

Introduction: Pelvic inflammatory disease (PID) refers to acute infection of the upper genital tract structures in woman involving any or all of the uterus, fallopian tubes, and ovaries and may involve neighboring pelvic organs.

Material and Methods: A woman with thirty-six years old, with a history of pavimentocelular invasive carcinoma underwent a total hysterectomy with pelvic lymphadenectomy and preservation attachments one year ago, was admitted in our hospital with lower abdominal pain and fever. The abdominal examination reveals diffuse tenderness greatest in the lower quadrants and the presence of a palpable adnexal mass and the pelvic ultrasounds demonstrate a tubo-ovarian abcess in the left and the presence of fluid in the cul-de-sac. We decided to carry out laparoscopy because the patient wasn’t clearly improving after approximately 48 hours of treatment for PID.

Results: We saw laparoscopic abnormalities consistent with PID (tubal edema, adhesions and purulent exsudate) and we decided for a left salpingo-oophorectomy and lysis of adhesions. There were no other lesions on peritoneal cavity exploration and peritoneal washing was positive for Staphylococcus Aureus. The histopathological examination diagnosed a inflammatory tissue. After surgery she had clinical features of sepsis and was transferred to an intensive care unit and new blood cultures were positive for Stenotrophomonas maltophilia. We changed the treatment and put a new abdominal catheter under ultrasound monitoring with significant clinical improvement.

Discussion: It was a surprising case of PID in a woman without a uterus and with bacteriological findings atypical.

HYSTEROSCOPIC OUTPATIENT LASER MYOMECTOMY

Diagnostic & Operative Office Hysteroscopy

Oral

Luigi Nappi*, Mele Giovanbattista, Casparrini Corinna, Carlucci Stefania, Sorrentino Felice, Greco Pantaleo

University of Foggia

Summary (4 lines): In our study we evaluate the benefits of minimally invasive techniques in hysteroscopy, focusing on the use of the diode laser in the treatment of submucosal and intramural myomas.

Introduction: Currently, submucous myomas itary development (G0) may be successfully treated in an outpatient setting with 5 Fr mechanical and bipolar instruments. Myomas greater than 1.5 cm or those with intramural development (G1-G2) are generally treated by using the resectoscope. In this study we describe the first experience in approaching this pathology by using a diode laser, with a 4 mm operative hysteroscope in an outpatient setting.

Material and Methods: In the last 18 months we performed 615 operative office hysteroscopic procedures. In 43 cases we used a diode laser fiber (Biolitec, Ceralas BFF603; 35-60 Watts) with a 4 mm operative hysteroscope (Karl Storz) to remove and vaporize submucosal and intramural myomas (G0-G2), ranging between 0.5 and 3.0 cm. In 32 (74.4%) cases myomas were removed at the time of the diagnosis, while the remaining 11 (25.6%) myomas were completed in a second step.

Results: After 6 months of follow-up we demonstrate 2 (4,6%) cases of pathology persistence. Histological examination showed accordance with the hysteroscopic diagnosis in all cases. Concerning patient compliance, 34 (79.0%) women accepted the procedure without discomfort, 7 (16.4%) with discomfort, and only 2 (4.6%) women with moderate pain.

Discussion: The combination of a 4 mm continuous flow operative hysteroscope and a diode laser fiber enables the endoscopic gynaecologist to perform office hysteroscopy for the treatment of submucosal and intramural myomas, with significant results in terms of persistence of the pathology and patient compliance.

1 YEAR EXPERIENCE OF TCRM AT KK HOSPITAL

Surgical Hysteroscopy

Poster

Robert Hunan Purwaka*

KK Women's and Children's Hospital

Summary (4 lines): TCRM is safe and effective for the treatment of submucous myoma. The consideration is for the type II myoma that still no satisfactory and might need second or other intervention.

Introduction: Submucous myoma is associated with a number of gynaecologic disorders, including abnormal uterine bleeding, recurrent pregnancy loss, and infertility. In studies of women presenting with AUB, 14% to 27% were specifically found to have submucosal myoma on ultrasound. Treatment options for submucous myoma vary dependent upon the clinical situation. Transcervical removal of myoma (TCRM) is safe, efficient, uniquely suited to manage submucous myoma.

Material and Methods: We collected 1 year data of TCRM during 2011-2012. Data were recorded and analyzed. The data included indications for TCRM, the size of myoma, operation time, total fluid required for irrigation, fluid deficit, complication during procedure, the application of diagnostic laparoscopy for guidance and post operative evaluation, including evaluation of symptom and size of myoma after treatment.

Results: 448 cases recorded. Main complain is menorrhagia. Patients aged between 31-60 years. Myoma sized ile on type II myoma, 80% patients have persistent complains even after procedure. We only found 1 complication.

Discussion: TCRM is a good method for controlling AUB caused by submucous myoma. Clinical remission was 80% to 100% during the follow-up period of 2 months to 1 year. However, the rate declines when the type of myoma is type II. TCRM has very low complication rate.

ROBOTIC SINGLE-INCISION TRANSUMBILICAL TOTAL HYSTERECTOMY USING A SINGLE-SITE ROBOTIC PLATFORM

Robotics

Video

Ali Akdemir*, Sendag Fatih, Öztekin Kemal

Ege University School Of Medicine, Department of O

Summary (4 lines): The combination of laparoendoscopic single-site surgery (LESS) and the da Vinci Single-Site robotic surgical platform seems to be a promising choice to overcome the technical difficulties of LESS.

Introduction: Laparoendoscopic single-site surgery (LESS) is a promising approach that can further enhance cosmetic satisfaction and reduce the risks of laparoscopic surgery. The combination of LESS and the robotic system seems to be a promising choice to overcome the technical difficulties of LESS. The da Vinci Single-Site robotic surgical platform is a novel semi-rigid robotic operating system. We present initial experience of robotic assisted single incision transumbilical total hysterectomy using the novel da Vinci Single-Site Platform.

Material and Methods: Five patients were underwent robotic single-incision transumbilical total hysterectomy and bilateral salpingo-oophorectomy using the da Vinci Single-Site Platform.

Results: The docking time and console time were 6 minutes and 116 minutes, respectively. Estimated blood loss was 66 ml and uterine weight was 150 grams. The postoperative course was uneventful. All the patients were pleased with the cosmetic appearance of the umbilicus.

Discussion: Robotic-assisted single-incision transumbilical total hysterectomy and bilateral salpingo-oophorectomy using the da Vinci Single-Site Platform is feasible, especially in select patients. Further experience and technical refinements will improve operative results. Further work is needed to advance the single-site robotic platform, the articulating of the instrumentation, and the instrumentation using bipolar energy.

OFFICE HYSTEROSCOPY BEFORE IVF TREATMENT – IS FERTILITY IMPROVED?

Diagnostic & Operative Office Hysteroscopy

Oral

Kristine Juul Hare*

Hvidovre University Hospital

Summary (4 lines): Several reviews state that both hysteroscopy (HS) and endometrial damage improves the success rates of in vitro fertilisation (IVF) and intracytoplasmatic sperm injection (ICSI). Investigators have performed these interventions as far as 6 month before the fertility treatment and still report an effect. The explanation of this phenomenon is poorly enlightened – so far. With this protocol we will explore whether office hysteroscopy (OHS) with endometrial biopsies has the same positive effect on assisted fertility.

Introduction: In Denmark, a tenth of all child births are the result of assisted fertility, methods include IVF and ICSI. In roughly 40% of subfertile women no explanation for the subfertile condition can be found. However studies describe intrauterine pathology in up to 45%. The golden standard to detect intrauterine conditions is HS. Recently OHS is introduced in diagnosing intrauterine pathologies. As the name indicates, no anaesthesia is required for this procedure, in contrast to HS.

Material and Methods: 300 subfertile women will be recruited before second IVF/ISCI protocol. Women are randomised to OHS or control. Control group: standard IVF treatment. Active group; OHS is performed in the cycle before treatment. During OHS, without anaesthesia, two endometrial biopsies are taken. After OHS the women are treated in the fertility clinic as control women. One biopsy is stored at –20 °C for later analyses. The other is examined for hyperplasia.

Results: Endpoint data will be positive serum HCG, and early pregnancy ultrasonic scans in week 7-8. Further we examine the endometrium of these subfertile women, whom have all ready undergone one IVF cycle and most likely several insemination trials to report any cases of hyperplasia.

Discussion: We expect to find a positive effect of OHS with biopsy as has all ready been reported with traditional HS. However we hope this much less invasive procedure will match the more comprehensive HS.

6 YEARS EXPERIENCE OF ENDOMETRIAL ABLATION AT KK HOSPITAL, SINGAPORE

Surgical Hysteroscopy

Poster

Robert Hunan Purwaka*

KK Women's and Children's Hospital

Summary (4 lines): Study of endometrial ablation for 6 years done at KK Hospital, Singapore. Total case is 23 cases. Satisfaction rate reached 91.3%. No complication occured during procedure.

Introduction: Minimally invasive methods of endometrial destruction have been evaluated as alternatives to hysterectomy in women with menorrhagia. Currently, second-generation methods of endometrial ablation are performed “blind” (without a hysteroscope), usually in the outpatient setting under local anesthesia, and require minimal cervical dilation. These methods include cryoablation, thermal balloon ablation, radiofrequency ablation, microwave ablation, and diode laser thermotherapy. This methods offers great satisfaction and safety to the patients.

Material and Methods: Cases of endometrial ablation for the last 6 years were collected. Data included age, parity, BMI, symptoms, pathology of uterus detected by ultrasound, time of procedure, complication during procedure, post operative symptom, follow up and satisfaction of the patients.

Results: 23 cases recorded. Main complain is menorrhagia. Patients age between 39-52 years. No complication found during procedure. Follow up done after 4 weeks, and most patient had spotting. The symptom decreased after 8 weeks. Satisfaction rate reached 91%, and only 2 patients had recurrent menorrhagia, and eventually need hysterectomy.

Discussion: Endometrial ablation using uterine balloon therapy to control menorrhagia is highly effective, with success rates in the range 80–90%. The potential cost savings of this treatment should not be overlooked. However, we need to improve our setting, and start using this methods as the office procedure.

AWARENESS OF ADHESIONS’ IMPACT IN OUR DAILY PRACTICE

Infertility and Reproductive Medicine

Video

Cláudia Andrade*

Centro Hospitalar Tondela-Viseu

Summary (4 lines): Video demonstrating the importance of adhesions formation in our patients, showing severe types and degrees of adhesions and their adhesiolysis by laparoscopy.

Introduction: Adhesions have become the most common postsurgical complication with great impact on the quality of life for millions of people worldwide. They are attachments of tissues at non-anatomical sites, resulting of surgical trauma. Adhesions are source of major concern because of their clinical significance. They are associated with bowel obstructions, persistent pain, dyspareunia and infertility.

Material and Methods: The authors combined surgical videos recorded at our Department since 2012 demonstrating several types and degrees of adhesions and their adhesiolysis by laparoscopy.

Results: Several types of adhesions are represented: dense, filmy, vascular or avascular. According to the Diamond and Nezhat classification, most of the adhesions are type 1 (A or B). Typical locations of adhesions are the abdominal wall, epiploic appendix and ovaries. Less frequent are the uterine and peri-hepatic adhesions.

Discussion: Postoperative adhesions are recognized as an important cause of morbidity in our patients, such as in bowel obstruction or infertility cases. Every abdominal surgery (by laparoscopy or laparotomy) can causes adhesions. A good surgical practice is the most important to reduce adhesion formation and prevent such complications.

CRYOPRESERVED FEMALE BODY TRUNK AS A MODEL FOR GYNECOLOGICAL LAPAROSCOPIC SURGERY TRAINING

Teaching & Training

Poster

Daniel Gracia Colera*, García Simón Raquel, Cañizares Oliver Silvia, Escolar Castellón Juan de Dios, Gascon Mas Elena, Gonzalez Ramos Pedro

HCU Lozano Blesa

Summary (4 lines): The difficulty of laparoscopic surgery has led professionals to design experimental models with animals or cryopreserved bodies, to enable the development of standardized learning techniques.

Introduction: Laparoscopic surgery is a difficult surgical technique, which requires a previous learning in different models like virtual models, animals or human cadavers. Cryopreserved bodies have the advantage that anatomy will be similar than alive humans, with those who we usually work. Thus, they let us learn dissection, cutting and suturing techniques, avoiding bleeding risk which facilitates the correct acquisition of the surgical technique to professionals.

Material and Methods: In Spain the use of cryopreserved bodies is regulated by the Spanish Anatomical Society. When a human cadaver is accepted by Medicine University and the body is not going to be used immediately, the cryopreservation process begins at -15 ° C. If the body is needed, it will be thawed in a cold room 4 ° to 6 ° C for a week, and 3-4 hours at room temperature.

Results: Using cryopreserved bodies is possible to learn the camera handling movements or the use of surgical laparoscopic instruments. They also allow us to identify easily human anatomical structures, improve section and dissection techniques, as well as electrocoagulation, cutting and suturing of differents humans tissues.

Discussion: The cryopreserved trunk body model allows us to recreate similar conditions to human anatomy in order to make easier the learning of the laparoscopic surgical technique. The growth of bodies donations to Spanish Medicine Universities increase the posibility to train in different gynecological surgical techniques to professionals.

LAPAROSCOPIC MYOMECTOMY DURING PREGNANCY: CASE REPORT AND REVIEW OF THE LITERATURE

Myomectomy

Poster

Alejandro Correa-Paris*, Suarez-Salvador Elena, Puig-Puig Oriol, Gracia Anna, Gil-Moreno Antonio

Hospital Vall d'Hebron. Universitat Autonoma de Barcelona. Barcelona

Summary (4 lines): We report the earliest laparoscopic myomectomy during pregnancy so far. A minimal invasive approach for myomectomy during pregnancy appears to be feasible in well-selected patients and with favorable obstetrical outcomes.

Introduction: A 36-year-old patient, G1P0, without any past medical history was sent to our hospital because of discordance between uterine height and gestational age. Findings on US examination were: a normal intrauterine singleton pregnancy with CRL 64mm (12 weeks’ gestation); and a large pedunculated uterine mass measuring 150x87x96 mm, suggesting a FIGO type 7 multi-lobulated myoma. During follow-up, we observed growth of the suspected myoma, and the patient referred important discomfort and recurrent pain.

Material and Methods: On physical examination a large abdominal mass up to the costal margin was found. Given the clinical progression and possible complications, we performed a laparoscopic myomectomy at 14weeks’ using closed entry (Veress) technique, without any complications. A 24cm diameter, 960g myoma was extracted by mechanical morcellation (12mm ROTOCUT, Storz). The 4-5cm uterine wound was closed in two layers with a continuous-running suture.

Results: Specimen analysis confirmed a leiomyoma. The remaining of pregnancy was uncomplicated, and an elective cesarean section was made at 39 weeks’ delivering a 3280g healthy newborn. Although myomectomy during gestation is not routinely performed because of its evident risks, most patients who do undergo surgery are usually summited to laparotomy.

Discussion: There is evidence that supports the advantages of laparoscopy over laparotomy in pregnant patients, and laparoscopic myomectomies have been accomplished during gestation. We reviewed the literature and found 9 previously published cases. No obstetric complications associated to the procedure were reported.

TUBO-OVARIAN ABSCESS- TO DRAIN OR NOT TO DRAIN?

Infertility and Reproductive Medicine

Oral

Dhiraj Uchil*, Squires Rachel

University Hospital Lewisham, London

Summary (4 lines): This retrospective case series of tubo-ovarian abscess compares the outcome for women following either primary or secondary surgery compared to those undergoing medical management.

Introduction: Tubo-ovarian abscesses are relatively rare gynecological conditions. Historically associated with active pelvic inflammatory disease, they may also result from the presence of an intrauterine contraceptive device. Surgery can be technically difficult due to active inflammation and tissue friability. Hence, there is a temptation to manage these with antibiotics alone. This can prolong the inflammatory process and adversely effect future fertility. Secondary surgery (after a period of antibiotics) may be very difficult due to dense adhesions.

Material and Methods: Retrospective case review of 39 women with tubo-ovarian abscesses treated over a 5 year period. Seven women (18%) underwent primary laparoscopic surgery with drainage of abscess and 21 (54%) had second line surgical management after attempted medical management with antibiotics. In these cases, the approach was either laparoscopy (n= 15) or laparotomy (n=6). Eleven women (28%) had non-surgical management; either antibiotic therapy alone (n=10) or antibiotics followed by ultrasound drainage (1)

Results: Primary laparoscopic management resulted in shorter hospital stay (mean 3.4 days) compared to delayed surgery (mean 6.5 days) and non-surgical management (mean 6.1 days). In addition, no women having initial laparoscopic management had critical care admissions or short-term postoperative complications. All four women requiring intensive care had second line surgery.

Discussion: Although limited by small numbers, this study suggests that surgical intervention is often required in tubo-ovarian abscesses and that primary laparoscopic management is associated with reduced postoperative stay and morbidity compared to delayed surgical management.

TRANSUMBILICAL LAPAROSCOPIC SURGERY FOR PREMALIGNANT AND MALIGNANT GYNECOLOGICAL DISEASES

Single Access Surgery

Poster

Stavros Diavatis*, Tzitzimikas Stergios, Fragkos Marios, Chastamouratidis Charalambos, Avgoustinakis Emmanouel, Papacharalampous Euaggelos

BioClinic

Summary (4 lines): Evaluating our data regarding transubilical laparoscopic surgery for premalignant and malignant conditions, we notice excellent recuperation and cost efficiency, but also steep learning curve and lack of standardized techniques.

Introduction: Transumbilical surgery performed either by multipuncture or single incision, is one of the latest developments in minimally invasive surgery, applied for both benign and malignant gynecological diseases. To the best of our knowledge, there are no data from Greece regarding this method in gynecologic oncology. The aim of this poster is to analyze a transumbilical laparoscopic approach using responsive tip instruments that mirror the surgeon’s hand movements and an energy source with multipurpose instrument.

Material and Methods: Eleven patients underwent transumbilical laparoscopic surgery. Diagnosis included four endometrial cancers, two suspicious ovarian masses, one CAH, adenomyosis, CIN III, CIS and Leydig ovarian neoplasm. The Thermal Seal™ energy generator and RealHand® HD laparoscopic instruments were used. Three 5mm umbilical SurgiQuest Anchor Port® trocars were inserted in triangular fashion: the central port accommodated a 30° scope and the adjacent two the thermal seal and the grasper. Vaginal vault suturing was performed with the V-Loc™ device.

Results: All patients but one was mobilized on the same day. Patient recuperation was uneventful. Technique limitations: • restricted instrument movement (Sword fighting effect) • requires highly specialized instruments • absence of standardized instrumentation/techniques • increased risk of umbilical hernia Hysterectomy seems easier to perform than adnexal surgery, due to larger extraction site (vagina vs. umbilicus).

Discussion: Transumbilical laparoscopic surgery is a feasible alternative technique, but highly depended on the industry and its own learning curve. It combines increased degree of instrument freedom, single site surgery, and cost comparable to conventional laparoscopy. No benefit for the patient was noticed except cosmesis and reduced pain perception.

LAPAROSCOPIC MYOMECTOMY IN AN UNIVERSITARY HOSPITAL AT OPORTO, PORTUGAL

Myomectomy

Poster

António José Cunha Braga*, Carvalho Ferreira Hélder , Cubal Rosália Maria, Pereira António Tomé

Centro Hospitalar do Porto

Summary (4 lines): Analyze laparoscopic myomectomy indications, surgical complications, number of fibroids removed, their localization and average diameter of all laparoscopic myomectomies carried out at our centre in the last 30.

Introduction: Uterine fibroids are the most common benign gynaecological tumor. Surgical treatment can be recommended when myomas become symptomatic, presenting with abnormal uterine bleeding, pain, causing infertility or when asymptomatic but growing rapidly. Laparoscopic myomectomy is a valid surgical option in many cases, offering benefits such as lower postoperative pain and shorter hospitalization time when compared to laparotomy. The objective of our study is analyze our experience in laparoscopic miomectomy.

Material and Methods: We conducted a descriptive retrospective study, that included 58 patients who underwent laparoscopic myomectomy during January 2011 to June 2013 at Centro Hospitalar do Porto, Oporto, Portugal. Parameters registered: myomectomy indications, surgical complications, number of fibroids removed, their localization and average diameter.

Results: We included 58 patients. Average age was 36,5 yeas. The main indication was abnormal uterine bleeding. In 82% one fibroid was removed (maximum four), with an avarege size of 5,4cm (maximum 10cm). Average hospitalization time was 2,3 days. There were no major complications during surgeries.We report 1 laparotomy conversion.

Discussion: Laparoscopic myomectomy is a safe procedure, presenting a shorter hospitalization time, a low complication risk, with good overall results and should therefore be a valid surgical procedure recommended in selected cases.

LAPAROSCOPIC SURGERY IN PELVIC ENDOMETRIOSIS IN AN UNIVERSITARY HOSPITAL AT OPORTO, PORTUGAL

Endometriosis: Surgery

Poster

António José Cunha Braga*, Carvalho Ferreira Hélder , Cubal Rosália Maria, Pereira António Tomé

Centro Hospitalar do Porto

Summary (4 lines): The goal of our study was to analyze surgery indications, operative time, surgical complications, conversion to laparotomy, length of hospital stay and impact in quality of life of laparoscopic surgery in patients with pelvic endometriosis, during the last 18 months.

Introduction: Endometriosis is a common condition that affects women at reproductive age with great impact on quality of life. The aim of this study was to analyze the surgical indications of laparoscopic surgery at our center in patients with endometriosis, the duration of the intervention, assessment of complications rate, the rate of conversion to laparotomy, the length of hospital stay and the impact of this treatment on the quality of life of these patients.

Material and Methods: We conducted a descriptive retrospective study, that included 61 patients who underwent laparoscopic surgery during January 2012 to June 2013 at Centro Hospitalar do Porto, Oporto, Portugal. Parameters registered: surgery indications, operative time, surgical complications, conversion to laparotomy, length of hospital stay, symptoms before and after surgery.

Results: We included 61 patients. Average age was 36,1 years. Main indications were dysmenorrhea and dyspareunia. Ovarian and rectovaginal endometriosis were the most common findings. Endometrioma extirpation and adhesiolysis were the most frequent procedures. Average hospitalization was 2,9 days. No intra-operative nor post-operative complications to report. 95% reported a symptomatology improvement.

Discussion: Laparoscopic surgery approach to rectovaginal and ovarian endometriosis is a safe procedure with good results, having a positive impact on quality of life and should be the primary surgical treatment of pelvic endometriosis.

LAPAROSCOPIC-ASSISTED RADICAL VAGINAL HYSTERECTOMY FOR EARLY-STAGE CERVICAL CANCER WITH 9 YEARS FOLLOW-UP

Oncology

Poster

Aldina Couso*, Zapico Álvaro, Fuentes Pedro, Valenzuela Pedro, Heras Irene, Marcos Victoria, Del Valle Cristina

Principe de Asturias Hospital.alcal de Henares.Mad

Summary (4 lines): The objective of this study is to study the feasibility, morbidity and outcome of early cervical cancer patients treated with laparoscopic assisted radical vaginal hysterectomy.

Introduction: The surgical management of cervical cancer has undergone considerable changes over the past years. The aim has been to reduce the morbidity associated with surgery without comromising the survival.In the recent years there has been a trend to evaluate the morbidity, recurrences rate and survival following laparoscopic assited radical vaginal hysterectomy.

Material and Methods: The study group included 35 patients with early cervical cancer (stage IA/IB1) undergoing laparoscopic-assisted radical vaginal hysterectomy.Data was collected on operating time, nodal yield, hospital stay, complications, recurrence rate and survival rate. The mediam follow up was 44,4 months (2-111) . 5 women had pelvic recurrence, and 3 patients developed distant metastatic disease and died. The overall mortality was 8,5 %.

Results: The median age was 48,7 years (26-68), the Quetelet index was 24,2 (18-32), the operating time was 232,6 minutes (70-360), and a hospital stay was 4,7 days (3-8). The median nodal yield was 14,8 (5-24), the median fall in haemoglobin was 2,3 g/dl (0,20-5,60).

Discussion: Vaginal radical hysterectomy with laparoscopic pelvic lymphadenectomy is feasible and safe with regards to mortality and has low morbility.

A COMPARISON OF LAPAROSCOPIC-ASSISTED RADICAL VAGINAL HYSTERECTOMY AND RADICAL VAGINAL HYSTERECTOMY IN EARLY-STAGE CERVICAL CANCER

Oncology

Poster

Aldina Couso*, Zapico Álvaro, Valenzula Pedro, Fuentes Pedro, Fernández Laura, Nebreda Lucía, Peco Soledad

Principe de Asturias Hospital.alcal de Henares.Mad

Summary (4 lines): The objective of this study is to compare peri-operative morbidity and recurrence-free survival of early stage cervical cancer patients treated by laparoscopic assisted radical vaginal hysterectomy with radical vaginal hysterectomy.

Introduction: The surgical management of cervical cancer has undergone considerable changes over the past years. The aim has been to reduce the morbidity associated with surgery without comromising the survival.In the recent years there has been a trend to evaluate the morbidity, recurrences rate and survival following laparoscopic assited radical vaginal hysterectomy compared with radical vaginal hysterectomy.

Material and Methods: The study group included 35 patients with early cervical cancer (stage IA/IB1) undergoing laparoscopic-assisted radical vaginal hysterectomy and 14 patients undergoing radical vaginal hysterectomy performed by the Gynecologic Oncology division at Principe de Asturias Hospital over a period of September 2001 - November 2011. A retrospective review was performed. Data was collected on operating time, nodal yield, hospital stay, complications, recurrence rate and survival rate

Results: Intraoperative morbidity characteristics analyzed (LARVH vs RVH) were fall in haemoglobin 2,3 g/dl (0,20-5,60) vs 3,11 (0,80-6,30)(pd was 14,8 vs 10,25 (p=0,8).

Discussion: The early cervical cancer can be treated successfully with laparoscopic-assisted radical vaginal hysterectomy with better efficacy, recurrence and mortality rates to radical vaginal hysterectomy. The major benefits are less intraoperative blood loss and shorter hospital stay and less operating time.

LAPAROSCOPIC REMOVAL OF RETROPERITONEAL POSTOPERATIVE FOREIGN BODY OF THE PELVIS

Case reports

Video

Alexander Ogurtsov*, Vedeneeva Natalie, Maltsova Julia, Naurbieva Marha, Komlev Dmitry

Yaroslavl region hospital

Summary (4 lines): We present postoperative foreign body of the pelvis. It laparoscopic removal was complicated by the injury of right internal iliac vein, managed with endoscopic suturing.

Introduction: Retained for 16 years postoperative surgical gauze of the pelvis is rare iatrogenic complication. It removal is associated with significant technical difficulties of avoiding intestines, ureteric and vascular injuries due to these masses are surrounding with fibrotic tissue and deep in the pelvis. We present the selective enucleation of such pelvic nodular mass, complicated with vascular injury, treated laparoscopically.

Material and Methods: A 24 year old woman complained from abdominal pain within a year after the first birth. She had laparotomies aged at 6 and 8 years because of vesicoureteral reflux. Ultrasound showed 8 cm right pelvic mass, attaching sidewall up to internal inguinal ring. Fibrotic tissue made difficult to find the cleavage planes to liberate the mass. The 2 mm injury of vessel wall, identified as internal iliac vein, was managed with intracorporeal suturing.

Results: The patient postoperative course was uneventful. Histology confirmed an organized encapsulat ed foreign body (gauze).

Discussion: Laparoscopic approach to pelvic retroperitoneal masses is feasible, even in the cases of previous surgery. We presented technical difficulties of such procedure, including vascular complication, to highlight the importance of recognising it intra-operatively and manage laparoscopically.

LAPAROSCOPIC SACROCOLPOPEXY USING 3-MM TROCARS

Innovation in Instrumentation and Surgical Techniques

Video

MARCELLI MAXIME*, aubert AGOSTINI, patrice CROCHET

hôpital la conception; marseille

Summary (4 lines): Laparoscopic sacrocolpopexy is the gold standard for the treatment of pelvic organ prolapse. One of our goals is to perform less invasive laparoscopic sacrocolpopexy that’s why we used 3 mm trocars.

Introduction:5-mm trocars currently used have in fact an external diameter of 9-mm in average. 3-mm trocars used in the video has an external diameter of 4-mm. when the external diameter is halved,incision sizes are reduced and we have many benefits:better aesthetic results and less post operative pain.

Material and Methods: We performed 10 laparoscopic sacrocolpopexy with3-mm trocars. All patients had pelvic organ prolapse stage 2 at least , according to POP-Q classification. For all procedures we used 3 of 3 mm trocars (one in the right iliac fossa , one in the left iliac fossa , one latero right umbilical ) and one umbilical trocar of 10-mm. All instruments used were 3 mm instruments. We evaluated the feasibility and operative times.

Results: Operative times were the same as those obtained with conventional trocars. No specific complications were noted. The incisions were smaller than that observed for trocars of 5mm diameter and could be closed by glue.

Discussion: With instruments and trocars of 3mm, there is no loss of strength or accuracy. For the operator there is almost no difference in use of instruments of 3 or 5 mm. Thanks to this minimal invasive approach we hope less post operative pain and better aesthetic results for the patient.

IS ABDOMINAL HYSTERECTOMY OBSOLETE? AN EXPERIENCE OF LAPAROSCOPIC HYSTERECTOMY IN A LONDON DISTRICT GENERAL HOSPITAL

Hysterectomy

Poster

Sukhera Sheikh*, Nalathambi Jothi, Duroshola Olugbenga

Hospital

Summary (4 lines): Laparoscopic hysterectomy has become increasingly commonplace over the last 20 years. We present the outcome of such procedures performed in our unit and ask is abdominal hysterectomy becoming obsolete?

Introduction: Up to a 100,000 hysterectomies are performed each year in the UK alone providing definitive treatment for women suffering with menorrhagia, symptomatic fibroids and early uterine malignancy. Although traditionally performed abdominally, both total and subtotal laparoscopic hysterectomies have gained increasing momentum over the past twenty years. Indeed with several trials suggesting greater patient satisfaction and total reduced costs with laparoscopic methods compared to abdominal approaches, we ask is ‘abdominal hysterectomy becoming obsolete?’

Material and Methods: We retrospectively identified fifty patients who had undergone a laparoscopic hysterectomy during the time period of 2011 to 2013. Using a standardised proforma we collated demographic data on each patient as well as indications for hysterectomy, intraoperative data (duration of surgery, complications, conversion to laparotomy, blood loss), immediate post- operative data and follow up. The information was transferred and analysed using Excel and percentages of each outcome were recorded.

Results: pending following analysis

Discussion: Our study determines the immediate and short term outcomes of laparoscopic hysterectomy and the subsequent impact on recovery. Although only containing 50 cases, our study describes how minimal access techniques can be adopted even in smaller units and supports the growing evidence base favouring laparoscopic approaches to hysterectomy.

LAPAROSCOPIC CORE NEEDLE BIOPSY OF UTERINE FIBROID PRIOR TO GLOBAL FIBROID ABLATION

Innovation in Instrumentation and Surgical Techniques

Oral

Markus Hahn*, Bernhard Kraemer, Dorit Kraemer, Andrei Taran, Sara Brucker

University Hospital of Tuebingen, Department of OB

Summary (4 lines): Core biopsies of uterine myomas targeted for treatment by laparoscopic ultrasound-guided global fibroid ablation yield benign masses in all cases.

Introduction: Large uterine myomas in premenopausal women rarely are leiomyosarcomas. However, biopsies of uterine myomas may be relevant prior to non-excision treatment techniques such as uterine artery embolization, high-intensity focused ultrasound, or ablation. Laparoscopic ultrasound-guided global fibroid ablation of uterine myomas permits both biopsy and ablation of all myomas within a uterus.

Material and Methods: Fifty premenopausal women with symptomatic uterine fibroids were randomized in a single-center study to either global fibroid ablation (GFA) or laparoscopic myomectomy. In GFA subjects, myomas were detected by laparoscopic ultrasound and core biopsies of the largest myomas were taken intraoperatively and percutaneously with a 16-gauge core needle (without coax needle). The 3.4-mm radiofrequency ablation probe was inserted in the biopsy tract and ablation was conducted. Pathological analysis of tissue biopsies was performed and recorded.

Results: Twenty-five subjects were randomized to ablation, and 26 myomas, 1.0–8.6 cm in size (sum of major diameters) were biopsied. Myoma types included subserosal (n=10; 38.5%), intramural (n=16; 61.5%), and submucosal (n=0). Prolonged bleeding from one biopsy site was coagulated by the radiofrequency probe. No malignancies were detected.

Discussion: Laparoscopic, ultrasound-guided global fibroid ablation permits detection, analysis and treatment of myomas, regardless their type and size and predicts—in a small heterogeneous population of women—benign occurrences.

MULTIMEDIA IN MEDICAL TRAINING: THE NEED FOR A NEW BREED OF TEXTBOOK

Teaching & Training

Poster

George Goumalatsos*, Smith CBJ, Modares M, Chappatte OA

Tunbridge Wells NHS Trust

Summary (4 lines): Delivery of medical knowledge with traditional paper textbooks is coming to an end. A new breed of multimedia-rich textbook is required. Sophisticated applications can assist us in this task.

Introduction: Conventional textbooks can no longer provide the vast amount of available knowledge. Authoring is strenuous, complicated and time consuming. Accompanying multimedia and/or internet access is required for a holistic approach. Clinicians search for pictures and videos using different sources, sometimes of questionable quality. E-textbooks containing pictures, diagrams, 3-D images, quizzes, videos in one place are now required. Many authoring applications are readily available with endless, unknown to the medical world, capabilities.

Material and Methods: All the e-authoring applications were identified by performing a Google and Pubmed search using the keywords authoring, multimedia education and were evaluated. We have chosen to present the iBooks Author application because of its user friendliness, versatility, learning curve and ease to produce impressive, easily customisable, multi-touch e-textbooks. Its applicability, acceptability, reliability and limitations were appraised by trainers and trainees using educational application evaluation rubric. Its use in training logbook creation is also postulated.

Results: iBooks Author is a free authoring application downloadable from the internet. It enables the creation of multimedia-rich e-textbooks, containing pictures, interactive objects, dynamic 3-D images and even videos. Although user-friendly, its limitation to read the e-textbook only on iPad, retsricts its target group.

Discussion: Never before the need for organised and filtered delivery of educational multimedia was more imperative. E-authoring applications can provide free, readily available, cross platform and device compatible e-textbooks, promoting on-line collaborative authoring and improving the surgical training and practice.

THE LUSTOR TRIAL: A RANDOMIZED CONTROLLED STUDY OF LAPAROSCOPIC UTERINE-SPARING TECHNIQUES, OUTCOMES, AND REINTERVENTIONS

Innovation in Instrumentation and Surgical Techniques

Oral

Sara Brucker*, Markus Hahn, Dorit Kraemer, Andrei Taran, Bernhard Kraemer

Tuebingen University Women's Hospital

Summary (4 lines): Outpatient, laparoscopic ultrasound-guided global fibroid ablation is associated with significantly less intraoperative blood loss and significantly shorter hospitalization than is laparoscopic myomectomy.

Introduction: The objective is to compare intraoperative blood loss and the hospitalization times in premenopausal women who undergo one of two uterine-conserving treatments for symptomatic uterine fibroids: laparoscopic ultrasound-guided global fibroid ablation and laparoscopic myomectomy.

Material and Methods: Fifty premenopausal women with symptomatic uterine fibroids were randomized in a single-center study in Germany to either laparoscopic global fibroid ablation or laparoscopic myomectomy. For both arms, laparoscopic ultrasound was used to map the uterus and locate all fibroids. Intraoperatively and immediately following laparoscopic ultrasound mapping, each subject was randomized either to global fibroid ablation or laparoscopic myomectomy.

Results: Twenty-five subjects were randomized to ablation and 25 to myomectomy. Mean intraoperative blood loss for the ablation and myomectomy groups were, respectively, 16±9 mL and 51±57 mL. Time from anesthesia induction to hospital discharge was 9.98±5.47 hours and 29.94±14.18 hours for the ablation and myomectomy patients, respectively (p

Discussion: Women desiring a uterine-conserving procedure for fibroids experience less intraoperative blood loss and earlier hospital discharge when treated by laparoscopic global fibroid ablation compared to those women undergoing the standard of care, laparoscopic myomectomy.

TORTION OF A OVARIAN TERATOMA AND THE LAPAROSCOPIC APPROACH DURING THE 2ND TRIMESTER OF PREGNANCY

Case reports

Poster

KONSTANTINOS LATHOURAS*, Bell Susie, Kirkpatrick Alison, Riddle Andrew, Elkington Nick, Beynon Gareth

Frimley Park Hospital NHS Foundation Trust

Summary (4 lines): During 19/40 of pregnancy a 24 year old woman diagnosed having a necrotic, torted 12cm right ovarian teratoma. Laparoscopic approach during the 2nd trimester of pregnancy is a safe approach.

Introduction: Adnexal masses are diagnosed 2% - 4% of all pregnancies at early gestation ultrasonography. The majority resolves spontaneously by the 16th week of gestation. 6% of adnexal masses operated during pregnancy are malignant. After 16th week of pregnancy only 0.3% are mature cystic teratomas. The exact percentage of adnexal masses that can be torted at pregnancy is unknown.

Material and Methods: A 24 year old woman G2P1, with insignificant past medical history and a known dermoid cyst presented at the emergency department while she was 19 week pregnant with a sudden unprovoked acute lower abdominal pain (scoring 9/10) and vomiting. Ultrasonography confirmed a 12 cm possible torted right ovarian dermoid cyst. A decision made for laparoscopical treatment. Pneumoperitoneum created with Veress needle through Palmer’s point due to the size of the uterus.

Results: Right adnexa was torted and necrotic. The adnexa was untwisted and a right salpingoophorectomy performed. With the help of a 15 cm endobag the dermoid cyst extracted intact. Recovery was unremarkable and patient discharged in less than 24 hours. Fetal heart rate activity confirmed before and after the operation.

Discussion: We believe that a dermoid cyst larger than 5cm should be treated in women that plan to conceive and that a laparoscopic management during the 2nd trimester of pregnancy is a safe approach. Laparascopy in pregnancy should be performed by an experienced surgeon or by a skilled laparoscopist under supervision.

SUPRACERVICAL LAPAROSCOPIC HYSTERECTOMY – ADVANTAGES AND RISKS

Hysterectomy

Oral

Nicolae Suciu*, Nuti Dana Oprescu, George Adrian Costin, Tudor Florea, Ioan Dumitru Suciu

IOMC "Alfred Rusescu" Dep Polizu Hospital

Summary (4 lines): One of the most debated issues in performing supracervical hysterectomy is related to the length of the learning curve and complications that may occur more frequently in both the “early“ and the “late“ case

Introduction: Recent reviews concluded that vaginal hysterectomy is preferable to abdominal hysterectomy and that a laparoscopic hysterectomy should be attempted when vaginal hysterectomy is not possible. Laparoscopic hysterectomies has been associated with shorter hospital stay, speedier return to normal activities, decreased blood loss and fewer abdominal infections when compared with abdominal hysterectomies. The choice of surgical approach depends upon the indications for the procedure, concomitant procedures, surgical outcomes of each approach, surgeon experience, and patient preference

Material and Methods: We used for material information the database of the Polizu Clinical Hospital of the last five years and recent reviews and meta-analysis published in prestigious international journals.

Results: Our practice confirm scientific data recorded by the majority of studies regarding laparoscopic supra-cervical hysterectomy. In the last 5 years, in “Polizu” hospital were performed 2620 hysterectomies. There were 2211 total abdominal hysterectomies, 104subtotal abdominal hysterectomies, 10 total laparoscopic hysterectomies, 19 supracervical laparoscopic hysterectomies and 275 hysterectomies using vaginal route.

Discussion: Laparoscopic total/supracervical are alternatives for classic abdominal surgery which would help us to approach, alongside the vaginal route, the minimally invasive trend in gynecologic surgery.

HYDROLAPAROSCOPY - TREATMENT OF INFERTILITY DUE TO PCOS AFTER FAILURE OF PHARMACOLOGICAL MANAGEMENT

Infertility and Reproductive Medicine

Poster

Pieta Wojciech*

MSS in Warsaw & Warsaw Medical University

Summary (4 lines): Retrospective file review of 18 women with PCOS resistant to clomiphene who had hydrolaparoscopy with ovarian drilling with bipolar energy, hysteroscopy and chromopertubation. Pregnancy occurred in 10 cases(55,5%).

Introduction: Evaluation hydrolaparoscopy outcome among women with infertility due to polycystic ovarian syndrome(PCOS) resistant to citrate clomiphene(CC).

Material and Methods: Mean age was 31,4 years (SD 6,5)[28-34,6 CI 95%] and mean BMI 26,6 kg/m2 (SD 6,9)[22,3-30,6 CI 95%]. Laparoscopic conversion was required in 3 cases(16,6%) due to failure with entrance to Douglas cavity.

Results: 17 women(94%) had positive chromopertubation and 2 women had uterine anomaly- 1 T-shaped uterine cavity and 1 endometrial polyp. Pregnancy occurred in 10 cases(55,5%), spontaneously in 5 cases(27%), after ovarian stimulation in 4 cases (22,2%), after IVF 1(5,5%).

Discussion: Ovarian drilling by hydrolaparoscopy is a minimal invasive method of treatment for clomiphene resistant PCOS. It let to check anatomy of reproductive organ. Procedure is a quick method which allows to help women underwent with pregnancy with small risk of complications and short time of convalescence.

THE IMPROVEMENT OF THE OUTPATIENT DIAGNOSTICS OF INTRAUTERINE PATHOLOGY

Imaging

Poster

Haykuhi Aghajanyan*

Moscow Sechenov Medical Academy

Summary (4 lines): The aim of study is to estimate diagnostic values of isolated and combined use of transvaginal ultrasound, saline infusion sonohysteroscopy, Pipelle and diagnostic hysteroscopy in outpatient diagnostics of intrauterine pathology.

Introduction: This is a blind prospective study of random 66 women of reproductive and postmenopausal periods, planned for operative hysteroscopy and D&C for pathological uterine bleeding (n30), abnormal pelvic ultrasound (n29) and cervical polyps (n7). The intrauterine pathology detected in 75,8% (n50) patients, in 12% (n8) - revealed more than one pathology. The final diagnoses: submucous myoma 18,2% (n12), uterine anomaly 3% (n2), sinechia 4,5% (n3), hyperplasia 13,6% (n9), polyp 45,5% (n30) and adenocarcinoma 7,6% (n5).

Material and Methods: The examination of patients conducted in outpatient and inpatient stages. The first stage consists of Pipelle (n64) and transvaginal ultrasound (n66), saline infusion sonohysteroscopy with Goldstein catheter (n55), diagnostic hysteroscopy (n64) and combined diagnostic hysteroscopy with saline infusion sonohysteroscopy (n64). The second stage - operative hysteroscopy and D&C (n66). The results of 89% operative hysteroscopy and D&C and 11% hysterectomies accepted as final diagnoses. All the technologies were used blindly - by 5 different gynecologists.

Results: Combined saline sonohysteroscopy with diagnostic hysteroscopy and Pipelle gives the right diagnosis in 100% of cases. No statistically meaningful difference between diagnostic hysteroscopy and saline infusion sonohysteroscopy found. Most false-negative results of isolated use of diagnostic tools was in cases of plural intrauterine pathologies (5/6).

Discussion: The qualitative outpatient diagnostics of intrauterine pathology is the combination of Pipelle, saline sonohysteroscopy and diagnostic hysteroscopy with 100% sensitivity, specifity and diagnostic accuracy. It is especially useful when plural intrauterine pathology is suspected. Basic disadvantage of saline sonohysteroscopy is a plenty of unsuccessful attempts – 17%.

ECTOPIC PREGNANCY ON A CESARIAN SCAR – CASE REPORT

Case reports

Poster

Paula Norinho Oliveira*, Leitão Susana, Costa Cristina , Ferreira Soledade, Teles Teresa Paula, Caldas Rita, Rodrigues Catia, KoK Mak Foo, Lanhoso António

Entre Douro e Vouga Hospital Center

Summary (4 lines): Description of a case of an ectopic pregnancy on a cesarian scar that was submitted to a laparoscopic surgery. To emphasis on the importance of early diagnosis of this rare condition and the advantage of laparoscopic surgery in this case.

Introduction: A 28-year-old woman with a history of cesarian section 16 months ago, presented with 5 weeks amenorrhoea, with abdominal pain and vaginal bleeding. An extrauterine pregnancy of 7 weeks, with a live embryo was diagnosed by ultrasound and diagnostic laparoscopy was subsequently performed. The ectopic pregnancy was removed from the cervical isthmus with hysterotomy and a single layer hysterorraphy performed, followed by cervical dilatation and curettage. The patient was discharged well after 4 days.

Material and Methods: Retrospective revision of the patient’s clinical profile.

Results: Histological report revealed direct invasion of trophoblasts into the entire uterine scar tissue of the previous cesarean incision.

Discussion:Cesarean scar pregnancy is one of the rare types of ectopic pregnancy. A combination of early diagnosis with ultrasound and laparoscopic surgery are essential for successful treatment and preservation of reproductive capability of the patient with an unruptured ectopic pregnancy in a previous caesarean scar.

HYSTEROSCOPY IN THE MANAGEMENT OF THE CAESAREAN SCAR PREGNANCY

Surgical Hysteroscopy

Oral

Dimitrios Panayotopoulos*, Hucke Jürgen

Bethesda Hospital Wuppertal

Summary (4 lines): Treatment options for caesarean scar pregnancy include surgery and/or medical therapy. Hysteroscopic resection represents an effective treatment option for this form of ectopic pregnancy.

Introduction: Caesarean scar pregnancy (CSP) is a rare but critical situation and is associated with an increased risk of uterine rupture and intraperitoneal hemorrage. In case of a CSP diagnosis a prompt termination of the pregnancy is indicated in order to prevent serious or even fatal complications. Due to the low number of reported cases, there are no existing treatment guidelines so far. Numerous methods of surgical and conservative treatment particularly using methotrexate have been issued.

Material and Methods: A 30year old woman with a history of two C-sections presented to us with slight abdominal pain in the sixth week of gestation. Sonography revealed an empty uterine cavity and a 15mm measuring gestational sac in the C-section scar with a myometrium thickness of 4mm above. We performed a hysteroscopic resection of the pregnancy with the monopolar loop. No complications occurred during and after procedure and the patient was dismissed on postoperative day 1.

Results: We demonstrate a case of CSP successfully treated with hysteroscopic resection with the monopolar loop under sonographic surveillance. However, the hysteroscopic treatment of CSP should be performed by experienced hysteroscopic surgeons since the risk of uterus perforation and urinary bladder lesion is explicit.

Discussion: CSP shows an increasing prevalence. Treatment with methotrexate (systemic as multidose protocol or local application under sonographic surveillance), local KCl application, uterine artery embolisation and curettage and combinations have been published. Hysteroscopic resection performed by experienced surgeons represents an effective and safe treatment option for patients with sonographic intact myometrium.

PLACENTAL SITE TROPHOBLASTIC TUMOR

Case reports

Poster

Faride Ojeda Claro*, Martinez Tercero Fatima , Carabias Lopez Esperanza, Palacios Rodriguez Antonio, Maldonado del Valle Maria Dolores, Cañete Palomo Maria Luisa

Hospital Virgen de la Salud

Summary (4 lines): We report a rare case of placental site trophoblastic tumor (PSTT) suffered by a 33-year-old woman after normal delivery. It was diagnosed after one year of postpartum amenorrhea with small accounts of beta-hCG continuining elevated.

Introduction: The ultrasound evidenced linear endometrium and a intracavitary hyperechoic image of 12x6 mm. Hysteroscopy and endometryal biopsy showed a trophoblastic proliferation compatible with PSTT. After a review of the literature and consensua of tumor´s committee, a total lapartoscopic hysterectomy was performed with a final report of a 3.5x2.5 cm PSTT.

Material and Methods The placental site trophoblastic tumor is a relatively uncommon form of gestational trophoblastic tumor (GTD) accounting for less than 3% of GTD cases. The tumor is composed of neoplastic implatation site intermediate trophoblastic cells than resemble those infiltrating into the endometrium and myometrium of the placental site during early pregnancy.

Results: PSTT occurs commonly following a normal pregnancy. However, spontaneous abortions have preceded the diagnosis of PSTT, how is chemoresistent and may still progress even if beta-hCG levels are low.

Discussion: The prognosis it depends on FIGO stage, metastasis involvement, long interval from the pregnancy, age, hCG levels, depth of invasion and high mitotic count. The mortality rate depends on its stage and can represent 15-30% in FIGO stage IV disease in contrast to 90% survival rate in FIGO stage I.

TOTAL LAPAROSCOPIC HYSTERECTOMY FOR ENLARGED UTERI WEIGHTING MORE THAN 500G: A RETROSPECTIVE COMPARATIVE STUDY

Hysterectomy

Poster

Giovanni Roviglione*, Ceccaroni Marcello, Clarizia Roberto, Mabrouk Mohamed, Bruni Francesco, Minelli Luca

Sacred Heart Hospital of Negrar

Summary (4 lines): we present a large retrospective series of consecutive patients treated by Total Laparoscopic Hysterectomy considering surgical outcomes of patients with uteri weighting >500g with respect to uteri weighting.

Introduction: we compared surgical outcomes and short term follow-up of all consecutive patients undergoing Total Laparoscopic Hysterectomy (TLH) from December 2001 to December 2012 at the Department of Gynecology and Obstetrics and in the Gynecologic Oncology and Minimally-Invasive Pelvic Surgery Unit of Negrar. Patient population was divided into two groups: group A consisted in all the patients with a uterus weighting less than 500g, whereas group B consisted in all patients uteri weighting more than 500g.

Material and Methods: Over 1557 patients, 1237 were included in group A and 320 patients in group B. TLH was performed for benign disease, endometriosis or oncologic indications in 78,5%, 13,9% and 7,5% of the cases, respectively. The uterus was removed by mechanical, cold knife and vaginal morcellation in 32,8%, 4,4% and 11,5% of the cases.

Results: Intraoperative blood loss and median operative time were significantly higher in group B than in group A and Intraoperative complications were similar in both groups. Seven patients were converted to laparotomy in group B. There were no statistical differences in terms of median hospital-stay and late complications between both groups.

Discussion: Despite longer operative times, higher intraoperative blood loss and higher rate of laparotomic conversion, TLH showed to be a feasible and safe technique in cases of enlarged uteri, with low rate of post-operative complications and with the same hospital-stay and time-to-recovery of patients with uteri of less than 500g.

LAPAROSCOPIC SURGICAL TREATMENT OF DIAPHRAGMATIC ENDOMETRIOSIS: A SINGLE-INSTITUTION 8 YEARS RETROSPECTIVE REVIEW

Endometriosis: Surgery

Oral

Giovanni Roviglione*, Ceccaroni Marcello, Clarizia Roberto, Mabrouk Mohamed, Bruni Francesco, Ruffo Giacomo, Minelli Luca

Sacred Heart Hospital of Negrar

Summary (4 lines): We present a large retrospective series of consecutive patients treated for diaphragmatic endometriosis at the “Sacred Heart” hospital of Negrar, from January 2004 to June 2013.

Introduction: Diaphragmatic endometriosis is a rare condition that may cause invalidating epigastric or thoracic pain and catamenial pneumothorax. During the past decades, laparoscopy has been proposed as an optimal tool for diagnosis and surgical eradication of the disease.

Material and Methods:we present a retrospective series of 3758 consecutive patients affected by diaphragmatic endometriosis, treated by laparoscopy at our institution, during a period of 8 years. Most of the symptomatic patients were treated by complete excision of the nodules, whereas only three patients referring right upper-quadrant abdominal pain and right shoulder cathamenial pain had superficial diaphragmatic endometriosis and were treated by diathermocoagulation.

Results: we identified 60 consecutive cases with of diaphragmatic endometriosis. We identified multiple diaphragmatic lesions in 42 patients and single lesions in 18. Implants were distributed on the right side in 52 patients; in 6 patients they were bilateral and 1 patient had a single lesion on the left hemidiaphragm.

Discussion: Diaphragmatic endometriosis should be included in the concept of eradication of endometriosis. This kind of surgery has shown to be feasible and cost-effective; however, it should be managed by an expert laparoscopic gynecologist with knowledge of oncological surgical techniques, with the support of a general surgeon and a trained anesthesiologist.

EXPERIENCE OF SIMULTANEOUS OPERATIONS IN GYNECOLOGIST’S PRACTICE

Operative Risk Management

Oral

Daria Simrok-Starcheva*, Zheltonozka Iuliia, Simrok Vasily

Lugansk state medical university

Summary (4 lines): The conducted analysis has revealed that the simultaneous operations in gynecological patients by the process and influence are more traumatic.

Introduction: Operative treatment of patients with combined gynecological and surgical disorders is a complex problem. doctors as well as patients always care about surgical stress, realistic human performance in each specific case and advisability of such type of surgery. Therefore the aim of our investigation was to analyze the clinical characteristics of conducting the simultaneous operations by gynecological patients.

Material and Methods: We have carried out an analysis of the medical records for 5 years. There have been analyzed 2029 clinical cases of surgery which included groups of the absolutely surgical pathology and absolutely gynecological pathology and we have found patients who have withstood the simultaneous operations.

Results: The conducted analysis has revealed that the simultaneous operations in gynecological patients by the process and influence are more traumatic and cost-cutting that requires work-out of the new approaches to the conducting of such operations.

Discussion: Our further researches will be devoted to the investigation of the pathogenetic mechanisms of the disturbing factors on a woman’s body of the simultaneous operations.

EFFICIENT USE OF CRYOPRESERVED FEMALE BODY TRUNK TO IMPROVE GYNECOLOGICAL SURGICAL SKILLS: II. LAPAROSCOPIC SURGERY

Teaching & Training

Video

Raquel Garcia-Simon*, Gracia Colera Daniel, Cañizares Oliver Silvia, Gascón Mas Elena, Escolar Castellón Juan de Dios, Gonzalez Ramos Pedro

Lozano Blesa Hospital

Summary (4 lines): Cryopreserved female bodies let professionals and trainees to improve and learn easily laparoscopic techniques than in alive humans.

Introduction: Professionals and trainees use to improve and learn the laparoscopic surgical technique cryopreserved bodies as they offer the possibility to perform training exercises avoiding the bleeding risk. It is suitable to recognize the generosity of people who donates their body to science. It is also important to emphasise that their use should be as efficient as possible to enforce donor's desire that their body was made the most of as optimally as possible

Material and Methods: Cryopreserved body trunks allow to achieve handling skills of laparoscopic instruments and to teach professionals the best ergonomic position during surgery. This model generally offers up to 30 hours practicing dissection techniques, cutting and stitching which will allow professionals to carry out surgeries as tubal ligation, salpingectomy, oophorectomy or radical hysterectomy with pelvic and lumboaortic lymphadenectomy. Cryopreserved trunks are also excellent models to learn the dissection technique related to get the paravesical and pararectal space.

Results: The model has demostrated to be superior to other models, like model animal, allowing professionals and trainees improve and learn laparoscopic techniques, avoiding innecesary risks in alive humans.

Discussion: Thanks to the cryopreserved female body model, professionals can achieve enough laparoscopic surgical skills to have the knowledge and the necessary security performing a laparoscopic surgery in living humans.

IUD REMOVAL DURING OFFICE HYSTEROSCOPY: ABOUT 36 CASES

Diagnostic & Operative Office Hysteroscopy

Poster

Anne-Julie CARIN*, Garbin Olivier

Hopitaux universitaires de Strasbourg

Summary (4 lines): We describe our experience in office hysteroscopy to remove stuck IUD, with vaginoscopic procedure. Our procedure is successful in 94,4% of 36 cases and most of the time well tolerated

Introduction: Intra-uterine device (IUD) represents the first contraceptive method around the world. It’s removal is not always easy, sometimes impossible. Then, gynaecologists usually remove it with forceps, blindly, which can be painful, unsuccessful, even if they are ultrasound-guided. Our work evaluates the use of office hysteroscopy to proceed to the removal of stuck IUD.

Material and Methods: We conducted a retrospective monocentric study, in Strasbourg University Hospital, between May 2005 and June 2012. 3 529 hysteroscopies were identified in our electronic base of gynaecologic consultations, 81 due to a problem in relation with IUD. Success in the removal and patient tolerance were studied. We used to proceed as Bettocchi: vaginoscopic procedure without Pozzi forceps, 5,5mm diameter hysteroscope, saline solution instillation, and eye-guided removal.

Results: 36 hysteroscopies were performed in order to remove stuck IUD. After hysteroscopic procedure, removal was effective in 34 on 36 cases (94,4%). Procedure was well tolerated in 12 cases, moderately tolerated in 10 cases, unconfortable in one case, and one patient presented a vasovagal syncope during examination.

Discussion: Already used by some specialists in an everyday practice to perform endometrial biopsies, polype resection, myoma resection, Essure® sterilization, and synechiae adhesiolysis, office hysteroscopy could be proposed in first place when IUD removal is impossible in consultation. In our cohort, this procedure was successful in 94,4% of cases.

PRINCIPLES OF ELECTROSURGERY

Teaching & Training

Poster

Nidhi Sharma Chauhan *

Self employed

Summary (4 lines): Principles and safety measures in electrosurgery.

Introduction: Principles and safety measures of electrosurgery must be well understood , thus forming the basis of patient safety.

Material and Methods: Through study of various texts was done to summarise principles and safety measures if electrosurgery ,

Results: Safety measures are important for patient safety . They must be understood by all the theatre staff

Discussion: Basic principles of electrosurgery form the basis to patient safety and success of the surgery.

TREATMENT FOR LOCALLY ADVANCED CERVICAL CANCER: 10 YEARS FOLLOW UP

Oncology

Poster

Aldina Couso*, Zapico Álvaro, Valenzuela Pedro, Fuentes Pedro

Principe de Asturias Hospital.alcal de Henares.Mad

Summary (4 lines): The objective of this study is review the approach to women with locally advanced cervical cancer, recurrence and survival rates.

Introduction: Women with locally advanced cervical cancer have a higher rate of recurrence and worse survival.For these women is recomended prymari chemoradiation rather tahn primary surgry or radiation therapy. For woman with para-aortic node involvement, the chemoradiation must be with extended field RT.

Material and Methods: The study group included 54 patients with locally advanced cervical cancer (stage >IB1) treated by the Gynecologic Oncology division at Principe de Asturias Hospital over a period of September 2001 - November 2011. A retrospective review was performed. Data was collected on stage, surgical and adyuvant treatment, complications, recurrence rate and survival rate.

Results: The surgical treatment was in 9 cases (16,7%) radical hysterectomy, in 6 cases (11,1%) laparoscopic transperitoneal pelvic and para-aortic lymphadenectomy, in 16 cases (29,6%) laparoscopic extraperitoneal para-aortic lymphadenectomy and in 6 cases (11,1%) laparoscopic transperitoneal para-aortic lymphadenectomy.6 women had pelvic recurrence,the overall mortality was 22,2%.

Discussion: For woman with locally advanced disease for whom primary chemoradiation is planned, it is necessary to evaluate the extent of disease with particular attention to lymph node metastases to provide information to design radiation fields.

OUTPATIENT RESECTOSCOPY: A VALUABLE THERAPY. AUDIT OF OVER 800 CASES

Surgical Hysteroscopy

Oral

Renata Verissimo*, Silva Vera, Batista Joana, Nogueira-Martins Nuno, Pipa Antonio, Nogueira-Martins Francisco

Dep ObGyn Viseu

Summary (4 lines): Ressectoscopy is an effective and safe technique to treat intrauterine benign lesions. 808 cases were audited.

Introduction: Resectoscopy techniques are performed under hysteroscopic visualization, using resectoscopic instruments to ablate or resect the endometrium. Ressectoscopy is an effective and safe technique to treat intrauterine benign lesions.

Material and Methods: Between January, 2008 and April, 2013, 808 patients were submitted to a resectoscopy in an outpatient setting, defined as length of stay in hospital for less than 24 hours. All procedures were performed by experienced surgeons, using a bipolar resectoscope under general anesthesia or sedation. Postmenopausal patients had done cervical preparation with vaginal misoprostol prior to intervention. Cervical dilatation was performed using Hegar bougies until 9 mm.

Results: In 740 (91,6%) procedures uterine cavity was reached. 556 (75,1%) polypectomies, 131 (17,7%) myomectomies, 27 (3,6%) myomectomies plus polypectomies and 26 (3,5%) endometrial ablations were performed. In 17 (2,10%) cases it was not possible to enter cavity. Complications rate was low (2,23%). Eight cases of endometrial carcinoma were diagnosed unexpectedly.

Discussion: As described in literature, our audit confirms bipolar resectoscopy performed in outpatient basis as a practical and safe surgical technique to treat benign endocavitary pathologies. The high level of training and experience of our surgeons may help justify the low rate of complications associated with ressectoscopies found in this study.

EFFICIENT USE OF CRYOPRESERVED BODY TRUNK FOR SKILLS ACQUISITION: GYNECOLOGICAL ENDOSCOPIC AND PELVIC FLOOR SURGERIES

Teaching & Training

Video

Daniel Gracia Colera*, Garcia Simon Raquel, Gonzalez Ramos Pedro, Ochoa Zarzuela Diego, Breton Hernandez Patricia, Escolar Castellon Juan de Dios

HCU Lozano Blesa

Summary (4 lines): In recent years, efficient use of cryopreserved body trunk has enabled learning and improving laparoscopic techniques, but also has extended its use to hysteroscopy and pelvic floor surgery.

Introduction: Hysteroscopic surgery and pelvic floor surgery are complex surgical techniques, which require previous learning. In the case of hysteroscopy, there are multiple virtual models, but there is little experience in human cadaver models. The human body has the advantage that the anatomy will be identical that usually work in surgery, although the conditions are modified by the status mortem.

Material and Methods: Spanish Anatomical Society regulates all the process of cryopreservation, so that when the body is accepted by the relevant medical school, if it is not going to be used immediately the cryopreservation begins at -15 ° C. When the body is needed is thawed in a cold 4 ° to 6 ° C for a week, and 3-4 hours at room temperature before. A video shows exercises in human cadaver by diagnostic and surgical hysteroscopy.

Results: The video begins with the exploration of the uterine cavity, managing movements of the camera and continues with the use of surgical instruments and how to perform an endometrectomy. Regarding pelvic floor surgery, it shows the placement of a sub-urethral mesh and then performing a cystoscopy and catheterize the ureters.

Discussion: Human cadaver body model is useful to acquire training histeroscopic techniques because anatomical conditions are very similar to real ones, with variations as rigidity of structures. Pelvic floor surgery training techniques are benefited by the application of endoscopic techniques such as cystoscopy, to visualize injuries or the complete anatomical integrity.

OFFICE VERSUS INPATIENT POLYPECTOMY FOR THE TREATMENT OF ABNORMAL UTERINE BLEEDING: OPT PATIENT PREFERENCE STUDY

Diagnostic & Operative Office Hysteroscopy

Poster

Natalie Cooper*, Middleton Lee, Smith Paul, Daniels Jane, Clark and The OPT trial collaborative group Justin

Birmingham Women's Hospital

Summary (4 lines): Results from the OPT patient preference study were consistent with the results of the RCT which found no significant difference between office and inpatient polypectomy. It demonstrates a high patient preference for outpatient treatment.

Introduction: It is unclear whether polypectomy performed as an office procedure is as effective as when performed under general anaesthesia.Data from a cohort of women with a preference for how they underwent polypectomy were collected alongside a RCT comparing the two treatments.

Material and Methods: We collected data from a cohort of women who agreed to take part in the OPT study comparing inpatient to outpatient polypectomy but who were unwilling to be randomised because they had a preference for how they wanted to be treated. The primary outcome was a successful treatment, determined by the women’s assessment of her bleeding at 6 months. Secondary measures included assessments of bleeding and pain post-polypectomy and procedure acceptability.

Results: 324 women had a preference for outpatient and 75 for inpatient treatment. The same proportion of women in each group reported successful treatment (82% vs. 82%, p>0.9). Mean pain scores were higher in the outpatient group (p

Discussion: When given the option of inpatient or office polypectomy the vast majority of women favoured outpatient treatment which seemed as effective as inpatient treatment at six months. Postoperative pain was higher in the outpatient group however similar proportions in each group were willing to recommend the treatment to others.

CANNULA DYNAMICS OF THE SYNERGY PORT FOR LAPAROSCOPY: A COMPARATIVE

Innovation in Instrumentation and Surgical Techniques

Oral

Douglas Ott*

Mercer University

Summary (4 lines): Abdominal access gas delivery using hollow tubes causes pressure drops, restricted distribution and high terminal velocity flow. A newly designed Synergy cannula corrects and improves these conditions.

Introduction: The physical structure and design of cannulas used for peritoneal access determine the distribution and parameters of gas flow. To date all cannulas for laparoscopic gas delivery are hollow tubes with gas entering the top and exiting the bottom. The side walls are continuous uninterrupted and smooth creating a characteristic physical and gas distribution signature due to its design. It was hypothesized that a newly designed cannula with perforations would show a difference.

Material and Methods: Testing and analysis was done comparing available trocar/cannulas (Ethicon, Covidien, Applied Medical) with the LEXION Medical Synergy Port. They were evaluated for seal leakage/failure, instrument insertion and removal seal drag, force to penetrate (without pre-incision), force to remove after penetration with no pre-incision and fascial footprint. Additional parameters evaluated were pressure drop with and without instrument in lumen, gas distribution pattern, maximum flow rate, time to create a pneumoperitoneum and terminal exhaust gas velocity.

Results: Statistically significant findings (p˂0.01) were higher flow rates (78% improvement), lower pressure drop (70% improvement), higher pressure to prevent seal failure (84% improvement), higher maximum flow (42% improvement), time to create a pneumoperitoneum (84% improvement) and gas terminal velocity (35% lower) using the Synergy Port compared to the others.

Discussion: Changing the design of a hollow tube cannula to one having internal grooves and multiple distal perforations significantly improves gas flow characteristics and flow rate, has higher pressure to seal failure, higher maximum gas flow, decreased time to create a pneumoperitoneum, lower gas terminal velocity and 99% gas dispersion pattern.

GAS DISTRIBUTION, PRESSURE DROP AND PNEUMOPERITONEUM COMPARING TRADITIONAL CANNULAS TO A NEW CANNULA PORT (SYNERGY)

Innovation in Instrumentation and Surgical Techniques

Poster

Douglas Ott*

Mercer University

Summary (4 lines): Changing cannula design improves physical and mechanical restrictions improving gas distribution pattern, flow rate, pressure drop and terminal velocity.

Introduction: Cannulas used for laparoscopy are hollow cylinders. The walls are continuous, smooth and uninterrupted top to bottom. This is a comparative analysis of traditional cannulas with a new perforated port design and the effects on gas flow dynamics, gas distribution, pressure drop and time to create a pneumoperitoneum.

Material and Methods: Tested devices were Ethicon, Covidien, Applied Medical and LEXION Medical Synergy Port. Insufflators used were Storz Thermoflator, Olympus UHI-3 and Stryker Pneumosure. Dispersion pattern, percent area coverage of the pneumoperitoneum dome, pressure drop and digital mass flow and time to create a pneumoperitoneum were measured.

Results: Gas distribution pattern for traditional trocars was circular, uni-directional and constricted covering 1% of the pneumoperitoneum. The Synergy covered 92%. Pressure drops, gas flow and time to pneumoperitoneum were significantly improved with the Synergy Port with or without an instrument present.

Discussion: Cannula design configuration determines gas flow characteristics. Currently available trocar/cannulas cause increased pressure drops, restricted gas distribution within the pneumoperitoneum and have longer time to create a pneumoperitoneum compared to the Synergy Port. The Synergy port design results in lower pressure drops, quicker pneumoperitoneum, and almost complete gas dispersion distribution.

ESSURE INSERTION UNDER HYPNOSIS

Innovation in Instrumentation and Surgical Techniques

Oral

Salvatore Garzarelli*, Parodi Michele

San Paolo Savona

Summary (4 lines): The Essure® system for permanent contraception was developed as a less invasive method of female sterilization. This procedure can be done in a variety of settings and with a range of anesthetic options. Six case reports of clinical experience with hypnosis is described. This report presents qualitative accounts from a pilot clinical study of six cases of Essure insertion under hypnosis. Our hypothesis was that a hypnotic procedure would help the Essure microinsert placement procedure. Pain was decreased in varying degrees.

Introduction: Hypnotism, as a method of inducing relaxation, has been utilized to a limited degree in gynecology. This report describes improvements in acceptance and tolerance of Essure insertion for patients who underwent pre-procedure hypnosis. The hypnotic procedures were approximately five minutes in duration as pre-procedure and were practiced by the operator . Pain was decreased in varying degrees and the hypnotic procedure helpeds microinsert placement.

Material and Methods: Six patients were treated, Pain assessments was based on Visual Analog Scale (VAS); Satisfaction was assessed by a visual analog scale Placement of the Essure microinsert involved a hysteroscopic transcervical technique without speculum or tenaculum. The hypnotic procedure comprised three stages: ratification, tracing, suggestion.

Results: All the patients were highly satisfied : All subjects by visual analog scale rated the method at 10 (high satisfaction degree), and none of the subjects rated it under 8.None of the three most common symptoms described in the literature, cramping, pain and nausea were referred from our patients.

Discussion: In the literature, anti-inflammatory agents , paracervical block, intravenous sedation has been used. Hypnotism has been utilized to decrease the perception of pain and tubal spasm. This clinical experience shows an overall reduction of fear and anxiety, variable degrees of pain elimination and additional advantages during Essure procedure.

IN VITRO COMPARISON OF TISSUE EXTRACTION RATES AND SURGICAL WORKLOAD AMONG LAPAROSCOPIC MORCELLATORS

Innovation in Instrumentation and Surgical Techniques

Oral

Piet HINOUL*, Greenberg James, Cohen Sarah, Roy Sanjoy

ETHICON

Summary (4 lines): Four morcellators were evaluated based on tissue-extraction rates and the Surgery Task Load Index (SURG-TLX) to assess the level of stress perceived by the surgeon during use of each device.

Introduction: Tissue-morcellators are essential to allow laparoscopic completion of many gynecologic procedures via small laparoscopic ports. There is limited data comparing extraction rates of different devices or related intra-operative stress, a key component of surgical performance that may indirectly affect patient safety. This study assesses extraction rates by timing procedures as well as perceived stress by using the SURG-TLX, a validated, surgery-specific, multidimensional workload tool that helps measure a surgeon’s perception of stress during a procedure.

Material and Methods: Four morcellators compared: MOREsolution™(BlueEndo, BEM), MORCELLEX SIGMA™(Ethicon, MS), Xcise™(LiNA, LX) and Rotocut G1 (Storz, SRG). Four surgeons (with one repeat trial) used each morcellator to extract 1,000 grams of bovine tongue from a laparoscopic trainer. Tissue-extraction was recorded every 2 minutes until 1,000 grams were removed. Average rates compared using parametric one-way ANOVA test. Immediately after procedures, surgeons completed a SURG-TLX questionnaire. Perceived stress was compared among the morcellators using Kruskal Wallis non-parametric rank test.

Results: The average rate of tissue extraction among the morcellators was 43, 43, 43 and 34 grams/minute for MS, LX, SRG and BEM, respectively. Over twenty morcellations, the following mean SURG-TLX scores were measured: MS: 20 (SD=16), LX: 27 (18), SRG: 28 (8) and BEM: 48 (9).

Discussion: This in-vitro study of laparoscopic morcellators demonstrated comparable tissue extraction rates, except for BEM which trended slower (NS, p=0.56) and also yielded a significantly greater perceived surgical stress (p=0.04). Neither surgeon nor order of use affected these findings. Reducing surgical stress may help improve surgical performance –benefiting surgeon and patient.

EFFECTIVNESS OF OUTPATIENT ENDOMETRIAL ABLATION

Innovation in Instrumentation and Surgical Techniques

Poster

Shreeya Tewary*, Saeed Maqsood, Newport Faye, Trail Charlotte

New Cross Hospital

Summary (4 lines): This study looked into the efficiency, acceptability and effectiveness of Novasure endometrial ablation carried out as an outpatient procedure.

Introduction: Novasure endometrial ablation is known to be very effective in managing menorrhagia and dysmenorrhoea. Few centres in the U.K are performing this as an outpatient 'walk in and walk out' service. This study showed outpatient ablation is efficient, safe, acceptable and well tolerated by patients. It is also very cost effective as it does not require an anaesthetist, theatre time or a ward bed for post operative nursing.

Material and Methods: This was a qualitative prospective study. A paper questionnaire was given to the first 20 patients having an outpatient Novasure ablation. This asked them about their pain score and whether they would recommend it to a friend. Patients were then followed up after 4 months to see how effective the procedure was in improving symptoms.

Results: Ninety percent of patients went home within one hour of the procedure and had a significant improvement of symptoms at follow up. The majority of patients had a pain score of 5/10. Overall the study showed the procedure to be efficient, safe, acceptable, well tolerated and cost effective.

Discussion: The apprehension of this procedure not being tolerated in outpatients was unfounded. Pain was controlled well with simple analgesia. It is cost effective as an anaesthetist is not required. This fits in with the drive towards ambulatory care and could be perfected to be provided in the primary care setting.

LAPAROSCOPIC MANAGEMENT OF A BLADDER INJURY INFLICTED DURING DISSECTION OF AN URACHAL CYST

Complications

Video

Athanasios Protopapas*, Vlachos George, Sotiropoulou Maria, Grigoriadis Themistoklis, Loutradis Dimitrios, Antsaklis Aris

University of Athens

Summary (4 lines): Laparoscopic dissection of an urachal cyst resulted in bladder injury. The cyst was excised along with part of the bladder dome, and the bladder was repaired laparoscopically with excellent results.

Introduction: Urachal remnants are rare. In order of frequency, the 4 types of urachal congenital anomalies are: permeable urachus (50%), urachal cyst (30%), urachal sinus (15%), and urachal diverticulum (5%). They may be asympromatic, or cause a variety of urological and low abdominal complaints. The indication for surgery in asymptomatic lesions arises from the possibility of infection and malignant transformation.

Material and Methods: A 26-years old woman was scheduled for laparoscopic removal of a persistent unilocular anechoic cyst measuring 4.8 x 4.6cm. The cyst was located in the midline and to the patient’s lower right abdominal quadrant and was misdiagnosed as a right para-ovarian cyst. During dissection the cyst ruptured and the bladder was inadvertently opened. Subsequently the cyst was radically excised along with part of the bladder dome and the bladder was repaired laparoscopically in two layers.

Results: The patient made an uneventful recovery. The Foley catheter was preserved for 10 days. After its removal bladder function was normal. At 8 weeks follow up the patient was well and asymptomatic.

Discussion: An urachal cyst may arise in close relation to the bladder wall and bladder injury during their dissection may become unavoidable. Nevetheless, such remnants should be excised with a bladder dome cuff due to their risk for recurrence and their potential to undergo malignant transformation to adenocarcinoma.

CONSERVATIVE MANAGEMENT OF A CLEAR CELL VAGINAL ADENOCARCINOMA, WITH LAPAROSCOPIC STAGING, OVARIAN TRANSPOSITION, AND BRACHYTHERAPY

Oncology

Poster

Athanasios Protopapas*, Vlachos George, Sotiropoulou Maria, Sarris Kyrillos, Loutradis Dimitrios, Antsaklis Aris

University of Athens

Summary (4 lines): A 24 years old nulliparous patient diagnosed with a clear cell adenocarcinoma of the vagina was managed with laparoscopic staging and bilateral ovarian transposition with tubal conservation, followed by brachytherapy.

Introduction: Clear cell adenocarcinomas (CCA) of the lower genital tract associated or not to previous in utero diethylstilbestrol exposure, are very rare tumors. Such a diagnosis in a young and nulliparous woman poses difficult dilemmas regarding treatment. Conservative management with preservation of fertility may be an option in carefully selected patients offering good results in terms of survival rates, giving a chance to achieve a pregnancy.

Material and Methods: A 24 years old nulliparous patient presented with irregular vaginal bleeding from a 2cm solitary isolated upper third exophytic vaginal lesion. Histology of colposcopically directed biopsies revealed the presence of a grade 2 vaginal CCA. Preoperative evaluation was negative for metastatic disease and the patient was managed with laparoscopic staging including systematic pelvic lymphadenectomy plus omentectomy, and bilateral ovarian transposition with tubal conservation, followed by brachytherapy.

Results: The procedure was completed without intraoperative complications. Ovaries and tubes were suspended separately with permanent sutures for future reconstruction. Twenty pelvic lymph nodes were excised. All specimens were negative for metastatic disease. The patient made an uneventful postoperative recovery, and recently concluded brachytherapy with complete disappearance of the vaginal lesion.

Discussion: Conservative approach including laparoscopic staging with ovarian transposition and tubal preservation, followed by brachytherapy may be a valid option in young patients with early lower genital tract CCA wishing to preserve their fertility.

3 D LAPAROSCOPY : OUR INITIAL EXPERIENCE OF 906 CASES

Innovation in Instrumentation and Surgical Techniques

Oral

Shweta Raje*, Sinha Rakesh, Rao Gayatri

Bombay Endoscopy Academy

Summary (4 lines): We evaluated our initial experience of 3D laparoscopic surgeries to determine any improvement in; time of surgery, morcellation time , blood loss and learning curve as compared to 2D laparoscopy.

Introduction: Perhaps the most important reason for slower acceptance of advanced laparoscopy is that the 2D view on flat screen laparoscopy is cerebrally intensive. Robotic assisted laparoscopic surgeries have the advantage of 3D view and articulating instruments but its capital expenditure , recurring cost and annual maintenance cost are high. The 3D HD laparoscopy with great depth perception and tactile feedback improves surgical precision and hand–eye coordination, shortens the learning curve and improves surgical results.

Material and Methods: A retrospective analysis of 906 cases of 3D laparoscopy between September 2011 and July 2013 was done .The surgeries were performed using 3D HD camera and Einstein Vision telescope (Schoelly-Fibreoptic GMBH, Germany). The largest uterus removed was 4.87 kg and the largest fibroid removed was 3.63 kg. The results were compared with TLH and LM done using 2D HD system to assess; duration of surgery and morcellation , average blood loss and the learning curve.

Results: 520 patients had Total Laparoscopic Hysterectomy , 220 had Laparoscopic Myomectomy and 166 were ovarian cysts, endometriosis, colpo-suspensions. We had two conversions to 2D laparoscopy . Duration of surgery and morcellation time was significantly less in 3D compared to 2D . Blood loss was comparable . Learning curve was short.

Discussion: 3D laparoscopy significantly facilitates gynecological surgery. As the tactile feedback is retained and depth perception is remarkable, the precision and accuracy of the surgery is improved . The duration of surgery is reduced . The initial investment and recurring cost are low compared to robotic assisted laparoscopies.

LAPAROSCOPIC STAGING AND RE-STAGING OF BORDERLINE ADNEXAL TUMORS: REPORT OF 8 CASES

Oncology

Poster

Athanasios Protopapas*, Chatzipapas Ioannis, Haidopoulos Dimitrios, Vlachos George, Athanasiou Stavros, Papaspyrou Eirini, Loutradis Dimitrios, Antsaklis Aris

University of Athens

Summary (4 lines): Laparoscopic staging and restaging of borderline ovarian tumors is safe and effective with a low rate of complications. The type of procedure may be tailored according to patient’s age and reproductive history.

Introduction: Borderline ovarian tumors commonly affect younger women and are frequently managed without proper staging in a non oncological set-up. Primary or secondary laparoscopic staging with fertility sparing surgery may be a valid alternative to laparotomy.

Material and Methods: We included 8 cases with borderline adnexal tumors treated laparoscopically from March 2009 to March 2013. Of these, 5 cases were managed with primary laparoscopic staging, and 3 were submitted to a restaging procedure. The procedure involved peritoneal cytology, exploration of the peritoneal cavity, ipsilateral cystectomy or adnexectomy, infracolic omentectomy, peritoneal biopsies, and when appropriate, contralateral oophorectomy, hysterectomy and appendectomy. One case with a tumor showing micro-invasion underwent pelvic and para-aortic lymphadenectomy.

Results: One patient was operated during pregnancy. The mean operative time was 183 minutes. Ipsilateral cystectomy was performed in 3, oophorectomy in 1 and radical surgery in 1 of our cases undergoing primary staging, respectively. No serious complications occurred. None of our cases were upstaged. No recurrences were observed.

Discussion: Laparoscopic staging and restaging of borderline ovarian tumours is a safe procedure. It is associated with a low rate of complications, minimizing the risk of iatrogenic infertility in young patients. Whenever staging of borderline ovarian tumours is to be considered in an individual patient, laparoscopy provides a suitable alternative approach.

PARASITIC MYOMAS AFTER LAPAROSCOPIC SUPRACERVICAL HYSTERECTOMY: A REPORT OF CASE

Case reports

Poster

Sleiman Zaki*, Hesseling Mathias

Université Saint Joseph

Summary (4 lines): Iatrogenic parasitic leiomyomas could be bits left after morcellation. Hence, this rare condition must be kept in mind whenever a patient presents with abdominal masses following laparoscopic myomectomy or hysterectomy.

Introduction: Parasitic myomas are rare pathologic phenomena. Although they have been known for some time, their etiopathogenesis is still uncertain. Classically two Theories have been adopted to explain this pathology. A pedunculated myoma becomes partially then completely separated from the uterus and receives blood supply from another organ. The other mechanism could be a metaplasia of the peritoneum. Recently many authors reported cases of parasitic myomas after laparoscopic hysterectomy with the use of a morcellator.

Material and Methods: We report a case of 42 years old woman G2P2A0, operated in October 2010 with a laparoscopic supracervical hysterectomy for a polymyomatous uterus with a large fundal myoma of 12 cm. An electric morcellator was used for the extraction of the uterus. she presented to the out patient department of our hospital in May 2013 with complaints of abdominal distension and urinary discomfort over the last 2 months.

Results: Vaginal ultrasound showed a 12 cm myoma in the pelvis. During laparoscopy we identify diffuse peritoneal myomatosis and a 12 cm myoma with a pedicule on the epiploic appendix of the rectum. We performed a laparoscopic polymyomecty with the use of morcellator for extraction.

Discussion: Iatrogenic aetiology of parasitic myomas has been highlighted recently due the wide use of morcellators. The fact that most publications on this topic are very recent further supports this theory. It is likely that the more this technique is used, the higher the frequency of parasitic fibroids will become.

LAPAROSCOPIC MANAGEMENT OF EARLY ENDOMETRIAL CANCER: RESULTS FROM OUR LEARNING CURVE

Oncology

Poster

Athanasios Protopapas*, Chatzipapas Ioannis, Haidopoulos Dimitrios, Vlachos George, Mavrelos Konstantinos, Athanasiou Stavros, Loutradis Dimitrios, Antsaklis Aris

University of Athens

Summary (4 lines): Laparoscopic surgery is safe and effective for the management of early stage endometrial cancer. Careful patient selection and strict adherence to a standardized technique are of paramount importance for minimizing the rate of complications during the development of one’s learning curve.

Introduction: Laparoscopic treatment is becoming a standard of care for early endometrial carcinoma, offering several advantages over laparotomy in terms of better convalescence. Nevertheless, it requires a high level of laparoscopic expertise to keep complications to acceptable levels during the development of a learning curve.

Material and Methods: We analyzed our first 14 cases with presumed early stage endometrial carcinoma treated laparoscopically from April 2009 to April 2013. Their management included total laparoscopic hysterectomy and systematic bilateral pelvic lymphadenectomy. All cases were operated by the same surgeon (AP). Parameters such as body mass index, operation times, blood loss, number of pelvic lymph nodes, intraoperative and postoperative complications, laparo-coversion and hospital stay were considered.

Results: Median BMI was 34. Median operation time was 189 minutes. Median number of nodes was 27. One case with a proved stage IIIb disease was laparo-converted to manage a bladder injury associated with heavy bleeding. Two cases developed lymphocysts that resolved spontaneously. All are alive and free of recurrence.

Discussion: Laparoscopy is a safe alternative to laparotomy in the treatment of early endometrial cancer. The operation’s learning curve is acceptable when good laparoscopic skills exist.

INTESTINAL METAPLASIA IN BLADDER ENDOMETRIOTIC NODULE IN PATIENT WITH CONGENITAL DIDELPHUS UTERUS

Endometriosis: Surgery

Video

Abri de Bruin*

Mediclinic Kloof

Summary (4 lines): A young patient with a midtrimester loss and a didelphus uterus. At laparscopy, a bladder endometriotic nodule was resected full thickness and intestinal metaplasia was found in the nodule as well as urothelial metaplasia in the peritoneal endometriosis. The double uterine cavity was repaired in 2 surgeries.

Introduction: The young patient presented with one midtrimester loss and on examination had a double uterine system. A laparoscopy and hysteroscopy was done. Endometriosis was resected from the bladder peritoneum and a nodule was full thickness that was resected. Intestinal metaplasia was found on histology.

Material and Methods: Video of the surgery as well as the histology pictures included.

Results: The nodule was resected, the bladder closed - good technique shown on how to suture a bladder. The defect in the bladder was closed and the uterine defect repaired. The technique of hysteroscopic repair of the defect is shown.

Discussion: This was a very interesting patient with congenital abnormalities complicated by a bladder nodule that infiltrated full thickness into the bladder and had intestinal metaplasia. The uterine defect was repaired in 2 surgeries.

REWIEW OF TWELVE HYSTEROSCOPIC MYOMECTOMY TECHNIQUES

Innovation in Instrumentation and Surgical Techniques

Selected abstract Oral

Marcos Lyra*, Maior Maria, Aguiar Mauro, Serra Glaucia, Soares Deyse

Pro Delphus

Summary (4 lines): The review provides a comprehensive survey of all hysteroscopic techniques used to treat fibroids found completely within the uterine cavity (G0) and those with intramural development (G1 and G2).

Introduction: Nowadays operative hysteroscopy represents the elective treatment of submucous and partially intramural fibroids. Hysteroscopic myomectomy currently represents the standard minimally invasive surgical procedure for treating submucous fibroids. There are different hysteroscopic techniques, but they were never compiled in a single work. This work aims at naming and describing each of the known and new hysteroscopic techniques.

Material and Methods: We searched the Cochrane library, MEDLINE,EMBASE, PsycINFO, CINAHL, Database of Abstracts of Reviews of Effects (DARE), LILACS, conference abstracts on the ISI Web of Knowledge, OpenSigle for grey literature from Europe, and ongoing clinical trials registered online. Besides that, the techniques developed and used in a minimally invasive gynecology surgery team at Pro Delphus – Recife Brazil are also depicted.

Results: Considering that the myomectomy is the most complicated hysteroscopic procedure, maneuvers which can be used to remove myomas are described: Devascularization, Hydrodynamic Massage, Divulsion, Bipartition or quadripartition, Removal of the lateral sustenance, Slice, Lateral cut, Lever, Mechanical traction and counter-traction, Vaporization, Retrograde cut and Tunnelization.

Discussion: The development of new myomectomy techniques simplifies the procedure, but the choice as well as the success of the technique mostly depends on the location, the intramural extension of the fibroid, as well as on personal experience and available equipment.

LAPAROSCOPIC EXCISION OF A TRANSMURAL POLYPOID ADENOMYOMA

Endometriosis: Surgery

Poster

Athanasios Protopapas*, Sotiropoulou Maria, Koutroumanis Pelopidas, Domali Aikaterini, Loutradis Dimitrios, Antsaklis Aris

University of Athens

Summary (4 lines): We present the case of a suspicious transmural uterine tumor with an irregular submucous component and increased vascularity, that was managed with complete laparoscopic excision. Histology was suggestive of a transmural polypoid adenomyoma.

Introduction: Polypoid adenomyomas are rare and usually present as polypoid submucous tumors projecting into the endometrial cavity resembling endometrial polyps. They usually cause irregular vaginal bleeding or menorrhagia, and occasionally they exhibit histologic atypia

Material and Methods: A 31 year old nulliparous patient presented with irregular vaginal bleeding and anemia. Pelvic ultrasonography revealed a 4.5cm well vascularized intramural uterine tumor, occupying the posterior aspect of the uterine cavity. She was managed with laparoscopic excision and uterine reconstruction.

Results: The operation was completed laparoscopically using vasopressin to control blood loss. Uterine reconstruction despite a relatively large gap of the posterior part of the endometrial cavity was very satisfactory. The patient’s periods were restored to normal. Hysteroscopic evaluation of the uterine cavity has been scheduled in the near future.

Discussion: Transmural polypoid adenomyomas are rare tumors causing menstrual irregularities. The possibility of atypia or even malignant change should be taken into account when managing such cases. Laparoscopic excision can be accomplished with good results.

RACE DIFFERENCES IN SEVERE ENDOMETRIOSIS

Endometriosis: Surgery

Oral

Abri de Bruin*

Mediclinic Kloof

Summary (4 lines): There are important racial differences in patients with severe endometriosis in South Africa. The white population has a significantly higher change of natural conception following surgery for severe endometriosis being 65%. The black population has a significantly higher chance of having vaginal infiltration, more vaginal breakdown following surgery and a higher success rate of IVF following surgery.

Introduction: There are no published data on racial differences in patients with severe endometriosis. This is the first article to look at differences found at surgery as well as racial differences in outcome, complications and fertility.

Material and Methods: A retrospective study was done on more than 800 cases of severe endometriosis operated in one unit that is a referral centre for severe endometriosis. The study looked at different outcomes, complications and fertility following the surgery.

Results: Significantly more black patients had vaginal mucosal endometriosis. A significantly greater number of black patients had complications following surgery for the vaginal infiltration. Pregnancy rates in the white population was greater in natural conception following surgery where the black population had a greater success with IVF.

Discussion: Differences might be due to late presentation at a referral centre. Traditional medical treatments and poor referral networks play a role. There is a huge problem if this significant differences only reflect private healthcare. Differences in vaginal complications, fertility is mostly due to infective issues common in the black population.

ADVANTAGES AND DRAWBACKS OF EXTRAPERITONEAL ROUTE FOR PARAAORTIC LYMPHADENECTOMY. OUR 10 PATIENTS EXPERIENCE

Innovation in Instrumentation and Surgical Techniques

Poster

Valentine Ronzino-Dubost*, Akladios Cherif Youssef, Wattiez Arnaud

Hopitaux universitaires Strasbourg

Summary (4 lines): To evaluate the feasability, advantages and drawbacks of extraperitoneal lymphadenectomy, in a surgeons team used to the transperitoneal route.

Introduction: Paraaortic lymphadenectomy is an integral part of staging and treatment of gynecologic malignancies. The extraperitoneal route seems to have many advantages.The goal was to evaluate, with a preliminary study, the extraperitoneal paraaortic lymphadenectomy advantages and drawbacks, in a group of 10 patients.

Material and Methods: We realized 10 extraperitoneal laparoscopic lymphadenectomy between 2012 and 2013. We analyzed the operative time, the number of lymph nodes, the loss of hemoglobine, the hospital stay and the complications during and after surgery.

Results: Between 3 and 20 paraaortic lymph nodes were removed with an average of 15. The average operating time was 163 minutes, decreasing continuously over time. One conversion into transperitoneal coelioscopy occurred. We met only one vascular intraoperative complication. No major postoperative complication was encountered so far.

Discussion: Extraperitoneal paraaortic lymph node dissection is a minimally invasive procedure with a low complication rate, sufficient number of lymph nodes, and short hospital stay. The learning curve is quite steep with goods results in a few number of procedures.

SELECT AND TREAT AT LAPAROSCOPY AND DYE TEST IMPROVES THE SPONTANEOUS PREGNANCY

Infertility and Reproductive Medicine

Poster

Kinza Younas*, Majoko Franz, Sheard Katherine, Edwards Christopher, Bunkheila Adnan

Singleton Hospital Swansea

Summary (4 lines): A 50% of women with unexplained infertility or minor abnormalities treated at laparoscopy and dye test conceived spontaneously, considering expectant management for up to twenty four months is appropriate.

Introduction: We conducted this observational study to determine the interval between laparoscopy and dye test and spontaneous conception in women with unexplained infertility and where minor problems identified and treated at the same time of procedure.

Material and Methods: We retrieved clinical records of women coded as having had laparoscopy and dye test or laparoscopy and tubal patency test between April 2007 and March 2010 from computerised theatre database. Operative notes were reviewed to extract information on abnormalities detected and whether any treatment was undertaken at the time of diagnosis. Pregnancies were identified through a computerised maternity booking system. We categorised women according to the operating surgeon and determined time to spontaneous conception.

Results: Spontaneous pregnancies were recorded in 162 women following surgery (37.5%) in 432 cases. A significant difference noted in conception rates between unexplained infertility and minor abnormalities treated at time of diagnosis (43% v. 58% respectively, p=0.019). Eighty percent of spontaneous conceptions were within 18 months of laparoscopy and dye test.

Discussion: Laparoscopy provides an opportunity for treating minor problems at the time of testing for tubal patency and thus improves chances of spontaneous pregnancy. We found that a significant proportion of women with unexplained infertility and minor problems treated at laparoscopy dye test conceived spontaneously.

TECHNIQUES FOR HEMOSTASIS DURING LAPAROSCOPIC MYOMECTOMY

Myomectomy

Video

Ana Fernández - sanguino *, Vazquez Alberto, Barri Pere, Cusido Maite, Ubeda Alicia

Institut universitari quiron Dexeus

Summary (4 lines): In this video we take a look at some different techniques to control bleeding during laparoscopic myomectomy.

Introduction: Surgical treatment is the treatment of choice for symptomatic myomas. In most cases, myomectomy is preferred over hysterectomy. Laparoscopic approach is the gold standard in selected cases when performed by a skilled surgeon, as suturing skills are required for this technique. The standardization simplifies the surgery, making it faster and reproducible helping future surgeons to shorten their learning curves.

Material and Methods: Massive bleeding is the most important and frequent complication of this procedure. Different techniques have been described to minimize blood loss such as the use of vasoconstrictor agents (adrenaline or vasopresine) or performing a transitory clipping of uterine arteries and infundibulopelvic vessels on both sides. In this videos we can see diferent techniques used to control bleeding in laparoscopic myomectomy performed by skilled surgeons at I.U. Dexeus.

Results: videos

Discussion: An optimal closure of the uterus defect requires enough time and good vision. For that reason we believe that the control of hemostasis is probably the most important step during a laparoscopic myomectomy.

THE PREVALENCE OF INTRAUTERINE ADHESIONS (IUA) AND RELATED LONG TERM REPRODUCTIVE OUTCOME POST MISCARRIAGE

Diagnostic & Operative Office Hysteroscopy

Oral

Angelo Hooker*, Lemmers Marike , Thurkow Andreas L., Heymans Martijn W. , Opmeer Brent C., Brölmann Hans. A.M., Mol Ben W., Huirne Judith

Zaans Medical Center

Summary (4 lines): IUA are encountered in one in five women after miscarriage; in more than 50% the adhesions were mild, while similar pregnancy outcomes were reported post miscarriage.

Introduction: Approximately 15-20 % of all clinically confirmed pregnancies end in a miscarriage. Intrauterine adhesions (IUA) are a possible complication after miscarriage, but the prevalence and contribution of possible risk factors have not been elucidated yet. In addition long term pregnancy outcome in relation to IUA has to be elucidated.

Material and Methods: We systematically searched the literature for studies that prospectively evaluated women who suffered from a miscarriage. To be included, women had to be systematically evaluated within twelve months by hysteroscopy either after spontaneous expulsion, medical or surgical treatment. Subsequently, long-term reproductive outcomes after expectant, medical and surgical management were assessed in women post miscarriage.

Results: IUA were detected in 19.1% [95% confidence interval (CI): 12.8% to 27.5%]. The extent of IUA was mild, moderate and severe in respectively 58.1%, 28.2% and 13.7%. Dilatation and curettage was the most important risk factor. Similar pregnancy outcomes were reported subsequent to conservative, medical and surgical management for miscarriage.

Discussion: D&C should be considered as an important risk factor in IUA formation, especially after recurrent procedures. This has implications for clinical practice, as D&C should be prevented as much as possible and adhesion formation should be taken into account when treatment options for miscarriage are discussed.

OVARIAN TORSION – THE CHALLENGE

Case reports

Video

António José Cunha Braga*, Carvalho Ferreira Hélder , Coutinho Lúcia, Fernandes Preza, Cubal Rosália Maria, Pereira António Tomé

Centro Hospitalar do Porto

Summary (4 lines): We report a clinical case of ovarian torsion in an infertility patient under ovulation induction submitted to conservative laparoscopic surgery at Oporto Hospital Center.

Introduction: Ovarian torsion is the complete or partial rotation of the ovary on its ligamentous supports, blocking its blood supply. Prompt diagnosis is important to preserve ovarian function and to prevent other associated morbidity. Making the diagnosis can be challenging because the symptoms, analytical findings and ecography are nonspecific. The laparoscopy is the first line approach to confirm or clarify the diagnosis and reverse it. We report a clinical case of ovarian torsion submitted to laparoscopy.

Material and Methods: 42 years old woman, with an history of infertility. This woman was under ovulation induction with clomifene and had an amenorrhea of 5 weeks. She presented at our emergency room with an acute hypogastric pain with 1h of evolution. She was hemodynamically stable with peritoneal irritation signs at physical examination. She was submitted to analytical blood work, pelvic ecography, and finally, diagnostic laparoscopy.

Results: All analitic parameters were normal, and ectopic pregnancy was excluded by a negative pregnancy test. Ecography showed an ovarian mass, heterogenous appearance of the ovarian stroma with decreased or absent Doppler flow. Diagnostic laparoscopy confirmed the ovarian torsion diagnosis. Normal blood circulation could be reestablished, permitting ovary preservation.

Discussion: A high level of clinical suspicion and an early minimally invasive approach were the key to the resolution of this case, preserving ovary and permit a quick recovery.

HYSTEROSCOPIC METROPLASTY: REPRODUCTIVE OUTCOMES

Surgical Hysteroscopy

Poster

Irena Kozachenko*, Adamyan Leila

Scientific Center for Obstetrics, Gynecology and P

Summary (4 lines): Surgical correction of the uterine septum significantly improves the pregnancy outcome. 132 patients with uterine septum were treated.There were significant differences in pregnancy rate (4.5% vs 55.6%), miscarriage rate (78.9% vs 23%), preterm births (29,6% vs 13,3%) before and after surgery.

Introduction: Septate uterus is a congenital anomaly which is commonly associated with a poor reproductive outcome, such as abortion and preterm delivery. Hysteroscopic metroplasty is a simple and safe approach for the removal of the septum. There is a large body of evidence that this operation improves live birth rate in patients affected by recurrent abortion.

Material and Methods: 191 Patients with septate uterus were recruited between 2009-2011. The procedure was performed with a 26-Fr resectoscope fitted with a monopolar electrode and with a 0-degree telescope. The electrical generator was set at 60–80Wpure cut current. The uterine cavity was distended with a solution (mannitol 5.4 p/v) at a constant inflow pressure of 60–90 mm Hg. Postoperative follow-up consisted of an hysteroscopic examination performed 3 month after surgery.

Results: The reproductive outcome was assessed in 132 patients. There were significant differences in pregnancy rate (4.5% vs 55.6%), miscarriage rate (78.9% vs 23%), preterm births (29,6% vs 13,3%) before and after surgery.

Discussion: Uterine septum is the most common uterine malformation and is associated with the worst reproductive outcome; surgical correction of the anomaly significantly improves the pregnancy outcome. On the other hand, the issue whether the septate uterus is a cause of infertility is controversial.

COMBINED TREATMENT OF WOMEN WITH CERVICAL PREGNANCY IN OPERATIVE GYNECOLOGY

Surgical Hysteroscopy

Oral

Andrey Kozachenko*

Scientific Center for Ob, Gyn & Perinatology

Summary (4 lines): Conducting resectoscopic removing of embryo with the cytostatic therapy with methotrexate in combination with leucovorin allows to save fertility in women with cervical localization of embryo.

Introduction: During past years considerable attention was paid to cervical pregnancy in the special literature. In the sources of available literature the cervical pregnancy is described as a variant of ectopic gestational sac location and its frequency is 0.1-0.4% with respect to all types of ectopic pregnancy and 0.002% in relation to all pregnancies.

Material and Methods: 26 women with cervical pregnancies were treated. Protocol included transvaginal ultrasound investigation, magnetic resonance imaging; definition of the blood flow intensity in the chorion, the definition of β-subunit of human chorionic gonadotropin (β-hCG) in serum in dynamics, general clinical research: clinical parameters, biochemical blood tests and hemostasis in the dynamics, diagnostic hysteroscopy and followed resectoscopy with material removed.

Results: Patients with cervical pregnancy received methotrexate at an average of 50 mg/every 48 hours, leucovorin administered at a dose of 6 mg after 28 hours after methotrexate injection. patients with cervical pregnancy underwent combined therapy with preoperative methotrexate chemotherapy and resectoscopic removing of cervical pregnancies for preserving fertility.

Discussion: The results of this study suggest that resectoscopic removing of embryo with previous cytostatic therapy with methotrexate in combination with leucovorin allows to save fertility in young women with early cervical pregnancy.

ROUTINE HAEMOSTATIC EVALUATION AND OUTCOME OF NOVASURE® FOR HEAVY MENSTRUAL BLEEDING

Diagnostic & Operative Office Hysteroscopy

Poster

Heleen Eising*, Huisman Marcel,

Gelre Hospital Apeldoorn

Summary (4 lines): To assess clinical outcomes of radiofrequency impedance controlled endometrial ablation (Novasure®) under local anaesthesia in an outpatient setting with a special interest in haemostatic evaluation. Outpatient Novasure® is effective in the treatment of heavy menstrual bleeding. Haemostatic evaluation is uncommon in routine practice in Gelre Hospital although standard laboratory evaluation and/or bleeding history before hysterectomy might improve care.

Introduction: VWD is the most common inherited bleeding disorder. Clinical expression of VWD in women is characterized by heavy menstrual bleeding (HMB). It is considered that endometrial ablation in women with VWD mostly fails due to underlying bleeding tendency or adenomyosis. Hysterectomy in VWD women results often (58%) in bleeding complications. Our aim was to assess the success rates of Novasure® and to investigate non-success was considered a reason to perform routine haemostatic evaluation.

Material and Methods: A computer search between January 2008 and December 2010, was performed. We identified 155 consecutive patients, 136 receiving Novasure at our outpatient clinic and 19 under general anaesthesia in theatre in Gelre Hospital Apeldoorn. All their medical records were reviewed. Data were collected on women's age, haemostatic evaluation, and hysterectomy within 2 years post procedure. Women were excluded if the data were incomplete or gynaecological abnormalities were diagnosed.

Results: The average age of women presented with HMB was 43.2 years, 93% undergone successful Novasure procedure. Hysterectomy rates were lower in the outpatient setting compared to theatre setting (5,1% vs 21,0%; P = 0,0309). Bleeding history questions were asked 54,5% of the unsuccessful cases, no specific laboratory evaluation was performed.

Discussion: Outpatient radiofrequency impedance controlled endometrial ablation is effective in the treatment of heavy menstrual bleeding. Haemostatic evaluation is uncommon in routine gynaecological practice in Gelre Hospital: standard laboratory evaluation and/or bleeding history before hysterectomy might improve care.

OFFICE HYSTEROSCOPY: TWO SESSION POLYPECTOMY FOR LARGE POLYPS IN ORDER TO AVOID THE O.R.

Diagnostic & Operative Office Hysteroscopy

Poster

Gladis Germano*, Dôrner Carolina, Russomanno Pierino, Medero Miguel,

Hospital Central de las Fuerzas Armadas

Summary (4 lines): We present 31 cases of large polyp treatment in two or three sesions in office hysteroscopy in order to avoid the oparating room.

Introduction: When we started the “See and Treat” office hysteroscopy, selection of patients was made based on localization and size of the polyp, and all the patients having large polyps were referred to resection in operating room. A number of patients wanted to avoid the O.R. , the anesthesia and the Hospital, so we offered the possibility, after completing the consentient form, and risks explanations, of doing the polypectomy in two and even three times.

Material and Methods: From 393 procedures, in 31 patients we began the polypectomy despite the polyp had a large size: from 3,5 to 7 cm. Material: Bettocchi System sheath, 2,9mm endoscope and Versapoint generator with bipolar Twizzle; distension media: saline solution. Methods: The procedure continues until we reach 30 min of procedure, or hiperhidratation of the endometrium or patient discomfort. The second session was performed between 7 and 28 days after.

Results: The follow up showed no complications. None of them had infection, nor pain. In only one case wasn’t possible to resect the whole polyp after three sessions so she was referred to the OR.

Discussion: We conclude that in the minimal invasive “era”, this is a safe option for selected patients, despite the length of the polyps.In the lasts months we performed 31 procedures with this methodology, and we want to share our experience with other colleagues.

OUR PURE NOTES JOURNEY

Innovation in Instrumentation and Surgical Techniques

Video

Masaaki Andou*

Kurashiki Medical Center

Summary (4 lines): We will describe our step by step journey to pure NOTES via transvaginal laparoscopy.

Introduction: Pure NOTES is the pinnacle of ultra-minimally invasive surgery. As a result, many surgeon aspire to perform NOTES. However, NOTES has proven to be a difficult goal due to immaturity of instrumentation and the technical demands that come with manipulation. We have worked to develop some original ultra-minimally invasive techniques on our way to designing our own NOTES procedure.

Material and Methods: We will show three minimally invasive approaches for ovarian cystectomy and adnexectomy. We used a transvaginal flexible fiberscope in all cases. In Case 1 we used 5mm and 3mm abdominal ports for manipulation. In Case 2, we used one abdominal port and 2 vaginal ports, one vaginal manipulation port and one umbilical port. Case 3 required no abdominal ports, only a trans-vaginal access platform with 4 trocars- one camera, two forceps and one uterine manipulator.

Results: All procedures were completed without conversion to open laparotomy or standard laparoscopic approach. The cosmetic result was excellent.

Discussion: With the right skills and equipment it is technically feasible to perform port reducing surgery in selected cases. We have succeeded in performing pure NOTES for adnexectomy and developing a number of ultra-minimally invasive techniques along the way.

45X-46XY MOSAICISM WITH TURNER PHENOTYPE: LAPAROSCOPIC FINDINGS IN A 19 YEAR-OLD GIRL

Case reports

Poster

Gladis Germano*, Rubal Agustín, Achard Arturo

Hospital Central de las Fuerzas Armadas

Summary (4 lines): We present a case of a patient that was referred for gonadectomy because of the dysgerminoma risk due to the Y chromosome component.

Introduction: The patient presents at 16 year-old with primary amenorrhea and absence of breast development. In the first evaluation, a Turner like phenotype was found, with short stature, webbing neck, low-set ears and broad chest. In the ultrasound scan couldn’t see uterus or ovaries. At TC scan, a 1 cm rudimentary uterus was found. FSH levels were in 99,5 mUI/ml.

Material and Methods: Karyotype test showed a mosaicism with 90% of the cells 45X0, and 10% of the cells 46XY. Medical treatment with estradiol valerate was performed, with breast and uterus response, with menarche 14 months after. Because of the dysgerminoma risk due to the XY component, the patient is referred for laparoscopic gonadectomy.

Results: We show the pictures of the laparoscopic findings in this patient, with a small uterus with large and thin Fallopian tubes, streak gonads, rudimentary round ligaments, and normal ureters.

Discussion: Gonadal dysgenesia is an infrecuent condition, and the profilactic gonadectomy must be done by laparoscopic access, so the gynecological endoscopist must be familar with the mannaging of this patients.

TECHNIQUE FOR TOTAL LAPAROSCOPIC HYSTERECTOMY WITH UTERI WEIGHED MORE THAN 1500 G

Hysterectomy

Video

Ferdhy Suryadi Suwandinata*

University of Indonesia

Summary (4 lines): With experience and specialized techniques, total laparoscopic hysterectomy can replace abdominal hysterectomy for large uteri.

Introduction: Laparoscopic hysterectomy for large uteri is technically a difficult procedure and requires more skill and experience. In this article, we report our experience with laparoscopic hysterectomy for fibroid uteri more than 1500 g in weight.

Material and Methods: General anesthesia was performed. Lee-Huang point and a 5-mm 30º-telescope were used. Three 5-mm ports were placed depending on the uterine size. The course of ureters is traced. Uterovesical fold is opened and the bladder dissected. The infundibulum ligaments are secured with smart bipolar. Uterosacral and cardinal ligaments are dissected. Vaginal vault is open and the specimen is detached. Vaginal cuff is closed with Vicryl no. 1. The specimen is retrieved by a 15-mm morcellator.

Results: From 2012 to 2013, 2 patients were successfully treated for large fibroid uteri with postoperative specimens weighing 1500 g and 2500 gr. Both have total laparoscopic hysterectomy with bilateral salphingoophorectomy. There is no postoperative complication and the patients were satisfied. Admission day was only one day after the surgery.

Discussion: Controversy exists for LH for uteri weighing >500g because of increased complications, bleeding, morbidities and high laparotomy conversion rate. To reduce bleeding, the vessel pedicle was secured by smart bipolar diathermy or endoscopic suturing. Complications such as hemorrhage, bladder injuries, and ureteric injuries are minimal.

LAPAROSCOPIC PROTESIC LATERAL SUSPENSION FOR GENITAL PROLAPSE: A MODIFIED APPROACH

Urogynaecology

Video

Francesca Dalprà*, Mereu Liliana, Del Pezzo Chiara, Nozza Arrigo, Perin Elena, Tateo Saverio

S.Chiara Hospital Trento Italy

Summary (4 lines): The present video shows a modified approch of laparoscopic lateral suspension using tension free titanised mesh, minilaparoscopic instrumentation and reduction in number of laparoscopic accesses.

Introduction: Genital prolapse occurs in 50% of parous woman. Its aetiology is complex and multifactorial. Laparoscopic promontocolpopexy is considered the gold standard for treatment of central compartment defects. Recent studies confirm that laparoscopic lateral suspension is a safe and effective technique for treatment of genital prolapse as an alternative to promontocolpopexy. We improved the conventional laparoscopic technique described by Dubuisson introducing the use of minilaparoscopy, of a tension free titanised polypropylene mesh and reduction number of laparoscopic accesses.

Material and Methods: Since January 2013 we introduced this technique in our clinic to manage genital prolapse in young women who desire to preserve the uterus. The genital prolapse condition were evaluated according the Baden-Walker Classification System. Patient underwent surgery with minilaparoscopic approach: 5 mm umbilical access and three 3.5 mm accesses. The bilateral iliac incisions were used for both minilaparoscopic instrumentation and extraperitoneal placement of tension free titanised polypropylene mesh.

Results: 5 patients underwent the procedure, median parity 2, age 45, HWS: anterior compartment grade 3, central compartment 2-3, posterior compartment 0. Median operative time was 93 minutes (range 55-150), no complications and good anatomic results. HWS: anterior compartment 1, central compartment 1, one case developed an asymptomatic rectocele grade 2.

Discussion: Lateral uterine suspension using a mesh for anterior and central genital prolapsed is an interesting alternative to promontocolpopexy with good anatomic results and short operating time after surgical procedures.

CAN OFFICE HYSTEROSCOPY BE USEFUL IN THE MANAGEMENT OF PERSISTENT PREGNANCY OF UNKNOWN LOCATION?

Diagnostic & Operative Office Hysteroscopy

Oral

Paul Bulmer*, Afors Karolina, Inder-Rieden Jan

St Georges Hospital London

Summary (4 lines): Women with a persistent pregnancy of unknown location (PPUL) may have an ectopic pregnancy and are often managed with laparoscopy or Methotrexate treatment. We propose using office hysteroscopy to locate these pregnancies and so avoid unnecessary intervention.

Introduction: A PPUL is when a pregnant woman has a non viable, serial rise in beta-HCG, but the pregnancy is not visible on ultrasound. The majority will be failed intrauterines, but some will be ectopics. The risk of ectopic prompts many gynaecologists to laparoscope these women or treat with Methotrexate. Because most PPULs are failing intrauterines, this means many women will have unnecessary intervention. We propose using office hysteroscopy to locate these pregnancies allowing individualised treatment.

Material and Methods: 5 women with PPUL entered a feasibility study. They consented to office hysteroscopy rather than proceeding to planned Methotrexate therapy. A vaginoscopic procedure was performed using a 1.8mm, 12 degree Storz Bettochi operative hysteroscope and saline distension. The cavity was inspected and targeted tissue biopsies taken using 5Fr cup forceps. Histology results were available within 24hours. A pregnancy was confirmed to be intrauterine if either a definite sac was visualised or, histology confirmed trophoblast.

Results: 2 women had definite intrauterine pregnancies. Both miscarried within 48hours. 1 woman had thickened endometrium but no trophoblast on biopsy. She miscarried within 24hours without further intervention. 1 woman had no intrauterine pregnancy and was successfully managed with Methotrexate. The procedure was incomplete in the fifth due to patient discomfort. She spontaneously miscarried.

Discussion: 4 out of 5 women in our study avoided Methotrexate following office hysteroscopy. 2 out of 5 women had confirmation of intrauterine pregnancy. 4 out of 5 spontaneously miscarried following the procedure, suggesting uterine instrumentation could also be therapeutic. We propose office hysteroscopy can be offered to women with PPUL allowing individualised treatment.

USE OF GLUE MESH FIXATION FOR LAPAROSCOPIC SACROCOLPOPEXY : A RETROSPECTIVE ANALYSIS OF 35 CASES

Innovation in Instrumentation and Surgical Techniques

Oral

Estrade Jean Philippe*

Bouchard clinic

Summary (4 lines): This study aimed to evaluate the efficacy and safety of glue (n-hexyl-cyanoacrylate) mesh fixation for laparoscopic sacrocolpopexy. 35 consecutives patients were enrolled and analysed after a period of 2 years.

Introduction: Pelvic organ prolapse (POP) is a common disease of women, the incidence of genital prolapse surgery is estimated at 11%. Laparoscopic Sacrocolpopexy provides restoration of the anatomical axis of the female genital tract by a mini-invasive approach avoiding vaginal scar and colpectomy. This technique requires specially trained and experienced surgeons. To improve feasibility of laparoscopic sacrocolpopexy, we propose a optimized operative strategy using glue (n-hexyl-cyanoacrylate) as safer and easier method of mesh fixation.

Material and Methods: Thirty five women presenting a genital prolaps assessed by a Pelvic Organ Prolapse Quantification (POP-Q) score (stage 2 to 4). Modified laparoscopic sacrocolpopexy using a glue to fix the mesh (polyester) to the vagina (anterior and posterior) and to the lavator ani. Two non absobable knots are used to secure the anterior mesh to the isthmus and to the promontary. Operative characteristics, Short and long term follow up have been analyzed.

Results: Age range : 35- 85 years, the average operative time was 68,4 minutes. No complications occured during the procedure and early follow-up. One patient (2,8%) experienced mesh exposure. Median follow-up of 13,2 months (rang : 6 - 24,7 months), the surgical success rate was 94,3%.The patient satisfaction rate was 87%.

Discussion: Glue mesh vaginal fixation during laparoscopic sacrocolpopexy is safe and effective. This new method of fixation optimizes the laparoscopic sacrocolpopexy procedure. This is the first study evaluating the glue fixation method during a sacrocolpopexy procedure. Other surgeries use glue with interresting results. More investigation remain necessary to confirm this interest.

OVERVIEW OF HYSTEROSCOPIC PRACTICE IN PORTUGAL

Teaching & Training

Oral

João Luís Silva Carvalho*

H CUF Porto / Faculdade Medicina Porto

Summary (4 lines): A quantitative and descriptive evaluation of hysteroscopic practice in Portugal.

Introduction: A quantitative and descriptive evaluation of hysteroscopic practice in Portugal in 2011 was made.

Material and Methods: A written inquiry was mailed to the Departments of Gynaecology and Obstetrics of all the hospitals in the country. The questionnaire includes questions about diagnostic and surgical laparoscopies and hysteroscopies. This presentation only concerns the data collected on hysteroscopy. The inquiry evaluates number of procedures, types and complication rates, qualification and training of Gynaecologists and residents.

Results: Data is still being collected and analysed.

Discussion: Data is still being collected and analysed.

SHORT-TERM COMPLICATION RATE OF OPERATIVE HYSTEROSCOPY USING BIPOLAR TECHNOLOGY: ANALYSIS OF 706 CASES

Surgical Hysteroscopy

Poster

Matthieu Mezzadri*, Jérémy Sroussi, Amina Hamidouche, Anne-Sophie Chevalier, Mathilde Piketty, Jean-Louis Benifla

Summary (4 lines): Short term global complication rate of 706 operative hysteroscopies in an endoscopic center using only bipolar technology was low (5.2%). Bipolar energy prevent from complications related to hyponatremia glycin induced.

Introduction: Glycin solution use in operative hysteroscopy is classical, but may induce serious complications. Therefore, bipolar energy with saline solution is now possible. The aim of this retrospective descriptive monocentric study was to evaluate short term complication rate of operative hysteroscopy using only bipolar energy with normal saline solution.

Material and Methods: Seven hundred and six operative hysteroscopies in six hundred and fifty eight patients were performed from 2009 to 2012, using only bipolar technology with saline solution. Clinical data was recorded, including context, indication, type of anesthesia, and one time procedure rate. Classical hysteroscopy complications were collected.

Results: Main indications of hysteroscopy were: endometrial polyp (221/706, 31.3%), submucosal myoma (212/706, 30%), and uterine synechiae (135/706, 19.1%). The procedure was complete in 569 cases (80.6%). Global complication rate was 5.2% (37/706). We collected 18 perforations (2.5%), and 12 anormal bleedings with hemostatic treatments (1.7%). No Turp syndrome was noted.

Discussion: Our global short term complication rate of operative hysteroscopy seems to be consistent with previous ones described for hysteroscopy using monopolar technology with glycin solution. However, exclusive use of bipolar technology with saline solution prevent from serious neurological complications related to hyponatremia glycin induced.

HYSTEROSCOPICALLY GUIDED LOCAL ANAESTHESIA FOR RESECTION OF ENDOMETRIAL POLYPS BY VAGINOSCOPIC MICROHYSTEROSCOPY IN POSTMENOPAUSAL WOMEN

Surgical Hysteroscopy

Oral

Henrik Skensved*

Gynaecology

Summary (4 lines): Hysteroscopically guided injection of local anaesthesia enabled resection of endometrial polyps during initial investigative vaginoscopic microhysteroscopy in 64% of postmenopausal women presenting with bleeding and/or thickened midline on transvaginal ultrasound.

Introduction: Cavity assessment with small caliber hysteroscopes plays a pivotal role in first line examination of women with postmenopausal bleeding and/or suspiciously thickened midline on ultrasound performed as part of the investigation of other disorders in the pelvis. However, pain has limited the concomitant resection of endometrial polyps during the diagnostic hysteroscopy. This study aimed to access the feasibility and efficiency of vaginoscopic hysteroscopy combined with focalized local anaesthesia in removal of polyps among postmenopausal women.

Material and Methods: Three hundred and twenty eight postmenopausal women (age 49 – 92) with endometrial polyps had a vaginoscopic hysteroscopy with a 3,5 or 5 mm hysteroscope. Through a 35 cm long needle, introduced through the working channel of the hysteroscope, local anaesthesia was injected at the base of the polyp(s) before resection with a bipolar electrode. Pain during injection was recorded on a 10 point visual analog scale. All procedures were recorded on digital video.

Results: Of 328 women, 303 (92,4%) had a successful hysteroscopy and 295 (89,9%) an eventless complete polypectomy. Two hundred sixty nine of these women (91,2%) had a VAS-score of 2 or less at the injection of the focal local anaesthesia. In 67 cases (22,7%) polyps were too large for microhysteroscopic retrieval.

Discussion: The literature demonstrates that despite introduction of minute hysteroscopes and development of new resection techniques, the majority of hysteroscopic polypectomies are performed in theatre often under general anaesthesia. Focalized subpolypal local anaesthesia during first visit vaginoscopic microhysteroscopy enabled resection of polyp(s) in two thirds of postmenopausal women with endometrial polyps.

HYSTEROSCOPIC REMOVAL OF RETAINED PRODUCTS OF CONCEPTION FOR REPEAT AND DELAYED PROCEDURES

Surgical Hysteroscopy

Poster

Hristina Raykova*

St Peters Hospital

Summary (4 lines): Our study evaluates the role of operative hysteroscopy in women presenting with clinical and ultrasound evidence of retained products of conception following previous surgical management of miscarriage or postpartum.

Introduction: Traditionally, retained products of conception are managed with uterine curettage. The blind nature of the procedure carries risk of uterine perforation, incomplete evacuation and need for repeat evacuation. The adhesions formation in the uterine cavity is as high as 40% with repeat evacuation.

Material and Methods: We present a study of 30 women who had retained tissues either post curettage or postpartum over period of 3 years. We used the wire loop of the resectoscope to mechanically scrap the pregnancy tissues without the use of electricity unless the products are densely adherent.

Results: 23 women had previous D&C after miscarriage and 7 had retained products postpartum. In 4 cases products were retained for >4 weeks. One of our patients had a bicornuate uterus. All patients did very well postoperatively and had no complications.

Discussion: The hysteroscope allows excellent direct visualization of the uterine cavity and the location of the retained tissues. This helps minimising the risk of uterine perforation and also ensuring the procedure is complete. We believe that hysteroscopic resection also reduces the risk of Asherman’s syndrome.

APPLICATION OF HYALOBARRIER GEL IN POST HYSTOSCOPIC MYOMECOTMY AND ABLATION SURGERY –PRELIMINARY EXPERIENCE

Diagnostic & Operative Office Hysteroscopy

Oral

Yi-Chen Chuang *

OBS&GYN

Summary (4 lines): hyalobarrier gel had a role in prevention of uterine cavity adhesion.

Introduction: Asherman syndrome occurs when trauma to the endometrial lining triggers the normal wound-healing process, which causes the damaged areas to fuse together, The present TX included hystoscopic lysis of adhesion and IUD insertion or ballon and Hormone TX . A novel concept is anti-adhesion barrier to prevent traumatized surface to contact each other .Hyalobarrer gel had been published in hystoscopic surgery to prevent inter-uterine adhesion ..

Material and Methods: 6 patients with menorrhagia , anemia , submucosa myoma or adenomyosis , received Transcervical Resection of submucosa myoma and ablation of endometrium . Hyalobarrier gel was applied into the uterine cavity immediately after ablation in 3 patients( group A) .Normal saline was injected into the other 3 patients( Group B).. 2nd look office hystoscopy and video-taped for evaluation of adhesion within one month post-operatively .No pts received IUD insertion or ballon and HRT.

Results: Group A ( Hyalobarrier gel )had almost free of uterine cavity adhesion . Group B had variable adhesion in the cavity . No adverse effect was noted in both groups. All patients were satisfied with their TCR operation in 3 months follow up.

Discussion: The preliminary experience shows hyalobarrier gel had a role in prevention of uterine cavity adhesion. More randomized clinical trials will be needed to prove its efficacy.

LAPAROSCOPIC TREATMENT OF DIE; OUR EXPERIENCE IN 100 CONSECUTIVE CASES PERFORMED BY A SINGLE SURGEON

Endometriosis: Surgery

Poster

Claudia Prasciolu*, Arena Ilaria , Pontis Alessandro, Lai Francesca, Angioni Stefano

Ospedale San Giovanni di Dio Cagliari

Summary (4 lines): The aim of our study was to evaluate the effectiveness of the surgical technique, the resolution of symptoms, intra-and postoperative complications in case of symptomatic deep infiltrating endometriosis (DIE)

Introduction: Deep endometriosis is a disease histologically defined by the penetration of endometriosis in the thickness of the peritoneum or pelvic organs to a depth of at least 5 mm. Medical therapy often is not able to obtain adequate relief from pain. Recent studies have shown that radical surgery is able to significantly reduce dysmenorrhea and chronic pelvic pain in case of endometriosis stage III-IV

Material and Methods: Between January 2007 and January 2012, a continuous series of 100 patients suffering from pelvic pain (dysmenorrhea, dischezia, dyspareunia, chronic pelvic pain) underwent surgical management for DIE. All operations were performed by a single operator. Clinical and surgical data were collected . Intraoperative, short-term and long term clinical complications were assessed.

Results: Endometriosis localizations: 90% recto vaginal septum; 42% vaginal mucosa; 3% ureteral; 8% bladder. A conservative surgery was performed. No intraoperative and late complications were reported. In 20% of the cases a postoperative medical therapy was prescribed. In 90% of patients a regression/ important relief of painful symptoms was obtained.

Discussion: Laparoscopic surgery is the gold standard in the treatment of patients with symptomatic infiltrating endometriosis. Despite this surgery requires a very experienced team cause to the high risk of complications, morbidity and perioperative mortality appears to be acceptable using a symptom tailored approach.

CHOOSING THE ROUTE OF HYSTERECTOMY FOR BENIGN DISEASE IN CORRELATION TO PREOPERATIVE SCORE

Hysterectomy

Poster

Mohamed Elessawy*, Alkatout Ibrahim , Mettler Liselotte , Jonat Walter , Schollmeyer Thoralf

UKSH-Frauen-Kilink, kiel

Summary (4 lines): When choosing the route of hysterectomy, the physician should take in consideration the most safest and cost-effective route to fulfil the medical needs of the patient.

Introduction: Hysterectomies are preformed abdominally, vaginally, or laparoscopic or with robotic assistance. We included data collected prospectively for all hysterectomy for benign indications in Kiel university hospitals from 2002 to 2010.

Material and Methods Data was collected and statistically tested to investigate relationship between the decision to route of operation and pre-operative score and number of parity at hysterectomy. Of the 785 women with complete data, Patients who had undergone a previous laparoscopy were given 1 point, for previous laparotomy 2 points, for (1x) caeserian section 3, for (2x) caeserian sections 4, for (3x) caeserian sections 5 and for no previous operation 0 points.

Results: AH average preoperative score 1.09, VH 0.75, LASH 1.04, LAVH 1.0. Highest score recorded by TLH 1.38. Prevalent scores by VH were 0 and 1, LASH, TLH showed prevalence over VH by preoperative scores 3 and 4 and AH showed prevalence over other methods by preoperative score 3 – 8.

Discussion: Significant differences by multipara by VH in comparison to other routes. Decision for AH was favoured with increase in preoperative score. Operation duration increased with a higher parity for all operation routes. Intraoperative complications is elevated by increase of uterus weight but not affected by increase of preoperative score.

LAPAROSCOPIC VIRTUAL REALITY AND BOX TRAINER IN GYNECOLOGY: A PROSPECTIVE, RANDOMIZED, CONTROLLED, AND BLINDED STUDY

Teaching & Training

Poster

Ali Akdemir*, Akdemir Ali, Sendag Fatih, Öztekin Kemal

Ege University School Of Medicine, Department of O

Summary (4 lines): Both the VR simulators and box trainers are more effective than classic surgical education by means of basic gynecological procedures. Training hospitals should construct a laparoscopic training laboratory.

Introduction: The purpose of this study was to assess the effect of a computer based virtual reality surgical simulator, a traditional box trainer (BT) on an actual laparoscopic operation, and to determine whether one has an advantage over the other.

Material and Methods: Forty first and second year residents were randomized into either a LapSim or a box trainer group. Twenty senior residents were allocated to the control group. The first and second groups trained on LapSim□ and BT respectively for four weeks. Both groups performed laparoscopic bilateral tubal ligation. Video records of each operation was assessed using general rating scale of objective structured assessment of laparoscopic salpingectomy (OSA-LS) and operation time in seconds.

Results: The LapSim group and the BT group performed significantly better in total score and time when compared with the control group. But there were no differences between LapSim and BT group.

Discussion: Novice residents trained on a computer based VR simulator or BT performed better live laparoscopic as compared to residents trained in standard clinical surgical education. Training with either a VR simulator or a BT should be considered before trainees carry out laparoscopic procedures.

NEGATIVE IMPACT OF ENDOSCOPICAL APPROACH ON THE PROGNOSIS OF MISSDIAGNOSED UTERINE SARCOMAS

Myomectomy

Oral

Pedro Barri-Soldevila*, Barri-Soldevila Pedro, Fargas Francesc, Cusido Maite, Fabregas Rafael

Instituto Universitario Dexeus, Barcelona

Summary (4 lines): Endoscopic approach is more and more frequent in the management of myomas. Although the incidence of sarcomas remains stable, the prognosis seems to decrease related to widespread of endoscopy.

Introduction: In our institution, in the last years, we have had a few cases of uterine myomas treated by laparoscopy who turned out to be sarcomas and whose prognosis has been dramatically worse than the patients treated by laparotomy. Therefore., a retrospective descriptive single-center study of sarcomas was settled. It is intended to analyse the impact of the type of surgery on the evolution of the disease and the prognosis of the patients.

Material and Methods: The data collected were uterine sarcomas diagnosed and/or treated in our center from 1996 to 2012. The variables evaluated were histological type, degree of differentiation, suspected diagnosis, primary surgery, recurrence, overall survival and disease-free survival depending on the surgery. 27 cases were diagnosed. Mean age at diagnosis was 44.26 years, with a mean tumour size of 80mm. 48% of patients were scheduled for surgery due to myoma growth and only 7.4% due to ultrasound suspicion.

Results: 66% underwent open surgery, 25.9% laparoscopy , 7.4% hysteroscopy. 44.4% of myomectomies. 22.2% of morcellation. 40% patients relapsed. 45% pelvic recurrences, 45% distant and 5% multiple. When morcellation was performed, all patients recurred. The DFS according to surgery, morcellation vs no morcellation, was 6,3 month vs 70,3 month. (p

Discussion: In case of sarcoma, morcellation causes an aggravation of the prognosis. It might be considered a iatrogenic effect. In absence of accurate diagnostic tools or in case of suspicion, morcellation should be discouraged, even if the laparotomy rate increases.

THE USE OF ULTRASONOGRAPHY VERSUS SALINE CONTRAST SONOHYSTEROGRAPHY TO EVALUATE CESAREAN SECTION SCAR

Imaging

Oral

Jayson Meyer*, Alves Silvia, Meyer Fernanda, Martinez de Oliveira Jose, Moutinho Jose, Dinis Sofia

Centro Hospitalar Cova da Beira

Summary (4 lines): In the last twenty years there is an evident rising in the number of cesarean section all around the world. Not only the immediate risk but also the long term complications concern patients and doctors. The clinical manifestations of the cesarean scar “niches” and their treatments have been studied in the last decade. We compared ultrasonography and sonohysterography findings of women submitted to a cesarean section in 2011, to indicate the best and safest possible treatment.

Introduction: The rising number of cesarean sections elevates the number of symptomatic cesarean scar defects. Although some of the cesarean scar niches are asymptomatic, it’s common to find them as the only sign in women with post menstrual bleeding, chronic or cyclical pelvic pain. The most commonly used exam to detect these defects is the ultrasonogray, but it underestimate the depth of the defect and its risks in subsequent pregnancy and hysteroscopy treatment options.

Material and Methods: 38 of the 53 women submitted to cesarean section in 2011 in Centro Hospitalar Cova da Beira contacted by phone call accepted to participate of the study. The exclusion criteria were pregnancy, high risk of PID, use of IUD, other uterine cars and uterine malformation. 23 selected patients answered a confidential and individual questionnaire about symptoms, obstetric and gynecologic history, demographic data and informed consent. They were submitted to ultrasound and saline contrast hysterosonography.

Results: The remaining myometrium (top of the niche) is thinner when evaluated by hysterossonography rather than ultrasonography. The length of the defects appear larger in patients with two or more cesarean. The remaining myometrium appear to be thinner in emergency cesarean sections and in higher gestational ages.

Discussion: The use of saline contrast hysterosonography might represent a valuable exam to determine the real depth, length and remaining myometrium. These data are important to determine the risk of posterior pregnancies and possible endoscopic treatment of symptomatic scar defects.

MüLLERIAN MALFORMATIONS AND ASSISTANCE REPRODUCTIVE TECHNOLOGY OUTCOMES

Infertility and Reproductive Medicine

Oral

Anne-Sophie Chevalier*, Jean-Marie Antoine, Nathalie Massin, Richard Balet, Nathalie Lédée, Jean-Noël Hugues, Joelle Belaich-Allart, Chadi Yazbeck, Jean-Louis Benifla

Hopital Trousseau,Pole de périnatalité

Summary (4 lines): The aim of this stud was to observe the Assisted Reproductive Technologies outcomes in a group of infertile patients who have a Müllerian malformation.

Introduction: Müllerian congenital malformations are more frequent in the population of infertile patients; they represent 7.3 to 8% of these couples. They result from a dysfunction of multifactorial development of the genital tract during embryogenesis. They can be the cause of infertility, or manifest as gynecological and/or obstetric complications more frequent than in the general population.

Material and Methods: This is retrospective multicentric study (2008-2010) with 45 infertile patients: 22 (48.9%) had septate uterus, 13 (28.9%) a bicornuate uterus and 10 (22.2%) a unicornuate uterus. Data collection was carried out on the basis of each computer center including criteria stimulation and pregnancy rates. Statistical analysis compared the data between the septate uterus group (n = 22) versus unicornate/bicornate uterus group (n = 23). A significance was recognized when p

Results: There were 86 cycles of ART (740 oocytes and 115 transferred embryos). Our results show a lower prognosis in ART for the patients who have a septate uterus compared to the other Müllerian malformations, with a fertilization rate of 31.4 vs 48.2% and an implantation rate of 18.6% vs 42.9%.

Discussion: This observed difference probably highlights a relationship between ovarian and endometrial functionality and resorption phase during embryogenesis. The proposed hypothesisis is the existence of a multifactorial pathophysiological mechanism where family HOXA gene could be a major player, already identified during embryogenesis of the female genital tract.

HISTORY OF LAPAROSCOPY - PAST, PRESENT AND FUTURE........

Teaching & Training

Poster

Fevzi Shakir*, Jan Haider, Kent Andrew

Royal Surrey County Hospital

Summary (4 lines): We present the history of laparoscopy, discussing its origin, identifying key individuals and technological advances that led to its rapid development. We then explore and discuss future potential advances.

Introduction: Laparoscopy, means to look or see in to the flanks, derived from Ancient Greek lapara, which means flank side and Skopeó meaning to see. Operating in the pelvis or abdomen as is done, should have been called a coelioscopy or peritonoscopy although this was too difficult to pronounce, hence the term laparoscopy was adopted. We explore the contributions of pioneering individuals and innovative companies in the nineteen hundreds which led to the development of laparoscopy.

Material and Methods: Medical literature, online journals and original surgical textbooks were searched to identify a timeline of key events and individuals who contributed and led to the innovation of laparoscopy, as we know it today.

Results: Key events such as the first laparoscopic procedures were identified together with developments by Palmer, Frangenheim , Semm as well as many others. However, none of this would have occurred without the advance of the endoscope, optics and technological developments by Georg Wolf and Karl Storz, which are described.

Discussion: We have come a long way from the development of the endoscope in 1806, and the reported first laparoscopic procedure in humans in 1910. Robotics has been a recent advance, which has great potential and whether this will form the future of laparoscopy, only time will tell.

TECHNICAL VIDEO: DEMONSTRATING THE STEPS OF HOW TO EXCISE AND REAPIR A UTERINE SACCULATION (NICHE)

Innovation in Instrumentation and Surgical Techniques

Video

Fevzi Shakir*, Jan Haider, Kent Andrew

Royal Surrey County Hospital

Summary (4 lines): We present a technical video showing the necessary stages, in a step by step fashion, involved with excising and repairing a uterine sacculation (niche) laparoscopically.

Introduction: Niche can be present in over 50% of caesarean section scars and of these, over 30% will experience symptomatic post menstrual spotting. It is therefore becoming a syndrome that we must consider, in select individuals, and know how to investigate and manage. This video highlights the preoperative and laparoscopic intraoperative steps required, to successfully excise, and then subsequently repair a sacculation.

Material and Methods: Using a genuine case of uterine sacculation syndrome (Kent and Waters 2009) that we managed as an example, this video has been edited to show the salient points during the laparoscopic niche excision and subsequent repair of the defect. Images and video from hysteroscopic findings are also included. Kent A, Waters N. Uterine Sacculation - a new syndrome of abnormal uterine bleeding after Caesarean section. Abstract ESGE Florence September 2009.

Results: This technique demonstrates an effective and reproducible method of laparoscopic uterine sacculation excision and subsequent repair.

Discussion: A sacculation is a sonographic finding of a uterine scar defect following caesarean section and is defined as a triangular, anechoic area. With the increasing caesarean section rate this will become more common. Our technical video highlights the important steps required to successfully excise and repair this defect laparoscopically.

HOW PRECISELY CAN WE IDENTIFY THE LINE OF RESECTION DURING LAPAROSCOPICAL SUPRACERVICAL HYSTERECTOMY?

Hysterectomy

Poster

Jekaterina Vasiljeva*, Lanowska Malgorzata, Köhler Christhardt, Schneider Achim, Mangler Mandy

Charite Universitatsmedizin

Summary (4 lines): Although clinical identification of internal os level seemed to be adequate, left endometrial tissue was found in nearly half of the patients. If there are indications to perform supracervical hysterectomy, there is a need to have a good concept for estimating the level of resection of the corpus uteri.

Introduction: Supracervical hysterectomy is performed to preserve a normal cerivx and the attached structures of the pelvic floor. Identifying the correct landmark for removal of the corpus uteri at the level of the internal os still remains a challenge in surgical practice.

Material and Methods: During the period from 10/2009 to 06/2013 we enrolled prospectively 19 patients at Charité – Universitätsmedizin, Department of Gynaecology who gave consent to take part in the study. All patients underwent laparoscopic supracervical hysterectomy with or without salpingoophorectomy. Following supracervical resection we excised the internal os of the cervix uteri per electrical Loop. The loop excision sample was histologically investigated with the question of presence of endometrial tissue.

Results: Mean age of patients was 47.2 years. Nearly all women were premenopausal. Six women were nulligravida, Only one patient used hormonal IUD, all other patients received no hormonal medication. The main reason for the operation was symptomatic uterine fibroids or adenomyosis. Mean weight of the removed uterus was 536.5 g

Discussion: In 7 patients it was impossible to evaluate the internal excision specimen of cervix uteri. In 5 of 12 (41.7%) patients we found endometrial tissue in the loop excision specimen.

LOW-PRESSURE LAPAROSCOPY WITH AIRSEAL® SYSTEM (7MMHG). A 42 PATIENTS PROSPECTIVE COMPARATIVE (15MMHG) PILOT STUDY

Complications

Poster

Matthieu Mezzadri*, Agnès Rigouzzo, antoine elies, Mathilde Piketty, Anne-Sophie Chevalier, Jean-Louis Benifla

Summary (4 lines): Low pressure pneumoperitoneum with AirSeal system (7 mmHg) allows efficient diagnostic and therapeutic laparoscopy, with decrease of shoulder post operative pain and intra operative EtCO2 when compared to a standard pressure (15 mmHg).

Introduction: Pneumoperitoneum in laparoscopic surgery may induce post operative shoulder pain. The aim of this prospective comparative pilot study was to evaluate feasibility of low-pressure pneumoperitoneum (7mmHg) with AirSeal® system in gynecological benign pathology, and to study benefits in terms of anesthetic intra operative parameters and post operative pain, compared to a standard-pressure group (15mmHg).

Material and Methods: Forty-two patients were operated for gynaecological benign pathology from January to June 2013,21 patients with 7 mmHg low pressure pneumoperitoneum, and 21 with 15 mmHg standard pressure. Intra-operative anesthetic parameters were collected (maximal systolic blood pressure, maximal EtCO2). After surgery, evaluation of post operative shoulder pain (Numeric Rating Scale, from 0 to 10) at H4,H8 and H24 was recorded. Morphine drugs use and possibility of discharge the day of the surgery were also collected.

Results: Laparoscopy was always possible with 7mmHg. Maximal EtCo2 was significantly lower with 7mmHg (36mmHg versus 40mmHg, p=0.01). Mean post operative shoulder pain NRS at H8 was lower with 7mmHg (0.8 versus 2.3, p=0.06).47.6% of patients operated with low-pressure estimated the discharge the day of the surgery was possible,versus 28%(p=0.2).

Discussion: Low pressure pneumoperitoneum (7 mmHg) allows efficient diagnostic and therapeutic laparoscopy, with decrease of post operative shoulder pain, and significant decrease of intra operative EtCo2. These findings may facilitate the development of outpatient laparoscopy.

FEMALE CASTRATION IN BREAST CANCER – OUTCOMES REVIEW

Oncology

Poster

Diana Almeida*, Dias João, Leite Tatiana, Lagoa António, Capela Eunice

Centro Hospitalar Vila Nova Gaia

Summary (4 lines): Premenopausal women with breast cancer and positive hormonal receptors are frequently submitted to castration. We will analyze this group of women, the type of castration performed and survival rates associated.

Introduction: Premenopausal women with breast cancer and positive hormonal receptors are frequently submitted to castration. The way how this is achieved will depend on several factors. Information on this subject is limited in scientific literature, which leads us to study this situation in our population.

Material and Methods: In retrospective study, the years between 2003 and 2012 were considered. We will study the group of premenopausal women with breast cancer and positive hormonal receptors. The sample will be divided in four subgroups – women who were submitted to surgical laparoscopic castration; women who underwent chemical castration; women who were submitted to surgical castration after failed chemical treatment and women who were proposed to a second chemical treatment after failure of the first one.

Results: Each group will be evaluated in terms of survival, considering an adequate characterization of the sample and tumors involved.

Discussion: When breast cancer affects premenopausal women, the survival and quality of life of a young group of population is in jeopardy. Realize which form of castration will allow these women higher survival with more quality of life is mandatory.

LAPAROSCOPIC MANAGEMENT OF PARASITIC FIBROIDS – DOES THIS CONTRIBUTE TO PULMONARY METASTASES?

Case reports

Poster

Ashleigh Simmonds*, Smith Charlotte B J, Goumalatsos Georgios, Chappatte Oliver A

Tunbridge Wells Hospital

Summary (4 lines): A case report of a patient who had laparoscopic management of parasitic fibroids and went on to develop pulmonary metastases.

Introduction: Uterine leiomyoma are the most common gynaecological tumour commonly occurring during the fourth and fifth decades of life. Occasionally these benign tumours are reported to spread to unusual sites including lung, lymph nodes, intravenous and the abdominal cavity. Aetiology is the subject of much controversy but the most widely accepted is haematogenous spread. Most patients have undergone myomectomy or hysterectomy which may suggest surgically induced haematogenous spread.

Material and Methods: A 30 year old woman was diagnosed with symptomatic fibroids and managed with goserelin. Following a trial of clomiphene for conception her uterus was 26 weeks size and she had an abdominal myomectomy. She then had a second abdominal myomectomy followed by a total abdominal hysterectomy after 2 failed cycles of IVF. She has subsequently been diagnosed with further parasitic fibroids in the pelvis requiring two laparoscopic excisions and now has pulmonary metastases.

Results: Despite having a total abdominal hysterectomy, this patient continued to develop pelvic fibroids. These have been excised twice laparoscopically. Despite this, she continued to develop pulmonary metastases and further rectus sheath and pelvic fibroids.

Discussion: Benign metastasizing leiomyoma is rare, with lungs the most common site of metastasis. Approximately 150 cases have been reported in the literature. The most widely accepted aetiology is haematological spread. Treatment aims to remove hormonal stimulation with analogues such as goserelin, or bilateral oophorectomy.

FETAL HEART ACTIVITY OBSERVED DURING LAPAROSCOPIC CORNUAL ECTOPIC SALPINGOTOMY

Teaching & Training

Video

Dr George Botros*

LIVERPOOL WOMEN'S HOSPITAL

Summary (4 lines): 35 yrs, old female 7 weeks pregnant was referred with an ultrasound scan highly suggestive of viable pregnancy in the left uterine cornu. 2 successive doses of systemic methotrexate were given. This is followed by fertility and left tube sparing laparoscopic salpingotomy with Vasopressin injection for haemostasis. During the procedure rare clips of 6+3 wks fetus observed extruding from the incision site with fetal heart activity seen.

Introduction: Laparoscopic left cornual incision and removal of 5-7cm ectopic pregnancy (mini laparoscopic hysterotomy) post injection of diluted vasopressin was used after unsuccessful use of systemic methotrexate.

Material and Methods: video case presentation

Results: Successful laparoscopic management of left corneal ectopic pregnancy. follow up of serum BHCG dropped to 6.1 IU/ml with negative urinary pregnancy test 2 weeks post surgery. Within 2 months post surgery the patient got pregnant with a positive pregnancy test. Trans-vaginal scan confirmed intrauterine 6 weeks pregnancy.

Discussion: Laparoscopic incision and evacuation of pregnancy tissue in combination with methotrexate systemic injection is a valid method for the conservative tube sparing management of corneal ectopic pregnancy.

LAPAROSCOPIC HYSTEROPEXY: RETROSPECTIVE ANALYSIS OF SAFETY AND COMPLICATIONS

Urogynaecology

Poster

Lutfi Shamsuddin*, Hoh Jennifer, Chamberlain Jonathan

Sunderland Royal Hospital

Summary (4 lines): Laparoscopic Sacral-Hysteropexy surgically treats middle vaginal compartment prolapse. Some techniques are associated with bowel injury. A review of our current technique showed adequate safety and low subjective recurrence rates.

Introduction: Laparoscopic Sacral-Hysteropexy elevates the middle vaginal compartment when the uterus/cervix is suspended to the sacral promontory. This technique retains the uterus and preserves vaginal capacity. We noted an association with late onset bowel obstruction when the uterus was suspended solely with Nylon suture material. Review of our current series of Mesh Sacral-Hysteropexy, where the uterus/cervix was suspended to the sacral promontory with polypropylene mesh confirms a safe and efficacious technique.

Material and Methods: 200 laparoscopic sacral-hysteropexy operations were reviewed; 73 suture sacral-hysteropexy performed between December 2004 and September 2008 and 127 laparoscopic mesh sacral-hysteropexy performed between October 2008 and December 2012. The electronic notes of patients were reviewed for evidence of intra-operative and post-operative complications. Subjective success rates were assessed by review of outpatient correspondence and any requirement for a subsequent middle vaginal compartment repair.

Results: 3 late onset bowel obstructions occurred in the suture sacral-hysteropexy group requiring laparotomy and 2 had small-bowel resection. No late onset bowel problems occurred in the mesh sacral-hysteropexy group. There were no intra-operative bladder, ureteric or bowel injuries in either group. Overall 14.5% had subsequent middle compartment surgery for prolapse.

Discussion: Laparoscopic Mesh Sacral-Hysteropexy is a safe and effective procedure for treating middle vaginal compartment prolapse. We changed to mesh sacral-hysteropexy following the late-onset bowel complications and have yet to see any similar post-operative problems after 127 cases. Recurrence rates appear lower than other surgical methods for treating a similar prolapse.

DESCRIPTIVE STUDY OF THE NEW DIAGNOSTIC-THERAPEUTIC HYSTEROSCOPIC MORCELLATOR SYSTEM

Diagnostic & Operative Office Hysteroscopy

Poster

Gemma Escribano *, Rovira jennifer, Degollada Maria, Garcia Tamara, Bresco Pere

Igualada Hospital

Summary (4 lines): The new mechanical hysteroscopic system, Truclear System®, is a diagnostic-therapeutic technique that allows polypectomies to be performed in the outpatient setting in patients with an ultrasound diagnosis of polyps, achieving 100% success rates in removing intracavitary lesions.

Introduction: The objective of our study was to describe our initial experience with the new mechanical Truclear (Smith & Nephew) hysteroscope in a number of polypectomies performed in the outpatient setting without having to refer the patient for surgery. Hypothesis was set as that the new morcellation system is a safe and effective diagnostic-therapeutic technique for the outpatient management of endometrial polyps.

Material and Methods: An observational prospective non-randomized study including 100 patients who underwent a hysteroscopy between June 2011 and January 2012 at the Hospital of Igualada. There were two patient groups: Group 1 included the first 55 patients who met the inclusion criteria for a hysteroscopy and Group 2 included 45 patients with ultrasound-suspected endometrial polyps.

Results: We performed 41 and 40 uneventful hysteroscopies in Group 1 and 2, respectively, and 56% and 82.5% were suspected endometrial polyps, respectively. The polypectomy was 100% successful in all cases, without having to refer any patient for surgery. Tolerance was moderate to good in 91.3% of the patients.

Discussion: The new morcellator system allows polypectomies to be conducted in outpatients with an ultrasound diagnosis of polyps, without having to refer the patient for surgery.

LAPAROSCOPIC DIAGNOSIS OF A PARASETIC INFECTION OF PELVIC AND ABDOMINAL CAVITY

Case reports

Poster

Dr George Botros*

LIVERPOOL WOMEN'S HOSPITAL

Summary (4 lines): A 36 years old lady para 6 presented to the gynaecology clinic with a history of chronic pelvic pain for more than 4 months. A diagnostic laparoscopy showed vesicular lesions in the Pouch of Douglas . Images of the lesions were taken and biopsies sent for histological assessment. The histology report confirmed Enetrobius Vermicularis eggs in the lesions highly suggestive of Pin worms infestations into the abdominal cavity. appropriate treatment given by the general practitioner. The chronic lower abdominal pains settled.

Introduction: as above

Material and Methods: case report

Results: as above

Discussion: it is very rare to find Pinworms eggs in peritoneal biopsies from the Pouch of Douglas and abdominal cavity. atypical lesions seen during diagnostic laparoscopy should be biopsied to reach an accurate diagnosis.

LAPAROSCOPIC PROMONTOPEKSY: PROSPECTIVE ANALYSIS OF COMPLICATIONS, ANATOMICAL AND FUNCTIONAL RESULTS

Complications

Poster

Bezhenar Vitaly*, Guseva Evgeniya, Botchorishvili Revaz

Summary (4 lines): We made the prospective analysis of intra-and postoperative complications of laparoscopic mesh-promontopexy. We estimated the functional and anatomical results of the operation, and evaluated the life quality of patients before surgery and in the period of 6/12/24 months after it. The average observation period was 4,5 ± 2,2 years. The safety and efficiency of the method and the satisfaction of the patients with the treatment was confirmed.

Introduction: In Russia laparoscopic promontopexy is used not widely enough and there is no literature data reflecting the current state of the problem. There is a clear need to undertake a comprehensive evaluation of the application of laparoscopic promontoficsation in the treatment of genital prolapse in order to determine the significance of this intervention in the present conditions and to find ways to optimize it.

Material and Methods: In 8 years have been operated 114 women with genital prolapse. Preoperative preparation includes ultrasound of urethra-vesical segment, evacuation proctography, urodimamic evaluation. The evaluation of the life quality with the use of questionnaires (PFIQ-7, PEDI-20) was made. In 33 cases vaginopexy was performed, in 70 cases cervicopexy, in 11 cases hysteropexy. 18 patients were operated due to recurrent prolapse after previous plastic surgery. Paravaginal mesh-reparation in 3,5%

Results: There was intraoperative injury of rectum in 0,9%, wound bladder in 0,9%. Erosion of the vaginal wall in 3,5%. Recurrence of prolapse after 3 months came in 0,9%. Incontinence DeNovo in 1,7%. Small bowel obstruction in 0,9%. Vein thrombophlebitis in 1,8%. Chronic constipation in the postoperative period – in 65%.

Discussion: Anatomic success of the operation was 99.1%. There is the minimum number of intraoperative complications, which makes the surgery as safe as possible. In order to prevent chronic constipation the patients were recommended the diet therapy, a course of physical exercise on special techniques, massage and regular use of laxatives.

THE HISTOPATHOLOGIC SIGNIFICANCE OF INTRAUTERINE LESIONS IN ASYMPTOMATIC POSTMENOPAUSAL PATIENTS: TO PERFORM HYSTEROSCOPY OR NOT?

Surgical Hysteroscopy

Oral

ROLANDAS ZIOBAKAS*, Rimkiene Jolanta, Isajeva Jelena , Zaliunas Bronius

Vilnius Maternity Hospital

Summary (4 lines): A retrospective descriptive study of 216 postmenopausal women subjected to hysteroscopy with an ultrasound indication of asymptomatic uterine lesions during 2009 - 2012 was carried out. Clinical implications: the risk of endometrial carcinoma in bleeding – free postmenopausal women with asymptomatic intrauterine lesions is low. Nevertheless, because malignancy occurs, although rarely, and because the operative risk is low, hysteroscopy and polyp resection can be recommended in patients with low operative risk.

Introduction: The objective of the study was to determine the pathologic significance of asymptomatic intrauterine lesions in bleeding – free postmenopausal women.

Material and Methods: A retrospective descriptive study of 216 postmenopausal women subjected to hysteroscopy with an ultrasound indication of asymptomatic uterine lesions during 2009 - 2012 was carried out. Data collected included age, parity, menopausal status, BMI, use of HRT, tamoxifen treatment in cases of breast cancer, other medical conditions associated with endometrial cancer (obesity, hypertension, diabetes) and the findings of ultrasound examination and hysteroscopy.

Results: Of the 216 patients with suspected intrauterine lesions, 192 (89%) focal lesions (mostly polyps and myomas) were confirmed by hysteroscopy. The total prevalence of malignancy was 1,9% (endometrial adenocarcinoma was diagnosed in 4 cases).

Discussion: The risk of endometrial carcinoma in bleeding – free postmenopausal women with asymptomatic intrauterine lesions is low. Nevertheless, because malignancy occurs, although rarely, and because the operative risk is low, hysteroscopy and polyp resection can be recommended in patients with low operative risk.

LAPAROSCOPIC MANAGEMENT OF A RETROPERITONEAL CYSTIC LYMPHANGIOM

Case reports

Poster

Heike Creutz*, Forner Dirk Michael

Sana-Klinikum Remscheid

Summary (4 lines): Due to acute abdominal pain laproscopy was indicated to a 38-year-old woman in spite of unremarkable ultrasound. A large retroperitoneal cystic lymphangioma was found which could be removed by laparoscopy.

Introduction: Retroperitoneal cystic lymphangiomas are rare. Malignancy is not described in the leading literature. Due to missing of specific symptoms classification to a particular organ system is difficult. Retroperitoneal cystic lymphangiomas are small cystic, half solid appearing tumors from extended lymphatic vessel with single- or multi-layer epithelium. Complications are mostly caused by increasing tumors. Spontaneous regression is uncommon. If preoperative classification is possible and dignity is clear, an expectant strategy by frequent control is reasonable.

Material and Methods As case report we picture the approach in case of a symptomatic lymphangioma. A suitable imaging mode to detect lymphangiomas is ultrasound or if applicable computer tomography or magnetic resonance tomography. In our case there were no pathological findings preoperatively but abdominal pain, hypermenorrhea and dilatation of renal pelvis. According to pronounced medical condition diagnostic laparoscopy was indicated. After dividing adhesions a remarkable retroperitoneal cyst was detected close to the caecum area and removed.

Results: To confirm a diagnosis is difficult because of localisation and not definable histological type. Only surgery offers a possibility to localise the tumor. After laparoscopic dividing of adhesions an 8 cm cyst was dissected retroperitoneal. Initially liquid was sucked out so that the cyst could be removed easily by bag.

Discussion: The difficulty to define diagnosis preoperatively is caused by uncomfortable retroperitoneal localisation. Actually this is why the diagnosis will not be confirmed preoperatively by ultrasound. Complete exstirpation preferable by laparoscopy is method of choice, also suitable in regard to an extended retroperitoneal cyst, located close to the caecum area.

DOES LAPAROSCOPIC OVARIAN DRILLING AFFECT OVARIAN RESERVE?

Infertility and Reproductive Medicine

Poster

Francesca Salvagno*, Canuto Emilie Marion, Picardo Elisa, Mitidieri Marco, gennarelli gianluca, revelli alberto, marchino gian luigi, benedetto chiara

Sant'Anna Hospital, University of Torino

Summary (4 lines): Laparoscopic ovarian drilling (LOD) is a surgical approach for anovulatory women with polycystic ovary syndrome (PCOS). LOD causes disruption of the ovarian capsule and stroma and could impair follicular reserve.

Introduction: LOD represents a second-line intervention for anovulatory women with PCOS. It is based on the experience of ovarian wedge resection and consists in multiple perforations of the ovarian surface and stroma.The presumed mechanisms of action include the decrease of circulating and intra-ovarian androgens and the enlargment of the space for follicular expansion. Compared to gonadotropin therapy LOD reduces multiple pregnancies and avoids hyperstimulation. Concerns about LOD are possible surgical complications and impairment of ovarian reserve.

Material and Methods: We performed a literature search throughout the Medline and Embase databases and the Cochrane database of Systemic Reviews, using as keywords LOD, laparoscopic ovarian diathermy, AMH, ovarian reserve, PCOS, premature ovarian failure (POF). We selected 7 references: two cross sectional studies, two prospective observational studies, a case series, two prospective controlled studies. The criteria used to assess ovarian reserve were: AMH, FSH, inhibin B, antral follicle count (AFC), ovarian volume, ovarian power Doppler indices.

Results: There were statistically significant differences in plasmatic and ultrasound markers of ovarian reserve after treatment in most of the reports, indicating a reduction in follicular reserve after surgery. Amer didn’t find significant changes of inhibin B after LOD, while Kandil and Selim found significant differences only after bilateral LOD.

Discussion: The changes in the ovarian reserve after LOD suggest to limit the application of this technique to those unfertile women with clomiphene-resistant PCOS. LOD should never be offered for other indications, as menstrual irregularity or hyperandrogenism. Moreover the delay of childbearing should be considered when approaching young women with PCOS.

LONG-TERM COMPLICATIONS OF MESHES IN PROLAPSE ORGAN SURGERY

Complications

Oral

Joao Alves*, Fernandes Rodrigo, Puga Marco, Redondo Cristina, Wattiez Arnaud

IRCAD EITS Strasbourg

Summary (4 lines): Management of Mesh-related complications can be challenging. Six patients with erosion, abscess, pain and recurrent cystocele after prolapse surgeries using meshes and their laparoscopic treatment are analyzed.

Introduction: Prevalence of pelvic organ prolapse (POP) appears to be increasing, with mesh still widely used in both vaginal and abdominal surgical routes. Several reports of mesh-related complications are nowadays one of the major concerns in POP treatment. Even if there are still some conflicting points in the management of these cases, there are several well-based recommendations that are usually omitted by clinicians making the evolution of the patient torpid.

Material and Methods: Retrospective analysis of the surgical records of patients with mesh related complications managed in the Department of Obstetrics & Gynecology of the University Hospitals of Strasbourg, between 2009 - 2012, are presented. Cases of both laparoscopic and vaginal surgery were included.

Results: Six patients were included: two mesh related abscess, two cases of mesh-related pain complains treated with laparoscopic surgical removal. One case of erosion dealt with vaginal partial mesh resection; and one cystocele recurrence managed with mesh removal and new mesh placement. In all cases follow up was uneventful.

Discussion: Surgeons working in prolapse surgery should be aware of the possibility of Mesh –related complications. Thorough informed consent when the mesh is considered in the management is mandatory. Expedient diagnosis and optimal management with minimally invasive techniques are fundamental in the rapid recovery of these conditions.

ARTERIOVENOUS MALFORMATION OF THE UTERUS

Case reports

Poster

George Suku*

University of Manchester

Summary (4 lines): We report a rare case of arteriovenous malformation (AVM) of the uterus.

Introduction: An AVM is an abnormal communication between arteries and veins. An accurate incidence of uterine AVM is not known due to its rarity. Associations have been made with uterine trauma, although congenital cases have been reported.

Material and Methods: A 54 year old lady with a history of a molar pregnancy presented with intermittent right sided abdominal pain radiating to her left hip and groin. On bimanual examination, the uterus felt pulsatile. Ultrasound scan showed increased vasculature, a thin endometrium and very little myometrium. Contrast CT showed early filling of pelvic veins, leading to strong suspicion of AVM of the uterus. The patient was successfully treated with a hysterectomy with salpingo-oophorectomy.

Results:Histology showed a thickened uterine fundus with increased vascularity. Dilated blood vessels were observed in the thickened areas, some of which were filled with clots. The myometrium exhibited vascular lesions and large dilated veins. The lesion involved the entire uterine wall, was more prominent posteriorly and extended into the cervix.

Discussion:We report this case because of the rarity of AVMs of the uterus. Percutaneous transcatheter embolization and laparoscopic bipolar coagulation of the uterine vessels have been described as fertility preserving treatments. Hysterectomy was the treatment of choice in this case.

A SERIES OF 2708 TOTAL LAPAROSCOPIC HYSTERECTOMIES FOR BENIGN DISEASE: A 15 YEARS OF EXPERIENCE

Hysterectomy

Oral

Adamyan Leila*, Irena Kozachenko

Summary (4 lines): From 1997 to 2012, 2708 total lapascopic hysterectomies were performed in our department in 15,8% of all 17111 operated patients.

Introduction: Laparoscopic hysterectomy has consistently gained in popularity since its worldwide introduction to the surgical palette in the early 1990s. Today, it is common knowledge that in cases of benign diseases, the laparoscopic approach is superior to abdominal hysterectomy with respect to blood loss, wound infection, hospital stay, and recovery period. In addition, patients claim to prefer this minimally invasive approach over abdominal hysterectomy for esthetical reasons and because of recovery considerations.

Material and Methods: Since the 1997 TLH is done routinely in our department and the number of laparoscopic procedures has continued to grow. Our uterine volume limit for laparoscopic hysterectomy was equivalent to 18–20 weeks of gestation, gonadotrophin-releasing hormone (GnRH) agonist were not used preoperatively to decrease the size of the uterus.

Results: From 1997 to 2012, 2708 total lapascopic hysterectomies were performed in our department. We found a 1.25% (n = 34) rate of total complications (minor and major) among the 2708 laparoscopic hysterectomies performed. The rate of minor complications was 0.9%, the rate of major complication was 0,25% after laparoscopic hysterectomy.

Discussion: Since the first laparoscopic hysterectomy was described by Reich et al. back in 1989 and the first subtotal hysterectomy was performed in the early 1990s, the laparoscopic approach has become the procedure of choice in gynecological surgery. Numerous advantages for the patient and the surgeon are detailed in the literature.

SAFETY EVALUATION OF THE NEW SPRAYABLE ADHESION BARRIER ADBLOCK SYSTEM AFTER LAPAROSCOPIC DE-NOVO MYOMECTOMY

Operative Risk Management

Oral

De Wilde Rudy-Leon*, Ziegler Nicole, Korell Matthias, Tchartchian Garri

Pius Hospital

Summary (4 lines): The safety of the new bioresorbable adhesion barrier system was evaluated in patients undergoing laparoscopic myomectomy. It was found that the use of the system was safe without major complications.

Introduction: Adhesions are the most frequent complications after abdominopelvic surgery. Many efforts have been made to develop and prove comprehensive adhesion reduction strategies. However, there is still a need for effective and safe agents to use alongside optimal surgical technique. Our objective is to explore the safety, manageability and usability of the new site-specific, sprayable ADBLOCK system after laparoscopic de-novo removal of myoma with its long-term goal to reduce incidence, severity and extent of postoperative adhesions.

Material and Methods: ADBLOCK is a novel bioresorbable gel composed of dextrin derivative and trehalose, which does not contain any colorant, however this allows excellent visualisation on the operative field. 32 patients, undergoing laparoscopic de-novo removal of myomas were randomized (2:1) to be treated with either the ADBLOCK (21) sprayed over all myomectomy sutures or with surgery only (11). Primary endpoint was evaluated by assessment of serious adverse events (SAE) up to 28 days.

Results: SAEs rate was 5% and 10% in ADBLOCK and control arm respectively, while any adverse event including pain and discomfort were recorded in 7 and 11 patients, respectively. There were no post-operative infections. No further adverse events reported between 28 days and 6 months.

Discussion: The results of our study showed a good safety profile for the ADBLOCK adhesion barrier. The main events reported were post-operative pain, nausea, vertigo, discomfort, and dysmenorrhoea. Two scheduled second look laparoscopies (one patient in each arm) were the only serious adverse events documented, following protocol definitions.

KAI-1 PROTEIN EXPRESSION IN NORMAL ENDOMETRIUM FROM PATIENTS WITH AND PATIENTS WITHOUT LAPAROSCOPICALLY CONFIRMED ENDOMETRIOSIS

Endometriosis: Diagnosis

Selected abstract Oral

Timologou Anna*, Zafrakas Menelaos, Grimbizis Grigorios, Miliaras Demosthenis, Kolioulis Ioannis, kotronis Konstantinos, Tarlatzis Basil C.

Summary (4 lines): Immunohistochemical analysis showed that KAI-1 protein expression was decreased in the endometrium of endometriosis patients as compared to that of women without endometriosis.

Introduction: Despite extensive research, the pathogenesis of endometriosis remains unclear. Sampson’s theory, supporting the implantation in ectopic sites of endometrial cells refluxed during menstruation, is the most widely accepted pathogenetic mechanism. According to this theory, endometriosis represents a paradigm of benign metastasis. Given that KAI-1 is a tumor-metastasis-suppressor gene that inhibits motility and invasiveness of cancer cells, we have analyzed immunohistochemically its protein expression in the endometrium of women with and without endometriosis.

Material and Methods: The study included 55 premenopausal patients, aged 17-45 years, undergoing operative laparoscopy during the proliferative phase of the menstrual cycle. Thirty four women had laparoscopically and histologically confirmed endometriosis, whereas 21 had other benign pathology, including uterine fibroids, benign ovarian cysts and hydrosalpinges. Endometrial samples were collected prospectively with Pipelle and/or curettage after signed written informed consent. Tissue samples were analyzed immunohistochemically using the KAI-1 sc-17752 antibody (Santa Cruz Biotechnology Inc., Heidelberg, Germany).

Results: Using a semi-quantitative immunohistochemical score, protein expression of KAI-1 was found to be lower in the eutopic endometrium of endometriosis patients as compared to that of patients without endometriosis. Lower protein KAI-1 expression in endometriosis patients was found in both the glandular endometrium and the stroma.

Discussion: Our findings are consistent with the well-established role of KAI-1 as a tumor-metastasis-suppressor gene, and with Sampson’s theory of benign dissemination of non-malignant endometrial cells. KAI-1 protein expression in the eutopic endometrium could be used as a marker for early and minimally invasive detection of endometriosis.

THE ROLE OF OUTPATIENT HYSTEROSCOPY IN THE EVALUATION OF PATIENTS WITH MENORRAGIA AND ENDOMETRIAL THICKENING

Diagnostic & Operative Office Hysteroscopy

Oral

Paula Norinho Oliveira*, Caldas Rita, Rodrigues Catia, KoK Mak Foo, Lanhoso António, Ferreira Soledade, Teles Teresa Paula

Entre Douro e Vouga Hospital Center

Summary (4 lines): To establish a correlation between hysteroscopic and patholological findings in patients with menorragia or sonographically thickened endometrium.

Introduction: Of the 162 hysteroscopies performed, the mean age of the patients was 53,6 years (minimum 30; maximum 102). The most frequent indication for diagnostic hysteroscopy were abnormal uterine bleeding (61,1%), endometrial thickening (34,1%), hematometra (1,2%) and fibroid (0,6%). Ultrasound was performed in 83,2% of the patients with the average endometrial thickness of 11mm±5,7mm. 44,3% of the patients were at menopause.

Material and Methods: A retrospective study was conducted between 1st of January and 1st of April 2011 where a total of 162 cases referred to the gynaecological clinic, were subjected to diagnostic hysteroscopy. Data collected included age, parity, indication of the hysteroscopy, ultrasound findings, menopausal status, hysteroscopic findings, histological result and complications during hysteroscopy. Statistical treatment with Statistical Package of Social Sciences (SPSS) version 20.0.

Results: Most frequent hysteroscopic diagnosis: polyps (51,5%), submucous fibroid (9,6%), normal cavity (19.1%). 79,3% of the patient with abnormal hysteroscopic findings had biopsy done; 43,1% were endometrial polyps, 10,2% fibroid, 7,2% normal histology, 2,4% with simple glandular hyperplasia without atypia, 1,2 % with atrophic endometrium and 0,6% had carcinoma endometrium.

Discussion: Outpatient diagnostic hysteroscopy is a safe, reliable and efficient method for the investigation of patient with abnormal uterine bleeding and thickened endometrium. The commonest pathology detected was endometrial polyps.

KISS-1 PROTEIN EXPRESSION IN ADENOMYOSIS LESIONS AND NORMAL ENDOMETRIUM: AN IMMUNOHISTOCHEMICAL STUDY

Hysterectomy

Selected abstract Oral

Kolioulis Ioannis*, Zafrakas Menelaos, Grimbizis Grigorios, Miliaras Demosthenis, Timologou Anna, Tarlatzis Basil C, Bontis John N, Tzevelekis Filippos

Summary (4 lines): Immunohistochemical analysis showed that KISS-1 protein expression was increased in adenomyosis lesions as compared to matched eutopic endometrium, as well as to endometrium of patients without adenomyosis.

Introduction: Adenomyosis, the presence of functional endometrial tissue within the myometrium, is usually a coincidental finding in hysterectomy specimens. Adenomyotic foci appear to be the consequence of benign dissemination of normal endometrial tissue in the myometrium. Given that KISS-1 is a tumor-metastasis-suppressor gene and that kisspeptins are involved in cell invasion through regulation of matrix metalloproteinases (MMPs), we have conducted an immunohistochemical analysis of KISS-1 protein expression in adenomyotic lesions and normal endometrium.

Material and Methods: Adenomyotic and normal endometrial tissue specimens from 50 premenopausal women have been analyzed, including 29 patients with histologically confirmed adenomyosis diagnosed after laporoscopic or open hysterectomy and 21 patients without adenomyosis treated laparoscopically, due to benign pathology (uterine fibroids, benign ovarian cysts and hydrosalpinges). KISS-1 expression was analyzed immunohistochemically in adenomyotic lesions and corresponding normal endometrium from adenomyosis patients, as well as the endometrium from patients without adenomyosis, collected prospectively with Pipelle and/or curettage.

Results: Using a semi-quantitative immunohistochemical score, KISS-1 protein expression was more abundant in adenomyosis lesions compared with matched eutopic endometrium, particularly in the endometrial-myometrial interface and in larger adenomyotic lesions. KISS-1 protein expression in the eutopic endometrium of adenomyosis patients was increased compared to that from patients without adenomyosis.

Discussion: KISS-1 protein expression appears to be up-regulated in adenomyosis lesions as compared to eutopic endometrium of adenomyotic patients as well as women without adenomyosis. These findings suggest that KISS-1 is involved in the pathogenesis and maintenance of adenomyosis.

ANTI NMDA (N-METHYL D-ASPARTATE) RECEPTOR ENCEPHALITIS IN A YOUNG WOMAN WITH BILATERAL OVARIAN DERMOID TUMOUR

Case reports

Poster

Mihai Gherghe*, Hardwick Christopher

Southern General Hospital

Summary (4 lines): Elective surgical treatment of a dermoid ovarian tumour was performed for a 24 year old woman diagnosed with anti NMDA receptor encephalitis. Further imaging revealed a contralateral dermoid ovarian cyst.

Introduction: There is an association between anti NMDA receptor antibodies in young female patients diagnosed with severe encephalitis and the presence of ovarian dermoid tumours. In a small case series of patients (Dalmau J et al., Lancet Neurol 2008;7:1091-98) treated for severe encephalitis, all diagnosed ovarian teratomas contained nervous tissue. Early removal of these tumours led to a better neurological outcome.

Material and Methods: CT thorax, abdomen and pelvis of a 24 year old woman diagnosed with anti NMDA receptor encephalitis, showed a small left ovarian mass, likely dermoid and a possible right ovarian dermoid cyst. Laproscopic left ovarian cystectomy was performed, right ovary appeared normal. One year following initial surgery serum anti NMDA antibody titres remained high and a further CT pelvis showed a small right ovarian dermoid cyst. This was electively removed with conservation of ovary.

Results: Pathology report confirms the presence of neural tissue in the left ovarian dermoid cyst. Plasma exchange, immunoglobulins and cytotoxic drugs complemented initial surgical treatment. 8 weeks post surgical procedure her condition improved significantly. She has no physical disabilities and she continued to be treated with immunosupressant therapy (Mycophenolate).

Discussion: Mortality remains as high as 100% in some case series therefore early imaging in this group of patients with a view of surgically removing incidental ovarian tumours is of great importance. There may be a place for interval imaging in patients with persisting positive serum anti NMDA antibodies.

LAPAROSCOPIC OVARIAN CYSTECTOMY FOR A BORDERLINE CLEAR CELL ADENOFIBROMA

Case reports

Poster

Mihai Gherghe*, Bollapragada Shrikant

Southern General Hospital

Summary (4 lines): A premenopausal 45 year old woman underwent elective laparoscopic ovarian cystectomy for a 7 cm complex ovarian cyst. The diagnosis of borderline clear cell adenofibroma was made on histological analysis.

Introduction: There are only 26 cases of borderline ovarian clear cell adenofibroma reported in the literature. Most of these were diagnosed on salpingo-oophorectomy specimens in postmenopausal women presenting with a pelvic mass. In our case the lady wished to retain fertility and requested minimal surgery. We believe this to be the first case of borderline clear cell adenofibroma where the diagnosis was made following laparoscopic ovarian cystectomy.

Material and Methods: An incidental 7 cm complex ovarian cyst was diagnosed by transvaginal ultrasound in a premenopausal woman. The rest of pelvic organs appeared normal. Histology showed borderline clear cell adenofibroma. Total hysterectomy, bilateral salpingo-oophorectomy and surgical staging were performed with no evidence of malignancy found on subsequent histology.

Results: Initial pathology report showed features of borderline clear cell adenofibroma along with evidence of pre-existing endometriosis. There was no evidence of frank malignant infiltration. No further evidence of malignancy was found on later specimens and 5 years follow up was considered appropriate.

Discussion: Although clear cell borderline ovarian tumors have been associated with endometriosis and adenofibromas, the molecular transformation pathways have not been elucidated.

RISK ASSESSMENT FOR HYSTERECTOMY FIVE YEARS FOLLOWING GLOBAL ENDOMETRIAL ABLATION

Surgical Hysteroscopy

Poster

Peter Orchard*, Baxter Ted, Connor Mary

University of Sheffield

Summary (4 lines): The efficacy of global endometrial ablation is variable. By identifying patient factors and subsequent outcomes we can evaluate predictors of treatment failure and better counsel women considering this surgical therapy.

Introduction: Treatment with a second generation endometrial ablation device is advocated for the management of women with heavy menstrual bleeding (HMB) and a normal uterus. However, some women subsequently undergo hysterectomy. Previous studies suggest that the risk of post-ablation hysterectomy is higher in women under 45 years of age, those with fibroids, a history of dysmenorrhoea and if sterilised. We reviewed our own results from 2004 to see if this applied to our patients.

Material and Methods: We reviewed the outcome of all patients who underwent global endometrial ablation using either a thermal balloon or a radio-frequency device in our hospital between 2004 and 2008. We identified patients who had required further surgical treatment for HMB with either a repeat endometrial ablation or hysterectomy between five and nine years following treatment. The results were stratified for analysis by the above risk factors, as well as the device used and treatment venue.

Results: A total of 411 women were identified. At least 104 (25.3%) required further treatment, with 24 (5.8%) undergoing a repeat ablation and 84 (20.4%) hysterectomy. Further analysis using the above stratification will be undertaken once data collection is complete.

Discussion: These results will help us to provide women seeking surgical treatment for HMB with refined information about their likely outcome should they undergo global endometrial ablation. We hope this will improve the service that we offer by enabling women and clinicians to make a more informed decision concerning their treatment.

SAFE ENTRY AT LAPAROSCOPY IN WOMEN WITH A SCARRED ABDOMEN

Complications

Oral

Prashant Mangeshikar*, Mangeshikar Abhishek

Mangeshikar M.A.G.I.C. for Woman

Summary (4 lines): To assess the safety, feasibility and reproducibility of the Trocarless EndoTip cannula at laparoscopy using the Lee Huang portal in women with previous abdominal surgery.

Introduction: Prospective study of 500 consecutive cases of women undergoing laparoscopic surgery with previous abdominal surgery in private practice setup. Laparoscopic surgery was performed for endometriosis, myomectomies, adhesiolysis, tubal pregnancies, ovarian tumors, pelvic floor repair or hysterectomies.

Material and Methods Trocarless cannula entry was accomplished using high pneumoperitoneum pressure (25-30 mmHg) and Ternamian Endotip system through the Lee Huang portal. This portal was described by Lee and Huang in 1991 and is a primary entry point at laparoscopy, midway between the xiphisternum and umbilicus. All laparoscopies were performed under general anesthesia, with an indwelling naso-gastric tube to deflate the stomach and the patients in a horizontal position.

Results: Safe entry was achieved in all 500 women with the EndoTip system. Adhesions due to previous surgery were encountered in 312 women (62.4%); in 106 out of 312 women (33.97%), these parietal adhesions involved the bowel at or below the umbilicus.

Discussion: The Lee Huang portal of entry using the Trocarless Ternamian EndoTip system at high pneumoperitoneum pressure is a safe and effective method of abdominal entry at laparoscopy in women with a scarred abdomen.

TOTAL LAPAROSCOPIC HYSTERECTOMY : OUR FIRST EXPERIENCE

Complications

Poster

Padma Vanga*, Vanga Padma, Allam Mohammed

NHS Lanarkshire

Summary (4 lines): Our study demonstrates that laparoscopic hysterectomy is a reproducible approach with minimal complications in a district general hospital setting. We were able to have good results due to careful case selection, 2 experienced surgeons operating together to improve training and learning opportunities.

Introduction: This procedure was introduced to our unit one year ago based on the recent Royal College of Obstetrician and Gynaecologists (RCOG) guidelines/recommendation. The later highlighted this procedure’s benefits for both patient and NHS.

Material and Methods Design: Retrospective cohort study in a district general hospital, Scotland Ligasure (COVIDIEN) or Enseal (ETHICON) was the main method for securing and dividing pedicles, V-Care (CONMED) was used for vaginal delineation. Vaginal vault was closed using either intra or extra corporeal sutures with 0/3 PDS (ETHICON) or V-Lock (COVIDIEN).

Results: A total of 21 cases of total laparoscopic hysterectomies were performed during the study period.Average intra operative blood loss was less than 100ml and maximal estimated blood loss was 300ml. We had no visceral injury or conversion to laparotomy or return to theatre. Average hospital stay was 2.5 days.

Discussion: Hysterectomy is the most commonly performed gynaecological surgery. Our study demonstrates that total laparoscopic hysterctomy is a safe and cost effective approach compared to traditional methods. Although the numbers are too small to draw any immediate conclusions regarding safety, it certainly gives confidence to continue the practice.

STRATEGIES TO PREVENT VAGINAL CUFF DEHISCENCE AND VAULT PROLAPSE FOLLOWING TOTAL LAPAROSCOPIC HYSTERECTOMY

Innovation in Instrumentation and Surgical Techniques

Poster

Prashant Mangeshikar*

Mangeshikar M.A.G.I.C. for Woman

Summary (4 lines): Vaginal Cuff dehiscence and vault prolapse has been reported following Total Laparoscopic Hysterectomy (TLH). Laparoscopic closure of the vagina enables full thickness closure and prevents these complications.

Introduction: The laparoscopic closure of the vagina at TLH enables full thickness closure in contrast to vaginal approach at closure. It enables secure approximation of the vaginal angles incorporating the full thickness of the vagina and the parametrium and the uterosacral ligament.

Material and Methods: 300 women underwent TLH using Bipolar coagulation and scissors dissection with mobilization of the uterus with Mangeshikar Uterine Mobilisar in a private clinic. Following circumcision of the vagina, the uterus was delivered by vaginal debulking or via laparoscopic morcellation. The left vaginal angle and then the right angle closed via Ipsilateral technique of Koh using Polysorb 2-0 in the shape of an Omega. The vagina was closed in a continuous manner.

Results: Of 289 women at Follow Up, one had vaginal bleeding, no case of vaginal dehiscence or vault prolapse noted.

Discussion: Laparoscopy facilitates the full thicknesss closure of the vagina in a single continuous layer after securing both angles. A second layer involving the pericervical fascia enables secure support to the vagina.

LAPAROSCOPIC MANAGEMENT OF OVARIAN TORSION IN A WOMAN WITH CLASS III OBESITY

Case reports

Oral

David Crosby *

Coombe Women and Infant's University Hospital, Dub

Summary (4 lines): We aim to discuss our laparoscopic management of this case and the laparoscopic techniques which can be used for tissue retrieval in morbidly obesepatients and the challenges associated with this.

Introduction: We present the case of a 25 year old woman with a variant of Prader-Willi Syndrome who presented to the gynaecology outpatients department with mild left iliac fossa ongoing for 4 months. Of note, she had a Mirena Coil inserted aged 22 under general anaesthesia for heavy menstrual bleeding and a laparoscopic right salpingo-oopherectomy aged 16 for tubo-ovarian torsion. Of note her body mass index was 59 kg/m2 (class III obese).

Material and Methods: A CT abdomen and pelvis showed a 6cm left ovarian cyst, consistent with a dermoid. Tumour markers were normal. A laparoscopy was performed, which revealed a torted tubo-ovarian mass. She underwent a laparoscopic left salpingo-oopherectomy. She was well post-operatively and went home on day 3.

Results: Prader-Willi in early childhood is associated excessive eating and gradual development of morbid obesity.

Discussion: We aim to discuss our laparoscopic management of this case and the laparoscopic techniques which can be used for tissue retrieval in morbidly obesepatients and the challenges associated with this.

TOTAL LAPAROSCOPIC HYSTERECTOMY IN PATIENTS WITH PREVIOUS CESAREAN SECTIONS

Hysterectomy

Selected abstract Oral

Gayatri Rao*, Sinha Rakesh, Raje Shweta

Bombay Endoscopy Academy of Minimally Invasive Sur

Summary (4 lines): Our study analizes the feasibility and techniques of bladder dissection in women undergoing total Laparoscopic Hysterectomy who have had previous cesarean sections causing severe adhesions between the bladder and the uterus.

Introduction: With Increasing number of Cesarean Sections world wide the problem needing to perform a hysterectomy in these patients is likely to increase.Previous cesarean section result in extensive adhesions between the bladder and the uterus and pose techinical difficulties when these patients ubdergo hysterectomy. The route of hysterectomy depends on the expertise of the surgeon.Laparpscopic approach offers a superior view of the anatomy and provides better exposure of adhesions.

Material and Methods: This is a retrospective study of 532 patients with history of previous cesarean sections who successfully underwent total laparoscopic hysterectomy at our centre. There were no exclusion criteria based on the size of uterus or number of previous cesarean sections. We use the lateral window technique for bladder adhesiolysis in these patients where the space between the leaves of broad ligament adjoining the uterocervical border is used to dissect the bladder off the cervix.

Results: Out of 532 patients 50% had undergone one cesarean section, 44% had two cesarean sections, 6% had three or more.Total duration of surgery was 80(30-240min),weight of specimen was 200(40-2375gm).Only 4 patients had a bladder injury(0.7%).

Discussion: In our series we found that the lateral window technique was effective for bladder adhesiolysis in all patients with previous cesarean sections irrespective of the number of cesarean sections or clinical size of the uterus.Incidence of bladder injury was only 0.7%.

THE IMPACT OF HYSTEROSCOPIC SURGERY FOR DYSMORPHIC UTERUS ON REPRODUCTIVE AND OBSTETRIC OUTCOMES: PILOT STUDY

Diagnostic & Operative Office Hysteroscopy

Oral

Christine De Bruyn*, Mestdagh Greet, Ombelet Willem, Campo Rudi

Ziekenhuis Oost-Limburg

Summary (4 lines): It seems that hysteroscopic surgery for dysmorphic uterus anomaly has a positive influence on reproductive and obstetrical outcome.

Introduction: The primary aim of this study is to look at the reproductive performance before and after the hysteroscopic surgery. The secondary aim is to review the obstetric outcomes after surgery. The uterus anomalies were subclassified based on the ESHRE–ESGE consensus classification of congenital uterus anomalies.

Material and Methods: A retrospective analyse of 56 operative hysteroscopies of class 1 dysmorphic uterus was performed between June 2007 and December 2012. The anomalies were classified as U1a T shaped uterus (38 patients) or U1c dysmorphic uterus, a combination of T-shaped and subseptate uterus (18 patients). During surgery all patients received 2D ultrasound to measure the fundal myometrium thickness in the sagittal plane to differentiate between U1c and U1c.

Results: Ultrasound measurement showed a significant difference in fundal size between U1a and U1c uterus (P= 0.00). Hysteroscopic control showed in 5 cases the indication for a second uteroplasty (4 incomplete results, 1 intra-uterine adhesions). Until now 81% became pregnant with mean interval of 3 months. One placenta retention was recorded.

Discussion: A combination of ultrasound and hysteroscopy examination is essential to differentiate between an U1a and an U1c type of dysmorphic uterus. Based on our results it seems that uteroplasty for dysmorphic uterus does improve the reproductive outcome with until so far no negative impact on the obstetric outcome.

HYSTERECTOMY FOR A NONPROLAPSED, BENIGN UTERUS IN NULLIPAROUS AND PAROUS WOMEN

Hysterectomy

Poster

Soo yoon Lee*, Lee Hee Suk , Kim Joo Myung , Joo Kwan Young , Choi Kyu Hong, Lee Si Won, Han You Jung

Cheil General Hospital and Women’s Healthcare Cent

Summary (4 lines): To compare hysterectomy methods and complication rates in nulliparous (group 1) and parous women (group 2).

Introduction: Recently, hysterectomy for nulluparous women is increasing because of change of several conditions. The aim of this study is to make a comparison of clinical aspects of hysterectomy between nulluparous and parous women.

Material and Methods: A review of the medical records in patients who underwent hysterectomies between March 2004 and December 2009 was carried out. Primary outcome was the rate of each method of hysterectomy. Secondary outcome include perioperative and postoperative outcomes of each group.

Results: Seventy seven cases of hysterectomies in group 1, the rate of vaginal hysterectomy (VH) was 10.4%, laparoscopic hysterectomy (LH) 79.2% and abdominal hysterectomy (AH) 10.4%. Seven hundred and thirty six cases of hysterectomies in group 2, the rate of VH was 48.8%, LH 45.8% and AH 5.4%.

Discussion: There were no significant differences in clinical chracteristics and complication rates between group 1 and group 2. Vaginal or laparoscopic hysterectomy for nulliparous women is feasible in most of cases in our experience, with a low complication rate.

OFFICE HYSTEROSCOPY FOR UTERINE INTRACAVITARY PATHOLOGIES: “SEE AND TREAT” APPROACH

Diagnostic & Operative Office Hysteroscopy

Oral

GIAMPIERO CAPOBIANCO*, Vargiu Nuccia, Farina Mario, Gallo Omar Emiliano, Milani Valentina, Dessole Francesco, Benigna Michela, Cherchi Pier Luigi

University of Sassari, Gynecol. and Obst. Clinic

Summary (4 lines): office hysteroscopy is a ease and acceptable tool for the study of the uterine cavity. “See and treat” polypectomy, without anesthesia, was effective in 610/706 (86.40%) cases.

Introduction: OBJECTIVE: to study the efficacy of a “see and treat” hysteroscopic approach for the diagnosis and treatment of uterine intracavitary pathologies.

Material and Methods: METHODS: 2515 patients underwent hysteroscopy (Gynecare, Ethicon), without anesthesia, because of abnormal uterine bleeding and thick endometrium at transvaginal ultrasonography from 2011 to 11 july 2013. A 10-cm visual analog scale (VAS) was used to rate patients’ pelvic pain. Polipectomy was performed by grasping forceps or hysteroscopic scissors.

Results: 706/2515 (28.07%) women had endometrial polyps (638 endometrial polyps, 53 endocervical polyps, 15 esocervical polyps); 107/2515 (4.25%) had myoma (97 submucous myomas, 10 intramural myoma); 510/2515 (20.28%) endometrial hyperplasia; 1007/2515 (40.04%) normal uterine cavity; 12/2515 (0.48%) endometrial carcinoma; 33/2515 (1.31%) uterine cavity not technically evaluable.

Discussion: Successuful resection can be performed in office in most endometrial polyps’ cases and represents a safe and effective alternative to resectoscopic polypectomy.

LAPAROSCOPIC MANAGING OF A MULLERIAN ADENOSARCOMA OF THE UTERUS: A CASE REPORT

Case reports

Poster

Gaelle Boulet*, Peeters Caroline , Jean-Christophe Verougstraete, Vincent Malvaux

clinique saint Pierre Ottignies

Summary (4 lines): We present a case of uterus adenosarcoma revealed by acute vaginal bleeding found its therapeutic modalities. Such sarcoma is characterized by benign epithelial proliferation and stromal sarcoma.

Introduction: Mullerian adenosarcomas are uncommon mixed tumor containing benign or mildly atypical epithelial element and a sarcomatous stromal component. The most common site is the uterine corpus. It can also be found out of the female tract. One-third of the patients are in the premenopausal period. Most common presenting symptoms are abnormal vaginal bleeding or lower abdominal pain. Two important adverse prognostic factors are deep myometrial invasion (more than 50 percent) and sarcomatous overgrowth.

Material and Methods: A 49-year-old premenopausal woman was admitted at the gynecological department for an acute abnormal massive uterine bleeding. She was regularly followed –up, her last check –up in12/2012 was normal. A necrobiosis myoma in expulsion was suspected. As the bleeding wasn’t controlled, she underwent an emergency laparoscopic partial total hysterectomy because of the initial dilatation of the cervix. Histology showed a seven centimeters Mullerian adenosarcoma with stromal proliferation and involved margin.

Results: Post-operative imaging let us suspect an extension to the anterior part of the sigmoid colon. Hence a trachelectomy associated to a pelvic lymphadenectomy and shaving of the sigmoid was decided. Histology showed no local spreading and free margin. An adjuvant pelvic radiotherapy was added to the surgical treatment.

Discussion: In closing, Mullerian adenosarcomas of the uterus are rare tumors. Poor awareness makes it difficult to diagnose correctly and timely. Laparoscopic approach seems to be possible but after a clear diagnosis. Cornerstone therapy remains surgery. Tumor free resection margins without residuals disease or spillage is the main prognostic factor.

RECTO-VAGINAL NODULES – DON'T COMPROMISE. BOWEL SURGERY WITHOUT ‘OSTOMY IS SAFE AND DOESN'T INCREASE COMPLICATIONS

Endometriosis: Surgery

Poster

Andrew Kent*, Jan Haider, Rockall Tim

MATTU Guildford

Summary (4 lines): We present the outcomes of a combined practice (gynaecology/colorectal) for management of severe DIE. We utilize a 2-stage approach with down-regulation and enhanced recovery. This approach is safe and works.

Introduction: The management of severe deep infiltrating endometriosis (DIE) of the recto-vaginal septum is controversial. Some advocate shaving the nodule off the bowel, avoiding bowel resection at all costs, even if it means leaving significant endometriosis behind. The oft quoted justification for this approach is that it is safer, but there is no evidence that this improves outcomes. The generally accepted complication rate for this complex surgery is quoted as around 10%.

Material and Methods: Prospective study of women undergoing resection of rectovaginal nodules with bowel involvement. Follow-up using validated questionnaires. The aim was to surgically remove all visible/palpable endometriotic nodules restoring the anatomy except in pelvic clearance. The energies of choice were Harmonic and CO2 laser. Surgery was tailored to the individual. The decision to carry out a shave/disc/segmental resection was made at the time of surgery depending on the extent of bowel involvement.

Results: n=177; Laparoscopy 95.5%; Laparotomy 4.5%; Conservative 67.8%; Clearance 32.2%; ‘ostomy – immediate 5.6%; Post-op complications – delayed 3%; Overall RTT rate 5.6%.

Discussion: Using a combined approach and 2-stage procedure with interval down regulation, it is possible to achieve a 95% laparoscopy rate with minimal ‘ostomy rates without avoiding bowel surgery. There were no intra operative complications of note and no compromise in terms of major postoperative complications. QoL outcomes were significantly improved.

LEARNING FROM THE MISTAKES

Complications

Video

Rajesh Modi*

Akola Endoscopy Centre

Summary (4 lines): A video presentation of the various complications that one encounters in laparoscopic surgery.

Introduction: Laparoscopic surgery has risk of complications due to the surgical pathology itself, as well as the laparoscopic technique. With experience one can learn to avoid or tackle these situations.

Material and Methods: Commonest difficulties faced during laparoscopic surgery are bleeding, bowel injury and bladder injury. In spite of the various techniques and equipment available, complications can happen during the surgical procedure. This video presentation includes the various complications encountered in our surgical practice.

Results: Good judgement requires experience, but experience comes from bad judgement. Complications are a way of learning from our own mistakes.

Discussion: It is better to learn from mistakes made by others than to make your own.

UTERINE SACCULATION/NICHE SYNDROME – DIAGNOSIS AND MANAGEMENT

Innovation in Instrumentation and Surgical Techniques

Oral

Andrew Kent*, Shakir Fevzi, Jan Haider

MATTU Guildford

Summary (4 lines): Uterine sacculation is an iatrogenic structural defect. It denotes a weakness in the myometrium replaced by scar tissue after LSCS. We describe the condition and discuss its diagnosis and management.

Introduction: The diagnostic triad includes menorrhagia, postmenstrual discharge and a history of lower segment Caesarean section. Suspicion is the key. Diagnosis is made by outpatient hysteroscopy. Ultrasound imaging may be useful. The appearances are of a large cavity in the anterior wall of the endocervical canal with the internal os at the apex leading into the uterine cavity proper. The sacculation is often lined with endometrium.

Material and Methods: Abnormal bleeding due sacculation syndrome is an iatrogenic phenomenon due to astructural defect rather than dysfunctional uterine bleeding arising from a normal cavity. The anterior cervix at this point is invariably very thin. Options are local medical treatments such as Mirena or systemic medical treatments aiming at ideally amenorrhea; surgical conservative options are laparoscopic excision of the sacculation/niche, endometrial ablative options should be considered risky; surgical clearance options, hysterectomy.

Results: Medical treatments may be of limited benefit and IUDs misplaced. Endometrial destruction offers limited benefit and risky if the sacculation is ablated. The sacculation can be excised laparoscopically and the endocervical canal repaired minus defect. TLH offers curative treatment and intrafascial dissection of the cervix will minimise inadvertent bladder trauma.

Discussion: Uterine sacculation syndrome (Kent and Waters 2009) is an increasingly common but generally unrecognised phenomeneon. The key is suspicion based on the diagnostic triad. Diagnosis is by hysterecoscpy. Treatment options can be medical or surgical, be it hysterectomy or laparoscopic excision and repair.

SONOVAGINOGRAPHY FOR THE STUDY OF BLADDER ENDOMETRIOSIS

Innovation in Instrumentation and Surgical Techniques

Oral

GIAMPIERO CAPOBIANCO*, Farina Mario, Gallo Omar Emiliano, Lutzoni Roberta, Dessole Francesco, Benigna Michela, Cherchi Pier Luigi

University of Sassari, Gynecol. and Obst. Clinic

Summary (4 lines): We performed sonovaginography that demontrated the presence of bladder endometriosis confirmed by further histological examination of the biopsy done under cystoscopic guidance. All six patients underwent laparoscopic partial cystectomy and now are free from disease and asymptomatic.

Introduction: Urological endometriosis as the primary and sole form of presentation is rare and the most common site of involvement is the urinary bladder. It may be very aggressive in terms of ingrowth and fibrosis of the ureter, periureteral structures and bladder leading gradually to nephrologic complications. Therefore, timely diagnosis to prevent irreversible deterioration in renal function is essential.

Material and Methods The sonovaginography examination consists of transvaginal ultrasonography combined with the introduction of saline solution to the vagina. The patient is asked to partially empty her bladder, thus leaving a small amount of urine within to enhance visualization of the anterior vaginal wall and of the vesicovaginal septum during the procedure. A 24-mm Foley catheter then is introduced into the vagina.

Results: Sonovaginography demontrated the presence of bladder endometriosis confirmed by further histological examination of the biopsy done under cystoscopic guidance. All six patients underwent laparoscopic partial cystectomy and now are free from disease and asymptomatic

Discussion: Sonovaginography is a reliable and simple method for the assessment of bladder endometriosis and provides information on location, extension, and infiltration of the lesions, which are important factors in selecting the kind of surgery.

FIRST PRELIMINARY CLINICAL EXPERIENCE WITH ULIPRISTAL ACETATE (ESMYA®) IN HYSTEROSCOPIC SURGERY OF DUTCH MENORRHAGIC WOMEN

Surgical Hysteroscopy

Poster

Benedictus Schoot*, Andreas Thurkow, Mark-Hans Emanuel, Veersema Bas

Catharina Hospital

Summary (4 lines): First Dutch experience with Ulipristal acetate (ESMYA®) in menorrhagic women prior to and during hysteroscopic surgery. Preoperative effects were confirmed (on bleeding and myoma volume). Mild side effects were noted. Effect on dissection was favorable.

Introduction: Treatment with ulipristal acetate for 13 weeks effectively controlled excessive bleeding due to uterine fibroids and reduced the size of the fibroids. Both the 5-mg and 10-mg daily doses of ulipristal acetate were noninferior to once-monthly leuprolide acetate in controlling uterine bleeding and were significantly less likely to cause hot flashes. Four large non university teaching hospitals pooled their first prospective data.

Material and Methods: 18 women with excessive bleeding and myoma were treated with Ulipristal 5 mgr daily before 1 April 2013. In 16 patients surgery was performed, whereas 2 patients are waiting for admission. TCRM was performed in 11 cases, whereas tcre was done in 5.

Results: 12 operated patients rapidly showed amenorrhea (hypomenorrhea in 5 women) Reduction of myoma volume was seen in 17 women (22-67% volume). Dissection was rated as easier (7 procedures) or equal (n=6). Resection appeared more difficult in the patient without reduction in myoma volume. Side effects were acceptable.

Discussion: This observational prospective preliminary study demonstrated the potential favorable effects of UPA on patiënts with abnormal uterine bleeding due to myoma. First impression concerning biological effect of UPA on myoma or disection planes was promising. No abnormal pathology was found. Further randomized controlled trials should be performed.

HYSTEROSCOPICALLY GUIDED FOCAL LOCAL ANAESTHESIA FOR RESECTION OF ENDOMETRIAL POLYPS BY VAGINOSCOPIC MICROHYSTEROSCOPY

Surgical Hysteroscopy

Video

Henrik Skensved*

Gynaecology

Summary (4 lines): Focalized subpolypal local anaesthesia – the focal local - during first visit vaginoscopic microhysteroscopy enables one step resection of endometrial polyp(s) in majority of women.

Introduction: The literature demonstrates that despite introduction of minute hysteroscopes and development of new resection techniques, the majority of hysteroscopic polypectomies are performed in theatre often under general anaesthesia. The main obstacle to first visit vaginoscopic microhysteroscopy with concomitant resection of polyp(s) is pain associated with the resection procedure itself. Hence, to further the transformation of polypectomies from a theatre in-house procedure to an outpatient one step procedure, overcoming this obstacle is quintessential.

Material and Methods: Subpolypal injection of 3-5 ml of Citanest® through a 35 cm long 23 Fr needle (COOK’s Williams cystoscopic needle or Vleugels Wing needle) introduced through the working channel of a 3,5 or 5 mm hysteroscope before resection by bipolar electrode.

Results: http://www.youtube.com/watch?v=ljeVRbF8CKY http://www.youtube.com/watch?v=tQ9WvTL6MvQ

Discussion: The addition of focal local anaesthesia to the armamentarium of the outpatient hysteroscopy facility significantly increases the number of polyps that can be resected cocomitantly to the diagnostic procedure.

THE SURGICAL TECHNIQUES OF LAPAROSCOPIC MYOMECTOMY FOR VARIOUS TYPE OF UTERINE FIBROID

Myomectomy

Video

Mari Kitade*

Juntendo University Faculty of medicine

Summary (4 lines): To evaluate safety and usefulness of laparoscopic myomectomy (LM) and assess the postoperative adhesion by second look laparoscopy (SLL).

Introduction: 660 patients underwent SLL 6 month after LM from January 2000 to August 2008.　Surgical tecniques for various type of uterine fibroids were demonstrated on VTR. Maximum size and counts of excised fibroids, duration of operation, estimated blood loss, and postoperative adhesions were also reviewed to evaluate the effects of LM.

Material and Methods: Surgical method was as follows; A horizontal incision was usually made with monopolar needle after injection diluted vasopressin. Uterine fibroids were pulled out by myoma screw and the myometrium was sutured closed in several layers. After extracting removed fibroids from abdominal cavity with electoric morcellator, uterine wound were covered with adhesion barriers. We will demonstrate the procedures of LM for difficult cases on VTR.

Results: The average number of removed fibroids per patient was 4± 3.8 (range:1-50) and average size of largest myoma was 7.1 ± 2.0 (cm). The SLL revealed uterine surgical adhesions in 235 patients (35.6%) and de novo adhesions of the uterine adnexa in 71 patients (8.9%).

Discussion: LM may be a safe and useful minimally invasive surgery especially for infertile women.

PATIENT SATISFACTION AFTER NOVASURE ENDOMETRIAL ABLATION TREATMENT

Surgical Hysteroscopy

Poster

Aleid Noortwijk*, Deurloo Koen

Diakonessenhuis Utrecht

Summary (4 lines): This is the largest case series concerning patient satisfaction after Novasure. The method is safe and successful when treating menorrhagia. Patient satisfaction is high and >50% of patients reaches amenorrhea.

Introduction: The Novasure treatment is known to be a safe and effective treatment for menorrhagia. Our objective was to retrospectively assess patient satisfaction after Novasure treatment and identify predictive factors. Secondary outcomes measured were amenorrhea and uterus extirpation.

Material and Methods Between October 2006 and December 2011 all treated cases were identified using our medical in-hospital database. All cases received a postal questionnaire concerning the Novasure treatment and their satisfaction. Validated questionnaires were used. In total 765 patients were identified. A total of 467 patients (60,7 %) completed and returned the questionnaire. Statistical analysis was performed with Chi-square test (SPSS 17.0).

Results: Excellent satisfaction was reached in 88% of the patients. Amenorrhea was achieved in 52% of patients. Uterus extirpation was performed in 37 cases (7,5 %). 4 (1%) procedures failed, in 3 (0,8%) cases resulted in a perforation. There was no significant difference in satisfaction in patients having longer uterine length.

Discussion: This case series concerning patient satisfaction after Novasure treatment, shows that it is a safe, successful method to treat menorrhagia. We did not find a relationship between uterine cavity length and patient satisfaction. Therefore we suggest that uterine cavity length should not play a role in counselling patients concerning satisfaction.

REVERSE HYSTERECTOMY: ANOTHER TECHNIQUE TO PERFORM A LAPAROSCOPIC HYSTERECTOMY

Hysterectomy

Oral

Pietro Litta*, Saccardi Carlo, Conte Lorena, Florio Pasquale

Department of women's and Children's Health

Summary (4 lines): Different strategies have been proposed with the aim to reduce bleeding and ureteral or bladder injuries. Reverse hysterectomy is an alternative approach to avoid urinary complications and potential bleeding

Introduction: The modified hysterectomy starts with the incision of the vescico-uterine fold and the subsequent transversal incision of the pubocervical fascia. Key step is the dissection of only the anterior layer of the broad ligament. The maintenance of the posterior leaf of the broad ligament allows the exposure of a triangular area whose sides are represented medially by the uterine vessels, laterally by the ureter. This uterine pedicle visualization permits a subsequent safe coagulation

Material and Methods One hundred and one women underwent total reverse laparoscopic hysterectomy in the Department of Women’s and Children’s Health of the University of Padua. Details related to the early and late complications, operative time, uterine weight, estimated blood loss, length of the hospital stay, time needed to return to normal activity and to work, were recorded. Patients’ satisfaction was evaluated subjectively one month after discharge with the use of a visual analogue scale (VAS)

Results: The mean operative time was 112.1 + 35.6 minutes, intra-operative mean blood loss was 79.5 + 138.4 ml. No ureter or bladder injuries occurred in any patients. No major post-operative complications were recorded. Patients returned to normal activities 6.18 + 2.89 days after surgery. Mean VAS was 8.47 +1.48

Discussion: The reverse hysterectomy is another technique to perform laparoscopic hysterectomy, which proved to be safe and efficient. We believe that this alternative approach could be proposed specially in cases of abnormal pelvic anatomy, such as big uteri, severe endometriosis, and previous gynaecological or pelvic surgery

ANTI-MULLERIAN HORMONE TREND AFTER LAPAROSCOPIC SURGERY IN WOMEN WITH OVARIAN ENDOMETRIOMA

Endometriosis: Surgery

Poster

Pietro Litta*, Conte Lorena, Leggieri Concetta, Saccardi Carlo, D'Agostino Giulia

Department of women's and Children's Health

Summary (4 lines): The cautious stripping of the endometriotic cyst performed using atraumatic grasping forceps, clear identification of the cleavage plane and intracortical suture avoiding coagulation, can respect functionality and ovarian reserve

Introduction: The stripping technique is the gold standard treatment of endometriotic ovarian cysts. It reduces recurrences and improves symptoms but it may result in ovarian reserve damage due to the removal of healthy ovarian cortex. The ovarian reserve also may be influenced by use of electrosurgical device. The use of intracortical suture minimize the trauma of the tissue and can preserve ovarian reserve. The AMH is currently the most reliable marker of ovarian reserve

Material and Methods Twenty-five women underwent excision of monolateral endometriotic ovarian cyst by stripping without coagulation of the ovarian parenchyma and performing an intracortical suture with a PDS 2.0 monofilament wire. The AMH serum levels were estimated in the early proliferative phase of the cycle, before surgery (time 0), 24 h after surgery (time 1), the first menstrual cycle after surgery (time 2) and the third menstrual cycle after surgery (time 3)

Results: The median level of preoperative serum AMH was 3.61 mg/L (IR 1.67- 5.00), 24 h after surgery was 3.32 mg/L (IR 1.47- 4.60), after 1 month was 2.90 mg/L (IR 1.17- 4.08) and after 3 months was 3.00 mg/L (IR 1.27- 4.08). AMH levels not statistically decreases after surgery

Discussion: When removing an endometriotic ovarian cyst, an appropriate and careful surgical technique, without the use of the bipolar coagulation on ovarian tissue, does not determine a significant reduction of ovarian reserve evaluated by AMH serum dosage.

HISTOPATHOLOGIC EVALUATION OF SMOOTH MUSCLE TUMORS REMOVED LAPAROSCOPICALLY: OUR EXPERIENCE IN 10 YEARS

Myomectomy

Oral

MAKEDOS ANASTASIOS*, Pados George, Makedos Anastasios, Almaloglou Konstantinos, Zaramboukas Thomas, Diamanti Konstantina, Ntinou Zaharoula, Konstadinidis Themistoklis, Tarlatzis Basil

1st Dept Obs & Gynae/ Aristotle University

Summary (4 lines): Presentation of the histopathology results of myomas after laparoscopic or hysteroscopic myomectomy in a period of ten years concluding that the risk of malignancy in myomas is extremely rare, nevertheless some degree of mitotic changes are not absent.

Introduction: Uterine leiomyomas are the most common tumors of the female genital tract. The purpose of this study was to evaluate the histopathologic features of leiomyomas removed laparoscopically within a decade (January 2003-December 2012), by the same laparoscopic team and evaluated by the same team of histopathologists.

Material and Methods In a period of 10 years, 1096 women underwent laparoscopic and hysteroscopic myomectomy (848 laparoscopic, 148 hysteroscopic), due to multiple symptoms arrising from leiomyomas, in the Centre for Endoscopic Surgery «Diavalkaniko» Hospital. From the study patients who underwent laparoscopic hysterectomy were excluded. The preliminary evaluation with vaginal and/or abdominal ultrasound scan was performed by the same clinician and when necessary MRI was suggested.

Results: From the 1096 patients, in 158 the histopathologic examination revealed leiomyomas with degeneration and/or infarction, while in 12 cases (1.2%) the diagnosis of leiomyomas with bizarre nuclei was given. No atypic myomas were found in the group of patients who underwent hysteroscopic myomectomy, while neither leiomyosarcomas were detected.

Discussion: Thorough preoperative evaluation is of utmost importance in patients with leiomyomas. Leiomyomas with malignancy are extremely rare, nevertheless to improve the accuracy of clinical behavior of these tumors, a multivariate approach should be adopted.

TRANSCERVICAL FETOSCOPY AS CONFIRMATION TOOL IN AMNIOTIC BAND SYNDROME

Imaging

Poster

LAZAROS LAVASIDIS*, KARAVIDA AIKATERINI, GROZOU FANI, PASCHOPOULOS MINAS

BIOCLINIC

Summary (4 lines): The use of fetoscopy to confirm and expand the ultrasonic diagnosis of anatomic defects at 13 weeks gestation is discussed in this case report

Introduction: Fetoscopy has been considered to be a very promising tool in the area of diagnosing fetal abnormalities and promoting ways of in utero treatment. Fetoscopy improves the quality and quantity of information obtained during the ultrasound scans, thus providing a potential tool for the improvement of training in fetal medicine

Material and Methods Deformity on both fetal hands was diagnosed during a routine 11-14week ultrasound scan, performed on a 32-year old, P0G0. 10 days prior to the procedure, during the basic work up, the patient had been diagnosed with abnormal levels of glucose. A second-opinion ultrasound scan was performed a week after the first and confirmed the initial diagnosis. The couple consented to have fetoscopic inspection of the gestational sack and its contents, prior to instrumental evacuation

Results: Fetoscopy confirmed the results of both scans, by documenting the deformity of both hands. It also revealed defects of toes, and, possibly, of ears. Ultrasound scanning missed the deformities of toes and the fact that both hands were adherent to the umbilical cord

Discussion: Fetal cytogenetic evaluation was not successful, but no chromosomal abnormalities in the parents’ caryotype were detected. The implication of gestational diabetes is worth mentioning. Our impression is that transcervical fetoscopy could improve the accuracy of ultrasound diagnosis, by revealing possibly important additional abnormalities

ANATOMY OF THE URETER

Teaching & Training

Video

Rodrigo Fernandes*, Puga Marco, Alves João, Redondo Cristina, Wattiez Arnaud

IRCAD

Summary (4 lines): The anatomy of the ureter is demonstrated in a didactical way, in an attempt to put into practice the theoretical knowledge.

Introduction: The ureter is a mobile organ that courses down the retroperitoneum, from the renal pelvis to the bladder. Up to 75% of ureter complications are diagnosed after the procedures. During pelvic surgery, and depending on the pathology of the patient, the ureter may be attached to different structures distorting its normal anatomy. A key factor for diminishing the ureteral injuries is the correct knowledge of its path.

Material and Methods Compilation of laparoscopic surgical videos where the anatomy of the ureter is demonstrated. Surgeries were performed at the Department of Obstetrics & Gynecology of the University Hospitals of Strasbourg and IRCAD, Strasbourg, France. Video edition and montage used Final Cut Pro X, Apple Inc. Several schematic designs using Adobe Photoshop CS6 are integrated in the video demonstration.

Results: The pelvic ureter is presented throughout its parts: parietal; retroligamentary; intraligamentary; retrovesical and intravesical. Along the ureter path, step by step, the relationships with other important structures are highlighted.

Discussion: The ureter is an important structure in female pelvis that, besides being a target of inadvertent injuries, is also a landmark in surgical dissection of retroperitoneal spaces. Consequently, during advanced procedures the ureter is a useful guide. This video provides an important educational tool regarding ureter anatomy.

LAPAROSCOPIC PARTIAL LIVER MOBILIZATION AND DIAPHRAGMATIC STRIPPING FOR THE MANAGEMENT OF DISSEMINATED GYNECOLOGICAL PELVIC MALIGNANCIES

Oncology

Poster

LAZAROS LAVASIDIS*, TZITZIMIKAS STERGIOS, MIKOS THEMISTOCLES, CHASTAMOURATIDIS CHARALAMBOS, FRAGKOS MARIOS, AVGOUSTINAKIS EMMANOUEL, DIAVATIS STAVROS, PAPACHARALABOUS EVANGELOS

BIOCLINIC

Summary (4 lines): We present a novel technique of laparoscopic partial liver mobilization and diaphragmatic stripping/peritonectomy in a woman with stage IV endometrioid adenocarcinoma, which may be applicable to other pelvic cancers

Introduction: Abdominal carcinomatosis from pelvic organ malignancies is associated with a very poor prognosis. However, survival may be prolonged with extensive surgical debulking and adjunct radio- and/or chemotherapy. Tumor intra-abdominal debulking, including hard to access diaphragmatic surfaces, has been shown to be of significant benefit in ovarian malignancies, but its role in uterine malignancies remains controversial

Material and Methods A 71 year-old woman presented with postmenopausal bleeding and hematometra. Endometrioid adenocarcinoma was diagnosed with metastases to upper abdomen. Laparoscopic evaluation and treatment required partial hepatic mobilization for diaphragmatic access. We coagulated, divided, and excised the falciform and round ligaments between the liver and anterior wall. We inspected peritoneal folds in the upper abdomen, and dissected the two folds of the falciform, achieving medial to lateral stripping. This appeared safer, and easier

Results: Infraumbilical laparotomy was required to complete the debulking, due to surgical emphysema. Postoperative bilateral hydrothorax responded to diuresis within 48hrs. Following hysterectomy, BSO and debulking, our patient received adjunct chemotherapy and radiation. She died from her disease 9 months post-surgery. Endometrioid adenocarcinoma was confirmed in all surgical specimens

Discussion: Laparoscopic diaphragmatic peritonectomy (stripping) is feasible, safe and applicable to multiple gynecological malignancies, offering the posibillity to abandon a planned laparotomy debulking, with minimal trauma for the patient. To our knowledge, this is the first case report applicable to endometrial cancer

LAPAROSCOPIC DAVYDOV PROCEDURE TO CREATE A NEOVAGINA IN AN INTERSEX PATIENT WITH VAGINAL AGENESIS

Innovation in Instrumentation and Surgical Techniques

Video

Natasha Waters*, English Jim, Thomas Phillip, Christopoulos George

Western Sussex Hospitals NHS Trust

Summary (4 lines): This video demonstrates the creation of a neovagina in a patient with intra-abdominal testes and vasa deferentia, female external genitalia and vaginal agenesis.

Introduction: Davydov procedure is the creation of a vaginal canal and utilisation of patient’s own peritoneum to create a tube and line the neovagina. This leads to good anatomical results and over 96% of patients report optimal sexual function. Biopsies of neovagina confirm vaginal epithelium 6-12 months after the procedure.

Material and Methods We present a 7 minute video demonstrating that it is laparoscopically very straightforward to develop a large peritoneal flap which may delivered through a neovaginal opening and be converted into a tube to line the neovagina (Laparoscopic Davydov Procedure). It is also easy to address other issues, such as removal of the streak gonad and inspection of the pelvis and closure of the neo-vault to prevent future vault prolapse.

Results: The peritoneal tube seem to be safe and free of other troublesome complications associated with the use of skin or bowel tissue. Laparoscopy allows better visualisation with modern high definition image quality, precision, better anatomical assessment and leads to a quicker recovery.

Discussion: The creation of a functional neovagina can be achieved by several methods: the use of a partial thickness skin graft from the thigh, which causes detachment and stenosis and poor cosmesis; the use of ileum or sigmoid, which can lead to necrosis, prolapse and often results in troubling mucoid discharge.

MAYER-ROKITANSKY-KüSTER-HAUSER SYNDROME AND LAPAROSCOPIC ASSISTED CREATION OF NEOVAGINA

Innovation in Instrumentation and Surgical Techniques

Poster

Ali Akdemir*, Sendag Fatih, Akman Levent , Öztekin Kemal

Ege University School Of Medicine, Department of O

Summary (4 lines): Laparoscopic Vechietti may be considered a good option for the surgical treatment of women presenting vaginal agenesis. This technique offers advantages such as: short operating time and no external scars.

Introduction: Mayer – Rokitansky-Küstner-Hauser(MRKH) syndrome is characterised by patients with vagina and uterine agenesia and normal seconder sexual characters with normal karyotype. It is required to create a new vagina for the patients having this syndrom since they do not have any phsycological and physical handicap for having a normal sexual life. Our aim is to announce our results in ten patients of our first experience of creating neovagina with laparascopic assisted by using ‘Neovagina Set’.

Material and Methods We performed laparascopic assisted neovagina (Modified Vecchietti) with ‘Neovagina Set’ in ten patients. The patients were evaluated preoperatively with full clinical examination, karyotype analysis, sonografic and magnetic resonance imaging. The results about operative technique (duration of operation, duration of hospitalisation, complication), function (anatomical and functional vaginal length, vaginal width, vaginal epithelialization), sexual life after operation (first time for intercourse, pain during intercourse, need of lubricant, satisfaction) are evaluated.

Results: There was no any complication. The mean operative time was 55 minutes. The mean hospitalization was 7 days. The results were judged to be satisfactory in all patients: the mean anatomical and functional vaginal length was 8.5 and 10 cm, respectively. The mean operation time was 55 minutes.

Discussion: Laparoscopic modified Vecchietti technique with using “neovagina set”, which was created and was standardized for this operation, to performe a neovagina should be kept in mind as one of the first step option for patients with MHRK syndrome.

LAPAROSCOPIC SUTURING: TIPS AND TRICKS

Tips & Tricks in Surgery

Video

James Kondrup*

Lourdes

Summary (4 lines): This video illustrates the tips and tricks of laparoscopic suturing for traditional and barbed suture including loading and entry techniques.

Introduction: One of the most sought after subjects at laparoscopic course is suturing. Several different techniques exist as well as suture assist devices to help the surgeon suture and tie. I am sure surgeons will find this video helpful.

Material and Methods 5mm backloading technique of a large needle is illustrated as well as passing a CT-1 needle down a 12mm trocar. Use of barbed suture is also illustrated.

Results: All suturing was successfully performed and no complications were encountered

Discussion: Surgeons can master laparoscopic suturing following standard simple movements and techniques. You must find what works for you under the surgical circumstance. Have a few different techniques available.

VAGINAL OR LAPAROSCOPIC CUFF CLOSURE AFTER TOTAL LAPAROSCOPIC HYSTERECTOMY: PROSPECTIVE RANDOMIZED SINGLE CENTRE STUDY

Hysterectomy

Poster

Fabrizio Romano*, Patrizi Lodovico, Cosentino Francesco, Perone Ciro, Piccione Emilio, Malzoni Mario

Tor Vergata University Hospital, Rome

Summary (4 lines): Vaginal suture of the vaginal cuff in total laparoscopic hysterectomy should reduce the incidence of dehiscence and vaginal spotting, similarly to abdominal and vaginal hysterectomy, conferring benefit to the patients.

Introduction: Hysterectomy is the most frequent major gynaecologic surgical procedure and can be executed by laparoscopic, laparotomic or vaginal route. Vaginal cuff dehiscence represents a serious post-hysterectomy complication. Several studies have been published about the rate of dehiscence based on different surgical approaches. The aim of this study was to assess the rate of vaginal cuff dehiscence and other complications in patients undergone to total laparoscopic hysterectomy, comparing laparoscopic and vaginal closure of the vaginal cuff.

Material and Methods The study was conducted at Malzoni Medical Centre in Avellino, Italy. It was a prospective randomized single centre study involving all patients undergone to total laparoscopic hysterectomy in a 12-month period. Randomization has been made 1:1 for consecutively admitted patients. All procedures were performed by the same surgical operator and using the same surgical materials. A follow-up visit was scheduled after 1 and 12 months after hysterectomy.

Results: A cohort of 197 patients was enrolled, 98 subjected to vaginal suture and 99 to laparoscopic one. Three vaginal cuff dehiscences occurred (1,52%), two after laparoscopic (2,02%) and one after vaginal suture (1,02%). Thirteen patients complained for vaginal spotting after laparoscopic closure compared to four after vaginal one (p=0.018).

Discussion: Vaginal suture of the vaginal cuff is a quick and reliable method for vaginal closure reducing the incidence of dehiscence and other complications, similarly to abdominal and vaginal hysterectomy. A further large randomized study is necessary to determine significant differences between surgical modalities and factors reducing the rate of complications.

LAPAROSCOPIC PARTIAL CYSTECTOMY AND BILATERAL URETERIC IMPLANTATION FOR FULL-THICKNESS BLADDER ENDOMETRIOSIS IN OBSTRUCTIVE NEPHROPATHY

Endometriosis: Surgery

Poster

Ghosh Donna*, Fricke Sarah Choi, Chou Danny, Aslan Peter, Cario Gregory, Rosen David

Summary (4 lines): This is a video presentation of laparoscopic bladder endometriotic nodule excision, partial cystectomy and bilateral ureteric implantation in a young lady with long-standing obstructive nephropathy caused by severe pelvic endometriosis.

Introduction: A 27-year-old lady presented with recurrent severe dysmenorrhea. Ultrasound and CT scans showed right hydroureteronephrosis and a shrunken right kidney, secondary to obstruction by a 4cm bladder mass at the right vesicoureteric junction. Cystoscopic examination showed a large exophytic bladder endometriotic nodule just above the trigone and adjacent to the ureteric orifices. The right ureteric orifice was obstructed and the left ureteric orifice was encased in endometriosis. Preoperative creatinine level suggested borderline renal function.

Material and Methods The laparoscopic procedures were: 1. ureterolysis; 2. dissection of bladder nodule from lower uterus, cervix and vagina; 3. partial cystectomy under cystoscopic control, where the disease free margin was outlined with cystoscopic guidance; 4. excision of right distal ureter together with bladder nodule, where vermiculation of intravesical ureter remained visible even after ureteric transaction; 5. bilateral ureteric implantation in tension-free manner; 6. closure of cystotomy after adequate bladder mobilization, and 7. bladder integrity test.

Results: The post-operative recovery was uncomplicated. Her creatinine level dropped after the operation. Subsequent contrast imaging showed that the right hydroureter resolved and the bladder was intact.

Discussion: Partial cystectomy and bilateral ureteric implantation was performed successfully with laparoscopy. The video contains footages of anatomical interest and demonstrates surgical techniques in bladder endometriotic nodule excision and ureteric implantation.

IMPACT OF LAPAROSCOPIC ENDOMETRIOMA STRIPPING SURGERY ON FERTILITY: PRE- AND POSTOPERATIVE CHANGES OF AMH LEVELS

Endometriosis: Surgery

Poster

luka andjelic*

General hospital,Subotica

Summary (4 lines): Despite all surgical efforts to be atraumatic, laparoscopic endometrioma stripping surgery nesessarily decreases AMH levels, especially in bil endometriomas. This data should be taken into account in infertile patients who are preparing for cystectomy.

Introduction: to investigate the impact of endometrioma(s) and laparoscopic stripping surgery on ovarian reserve by measuring serum levels of Antimillerian hormone (AMH). To evaluate clinical significance of changes in the level of serum AMH

Material and Methods Methods: prospective study, one center, one surgeon method is used. 42 reproductive- aged women underwent laparoscopic stripping surgery for endometrioma(s).Levels of AMH was measured by the third day of the cycle, pre- and 6 months postoperatively. Results were analyzed by standard software SPSS.Results: Findings: endometrioma(s) unil 28 (66, 66%), bilat14 (33, 33%).

Results: The mean AMH levels was in unilat endometrioma 2.5 ± 1, 8 ng/mL prior and 1.3 ± 1.0 ng/mL post-surgery, and in bilat. endometriomas 2.0 ± 1.2 ng/mL before and 0.7 ± 0.5 ng/ml postoperatively. Levels of AMH

Discussion: There were significantly decrease of mean AMH levels postoperatively (mean±SD: preoperatively 2,3± 1,7 to 1,1± 0,9 postoperatively, p

ASHERMAN´S SYNDROME-HYSTEROSCOPIC TREATMENT RELATED TO PREGNANCY RATES AND COMPLICATION: A FIVE YEAR FOLLOW UP

Surgical Hysteroscopy

Oral

Cornelia Bormann*, Nugent Andreas, Möller Claus, Gallinat Adolf

Tagesklinik Altonaer Strasse

Summary (4 lines): The study objective was to characterize the risk factors of Asherman´s syndrome and to evaluate the efficacy of hysteroscopic treatment related to pregnancy rates and complications.

Introduction: In our free-standing gynecological day surgery unit we initialized a retrospective long term study from June 2003-June 2008 concerning the outcome of 85 patients diagnosed with severe Asherman´s syndrome (AS) according to the classification the European Society for Gynecological Endoscopy (ESGE) after hysteroscopic treatment. The aim was to characterize the risk factors of AS and to evaluate the efficacy of hysteroscopic treatment related to pregnancy rates and complications.

Material and Methods 85 patients with a mean age of 33 years were followed. For the synechiolysis the Nd:YAG laser in combination with the bifunctional forceps was used in 75,3% of the cases, the bifunctional forceps alone in 24,7%. The uterine cavity was restored after one (n=21 ), two (n=40), three (n=10), four (n=10) or more (n=4) hysteroscopic procedures. 91,76 % had a postoperative hormonal treatment.

Results: 95,2% had a resumption of menstruation. Pregnancy index rate after surgery was 52 (61%) of 85 . 16 pregnancies ended with abortion (18,8%) and 36 patients had a live birth (baby take home rate 42,4%). 24 of these patients (77,4%) had a complication (placenta accreta, cervical insufficiency) during pregnancy .

Discussion: According to the literature there are different hysteroscopic methods for the treatment of Asherman´s syndrome leading to different pregnancy rates. Our results show that pregnancy rates can be doubled and approximately 60% can be achieved.

THE USE OF MODIFIED VIRTUAL COLONOSCOPY FOR THE DIAGNOSIS OF RECTOGENITAL AND DISSEMINATED ENDOMETRIOSIS

Endometriosis: Diagnosis

Oral

JOHAN VAN DER WAT *

PARKLANE CLINIC

Summary (4 lines): The diagnosis of rectogenital and disseminated endometriosis is problematic because ultrasound and MRI mainly focuses on the rectogenital area thus requiring further investigations to diagnose urogenital and disseminated disease to proximal bowel and abdominal organs.

Introduction: Modified Virtual Colonoscopy was designed to study rectogenital and disseminated endometriosis in a single comprehensive investigation.

Material and Methods The technique of MVC will be presented and images illustrating its capabilities in the diagnosis in advanced endometriosis will be shown.

Results: Studies showing the accuracy and the benefits of this technique will be presented.

Discussion: By using Modified Virtual Colonoscopy and subsequent studies have shown that there is a 30% increase in the detection of lesions beyond the rectogenital space by using this technique.

SINGLE SITE SURGERY COMPARED TO LAPAROSCOPY FOR TREATMENT OF GYNECOLOGICAL BENIGN DISEASE: A RETROSPECTIVE STUDY

Single Access Surgery

Poster

Ivana Nupieri*, Surico Daniela, surico daniela, Surico Daniela

Experimental Endoscopic Surgery Centre, University

Summary (4 lines): Laparo Endoscopic Single-Site Surgery (LESS) is one of the recent innovation of minimally invasive surgery.

Introduction: The most important advantages of LESS are that this mini-invasive technique increases the benefits of traditional endoscopic surgery (LPS) in term of reduction of post-operative pain and blood loss, faster recovery time, fewer complications, improved quality of life and better cosmetic results for a relatively hidden umbilical scar.

Material and Methods We conducted a single-institutional, retrospective study comparing 28 patients treated by LESS and 59 patients treated by LPS for benign disease. For LESS group, an uterus smaller than 12 weeks’gestation was an inclusion criterion.

Results: Demographic characteristics of groups were comparable, except for BMI, higher in LESS group. No statistically significant differences have been reported for complications, blood loss, operative time, uterus weight and ovarian cysts sizes. A statistically differences have been shown in hospitalization, shorter in LESS and post-operative pain control, better for LESS

Discussion: In gynaecology, for benign disease, LESS is feasible, with peri-operative outcomes comparable to conventional laparoscopy, and it seems to be associated with a lower hospitalization time and post-operative pain, also in obese women.

THE LAPAROSCOPIC MANAGEMENT OF A LARGE RUPTURED OVARIAN THECOMA IN THE SECOND TRIMESTER OF PREGNANCY

Case reports

Poster

Kirsty Cleverly*, Ball Elizabeth, Sharizan Emira Muhammad

NHS

Summary (4 lines): Case report detailing the laparoscopic techniques used to manage a ruptured ovarian tumour during pregnancy. This is followed by a discussion of the use of minimal access techniques during pregnancy.

Introduction: Thecomas of pregnancy are caused by hyperplasia of luteinised ovarian cells that demonstrate an atypical response to β-HCG. Hyper-secretion of androgens is seen resulting in virilisation of the mother and fetus. These rare tumours spontaneously regress postnatally, but due to their size are at risk of acute complications requiring emergency surgery. The operative technique used to ensure the successful emergency laparoscopic management of this rare ruptured tumour are presented in this case report.

Material and Methods A 27 year old Black Brazilian in the 14th week of a spontaneous pregnancy presented to the emergency department with severe abdominal pain. Transvaginal ultrasound scan showed large bilateral multicystic ovaries. She underwent emergency palmers point laparoscopy where bilateral thecomas were found. The right ovary measured 150mm and the left ovary, measuring 100mm, had ruptured. Successful left laparoscopic oophorectomy was performed. Histopathology confirmed the diagnosis. She made a good recovery and the pregnancy continued.

Results: Minimal access techniques are particularly advantageous in pregnancy. Laparoscopy in the presence of a large pelvic mass is technically more challenging, especially when uterine manipulation is not possible. In our tertiary service we used Palmer’s point entry, higher secondary ports and optical entry systems to achieve a successful outcome.

Discussion: There are no randomised controlled trials comparing laparoscopy with open techniques during pregnancy but published case series suggest similar obstetric outcomes. The reduction in post-operative pain and time to mobilise seen with minimal access techniques are likely to be of particular benefit to the pregnant patient.

EPAQ-MPH: PATIENT AND CLINICIAN RESPONSES FOLLOWING ITS USE IN THE GYNAECOLOGY CLINIC

Endometriosis: Diagnosis

Poster

Marcin Klingbajl*, Connor Mary, Radley Stephen, Jones Georgina

University of Sheffield

Summary (4 lines): ePAQ-MPH, an electronic questionnaire for women with menstrual, pelvic pain and hormonal disorders has been developed and validated. Patients’ and clinicians’ experience using the ePAQ-MPH in clinical practice was evaluated.

Introduction: ePAQ-MPH is a web-based, electronic personal assessment questionnaire for women with common gynaecological symptoms, including abnormal uterine bleeding, pelvic pain, and hormonal problems. Initial validation in over 200 women has confirmed the reliability of the domain scoring system, and secondary factor analysis (Varimax rotation) confirmed viability of the domain structure. The objective of this study was to evaluate patients’ and clinicians’ experience using ePAQ-MPH in the gynaecology clinic.

Material and Methods Women attending the gynaecology clinic with relevant symptoms were identified in advance and asked to complete ePAQ-MPH at home or on arrival at the clinic. The completed questionnaire was printed and used during the consultation. Following the clinic visit women completed the QQ-10 questionnaire, a validated ten-item questionnaire to investigate the value and burden of ePAQ-MPH. Clinicians who used ePAQ-MPH with patients were asked to complete a separate and specific QQ-10 questionnaire.

Results: Analysis of the initial 33 patients' QQ-10 responses show most (73%) would be happy to use ePAQ-MPH again and 70% found it helped communicate about their condition. However, 12% found it too embarrassing and 9% too complicated. The response from clinicians awaits further use of ePAQ-MPH with their patients.

Discussion: ePAQ-MPH appears to be a user-friendly tool for clinical practice, providing reliable, valid comprehensive assessment of symptoms and quality of life for women with menstrual, pain and hormonal disorders. It is hoped that it will prove a useful tool for evaluating response to treatment, as well as initial assessment.

DIAGNOSTIC AND THERAPEUTIC VALUE OF OFFICE HYSTEROSCOPY IN ABNORMAL UTERINE BLEEDING

Diagnostic & Operative Office Hysteroscopy

Poster

Joana Santos*, Morais Marta, Andrade Cláudia, Nogueira Martins Nuno, Pipa António, Nogueira Martins Francisco

Centro Hospitalar Tondela/Viseu - H. São Teotónio

Summary (4 lines): Office hysteroscopy is a well-tolerated evaluation method of abnormal uterine bleeding. It is also an effective therapeutic method and allows a better definition of the surgical plan for each patient.

Introduction: Abnormal uterine bleeding (AUB) affects millions of women worldwide of all age ranges and is one of the most common indications for gynecology appointments. Hysteroscopy, allowing direct visualization of the uterine cavity, is a valuable method in both diagnosis and treatment of the conditions associated with AUB. When treatment procedures are not possible in an outpatient setting (eg. patient intolerance, large intracavitary lesion) hysteroscopy allows a correct planning of an elective surgery.

Material and Methods Retrospective, descriptive study involving 4503 patients evaluated by office hysteroscopy from February 2006 to April 2013. A total of 1290 patients referred for AUB were included in the study. All patients underwent diagnostic hysteroscopy. Biopsies and polypectomies were performed according to hysteroscopic findings. When indicated, patients were oriented to surgical treatment.

Results: Postmenopausal bleeding was the most frequent indication for hysteroscopy (n=801). Intracavitary anomalies were detected in 864 patients. Biopsies were performed in 556 cases and 75 patients were submitted to polypectomy during the same procedure. Endometrial carcinoma was diagnosed in 65 patients, who were promptly referred to surgical treatment.

Discussion: Being an outpatient, minimally invasive method, office hysteroscopy is very useful in etiological diagnosis and management of abnormal uterine bleeding secondary to intracavitary lesions. When operative procedures are not possible in an office setting, hysteroscopy plays an important role in the definition of the surgical plan for each patient.

HYSTEROSCOPIC FINDINGS IN POSTMENOPAUSAL WOMEN WITH ENDOMETRIAL THICKENING

Diagnostic & Operative Office Hysteroscopy

Poster

Joana Santos*, Batista Joana, Veríssimo Renata, Nogueira Martins Nuno, Pipa António, Nogueira Martins Francisco

Centro Hospitalar Tondela/Viseu - H. São Teotónio

Summary (4 lines): Hysteroscopy is the most appropriate method for assessment of the uterine cavity in postmenopausal women presenting with endometrial thickening, as it allows direct visualization and guided biopsy, when indicated.

Introduction: Endometrial cancer is the most common gynecological cancer in developed countries. Three out of four cases occur in postmenopausal women and abnormal vaginal bleeding is a common presentation. Transvaginal ultrasound has been explored as a noninvasive technique for indirect endometrial evaluation. Endometrial thickening is considered a marker for intrauterine pathology and when present, a diagnostic hysteroscopy is generally offered. Its main advantage is that biopsies are possible, improving diagnostic accuracy, particularly in focal lesions.

Material and Methods Retrospective analysis of 1467 hysteroscopies performed between February 2006 and April 2013 in the Obstetrics/Gynecology Department in São Teotónio Hospital for endometrial thickening in postmenopausal women. A total of 1122 patients were asymptomatic, while 345 had postmenopausal bleeding (PMB). Hysteroscopic findings and histological results in symptomatic and asymptomatic patients were compared.

Results: Intracavitary anomalies were detected in 295 (85,5%) patients with PMB, as well as in 794 (70,8%) asymptomatic patients. Endometrial carcinoma was diagnosed in 33 women with PMB (9,5%) as well as in 26 women referred for incidental endometrial thickening(2,3%). Endometrial hyperplasia was also more frequent in symptomatic patients (11,6% vs 7,9%).

Discussion: Vaginal bleeding is the presenting sign in the majority of postmenopausal patients with endometrial carcinoma. Hence, endometrial thickening in these patients should trigger further evaluation. The significance of endometrial thickening in asymptomatic, postmenopausal patients is not well established. Nevertheless, only hysteroscopy (with eventual guided biopsy) can exclude intracavitary malignant/premalignant lesions.

LAPAROSCOPIC HYSTERECTOMIES FOR BENIGN INDICATION: AN ANALYSIS OF 380 CASES BETWEEN 2005 AND 2012

Hysterectomy

Oral

M. Cecilia Haladjian*, Mañalich Laura, Suarez Elena, De La Torre Javier, Capote Sira, Hurtado Ivan, Gorraiz Veronica, Bernabeu Andrea

Hospital Vall d'Hebron

Summary (4 lines): All the hysterectomies performed in our hospital in the last eight years were reviewed and data analyzed to find differences in time.

Introduction: Hysterectomy is one of the most frequently performed surgical procedures in gynecol-ogy. The most common indications are leiomyomas. When choosing the route and me-thod of hysterectomy safety and cost-effectiveness should be considered. Faster return to normal activity, shorter duration of hospital stay and lower blood loss are well-known advantages.

Material and Methods This study is based on a retrospective chart analysis of patients undergoing a laparo-scopic hysterectomy between 2005 and 2012 for benign gynecological conditions. Clinical, surgical and hystopathological data was collected from the medical history. Descriptive analysis was done with SPSS 17.0 . The median postoperative hospital stay, the rate of operative complications and the rate of conversion to laparotomy was analysed for every year of the study.

Results: Comparing year by year there were no statistical differences in the operative complica-tion’s rate (13%) and in the laparotomies conversion’s rate(6.3%). However, significant differences were found in hospital stay ≤2 days (25%in 2005 versus 68%in 2012) and in total/subtotal hysterectomy (in 2005 22% versus 78%, in 2012 40% versus 60%).

Discussion: In our experience laparoscopic approach to hysterectomy for benign gynaecological disease is feasible with similar indications to laparotomic approach; with less complica-tions and lower hospital stay. A decrease in the median postoperative hospital stay was noted, probably due to the traineeship and experience of medical team.

UTERINE PERFORATION ASSOCIATED WITH INTRAUTERINE DEVICES

Complications

Poster

Joana Santos*, Andrade Cláudia, Pinto Rita, Cerveira Isabel, Santos Paulo António, Pipa António

Centro Hospitalar Tondela/Viseu - H. São Teotónio

Summary (4 lines): Uterine perforation is the most serious complication associated with intrauterine contraceptive devices. Clinical presentation is variable. Minimally invasive techniques, such as laparoscopy, are very useful in the management of this complication.

Introduction: Intrauterine devices (IUD) are a widely used and highly effective contraception method and their insertion is one of the most commonly performed procedures in gynecological practice. Uterine perforation is a rare, but serious complication associated with the use of IUD. Symptoms are generally mild and most women may be asymptomatic. Therefore, uterine perforation can remain undetected long after IUD insertion. Potential complications of uterine perforation include visceral lesions, adhesions and pregnancy.

Material and Methods Three cases of uterine perforation caused by IUD are presented. All cases were diagnosed and treated at the Obstetrics/Gynecology Department – São Teotónio Hospital in Viseu (Portugal). In all three cases, the location of the devices was suspected by ultrasound and X-ray and confirmed in laparoscopy.

Results: One patient presented with abdominal pain two days after the IUD insertion. A second patient had complaints of chronic lower abdominal pain three years after insertion and the third patient was asymptomatic. The devices were located and removed from the pelvic cavity in all three cases with no reported incidents.

Discussion: Although uncommon (1/1000 insertions), uterine perforation is a serious complication of IUD insertion. Ultrasound control after insertion allows early detection. Moreover, abdominal pain or changes in bleeding patterns should lead to prompt investigation. Minimally invasive techniques, like laparoscopy, generally allow location and retrieval of the devices, with low risk of complications.

DIAGNOSTIC AND OPERATIVE OFFICE HYSTEROSCOPY: AN AUDIT OF OVER 6900 CASES

Diagnostic & Operative Office Hysteroscopy

Poster

Joana Santos*, Joana Batista, Morais Marta, Nogueira Martins Nuno, Pipa António, Nogueira Martins Francisco

Centro Hospitalar Tondela/Viseu - H. São Teotónio

Summary (4 lines): In this study we audited the data from twelve years of office hysteroscopies performed at our Department.

Introduction: Hysteroscopy is a valuable endoscopic procedure accepted as gold standard for the evaluation and treatment of the uterine cavity. Diagnostic and, very often, operative hysteroscopy can be accomplished in an office setting, avoiding the use of general anesthesia and patient hospitalization. The possibility of performing a surgical procedure in an office environment is an asset of this technique.

Material and Methods We retrospectively analyzed 6966 patients submitted to a hysteroscopic exam at our Department since 1996. The hysteroscopic approach was made through vaginoscopy, using mostly saline as distension medium, without any analgesia or anesthesia.

Results: Main indications: suspected intracavitary lesion (3916), post-menopausal bleeding (1024) and pre-menopausal abnormal uterine bleeding (671). 6966 women submitted to hysteroscopy - 4769 (73,6%) with uterine pathology. Biopsy performed in 2436 patients. 1437 cases of operative hysteroscopy: 715 treatments for benign intrauterine pathology, 722 for definitive contraception. 137 endometrial carcinomas diagnosed.

Discussion: Hysteroscopy is a highly effective and relatively cheap minimally invasive method to reach the intrauterine cavity. It allows us to diagnose pathology but also to treat a significant number of uterine conditions. The office environment provides an excellent setting for the patient, ensuring high tolerance, whilst avoiding anesthesia and hospitalization.

LAPAROSCOPIC GENITOURINARY FISTULA REPAIR -THE EXTRAVESICAL APPROACH

Urogynaecology

Poster

Meenal Dhabalia*

Aditi superspeciality hospital

Summary (4 lines): We have reported largest and only series exclusively using laparoscopic extrovesical technique. It involves minimal dissection, no cystostomy, shorter suturelines which remain naturally separated by tissue pull with excellent results.

Introduction: Laparoscopic repair of genitourinary fistula has been reported using initial cystostomy ( limited or classical bihalving). The disadvantageous of this technique – initial cystostomy and hence long suturelines and more tissue dissection resulting in longer operative time is overcome in the extravesical approach. Further limited tissue dissection keeps the suture lines naturally separated because of surrounding tissue pull. We have reported exclusive use of this technique laparoscopically with excellent comparable results even in recurrent cases.

Material and Methods 124 patients (64 recurrent,II - IV attempt ) were operated. It included vesicovaginal, vesicouterine , ureterovaginal , & ureterovaginovesical fistulae due to obstetric / gynecological surgery , radiation , tuberculosis , migrated CuT trauma. Fistula size varied 1 to 6 cm. Technique involved peritoneal incision, transverse vault incision, limited extravesical bladder & vaginal dissection , single layer closure of vault & bladder defect along lines of least resistance with omental interposition in all cases.

Results: 64 of 124 patients were recurrent : II– 48 , III– 14 , IV – 2 . Operative time , blood loss ranged 80 - 330 min and 80 – 370 ml respectively. 4 patients were converted to open .Follow up ranged 8 months to 6 years

Discussion: Extravesical approach overcomes all disadvantages of transvesical initial cystostomy approach namely extensive dissection, longer bladder suturelines and hence longer operative time. Also limited dissection keeps suturelines naturally separated because of surrounding tissue pull. Extravesical dissection & suturing is difficult to perform by open surgery. Laparoscopy is particularly suited for it.

THE CONTINUOUS BENEFIT OF A LAPAROSCOPIC SIMULATION CENTER FOR MEDICAL RESIDENTS TRAINING IN SPECIALTY

Teaching & Training

Poster

Elena Cupsa*, Nicolae Zisu, Vlad Tica

Emergency County Hospital St Andrew Constanta

Summary (4 lines): A simulation center in gynecological laparoscopy seems to be an affordable and efficient solution of training young surgeons for continuously improving laparoscopic basic surgical skills.

Introduction: The spectacular development of gynecologic minimally invasive surgery in the last years has led to concerns regarding the proper ways of acquiring laparoscopic basic skills under optimum conditions for both practitioner and patient. Pelvitrainers seem to promote a type of training that avoids / minimizes intraoperative errors, leading to increased safety of the patient. The aim was to investigate the continuous benefit of training after a proven improvement of two previous series of exercises.

Material and Methods The study included 11 residents who trained in a simulation center organized and run by themselves under the Head of the Clinic supervision. We used the department’s outdated equipment. Progress was monitored by executing 2 exercises (developed by us) with the aim of handling one or two instruments. Participants were assessed through a third series of exercises (5 repetitions, each, as previously) by the time needed for accomplishing them.

Results: Time reduction was observed (50.30, SD = 17.3401 and 147.40, SD=52.3751, respectively), if compared to the one of the final test of the previous series (66.80, SD=55.1096 and 155.70, SD=83.1452), but not significant. Improved statistical signification was observed if compared to the initial control test (0.01948 and 0.0126, respectively).

Discussion: A simulation center in gynecological laparoscopy can be created with relatively low costs and results in more efficient training of young surgeons, better surgical skills and improved working relationship. Exercising on pelvitrainers can be considered an important educational tool for acquiring basic laparoscopic skills. Improvement is continuous.

VAGINAL NATIVE TISSUE REPAIR FOR PELVIC ORGAN PROLAPSE: DOES LAPAROSCOPY CONTRIBUTE TO PATIENT´S SAFETY?

Complications

Poster

Anke Regina Mothes*, Marc Phillip Radosa, Ingo Bernhardt Runnebaum

Department of Gynecology, Jena University Hospital

Summary (4 lines): Combining vaginal site specific prolapse repair with LAVH leads to low complication rates but longer operating time. Authors suggest use of complication classification systems such as Clavien-Dindo for comparability.

Introduction: Controversy in prolapse surgery concerning native tissue repair v/s vaginal mesh implants should lead to standardised analyses of surgical complication rates. This single-centre retrospective study concerning patient´s safety and complication rates in native tissue vaginal prolapse repair is focussing on the role of laparoscopic assisted vaginal hysterectomy in prolapse patients in whom hysterectomy is indicated or asked for by the patient. It is hypothetic that laparoscopy reduces risks by meeting particular findings in prolapse patients.

Material and Methods 167 patients who underwent prolapse repair and LAVH between January 2009 and February 2013 were analysed concerning concomitant hysterectomies and peri-operative complications using hospital database search software, hand written and electronic patient charts. For analysis of surgical complications valid Clavien-Dindo classification was used. Surgical complication was defined as “any deviation from the ideal postoperative course that is not inherent in the procedure and does not comprise a failure to cure” [Dindo et al. 2008]

Results: Overall morbidity ranged at 15,5%. (Dindo I: 5,4%, II: 7,7, IIIa: 1,2%, IIIb: 1,2%). Operating time included three compartment vaginal repair, LAVH, salpingectomy or salpingoophorectomy, concomitant procedures, e.g. adhesiolysis, preparation in > 50% grade IV. prolapse and changing patients position on table two times. It ranged at 154± 59 min.

Discussion: Although the uterus might not be large in size, elongation of cervix, pelvic varicosis and unexpected findings increase risk for complications. Complications reported range at low rates compared to vaginal prolapse surgery without additional laparoscopic approach. Bilateral salpingectomy was performed like recommended for post-reproductive situation. Laparoscopy requires longer operating time.

RECURRENT VAGINAL CUFF DEHISCENCE AFTER LAPAROSCOPIC HYSTERECTOMY – A CASE REPORT

Complications

Poster

Inês Pereira*, Osório Filipa, Barata Sónia, Calhaz-Jorge Carlos

Hospital de Santa Maria, Lisboa

Summary (4 lines): The authors report a case of recurrent vaginal cuff dehiscence after laparoscopic hysterectomy in a woman with structural cardiovascular defects and a history of heavy smoking.

Introduction: Vaginal cuff dehiscence is an uncommon event following hysterectomy. With an incidence of 0.03% to 4.1%, it is more frequent after total laparoscopic or robotic assisted hysterectomy compared to the trans-vaginal or trans-abdominal approaches. Despite several reports of vaginal cuff dehiscence after laparoscopic or robotic assisted hysterectomy – sometimes with evisceration of different intraabdominal organs - to our knowledge, there are no reported cases of recurrent vaginal cuff dehiscence in a non-oncologic patient.

Material and Methods The authors report a case of recurrent vaginal cuff dehiscence after laparoscopic hysterectomy in a 43 year-old non-oncologic patient. Data on clinical presentation, physical examination, laparoscopic findings, multiple surgical interventions and short time outcome are described.

Results: A multiparous with mitral valve prolapse and thoracic aorta aneurysm underwent total laparoscopic hysterectomy for myomatous uterus. Two episodes of vaginal cuff dehiscence occurred five and nine months after surgery, the first after resumed sexual intercourse and with small bowel extrusion. Laparoscopic vaginal re-suture was performed in both cases.

Discussion: Vaginal cuff dehiscence occurs most commonly during the first three months after surgery. Both sexual intercourse prior to complete vaginal healing and the colpotomy/colporrhaphy techniques represent risk factors for vaginal cuff dehiscence. In the reported case we emphasize the concomitant cardiovascular conditions possibly indicative of a connective tissue disorder.

LAPAROSCOPIC SURGERY FOR ECTOPIC PREGNANCY TREATMENT

Case reports

Video

Nuno Oliveira*, Maia Susana, Oliveira Mário

CHVB - Aveiro

Summary (4 lines): Laparoscopic surgery in women with ectopic pregnancy is a safe and effective approach. This video presents different cases of ectopic pregnancy treated by laparoscopy.

Introduction: Ectopic pregnancy is a common condition with immediate risk of life-threatening hemorrhage, whose incidence is increasing globally. Laparoscopy became the primary approach in the diagnosis and treatment of an ectopic pregnancy due to its safety and efficacy. While salpingostomy is the procedure of choice when unrupted tubal pregnancy is found, salpingectomy is a better treatment to severely damaged fallopian tube, recurrent ectopic pregnancy, large tubal pregnancy and heterotopic pregnancy.

Material and Methods The video presents cases of women that underwent laparoscopic surgery for treatment of ectopic pregnancy who were not suitable to or have failed methotrexate treatment. Both salpingectomy and salpingostomy were performed through laparoscopy.

Results: All patients were discharged on the postoperative day 1. No conversion to laparotomy was necessary and there was neither intraoperative or postoperative complications.

Discussion: Laparoscopic treatment of ectopic pregnancy presents many advantages including less adhesion formation. Salpingostomy and salpingectomy present a comparable fertility rate. The main goals are an early diagnosis and to provide the most effective and least invasive procedure.

DETECTION OF ESR1 PVUII AND FSHR SER680ASN POLYMORPHISMS IN WOMEN WITH ENDOMETRIOSIS: A PILOT STUDY

Endometriosis: Diagnosis

Poster

Ioannis Douridas*, MAVROGIANNI DESPINA, GIANNOULIS GEORGES, ANAGNOSTOU ELLI, PROTOPAPAS ATHANASIOS, LOUTRADIS DIMITRIOS

Alexandra Hospital Athens

Summary (4 lines): Endometriosis seems to be associated with ESR1 PvuII and FSHR Ser680Asn polymorphism.This is the first study to examine both polymorphisms in fourteen women with endometriosis.All samples except one showed showed the same polymo

Introduction: Endometriosis is an estrogen-dependent disorder affecting 6-10% of women in their reproductive years and 20-50% of women with infertility. Studies have shown that endometriosis risk is associated with single nucleotide polymorphisms in genes involved in the biosynthesis and response to estrogen and progesterone, including ESR1 PvuII. Additionally the Ser680Asn polymorphism of FSH receptor gene has been shown to be related to a significantly lower risk of endometriosis.

Material and Methods Fourteen women with endometriosis were studied. DNA was extracted from endometrium, ovaries and peripheral blood. The genotyping for the detection of ESR1PvuII and FSHR Ser680Asn polymorphisms was performed using real-time polymerase chain reaction. The SPSS program was used for the statistical evaluation of the results.

Results: All women except one were detected with the same ESR1 PvuII and FSHR Asn/Ser polymorphic pattern, independently of the tissue examined. No statistically significant association was observed between the polymorphisms and the presence of endometriosis, the number of pregnancies, the number of abortions, and the presence of infertility problems.

Discussion: The present study is the first to examine the ESR1PvuII and FSHR Asn/Ser polymorphisms, alone and in combination, in women with endometriosis. A larger number of samples will be studied in order to detect the presence of associations between the polymorphisms and other clinical characteristics.

LAPAROSCOPIC MANAGEMENT OF A CESAREAN-SCAR ECTOPIC PREGNANCY

Case reports

Video

Alejandro Correa-Paris*, Suarez-Salvador Elena, Sanchez-Iglesias Jose Luis, Gorraiz-Ochoa Veronica, Gil-Moreno Antonio

Hospital Vall d'Hebron. Universitat Autonoma de Barcelona. Barcelona

Summary (4 lines): A 32-year-old patient, G4P2, with 2 previous cesarean sections and no other relevant past medical history, came to the ER complaining of menorrhagia. Her pregnancy test was positive.

Introduction: US examination revealed a 25mm gestational sac underlying the uterine scar of her previous CS. A diagnosis of cesarean-scar ectopic pregnancy was made and given her clinical stability the patient was treated with a multiple-dose regimen of methotrexate (4 doses, 1mg/kg). Levels of beta-HCG fell slowly from 7335 UI/L to 361 UI/L seven weeks after initiation of treatment. However, the gestational sac image on US persisted and the patient complained of recurrent abdominal pain.

Material and Methods After failure of conservative management, we performed a laparoscopy using the closed-entry technique (Veress), and 4 trocars for instrumentation. Dense adhesions were found between the bladder and uterine segment, where the ectopic pregnancy was located. Careful dissection using blunt-dissection and scissors was made to separate the bladder from the uterine segment, cervix and vagina. Hemostasis was controlled by monopolar/bipolar coagulation. The entire mass was successfully excised leaving a small defect on the anterior uterine wall.

Results: Wound closure was done in a single-layer with a monofilament absorbable PDS (polydioxanone/2-0) suture using single knots tied extra-corporeally. Finally, we confirmed bladder integrity by performing a methylene-blue dye test. Operative time was 120min, and estimated blood loss 100mL. The hospital stay was 2 days, and there were no complications.

Discussion: Histopathology was unremarkable (ectopic pregnancy, chorionic villi, decidua, myometrium). The patient's recovery was uneventful, and a postoperative ultrasound 3weeks after surgery confirmed integrity of the hysterorrhaphy. The laparoscopic approach appears to be safe and feasible for managing unusual ectopic pregnancies such as cesarean-scar ectopic pregnancy whenever medical treatment has failed.

LAVH VS. ABDOMINAL HYSTERECTOMY FOR BENIGN PATHOLOGY WITHOUT UTERINE DESCENT: A UK SINGLE CENTRE EXPERIENCE

Hysterectomy

Oral

Neeraja Kuruba*, Palihawadana Thilina, Sule Medha

Norfolk and Norwich University Hospital

Summary (4 lines): We compared two patient groups who underwent either LAVH or open abdominal hysterectomy for abnormal vaginal bleeding without uterine descent. It demonstrated that LAVH was able to reduce the post-operative analgesia requirement and the hospital stay.

Introduction: Minimal access methods are gaining popularity for many gynaecological surgeries. Laparoscopic hysterectomy has the advantage of a faster recovery compared to an open approach. However, the cost has limited the widespread use of total laparoscopic hysterectomy(TLH) for benign pathology. LAVH provides a low cost alternative to TLH in benign pathology without significant uterine descent. In this study we compared LAVH and open hysterectomy with regard to operating time, complications, hospital stay and analgesic requirements.

Material and Methods 22 patients who underwent LAVH and 20 that underwent open hysterectomy were selected for the comparison. All subjects had abnormal vaginal bleeding and no significant uterine descent. The clinical notes were reviewed retrospectively and information recorded. The basic demographic data and the details of the surgery including operative time, total time in theatre and complications were recorded. The post-operative analgesic requirements and the hospital stay were also noted.

Results: The LAVH group had a higher mean operating time (110mins vs. 81, P=0.001), a mean time spent in theatre (140mins vs. 106, P=0.002). The hospital stay after LAVH was lower (33hrs vs. 59, P=0.001) and so was the analgesia requirement during their hospital stay. The complications were rare for comparison.

Discussion: This study demonstrated that though LAVH has a higher operation time, it reduces the postoperative hospital stay and is associated with lesser postoperative pain. Since bed occupancy has become an important rate-limiting factor, introduction of minimal invasive methods such as LAVH should be explored with an emphasis on cost analysis.

INHALED-ANALGESIA WITH KALINOX® VS OTHER ANALGESIC TECHNIQUES ON THE INSERTION ESSURE ® DEVICE: PILOT STUDY

Diagnostic & Operative Office Hysteroscopy

Poster

Cristina del Valle Rubido*, Solano Calvo Juan Antonio, Delgado Espeja Juan Jose, González Hinojosa Jeronimo, Del Valle Rubido Cristina, García Pineda Virginia, Peco Adrovers Soledad

Hospital Universitario Príncipe de Asturias

Summary (4 lines): The aim is to show that the inhalation analgesia with a 50% nitrous oxide/oxygen premix (Kalinox®) has great benefits in Essure device insertion (less pain and better tolerance).

Introduction: Tubal sterilization via hysteroscopy (Essure) is a short but painful procedure therefore an effective analgesia is required. We compared different type of analgesia in the insertion of Essure: self- inhalation of nitrous oxide/oxygen premix (50%) (Kalinox), paracervical block and a control group.

Material and Methods In a pilot study we evaluated the perceived pain during the insertion of the Essure device, comparing three analgesic techniques: Kalinox, paracervical block with Lidocaine 1% and control group. Vital signs like oxygen saturation, blood pressure and heart rate were controlled before, during and after the procedure. We collected as well, the complications of each technique. The pain has been rated subjectively by each patient by “visual analogue scale (VAS)”.

Results: 362 women asked for ESSURE device. We observed a linear correlation between the score of the pain’s severity given by the patient with the use of Kalinox in front of paracervical block (p=0,039) and compared with no treatment (p=0,008). The main complications of Kalinox were dizziness and nausea.

Discussion: Waiting for definitive results of our randomized clinical trial, our preliminary results suggest that the inhalation oxygen and nitrous oxide (premix 50%) in hysteroscopic procedures, like Essure insertion has better benefits than paracervical block and better than the no treatment.

AN AUDIT ON OUTPATIENT HYSTEROSCOPY (OPH) IN THE EVALUATION OF ABNORMAL UTERINE BLEEDING

Diagnostic & Operative Office Hysteroscopy

Poster

Neeraja Kuruba*, Palihawadana Thilina, Sule Medha, Grover Sonal

Norfolk and Norwich University Hospital

Summary (4 lines): We report a series of OPH for evaluation of abnormal uterine bleeding. Pelvic ultrasound has a better positive predictive value in postmenopausal compared to premenopausal bleeding to detect endometrial pathology.

Introduction: OPH has gained popularity in evaluation of abnormal uterine bleeding. It is used in premenopausal as well as postmenopausal age groups and is considered complementary to imaging such as ultrasonography. We report a series of 250 patients who underwent outpatient hysteroscopy in the evaluation of abnormal uterine bleeding and analyse the positive and the negative predictive value of pelvic ultrasound in the diagnosis of uterine polyps in the pre and post menopausal age groups.

Material and Methods The study sample included 152 pre-menopausal and 98 postmenopausal women who underwent OPH between 2009-2011. The indication for hysteroscopy was according to the department clinical protocols of evaluation of uterine bleeding and postmenopausal bleeding. Most patients had an ultrasound evaluation prior to the procedure. See and treat approach was taken in the presence of a polyp and endometrial biopsy was undertaken in others.

Results: Pelvic ultrasound for polyps had a Positive predictive value (PPV) of 43.9% and Negative predictive value (NPV) of 81.3% in premenopausal women. In postmenopausal women the PPV was 62.5% and NPV was 37.7%. Endometrial malignancies were detected in 4 premenopausal patients and were found in the polyps that were removed.

Discussion: The procedure had to be abandoned due to discomfort only in a minority (6/250). This analysis demonstrates that ultrasonography has a limited place in evaluation of endometrial pathology, especially in the premenopausal women. Such assessment should be complemented by OPH when clinically indicated.

TOTAL LAPAROSCOPIC HYSTERECTOMY – EXPERIENCE OF A UNIVERSITY HOSPITAL

Hysterectomy

Poster

Ana Sofia Cardoso*, Ferreira Helder, Cubal Rosalia, Reis Patrícia, Sousa Rita, Maciel Raquel , Lourenço Claudia, Marques Claudia, Pereira António

Centro Hospitalar do Porto

Summary (4 lines): To assess laparoscopic hysterectomy indications, clinicopathological factors, operative time and evaluate blood loss, surgical complications and sequelae of 194 laparoscopic hysterectomy procedures in a university hospital.

Introduction: To assess laparoscopic hysterectomy indications, clinicopathological factors, operative time and evaluate blood loss, surgical complications and sequelae of laparoscopic hysterectomy procedures in a university hospital.

Material and Methods Design: Retrospective, descriptive study of 194 consecutive cases of total laparoscopic hysterectomy performed in our hospital between January 2010 and May 2013. Setting: University Hospital. Patients or participants: One hundred seventy patients (ages 34-76) submitted to total laparoscopic hysterectomy for different reasons.

Results: The most common indication for hysterectomy was abnormal uterine bleeding (42,8%) followed by leiomyomas (38,7 %), pelvic organ prolapses (7,7%), endometrial hyperplasia/recurrent polyps (6,2%) and cervix pathology (4,6%). Complications occurred in 2,1%

Discussion: Since we started laparoscopic hysterectomy technique, we have a large volume of patients benefitting from the advantages of laparoscopy. It is a feasible and safe procedure with low complication rates and therefore it is more often the chosen method in selected patients.

ONE-STEP LAPAROSCOPIC SENTINEL LYMPH NODE BIOPSY (SLN) IN ENDOMETRIUM CANCER USING INTRAOPERATIVE FREEHAND SPECT IMAGING

Innovation in Instrumentation and Surgical Techniques

Poster

Hornung René *, Bolla Daniele, Müller Joachim, Wendler Thomas, Ray Alessandra, Alexander Markus

Kantonsspital St. Gallen - Schweiz

Summary (4 lines): Intraoperative hysteroscopical SLN marking and mapping using laparoscopic freehand SPECT was evaluated. SLN detection was successful in 5 of 7 patients recruited to date. Preoperative staging showed impact on detection.

Introduction: Laparoscopic SLN biopsy is a promising technique for nodal staging of early endometrium cancer patients. Its adoption in the routine is challenged by a) a steep learning curve, b) high user dependency and c) the complicated logistics of the marking the day before surgery. Freehand SPECT is an intraoperative imaging and navigation tool that can replace conventional preoperative lymphatic mapping and thus enable intraoperative marking and image-guided localization of the SLNs.

Material and Methods To date 7 endometrium cancer patients (41-68, BMI 23-42) were injected hysteroscopically Tc-99m-nanocoll in the OR. After preparation of the operating field a 3D freehand SPECT image of the lymphatic basins on each pelvic side and along the aorta was acquired by scanning with a laparoscopic gamma probe. The freehand SPECT image was then used for image-guided localization of SLNs. After resection a new freehand SPECT image was created to verify complete resection.

Results: Lymphatic mapping using freehand SPECT failed in 2 patients (1 pT1a, 1 pT3a) and was successful in 5. The 2 failed were the 2 patients with an indicated radical lymphadenectomy. In remaining 5 patients, 9 SLNs were found (2 in fossa obturatoria, 6 in along A. iliaca externa, 1 paraaortal).

Discussion: Intraoperative hysteroscopical SLN marking and mapping using laparoscopic freehand SPECT imaging is feasible and safe. Laparoscopic freehand SPECT enables easy and fast localization of SLNs. Findings suggest that patient selection plays a role in detection rate of SLNs.

FEASIBILITY EVALUATION OF LAPAROSCOPIC SENTINEL LYMPH NODE BIOPSY IN CERVICAL CANCER USING INTRAOPERATIVE FREEHAND SPECT

Innovation in Instrumentation and Surgical Techniques

Poster

Hornung René *, Markus Alexander, Müller Joachim, Wendler Thomas, Ray Alessandra, Daniele Bolla

Kantonsspital St. Gallen - Schweiz

Summary (4 lines): Feasibility of laparoscopic freehand SPECT imaging for image-guided sentinel lymph node biopsy was evaluated in two cervical cancer patients. Findings suggest that freehand SPECT can detect more SLNs than SPECT/CT.

Introduction: Laparoscopic sentinel lymph node (SLN) biopsy is a technique for nodal staging of early cervical cancer patients that is getting established. Its adoption in the routine has been slow due to a steep learning curve and high dependence of surgeon experience. Freehand SPECT is an intraoperative imaging and navigation tool that can facilitate adopting of the technique by enabling image-guided localization of the SLNs.

Material and Methods To date 2 cervical cancer patients (30 and 41, BMI 18 and 30, both pT1b) have been recruited within the “Lapsent” study. Preoperatively patients were injected Tc-99m-nanocoll and underwent SPECT/CT imaging. Intraoperatively a 3D freehand SPECT image of the pelvic lymphatic basins was acquired by scanning with a laparoscopic gamma probe. The freehand SPECT image was then used for image-guided localization of SLNs. After resection a new freehand SPECT image was created to verify resection.

Results: SPECT/CT and freehand SPECT both detected 1 SLN close to the common iliac artery in the first patient and 2 SLNs on side of the obturatorial fossa in the second patient. Freehand SPECT detected additionally 2 SLNs along the right internal iliac artery in the first patient.

Discussion: Intraoperative mapping using laparoscopic freehand SPECT imaging is feasible and safe. Laparoscopic freehand SPECT seems to enable an easy, standardized and fast localization of SLNs. If the trend of these first results remains, SPECT/CT may not be necessary while SLN biopsy may turn easier.

A PILOT STUDY: INTRODUCTION OF KALINOX (NITROGEN PROTOXID-OXIGEN) IN DIAGNOSTIC HISTEROSCOPY

Diagnostic & Operative Office Hysteroscopy

Poster

Delgado Espeja Juan Jose *, , Solano Calvo J. A, Fernandez Muñoz Laura , Nebreda Calvo Lucia, Peco Adrover Soledad, Del Valle Rubido Cristina, Zapico Goñi Alvaro

Hospital príncipe de asturias madrid

Summary (4 lines): Diagnostic hysteroscopy is an exploratory procedure minimally invasive, generally performed in an outpatient setting, which, ocasionally, can produce pain and certain degree of discomfort and anxiety.

Introduction: In our department, Kalinox was introduced as analgesic trying to minimize all the discomfort related to hysteroscopy. A total of 4073 outpatient hysteroscopies were performed from 2006 to 2012. 179 patients (4,4%) used self-administrated Kalinox as analgesic in the Hysteroscopic Unit, University Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, Spain.

Material and Methods Mean age was 48,7 years (28-84). 116 patients ( 63,1%) were premenopausal and 63 (34,1%) postmenopausal. The main reasons for referral to outpatient hysteroscopy were: 51 patients (28,5%) abnormal uterine bleeding; 24 (13,4%) abnormal ultrasound scan; 2 patients (1,1%) suspected uterine malformation. The mean operative time was 5,3 minutes (2-20)

Results: Perception of pain was categorized with a visual scale ( 0-10) The average result was 3,5. Level of satisfaction : 9,02 (0-10). 72% patients would repeat the technique with the same type of analgesia. Only mild complications appeared in 5%: 4 cases of slight dizziness and one case of agitation

Discussion: The use of Kalinox (nitrogen protoxid-oxigen) as analgesic during an outpatient hysteroscopy is a simple analgesic technique, self administrated, well tolerated and safe, which increase the patient tolerance to the exploration. It also facilitates the procedure by the hysteroscopist, increasing the time available for polipectomies, tubaric sterilization, etc.

TREATMENT OF ENDOMETRIOSIS WITH LOCAL INJECTION OF MONOCLONAL ANTIBODIES WITH ANTI-ANGIOGENIC EFFECTS

Innovation in Instrumentation and Surgical Techniques

Poster

Viktoriya Yevdokymova*

Odessa national medical university

Summary (4 lines): We confirmed the role of the antiangiogenic effects of the Avastin® to suppress the ectopias of endometriosis in peritoneal cavity of animals. The effect of the blockade was confirmed morphologically and is dose-dependent comparing with group with placebo.

Introduction: The treatment of endometriosis (EMS) today remains controversial. New methods and special endometriosis (EMS) treatment need to be developed tested prior to being implement in clinic. Aim of this research was to examine anti-angiogenic effects of of monoclonal antibodies (Avastin®) application in experimental rats (Vistar line) model. Our objective was to evaluate peritoneal endometrium autoimplants size reduction due to treatment with Avastin® and it dependence from number of injections.

Material and Methods We used 60 female adult rats, weight of was 280-300 g, age 4– 4.5 months, nulliparous. Four groups were formed, each group was divided to experimental and control subgroups. Animals in experimental subgroups received from one to four intraperitoneal injections of Avastin®0.35 mg (0.3 ml) corresponding to group number. Animals in control group received the same amount of 0.9% sodium chloride solution. Data was monitored and logged.

Results: At autopsy we observed that the foci of inducted EMS had smaller size after one injection and almost complete disappearance after four injections of Avastin®. It was confirmed macroscopicaly and morphologically. Further analysis showed simmilar dynamics in different groups.

Discussion: Our findings allow to simulate the use of angiogenesis depression. The size reduction and almost complete disappearance of peritoneal EMS was dose dependent and to determine the duration of therapy in the experimental conditions.

DIAGNOSIS, FINDINGS AND MANAGEMENT OF AN INCARCERATED GRAVID UTERUS WITH URINARY RETENTION. A CASE REPORT

Case reports

Poster

Ralf Joukhadar*, Radosa Julia, Solomayer Erich-F.

Department of obstetrics and gynecology, university of Homburg (Saar), Germany

Summary (4 lines): Urinary retention and overflow in a pregnant patient in late first or early second trimester with a retroverted uterus could be the first clinical signs of an incarcerated gravid uterus.

Introduction: A retroverted uterus is found in about 15% of women. During pregnancy the uterus usually moves into an upward position before reaching 14 weeks’ gestation. In very few cases the uterus remains retroverted leading to miscarriage some cases. In the remaining ones incarceration may occur by entrapment below the sub-promontory sacrum. Early symptoms are lower abdominal pain, urinary retention and overflow. Later hydronephrosis, uraemia, gangrene or rupture of the bladder and uterus sacculation could occur.

Material and Methods A case of a primigravida at 13+0 weeks’ gestation presenting with acute urinary retention. Physical examination: anterior displacement of the cervix behind the pubic symphysis and a mass filling cul-de-sac. Pelvic-floor-ultrasound: elongated displaced cervix compressing the urethra against the pubic symphysis, a superiorly-displaced bladder and presacral Location of uterine fundus. Manual reduction is successfully performed in dorsal lithotomy position after bladder emptying. Then a silicone cube pessary size 37 mm. is placed in the vagina.

Results: The pessary remained in place until 17+4 weeks’ gestation to exclude recurrence. Before removing the pessary physical and ultrasound examinations showed a uterus big enough to make a recurrence unlikely. At times the patient reached 25 th week of gestation. All findings show normal pregnancy with normal uterine position.

Discussion: Early diagnosis and adequate follow-up are crucial for the obstetric management of an incarcerated gravid uterus to prevent critical complications. Physical examination and pelvic-floor ultrasound can give sufficient evidence of the underlying situation and should be regarded as the tools of diagnosis.

VAGINAL HYSTERECTOMY. BIPOLAR VS. SUTURE

Hysterectomy

Poster

Alexander Slobodyanyuk*, Mazokhin Igor, Suchalko Marina, Kashina Natalya, Slobodyanyuk Boris

Zhukowsky city hospital

Summary (4 lines): This is a prospective study comparing different surgical modality of vaginal hysterectomy. Analysis performed in 300 cases.

Introduction: In 19th century professor D.O. Ott form Saint-Petersburg report about removal of 8 kilo uterus vaginally. We haven’t met such reports in contemporary literature.

Material and Methods We try to compare duration, blood loss and recovery of vaginal hysterectomy using conventional technique and bipolar vessel sealer. Since 2005, 300 consecutive patients were scheduled for VH with 0-1 stage of POPQ; age was 36-80. Pathology: adenomyosis, uterine fibroids, necrosis of myoma after embolization, uterine and cervical cancer. Uterine size was up to 16 weeks (1500 g). Patients were divided into two groups: 65 with suture, 235 with bipolar coagulation (GyrusPlasmaKineticSuperPulseGenerator).

Results: Mean time was 58and 29min respectively (p>0.05). Blood loss 130ml and 60ml (p>0.05). For prophylactic of vault prolapse we use McCall. For concomitant SUI we used slings, needle suspension techniques. We have 1bladder injury during morcellation, repaired intraoperatively. In second group thermal injury of ureter witch required dilatation uetral stent.

Discussion: Bipolar VH can be performed in standard technique in challenging patients: with compromised history, pathologic obesity, nulliparous, no prolapse, enlarge uterus and cancer of uterus and cervix (1А). Electrosurgical bipolar system is safe procedure which decreases timing of the operation, blood loss and provides practically painless postoperative period.

A MODIFICATION OF LAPAROSCOPIC SACROPEXY: BILATERAL SACRAL FIXATION BY MESH-REPLACEMENT OF THE UTEROSACRAL LIGAMENTS

Innovation in Instrumentation and Surgical Techniques

Video

Ralf Joukhadar*, Solomayer Erich-F.

Department of obstetrics and gynecology, university of Homburg (Saar), Germany

Summary (4 lines): Laparoscopic and abdominal sacropexy are regarded gold standard procedures in the treatment of uterine and vaginal vault prolapse. We present a modification of this procedure by a selected case report.

Introduction: A case of a 62 year old patient presenting with prolapse specific complains. In addition dry urge, frequency (10-12 voids/day, nocturia 1 void/night) and intermittent urinary stress incontinence grade- 1.

Gynecologic examination measured at maximum valsalva revealed a uterus descending 3 cm below the hymen along with a lateral vaginal defect and cystocele descending 1 cm below the level of the hymen. POP-Q-score: Aa=+1, Ba=+1, C=+3, tvl=9. (POP-Q Stage 3). Urinary residual volume 150 ml.

Material and Methods We performed laparoscopic supracervical Hysterectomy and oophorectomy then a cervical sacropexy. We used a special mesh consisting of a central portion to attach to cervical stump, two thin arms to be placed laterally to the pelvic wall along the anatomical position of the uterosacral ligaments and two ends for sacral fixation at the level of S2. Thus replacing the weakened uterosacral ligaments by thin mesh stripes. The mesh consists of polyvinylidene fluoride (PVDF) monofilament structure.

Results: Examination 3 days after the operation and Follow-up at 3 months show: good elevation of cervix and vaginal vault, mild lateral vaginal defect. POP-Q-score: Aa=-3, Ba=-3, C=+-7,5, tvl=9. (POP-Q Stage 0). Urinary residual volume

Discussion: Uterosacral ligaments are the major suspension for uterus and vaginal vault. In the presented modification of sacropexy, we aimed to place the mesh stripes in a way to best reconstruct and resemble normal pelvic anatomy. The first results are good. For better evaluation more experience and longer follow-up is needed.

OUTCOMES IN THE LAPAROSCOPIC MANAGEMENT OF BLADDER ENDOMETRIOSIS: PRELIMINARY REPORT OF 55 CASES

Endometriosis: Surgery

Oral

Joao Alves*, Puga Marco , Fernandes Rodrigo, Redondo Cristina, Wattiez Arnaud

IRCAD EITS Strasbourg

Summary (4 lines): Bladder endometriosis surgery is associated with significant relief of pain and low recurrence. The procedure is not exempt of complications, which are frequently related to treatment of concurrent endometriosis elsewhere.

Introduction: Bladder is the most common affected site of the urinary tract endometriosis. The complete excision of the disease can be obtained by partial cystectomy leading to good results in terms of pain. Nevertheless, this treatment is not exempted of complications and more conservative approaches have been introduced. The objective of this study is to report the performance of the different techniques in bladder endometriosis. Pain scores, complications and recurrence are described

Material and Methods Retrospective study of patients with bladder endometriosis managed at the University Hospitals of Strasbourg between January 2006 and June 2013. Only cases of deep infiltrating endometriosis (DIE) were included (detrusor invasion). The groups were divided in partial cystectomy (PC) and partial-thickness excision (PTE). The information was obtained from the medical records of the patients and by telephonic interview.

Results: Thirty-three patients (60%) underwent PC, and the remaining patients underwent PTE. The pain relief was reduced in both groups. No bladder recurrences were found. Major complications developed in 8 PC patients, six of them primarily related to bowel resection or ureteral surgery.

Discussion: Laparoscopic management is feasible and associated with reduction of pain and low recurrence rates. As expected, complications were associated with bigger resections and, in our series, only to cases of partial cystectomy. Interestingly, the majority of complications where primarily related to associated procedures.

LAPAROSCOPIC APPENDECTOMY IN PREGNANCY

Case reports

Oral

Stavros Diavatis*, Karavida Aikaterini, Avgoustinakis Emmanouel, Chastamouratidis Charalambos, Lavasidis Lazaros, Vrantzas Athanasios, Tzitzimikas Stergios

BioClinic

Summary (4 lines): We present a case of acute appendicitis during the second trimester, which was treated with laparoscopy. Diagnosis, technique and comparison with open appendectomy are discussed.

Introduction: Acute appendicitis is the most common non-obstetric emergency requiring abdominal exploration during pregnancy. Diagnosis is often difficult due to altered physiology and anatomy of pregnant women. Its incidence ranges from 0,05-0,1% being identical to non-pregnant population. Perforation is much more frequent during the third trimester and peritonitis greatly increases preterm delivery and fetal mortality. Despite the advantages of laparoscopy over open procedures, there is still controversy for its safety during the third trimester.

Material and Methods A 28-year old woman at 17 weeks of pregnancy complained of right lower quadrant pain, nausea, anorexia, leukocytosis and fever. No signs of threatened abortion or chorioamnionitis were found. UTI was excluded and laparoscopic exploration was decided. Pneumoperitoneum established using Verres needle. Pressure maintained between 10-12mmHg to avoid fetal depression. First trocar was inserted supraumbilically, second in the right lower quadrant and third in the right upper quadrant. Phlegmonus appendix dissected and ligated with endoloop.

Results: Histopathology confirmed acute appendicitis. Post-operative period was uneventful and no complications were observed. The patient was discharged on the third day and had a full-term normal delivery. No developmental abnormalities to the fetus were reported. Birth weight of the infant was 3600gr and the Apgar score 10.

Discussion: Laparoscopic appendectomy features many advantages (reduced postoperative pain, drugs, hospitalization, embolic events, improved cosmesis). Major concerns are potential effects of pneumoperitoneum on fetus and possible uterus injury, which can be prevented if pressure is limited to 10–12 mmHg for less than 60’, Hasson technique used instead of Verres needle.

KEEP IT SIMPLE: A UNIQUE TECHNIQUE FOR VAGINAL VAULT CLOSURE DURING TOTAL LAPAROSCOPIC HYSTERECTOMY

Innovation in Instrumentation and Surgical Techniques

Video

Michal Shaubi*, Beller Uzi, Zuckerman Boris, Khatib Fayez

Shaare zedek medical center

Summary (4 lines): we wanted to evaluate the quality and safety of our simple and uniqe technique for vaginal vault closure during total laparoscopic hysterectomy.

Introduction: Several methods have been described for suturing the vaginal vault during TLH. In our institute, since 2003, we conclusively use a simple technique for vaginal vault closure during TLH, a single figure-8 mass suture. It includes 4 entrances through the vaginal vault, including peritoneum and vaginal mucosa. Entrance in the right upper side of the vaginal vault, to the left lower side, trough the left upper side and the last through the right lower side.

Material and Methods We conducted a retrospective cohort study. In order to evaluate the safety of our technique we compared the complications rate, between the TLH cases and all total abdominal hysterectomies were performed during the same time duration in our institute. To mention, traditional methods of vaginal vault suturing were used among the TAH cases. The documented complications were vaginal cuff dehiscence and bowel evisceration.

Results: All patients who underwent TLH and TAH during Jan2003 through Jun2013 were included. In total, 204 cases of TLH and 1154 cases of TAH. Four cases were followed by complications (vaginal cuff dehiscence or bowel evisceration). One following TLH and three after TAH (0.5% versus 0.26%).

Discussion: From our clinical experience as detailed above, we hypothesize that the single figure-8 mass suture for TLH is simple and safe, comparing to other common used techniques

ROBOTIC RETROPERITONEAL HYSTERECTOMY AT LOW COST FOR GESTATIONAL TROPHOBLASTIC DISEASE: CASE REPORT AND TECHNIQUE PRESENTATION

Robotics

Poster

Stavros Diavatis*, Avgoustinakis Emmanouel, Chastamouratidis Charalambos, Fragkos Marios, Lavasidis Lazaros, Karavida Aikaterini, Papacharalampous Euaggelos, Tzitzimikas Stergios

BioClinic

Summary (4 lines): We present a case of gestational trophoblastic disease (GTD) treated with robotic-assisted hysterectomy, utilizing the da Vinci® Surgical system, equipped with Ultracision® Harmonic Scalpel. A retroperitoneal approach is described.

Introduction: During the last decade robotic surgery seems to comprise the technological evolution of minimal invasive surgery, able to overcome the inherent limitations of laparoscopy. Gynecological oncology is probably the scientific/surgical field best suited for robotics regarding cost and patient benefit. The high cost of robotic surgery seems to be the main reason for its limited use in our country. Da Vinci robotic system equipped with Bipolar Forceps and robotic Ultracision® was used.

Material and Methods A 50-year old patient was diagnosed with GTD. Retroperitoneal approach and hysterectomy: • Cavitation of peritoneum towards the triangle formed by the round ligament/external iliac vessels/suspensory ligament • Peritoneum cut parallel to external iliac vessels, up to bifurcation point of the ovarian vessels • Blunt dissection of paracystic/pararectal space, ligation of uterine arteries at their origin • Posterior leaf of broad ligament opened. Extending the incision cranially and caudally isolates ovarian vessels • Circular colpotomy, transvaginal removal of the specimen

Results: Only two arms/instruments were used, combined with suction/irrigation and grasping forceps through the accessory port. Histopathology reported molar pregnancy. Post-operative period was uneventful and β-hCG levels declined steadily. No later complications were documented. The patient is symptoms free for the last 24 months.

Discussion: To the best of our knowledge, this is the first documented retroperitoneal robotic hysterectomy. Trophoblastic disease could be an indication for robotic surgery, due to its malignant potential, as well as the high surgical skills requirement (enlarged pregnant uterus). The described technique and use of equipment lower the overall cost.

HOW OFTEN ARE ENDOMETRIAL POLYPS PREMALIGNANT OR MALIGNANT IN A POSTMENOPAUSAL PATIENT? OUR EXPERIENCE

Oncology

Poster

Delgado Espeja Juan Jose *, Peco Adrover Soledad , Solano Calvo J.A., Fernandez Muñoz Laura , Nebreda Calvo Lucia , Gonzalez Hinojosa Jeronimo, Zapico Goñi Alvaro

Hospital príncipe de asturias madrid

Summary (4 lines): Endometrial polyps are involved in most of our time in an hysteroscopy office setting. They affect both premenopausal and postmenopausal women and also carry a small risk of cancer.

Introduction: Postmenopausal women with vaginal bleeding must be studied due to the risk of cancer (nearly 10%). But in an asymptomatic postmenopausal patient with abnormal ultrasound scan, the risk of cancer is unknown yet. In our study, we assess the prevalence of endometrial adenocarcinoma and atypical hyperplasia in symptomatic and asymptomatic patients.

Material and Methods Database statistical analysis from February 2009 to March 2013 were performed by Hysteroscopy Unit, Department of Obstetrics and Gynecology, University Hospital, Príncipe de Asturias, Alcalá de Henares, Madrid, Spain.

Results: Retrospective study involving 4073 diagnostic hysteroscopy. 293 patients with endometrial polyps, among 1518 postmenopausal patients were identified. 4 endometrial adenocarcinoma cases and 2 atypical hyperplasia cases were reported. One patient with abnormal scan, (endometrial polyp) had endometrial adenocarcinoma into the polyp, but she belonged to the asymptomatic group.

Discussion: Ultrasound scan and outpatient hysteroscopy are essential in triaging and managing women with suspected endometrial pathology. In our experience, the risk of endometrial cancer in asymptomatic women with endometrial polyps was 1,56%. However, if any symptom were presented, that risk reached 5,9%.

CONTINUOUS ULTRASOUND FETAL MONITORING DURING MATERNAL LAPAROSCOPIC SURGERY

Case reports

Selected abstract Oral

Stavros Diavatis*, Karavida Aikaterini, Chastamouratidis Charalambos, Avgoustinakis Emmanouel, Lavasidis Lazaros, Athanasiadis Apostolos, Tzitzimikas Stergios

BioClinic

Summary (4 lines): We present a case of laparoscopic surgery for a suspicious ovarian mass on a 14 weeks pregnant patient, during which the fetus was continuously monitored by ultrasound.

Introduction: Documentation of the fetal heart rate before and after laparoscopy is commonly practiced, as intraoperative fetal monitoring is considered difficult or technically not possible. We attempted to demonstrate the feasibility of real time ultrasound imaging for the duration of the laparoscopic procedure. We also recorded our observations regarding the effects of anesthesia and laparoscopy on the fetus and the pregnant uterus, as relevant published data is derived almost exclusively from animal model studies.

Material and Methods A 24 years old patient, 14 weeks singleton pregnancy, that underwent laparoscopic oophorectomy for a cystic ovarian mass showing vascularized papilary projections in preoperative imaging. The fetus was monitored continuously with real time ultrasound, starting with transvaginal probe 10 min before induction of anesthesia in the operating room, and continuing transabdominally 30 min after maternal recovery. Monitoring parameters were a) fetal movements, b) fetal heart rate, c) ductus venosus Doppler indices, d) uterine artery resistance.

Results: Imaging of the fetus and uterus was optimal throughout the procedure (45 min) and recovery. Pelvic structures and surgical instruments were visualized when in contact with the uterine wall. The fetus was immobilized immediately following i.v. anesthetic injection to the mother and remained so until 20 min after maternal recovery.

Discussion: Continuous ultrasound monitoring of the fetus during laparoscopy is feasible. Fetal recovery from anesthesia is delayed. Creation of pneumoperitoneum, laparoscopic manipulation of the andnexa and use of energy instruments do not seem to have ultrasonografically detectable effect on the fetus and pregnant uterus.

OVARIAN TUMOR MIMICKING ENDOMETRIOSIS

Endometriosis: Diagnosis

Video

Inês Reis*, Pereira Inês , Barata Sónia, Alho Conceição, Osório Filipa, Calhaz-Jorge Carlos

CHLN-Hospital de Santa Maria

Summary (4 lines): The authors report a clinical case interpreted as endometriosis that revealed to be a borderline ovarian tumor with laparoscopic findings suggestive of a disseminated malignant disease.

Introduction: Endometriosis is a common, benign disorder frequently occurring in young nulliparous women. However, clinical and imagiological presentation may be similar to a malignant infiltrative pelvic disease in rare patients. The optimal way to diagnosis is direct visualization of the implants.

Material and Methods Data on clinical presentation, physical examination and imaging findings are described. Laparoscopic findings and procedures during primary surgical intervention are presented and commented in the video. Histopathological diagnosis is then reported and discussed.

Results: A 30-year-old nulliparous presented with severe dysmenorrhea, dyschezia, dysuria and dyspareunia. Physical and imaging findings were indicative of deep endometriosis. Laparoscopy revealed left ovarian enlargement and multiple peritoneal implants with extemporaneous examination of “serous papilar tumor”. Left adnexectomy and multiple biopsies were performed. Histopathology described a papillary serous borderline tumor.

Discussion: The misdiagnosis of endometriosis/ovarian tumor, although rare, may impose an intraoperative change of the proposed intervention. Documentation of surgical findings is crucial for further multidisciplinary evaluation. Considering age and desire for pregnancy, the present patient was proposed a uterus sparing surgical staging versus hysterectomy with complete surgical staging,

SEVERE URETERAL ENDOMETRIOSIS AND SILENT LOSS OF RENAL FUNCTION – 3 CASES OF LAPAROSCOPIC NEPHRECTOMY

Endometriosis: Surgery

Oral

Inês Reis*, Pereira Inês , Barata Sónia, Alho Conceição, Leitão Tito, Varela João, Osório Filipa , Calhaz-Jorge Carlos

CHLN-Hospital de Santa Maria

Summary (4 lines): The authors report three cases of deep endometriosis with ureteral involvement causing nonfunctioning kidney, managed by a laparoscopic nephrectomy.

Introduction: Ureteral endometriosis occurs in approximately 1% of pelvic endometriosis cases. Severe ureteral endometriosis is frequently associated with deep rectovaginal endometriosis and can potentially lead to urinary tract obstruction, ureterohydronephrosis and, more rarely, silent loss of renal function. The main goal of intervention is kidney function recovery, when possible. A nonfunctioning kidney with persistent hydronephrosis is a risk factor for hypertension, pyelonephritis and nephrolithiasis. Few cases of ureteral endometriosis with severe kidney impairment have been reported.

Material and Methods We performed a retrospective review of women with ureteral endometriosis and unilateral renal cortical loss, submitted to a laparoscopic surgical procedure involving nephrectomy. From January 2011 to June 2013, we reviewed clinical presentation, imaging endometriosis findings, surgical management and short time postoperative outcome.

Results: Three patients were identified, all referred for severe dyspareunia, dysmenorrhea and dyschezia. Physical examination was suggestive of deep endometriosis. For all cases, imaging documented nodular rectovaginal endometriosis, unilateral ureterohydronephrosis, significant renal cortical atrophy and negligible renal function. Laparoscopic adhesiolysis, ureterolysis, unilateral nephrectomy and excision of rectovaginal nodule were performed.

Discussion: As illustrated by the presented cases, patients with renal function loss as a consequence of ureteral endometriosis frequently do not show urological symptoms. This emphasizes the need to evaluate urinary tract involvement in patients with infiltrative endometriosis. Nephrectomy should be considered for significant renal impairment associated with persistent ureterohydronephrosis.

ANXIETY LEVEL IN PATIENTS UNDERGOING OFFICE HYSTEROSCOPY

Diagnostic & Operative Office Hysteroscopy

Poster

Igor Klyucharov*, Hassanov Albir, Yakhin Kaussar , Cleveland Gulnara,

Kazan State Medical University / RCH

Summary (4 lines): Anxiety level of patients varies depending on the method used. Patients showed a fairly high level of anxiety by Sheehan method. Despite the fact that the average pain score during both diagnostics and surgical procedure was low individual patients showed need of analgesia. There is insufficient data to conclude that the increased levels of anxiety affects patient’s pain level during the procedure. Further research is needed.

Introduction: The objective of the research is to define prevalence of level of the increased anxiety in patients undergoing office hysteroscopy and to determine whether it has impact on the pain level of the patient during the procedure.

Material and Methods 59 women, who underwent office hysteroscopy, have been investigated. Spielberger-Khanin anxiety inventory test, Sheehan anxiety scale, Yakhin-Mendelevich questionnaire for revealing and an estimation of neurotic conditions were used before the procedure. Visual Analogue Scale of pain intensity was used after the procedure.

Results: Patients were characterized by: elevated in 27(48,2%), significant anxiety in 16(28,6%); situational and personal anxiety low, medium and high in 19(33,3%) and 15(26,3%), 32(56%) and 38(66,7%), 6(10,5%) and 4(7,0%). Morbid character of changes in 12(20,3%), neurotic-depression in 20(33,9%), asthenia in 11(18,6%), hysterical in 17(28,8%), obsessive-phobic in 11(18,6%), vegetative in 15(25,4%)

Discussion: Patients’ anxiety level varies depending on the method used. A fairly high level of anxiety is determined by Sheehan’s test. There is insufficient data to conclude that the increased levels of anxiety affects patient’s pain level during the procedure. Further research is needed.

SURGICAL TREATMENT OF OVARIAN ENDOMETRIOMAS: MODIFIED STRIPPING TECHNIQUE

Tips & Tricks in Surgery

Video

Vesna Salamun*

UKC Ljubljana

Summary (4 lines): We would like to show the modified or controled stripping technique for treatment of endometriomas that is based on the stripping technique. This is a different aproach and it seems to be accurate and efficient surgical method .

Introduction: There are many surgical techniques for treatment of endometriomas but determination of the ideal laparoscopic technique remains controversial . There are two risks associated with the surgical treatment of endometriomas: the risk of excessive and the risk of incomplete surgery. We would like to display some tricks and tips that make cystectomies less aggresive and more precise and effective.

Material and Methods The modified or controled stripping technique consists of a six steps. Ovary should be completely mobilized. The incision with the scissor should be made on the antimesenteric surface of the ovary, regardless of the existing endometrioma's rupture. The incision is important for identification of the cortex and the capsule. Separation of the capsule from the cortex and stroma with gliding moves, using the scissors. Other steps are the same as in the stripping techniqe.

Results: Excellent operating technique is crucial in maintaining ovarian reserve. The ideal treatment of endometriomas consists of removal of the whole capsule and restoration to normal anatomical structure without detrimental effect on the ovarian reserve. This technique enables removal of endometriomas easily in more controlled manner and usually in one piece.

Discussion: A prospective study should be carried out for evaluation of this technique by determining ovarian reserve before and after the operation, examining the rate of the recurrence of the endometrioma, pain and the rate of spontaneous pregnancy in previously subfertile women.

EIGHT YEARS OF URETER SURGICAL TREATMENT IN ENDOMETRIOSIS: PRELIMINARY REPORT OF 158 CASES

Endometriosis: Surgery

Oral

Joao Alves*, Fernandes Rodrigo , Puga Marco , Redondo Cristina, Wattiez Arnaud

IRCAD EITS Strasbourg

Summary (4 lines): We describe our experience in endometriosis laparoscopical treatment of affected ureter as well as patients outcomes and complications.

Introduction: Ureteral endometriosis is a rare entity that can lead to ureteral obstruction with subsequent hydroureter, dilatation of the renal pelvis till kidney failure. When present it is often associated with deep endometriosis of the posterior compartment. Treatment of concurrent endometriosis can increment the surgical morbidity. Our goal is to describe the outcomes of laparoscopic surgery for ureteric endometriosis.

Material and Methods Retrospective study of the outcomes of patients who underwent laparoscopic surgery due to endometriosis in which there was ureterolysis, resection with end-to-end anastomosis or ureter re-implantation. The settling was in Department of Obstetrics and Gynecology, Strasbourg University Hospitals, between 2006 and June 2013. Data were collected from clinical files and included a telephone interview.

Results: We included 158 patients: 138 with ureterolysis and 20 patients with resection and end-to-end anastomosis. Associated procedures were: 13 patients - segmental bowel resection, 15 - shaving of recto-vaginal nodule and 23 - resection of bladder endometriosis nodule. We founded 9 major complications from which 4 uretero-vaginal fistula.

Discussion: Ureteric involvement is usually asymptomatic, and therefore in patients with evidence of deep endometriosis it must be excluded. Laparoscopic treatment of ureteric endometriosis is feasible, but associated with non-negligible complications. Surgeons that perform this surgery should be able to deal with its complications.

OPTIONS OF VULVARECONSTRUCTION IN VULVAR CANCER- FROM LOCAL FLAPS UP TO MUSCULO- CUTANEOUS FLAPS ?

Tips & Tricks in Surgery

Oral

Sascha Baum*, julia radosa, panagiotis sklavounos, Michael Friedrich, Solomayer Erich

Gynecological department university saarland

Summary (4 lines): Overview and technical description of different local and myocutaneous flaps in vulvar cancer.

Introduction: In the last decade an increasing number of young women with vulvar cancer is recognized. Cause of the young age of these patients at the point of diagnose there is further more a higher number of vulvar cancer recurrence found in the last years. Additionally to the increasing number of young patients with vulvar cancer, there is a growing number of women with high grade vulvar intraepithelian neoplasia.

Material and Methods Our aims are to give first a systematic overview about the possibilities and techniques of plastic reconstruction of the vulva with different local flaps like VY- flap and others for example. Furthermore we want to show methods of covering large defects with different musculo- cutaneous- flaps like VRAM (= vertical rectus abdominis myocutaneous flap ) or TFL ( = tensor fasciae latae flap ) in situations of extendet vulvar cancer or vulvar cancer recurrence.

Results: These different flaps allows not only the covering of defects. It is further more possible to make a plastic reconstruction of the vulvar.

Discussion: It is important to offer different options of local and distant flaps in vulvarsurgery not only for defect covering. It is further more important for avoiding mutilate surgery.

LAPAROSCOPIC FERTILITY SPARING CYTOREDUCTIVE SURGERY FOR ADVANCED STAGE BORDERLINE OVARIAN CARCINOMA, REPORT OF TWO CASES

Oncology

Oral

Tzitzimikas Stergios*, Marios Fragkos, Lavasidis Lazaros, Chastamouratidis Charalambos, Diavatis Stavros, Karavida Aikaterini, Papacharalambous Evangelos

Papageorgiou University Hospital

Summary (4 lines): We present two cases of advanced stage borderline ovarian tumors in young women, both successfully managed laparoscopically with fertility sparing cytoreductive surgery, thus allowing preservation of future reproductive potential.

Introduction: Ideal surgical management of borderline ovarian tumors (BOT) affecting women of reproductive age remains controversial. BOTs have excellent survival prognosis, even in advanced stages associated with non-invasive implants. Surgical management remains the gold standard; chemotherapy has uncertain efficacy, and lymphadenectomy has no impact on survival. Advanced laparoscopic surgery seems a safe and feasible surgical alternative. Laparoscopic fertility sparing techniques and advances in assisted reproductive techniques (ART) allow women to retain their reproductive potential.

Material and Methods Two nulliparous women, 19 & 22, underwent laparoscopic unilateral oophorectomy and biopsy-based staging for ovarian mass (stage 3a BOT). They both opted for fertility-sparing laparoscopic management. Case 1 underwent secondary platinum-based chemotherapy and subsequent laparoscopic completion oophorectomy, omentectomy, pelvic lymphadenectomy with uterine preservation. Seven years follow up was performed, and underwent successfully ART treatment. Case 2 had secondary laparoscopic partial contralateral oophorectomy, infragastric omentectomy, preserving a near-complete ovary and uterus, and initiated appropriate follow up.

Results: Both operations were completed without conversion to laparotomy. Histopathology confirmed seropapillary BOTs with non-invasive implants on ovary/omentum/parietal peritoneum. Peritoneal washings were positive, lymph nodes negative. The first patient had successful reproductive outcome with IVF; gave birth to twins at 7 years and remains well with no evidence of recurrence.

Discussion: Advanced stage BOTs can be successfully managed laparoscopically. Fertility sparing laparoscopic surgery emerges as a feasible and safe option for women of reproductive age. Efficacy of such laparoscopic operations is enhanced by the meticulous application of oncological rules and by the thoughtful awareness of the technique’s inherent limitations.

EVALUATION OF PELVIC PAIN IN OFFICE TRANSVAGINAL HYDROLAPAROSCOPY

Infertility and Reproductive Medicine

Selected abstract Oral

Pierluigi Giampaolino*, Pellicano Massimiliano, Bifulco Giuseppe, De Rosa Nicoletta, Simioli Stefania, Santangelo Fabrizia, Morra Ilaria, Nappi Carmine

Department of Gynaecology and Obstetrics, and Path

Summary (4 lines): we have evaluated pelvic pain during office transvaginal hydrolaparoscopy. Chromosalpingoscopie’s stage proved more painful than other stages. We belive office transvaginal hydrolaparoscopy can be performed if the patient is properly informed.

Introduction: to asses pelvic pain in patients underwent office transvaginal hydrolaparoscopy ;it is mini-invasive technique which allows exploration of the posterior pelvis. The procedure was performed in out-patient departments with local anesthesia, through the use a 3.9 mm diameter’s trocar inserted into the posterior fornix to 10-20 mm from the cervix, with a mini endoscope of 2.7 mm in diameter, a 30 ° optics used to view the posterior pelvis.

Material and Methods 40 infertile women, referred to our department , underwent office transvaginal hydrolaparoscopy. We have evaluated pelvic pain during five stages: stage 1 intrauterin introduction catheter, stage 2 introduction verres needle in douglas; stage 3 introduction trocar in pelvis; stage 4 viewing pelvic’s organs; stage 5 chromosalpingoscopy. Pelvic pains were evaluated with likert’s scale (0-5)

Results: stage 5 is associated with most painful symptomatology than stages 1-4 (ps 2-3(p=0.001); there is no statistically significant difference between stages 1,2,3.

Discussion: office transvaginal hydrolaparoscopy technique is well tolerated by patients. Chromosalpingoscopie’s stage turned out the less tolerated; although it does not adversely affect on the procedure execution which can be adequately accomplished by performing a proper counseling.

HYPERANDROGENISM DUE TO A TESTOSTERONE-SECRETING OVARIAN LEYDIG CELL TUMOR

Case reports

Poster

Carla Nunes*, Barros Joana, Henriques Alexandra, Ribeirinho Ana, Lourenço Alexandre, Calhaz-Jorge Carlos, test 1 test 1

Departamento / Clínica Universitária de Obstetrícia e Ginecologia, CHLN - Hospital Universitário de Santa Maria, Faculdade de Medicina da Universidade de Lisboa, CAM - Centro Académico de Medicina de Lisboa

Summary (4 lines): The authors report a case of a Leydig cell tumor in a postmenopausal woman who first presented with clinical hyperandrogenism.

Introduction: Androgen-producing tumors of the ovary are rare in postmenopausal women and are revealed by severe virilization. Leydig cell tumors are the most frequent postmenopausal virilizing tumors. They produce testosterone leading to hyperandrogenism.

Material and Methods The laboratory, imageology and pathologic findings of our case are described. In addition, the pertinent literature is summarily reviewed.

Results: A 75-year-old woman presented with a history of gradual alopecia and deepening of voice, which began a year before. Laboratory tests showed elevated levels of testosterone and a transvaginal ultrasonography disclosed a left ovarian tumor. Bilateral laparoscopic adnexectomy was performed and an ovarian Leydig cell tumor was diagnosed.

Discussion: Androgen-secreting ovarian tumors represent a diagnostic and therapeutic challenge. They have to be considered in the differential diagnosis of severe hyperandrogenism.

HYSTEROSCOPIC TUBAL OCCLUSION (ESSURE ®). RESULTS AND COMPLICATIONS

Diagnostic & Operative Office Hysteroscopy

Poster

Julio F. Garrido*, Deulofeu Pere, Gatell Margarita

Hospital Municipal de Badalona

Summary (4 lines): Essure ® for tubal occlusion has shown safe, effective and irreversible. In this communication, we review our results and the circumstances of the few complications in the insertion of the devices.

Introduction: The Essure ® method for tubal occlusion has been shown safe, effective and irreversible. In this communication, we review our results and the circumstances of the few complications in the insertion of the devices. Most of them happened at the start of the series and the success in the final series is 95% with very few complications.

Material and Methods We started using it in July 2006. We developed 147 indicated occlusions and excluded 2 cases (an unsuspected malformation and a patient with anxiety). In 7 cases we had to repeat the procedures. We divided the patients in three groups along time and statistically compared their results and need of medication. We concluded successfully the method in 133 cases(91.7%). Main reasons for failure at first attempt were tubal spasm(73.7%), pain at distension(21%) and uterine malformation(5.3%).

Results: There were 2 patients who failed to radiological control. 22(16.5%) needed exam by hysterosalpingography, two showed tubal patency (migration in 1 case). We had one case of tubal perforation and one patient with an uneventful pregnancy. Removing unconcluded procedures and complications, hits were 89%. Results improved along time with experience

Discussion: Our results and complications are similar to those reported in literature, most of them happened at the start of the series, since in the last 41 the successful cases were 95.2%, confirming safety of the procedure. The complications were very few and all of them are described in this paper.

HYSTEROSCOPY AND DETECTION OF ENDOMETRIAL PATHOLOGY

Diagnostic & Operative Office Hysteroscopy

Poster

Marta Sousa*, Nunes Carla , silva cristina, Osorio Filipa, Barata Sonia, Calhaz-Jorge Carlos

University Hospital of Santa Maria

Summary (4 lines): The purpose of this review was to evaluate the accuracy of transvaginal ultrasonography and hysteroscopy in the study of endometrial pathology and its correlation with histopathological findings.

Introduction: Hysteroscopy is a safe diagnostic and therapeutic procedure with a wide range of applications. It has high sensitivity and specificity for the diagnosis and treatment of endometrial pathology. Furthermore, it can be performed in an outpatient setting with lower costs and few complications. We propose to evaluate its accuracy and correlation with transvaginal ultrasonography and histopathologic findings.

Material and Methods Retrospective study of women with suspected endometrial pathology submitted to hysteroscopy in our Department between 2008 and 2013. The following data were collected: age, hormonal therapy use, body mass index (BMI), symptoms, ultrasound diagnosis, hysteroscopic findings, type of procedure and histopathologic results. The correlation between ultrasonographic, hysteroscopic and histopathologic results was evaluated.

Results: 600 cases were review.93% were caucasian. The mean age was 48 years;47.8% were postmenopausal; and 92.2% had never used hormonal therapy. Endometrial polyp was the most common entity found by hysteroscopy(58%). Hysteroscopic evaluation confirmed the ultrasound diagnosis in 56.5% of cases. There was 78% concordance between hysteroscopic and pathologic diagnosis.

Discussion: Despite a modest correlation between ultrasonography and hysteroscopy, this study demonstrates that the accuracy between hysteroscopy and histopathologic findings is far superior for detection of uterine pathologies, allowing us to state that hysteroscopy provides a precise diagnosis with direct visualization and therapeutic procedures.

CESAREAN SCAR ECTOPIC PREGNANCY – COMBINED LAPAROSCOPIC AND HYSTEROSCOPIC MANAGEMENT

Tips & Tricks in Surgery

Video

Inês Reis*, Godinho Beatriz, Barata Sónia, Alho Conceição, Osório Filipa , Clode Nuno, Calhaz-Jorge Carlos

CHLN-Hospital de Santa Maria

Summary (4 lines): The authors report a case of cesarean scar ectopic pregnancy, managed by a combined hysteroscopic and laparoscopic approach.

Introduction: Cesarean scar ectopic pregnancy is a rare event, with an estimated incidence of 1:1800 to 1:2226. Multiple therapeutic options have been proposed, including methrotexate administration, potassium chloride intraamniotic injection, uterine aspiration, perhysterocopic gestacional sac removal and laparothomy or laparoscopic surgical approach.

Material and Methods Data on clinical presentation, physical examination and ultrasonographic diagnosis are described. Laparoscopic and hysteroscopic findings are presented and commented in the video.

Results: A 36-year-old woman with clinical and ultrasonographic evidence of a cesarean scar ectopic pregnancy was initially managed with intramuscular and intra-amniotic methotrexate administration. She was readmitted 5 days later, with abdominal pain and moderate haemoperitoneum. A combined laparoscopy/hysteroscopy was performed involving hysterotomy, gestacional sac removal and double suture hysterorraphy.

Discussion: Due to the rarity of this clinical entity, its adequate management is not well established. Laparoscopic approach may be a valuable option, having in mind fertility preservation. It should be considered when medical therapy is unsuccessful.

ATYPICAL FIRST PRESENTATION OF DEEP ENDOMETRIOSIS

Case reports

Poster

Carla Nunes*, Sousa Joana, Barata Sónia, Alho Conceição, Osório Filipa, Calhaz-Jorge Carlos

Departamento / Clínica Universitária de Obstetrícia e Ginecologia, CHLN - Hospital Universitário de Santa Maria, Faculdade de Medicina da Universidade de Lisboa, CAM - Centro Académico de Medicina de Lisboa

Summary (4 lines): The authors report a case of a woman with deep endometriosis, whose first clinical manifestation was a profuse vaginal bleeding, without any previous clinical history suggestive of endometriosis.

Introduction: Endometriosis is a complex disease with unclear pathogenesis. A profuse and isolated vaginal bleeding is not a typical symptom of endometriosis. The specific involvement of the rectovaginal septum leads to intense symptoms as dysmenorrhea, pelvic pain, deep dispareunia and dyschezia in young and middle aged women during periods. Deep endometriosis is suspected clinically and can be confirmed by vaginal examination, ultrasonography and / or magnetic resonance imaging.

Material and Methods The clinical, radiological and laboratory findings of our case are described. In addition, the pertinent literature is summarily reviewed.

Results: 28-year-old nulliparous woman presented in emergency department with a profuse vaginal bleeding not associated with menstruation or trauma. She was under oral contraceptives and denied dysmenorrhea, dyspareunia, dyschezia, dysuria or pelvic pain. It was identified a hemorrhagic endometriosis nodule of the rectovaginal septum. Bleeding was controlled with a hemostatic suture.

Discussion: Deep infiltrating endometriosis is a global pathology that may involve different structures and may cause many symptoms. A profuse and isolated vaginal bleeding is a rare initial manifestation of the disease. Endometriosis represents a diagnostic and therapeutic challenge and is important to be alert for the atypical signs and symptoms.

COMPLICATIONS OF DIAGNOSTIC HYSTEROSCOPY. 5 YEAR’S EXPERIENCE IN A TEACHING HOSPITAL

Complications

Poster

Delgado Espeja Juan Jose*, Fernandez Muñoz Laura, Marcos Gonzalez Maria Victoria, Solano Calvo Juan Antonio, Zapico Goñi Alvaro, Nebreda Calvo Lucia

Hospital príncipe de asturias madrid

Summary (4 lines): Our objetive is to describe the incidence and treatment of complications that took place during the 4363 diagnostic hysteroscopy procedures made in Hysteroscopy Unit, University Hospital Princice Asturias, Madrid, Spain.

Introduction: The complications rate is highly dependent on the surgeon’s experience. Therefore, it’s expected that a teaching hospital may have higher complications rate than another hospital with more experienced staff. The complication rate over the 5 years declined an average of 1.8 % per year in our center

Material and Methods 4363 cases of diagnostic hysteroscopy performed at our center from 2009 to June 2013 were collected. We analyzed the 476 cases in which complications occurred. Bettocchi hysteroscope 3.6 mm is used in all cases. Uterine distention were achieved by Endomat pump saline. Grasping forceps, hyteroscopic scissors and Versapoint were used as surgical supplies depending on each case.

Results: 22 Cases of major bleeding (4,62% of all complications) suspending procedure in one occasion. 72 Vasovagal syncopes(15,12%). 6 Uterine perforation(1,26%) and 8 false passages(1,68%) 281 Cervical stenosis(59,03%). Only 18 cases required the suspension of the procedure. 87 Cases of other complications(18,28%)such as mild pain or lack of colaboration of pacient.

Discussion: Diagnostic hysteroscopy is a generally safe procedure. The complications are often mild, if the safety criteria established for technique are followed. It is also essential both prior knowledge of its existence and prompt intraoperative diagnosis. The surgeon experience minimizes the risk

15 YEARS STUDY: RADICAL HYSTERECTOMY BY LAPAROTOMY VS LAPAROSCOPY-ASSISTED VAGINAL HYSTERECTOMY IN CERVICAL CANCER

Oncology

Poster

Celia Navejar*, Rivera Selene, Vidal Oscar, Saldivar Donato , Garza Jose, Castillo Lorena, Avila Axdruval

Hospital Universitario Dr Jose E Gonzalez

Summary (4 lines): Cervical cancer is the major malignancies affecting women worldwide. In Mexico, 4,000 deaths occur annually and is the leading cause of mortality

Introduction: Until the 90s, the standard for patients with stage IA2 and IB1, was abdominal radical hysterectomy and lymphadenectomy .Nezhat in 1992 described the first laparoscopic radical hysterectomy with lymphadenectomy. So gynecologic oncologists began using laparoscopy in order to lower morbidity. However, there are few comparative studies in the literature that have reported long-term follow-up of these patients.

Material and Methods An observational, cross-sectional, descriptive, retrospective, unblinded in 86 patients with IA2-IBI cervical cancer, 23 treated with laparoscopic radical hysterectomy and 63 with abdominal radical hysterectomy, performed by the same surgeon at the Hospital Universitario "Jose E. Gonzalez "of the Universidad Autonoma de Nuevo Leon, from September 1992 to August 1998. They conducted follow-up 15 years after using European scale quality of life for cancer research and treatment

Results: No statistically significant differences were found in terms of quality of life between both surgical techniques, finding only that there is a higher prevalence in the laparotomy group compared to the same physical and emotional concept of sex before the disease than in the group of laparoscopy (p = 0.034).

Discussion: There is no difference in survival and morbidity after 15 years of follow up comparing both techniques and the current status of the patients coincides with that reported in the traditional method.

HISTEROSCOPIC STERILIZATION: 4-YEARS OF EXPERIENCE

Complications

Poster

Ana Caeiro*, Miranda Mariana, Costa-Diniz Teresa, Pedro Amelia, Silva Pereira José, Thorne Adriana, oliveira ana

Hospital Prof. Dr. Fernando Fonseca

Summary (4 lines): Authors aimed to evaluate the histeroscopic sterilization experience at Hospital Prof. Dr. Fernando Fonseca.

Introduction: The Essure Permanent Birth Control system® is a permanent, non-surgical hysteroscopic sterilization procedure that consists on the placement of a micro-insert in the proximal section of each fallopian tube lumen. An alternative method of contraception is required for 3 months after the placement as the tissue reaction to occlude the fallopian tubes need to occur. A confirmation test is needed, transvaginal ultrasound or x-ray, to confirm the success of the sterilization.

Material and Methods A retrospective study of hospital Prof. Doutor Fernando Fonseca admissions for female sterilization with Essure® from November 2008 to June 2012. The statistical analysis was based on Excel 2007.

Results: 92 Essure® were placed at our Hospital. The mean age was 39. The mean procedure time was 3,66 minutes. In 17 the procedure failed. 5 didn’t conclude follow-up required. 20 were proposed to an alternative method. Adverse events occurred in 4 – abdominal cramps (1), wrong location (2), pregnancy (1).

Discussion: Although the devices are expensive, the relative safety of hysteroscopic tubal occlusion over other methods and the ability to place the implants in the office is a cost-saving opportunity. Adverse effects occurred in women who didn’t complete follow-up or didn’t have an alternative contraception method. Our failure rate was 18%.

MAKING THE MOST OF EXPOSURE IN LAPAROSCOPY: 10 USES OF THE T-LIFT ®DEVICE

Innovation in Instrumentation and Surgical Techniques

Video

Marco Puga*, Alves Joao, Fernandez Rodrigo, Redondo Cristina, Meier Rose, Wattiez Arnaud

Clinica Alemana

Summary (4 lines): The use of T-lift device is simple and can be applied to multiples techniques. The main benefits are to improve exposure and to free the assistant to help the surgeon.

Introduction: Adequate exposure of the surgical field is a key point in the success of surgery. The organ suspension is a fundamental step to improve the visualization of the field and to liberate the assistant to help the surgeon. Nevertheless, organ suspension techniques can be challenging and even risky. The objective is to present multiple uses of the T-lift device and discuss its benefits

Material and Methods Review and compilation of laparoscopic surgical videos where the organ suspension by means of the T-lift device ® was used. Surgeries were performed at the Departments of Gynecology & Surgery of the University Hospitals of Strasbourg.

Results: 10 different applications of the T-lift device during diverse surgeries were collected and are presented in a didactical way. The technique of suspension is described, as well as its advantages and limitations.

Discussion: The use of the T Lift device ® is simple and fast. It permits to seize the benefits of the organ suspension in a safety way, reducing the manipulation of straight needles and simplifying the procedure.

SUCCESS AND FAILURE OF ESSURE® METHOD WITHOUT ANAESTHESIA FOR PATIENTS WITH TWO TUBES

Diagnostic & Operative Office Hysteroscopy

Selected abstract Oral

Pierre Panel*, Bouqier-Pariente Julie, Heckel sergine, Engrand Jean Bernard, Hsiung Remy, Agostini Aubert, Villefranque Vincent, Kutnaorsky Richard, lopes Patrice, Martigny Hugo, Marchand Fabienne, Chis Carmen, Coudray Jean , Dhainaut Caroline, Fernandez Hervé

Centre hospitalier de Versailles

Summary (4 lines): In intention to treat and in non selected population, succes of procedure and success of protocol may be lower than expected.

Introduction: This is part of a French multicentre cohort study about hysteroscopic tubal sterilisation conducted in 13 facilities from September 2008 through Mars 2011.

Material and Methods Standard control protocol is based on X ray for normal insert placement procedure or hysterosalpingography (HSG) in case of difficulties during Essure® placement. When X ray didn’t reach acceptable criteria, HSG was recommended but 2D ultrasound could also be done. This study included 2567 patients; patients with single tube, malformation and procedure done with anaesthesia or IUD in place were excluded.

Results: Upon 1474 patients, 1454 had a procedure. 94% of placements were successful and 92,7% had control at three month ; 2% were a protocol failure. 14% of patient had VAS>7 during procedure and 4% after procedure. Patients were satisfied in 95,4% of cases related with success and pain.

Discussion: Upon 291(19,7%) patients with retroverted uterus, success rate of placement was significantly lower (86,3%) but also pain. In intention to treat, success rate is lower than expected. Despite an active control policy, lost of follow up was 7,24% in this population.

3D-SONOHYSTEROGRAPHY IN THE ASSESSMENT OF THE UTERINE CAVITY AFTER HYSTEROSCOPIC METROPLASTY

Surgical Hysteroscopy

Poster

Artur Ludwin*, Ludwin Inga, Kudła Marek, Pityński Kazimierz, Banas Tomasz, Jach Robert

Department of Gynecology and Oncology, Jagiellonian University, Medical Colege

Summary (4 lines): 3D-SIS can replace hysteroscopy as a diagnostic reference standard after hysteroscopic metroplasty. The use of hysteroscopy should be limited to cases diagnosed as requiring supplementary surgical intervention.

Introduction: Most institutions, routinely perform second-look hysteroscopy (relatively invasive and expensive procedure) after hysteroscopic metroplasty. The use of traditional methods is limited because of high costs (NMR) or inadequate diagnostic accuracy for IUAs (2D-TVS, 3D-TVS) and small uterine disorders (residual septum/fundal notch) (2D-TVS, 2D-SIS, hysterosalpingography). The objective of study was to estimate the diagnostic accuracy of 3D-SIS relative to second-look hysteroscopy after hysteroscopic metroplasty and determine the inter- and intra-observer agreements for 3D-SIS.

Material and Methods Double-blinded diagnostic tests study included women who qualified for hysteroscopic metroplasty following infertility, miscarriage and presence of septate uterus. Postoperative diagnosis (3D-SIS and hysteroscopy) covered 3 assessment categories as follows: the shape of the uterine cavity; the length of the fundal notch: (≥1cm,

Results: Among 141 women,the abnormalities occurred in 18 (12.8%) cases.From the results of 3D-SIS showed accuracy(97.2%), sensitivity(97%), specificity(100%), and AUC (0.98; 0.95% CI 0.96–1.0) did not differ significantly from those of hysteroscopy. 3D-SIS showed perfect reproducibility in the assessment of uterine cavity shape or fundal notch and substantial for IUAs.

Discussion: The significant additional benefits (information regarding the external contours of fundus and the myometrium) of 3D-SIS are important. There are cases (uterus septate with external intercornual cleft) wherein, despite the incorrect uterine cavity shape, further correction is either impossible or must remain limited (risk of fundal perforation or excessive thinning).

SUCCESS AND FAILURE OF ESSURE® METHOD FOR PATIENTS WITH A SINGLE TUBE

Diagnostic & Operative Office Hysteroscopy

Poster

Pierre Panel*, BOUQUIER PARIENTE Julie, Heckel Sergine, Engrand Jean Bernard, Hsiung Remy, Agostini Aubert, Villefranque Vincent, Kutnahorsky Richard, Lopes Patrice, Martigny Hugo, Marchand Fabienne, Chis Carmen, Coudray Jean, Dhainaut Caroline, Fernandez Hervé

Centre hospitalier de Versailles

Summary (4 lines): Patients may have a single tube because of unicornuate uterus and previous salpingectomy or adnexectomy. Specific results of Essure method for those patients are analysed.

Introduction: This is part of a French multicentre prospective cohort study about hysteroscopic tubal sterilisation conducted in 13 facilities from September 2008 through Mars 2011.

Material and Methods The aim of this study was to analyse modalities and results of hysteroscopic tubal sterilisation by Essure® for patients with a single tube. Standard control protocol is based on hysterosalpingography (HSG) but 2D ultrasound could also be done.

Results: This study included 73 patients. In 62 cases, placement was successful. 87% of patients had control at three month and 4 cases were a protocol failure. 7,1% of patients had VAS>7 during procedure but 0% after procedure. 86,3% of patients were satisfied, related with success.

Discussion: Those results are significantly lower than after standard bilateral procedure. Risk factors for procedure and protocol failure are analysed. Control modalities are discussed.

TECHNIQUE OF NERVE- SPARING AND UTERINE ARTERIES CONSERVING RADICAL LAPAROSCOPIC TRACHELECTOMY

Oncology

Poster

Sascha Baum*, panagiotis sklavounos, Michael Friedrich , Erich Solomayer, Julia Radosa

Gynecological department university saarland

Summary (4 lines): Description of the technique of laparoscopic nerve- sparing and uterine arteries conserving radical laparoscopic trachelectomy in cervical cancer.

Introduction: There is an increasing number of women who are delivering their first child in an higher age. So it is a growing number of women with cervical cancer who have not finished their family planing at the point of diagnosis. The number of enquiries for fertility protection is growing.

Material and Methods Here we describe the technique of the laparoscopic radical hysterectomy. The surgery is performed by conserving both uterine arteries and protecting the urinary bladder innervating nerves. For the cutting of the cervical part from the uterine body a monopolar sling is used to get straight surgical margins.

Results: The radical laparoscopic technique is a oncologicaly save procedure. But it is more difficult to perform than the normal radical laparoscopic hysterectomy.

Discussion: The radical trachelectomy is an important technique for women with cervical cancer and uncompleted family planing. It is possible to be as radical as in radical hysterectomy in the paracervial area but to conserve the body of the uterus. It is important to respect the contraindications.

LUMBOAORTIC AND ILIAC LYMPHADENECTOMY FOR STAGING OF CERVICAL CANCER: WHAT IS THE ROLE TODAY?

Oncology

Video

Saska Gocevska*, Rouanet Philippe

ICM, Institut régional du Cancer de Montpellier - Val d'Aurelle

Summary (4 lines): This video will focus on the performance of lumboaortic and pelvic lymphadenectomy in cervical cancer.

Introduction: Lymphatics are the main pathway of dissemination for gynaecologic malignancies. The evaluation of lymph node status is essential for the diagnosis, prognosis and treatment of patients with cervical cancer. Compared to the FIGO clinical staging, staging surgery improves the accuracy of diagnosis in 24% of Stage IB, 52% of stage II and 45% of stage IIIB.

Material and Methods Surgical staging aims to define radiation fields and eliminate a diffuse carcinomatosis. The irradiation volumes are based on tests imaging and the results of para-aortic lymphadenectomy.

Results: The surgeon must be familiar with lymphatic anatomy and the ability to perform a systematic retroperitoneal pelvic and lumboaortic lymph node dissection. As operative laparoscopy is evolving, new techniques and instrumentation are being developed to make the procedures safer and more efficacious.

Discussion: Total laparoscopic lumboaortic and pelvic lymphadenectomy is a technically feasible and safe procedure. Larger studies and long-term follow-up are required to determine the oncologic outcomes of these patients.

LAPAROSCOPIC DETORSION OF GANGRENOUS TWISTED ADNEXA WITH LARGE OVARIAN CYST

Case reports

Poster

Sonali Gaur*, Penny James

Surrey and sussex nhs trust

Summary (4 lines): □ Laparoscopic detorsion should be the first choice treatment in the management of ovarian torsion, regardless of the color or number of twists of the ovary, especially in young women.

Introduction: □ The standard option to treat twisted ischemic adnexa is adnexectomy. Conservative therapy for preservation of ovarian function is preferred and supports efforts to preserve fertility. We present a young female with ovarian cyst with adnexal torsion who was successfully managed with conservative treatment of laparoscopic detorsion.

Material and Methods A 23 year old presented at midnight with history of worsening abdominal pain and vomiting. On examination she had rebound tenderness and voluntary guarding. She was afebrile with normal inflammatory markers in the blood. Transvaginal scan revealed 8x7 cms simple ovarian cyst with some anechoic fluid in the pelvis. Laparoscopy demonstrated approximately 10-12cm twisted Adnexa of gangrenous bluish black discolouration filling up the pelvis, twisted, with two and a half turns involving Ovary and Tubes.

Results: Laparoscopic de-torsion of adnexa was performed and 200mls of cyst fluid drained. During follow up, the patient remained asymptomatic with no evidence of sepsis on blood markers. Follow up Ultrasonography revealed restoration of ovary with follicular growth along with restored blood supply on Doppler examination

Discussion: Although twisted Adnexa may appear to be ischemic it can safely be revived by Detorsion with preservation of function. The ability to retain viability even after prolonged ischemia was proved by the excellent results and blood perfusion can still be gained from either the ovarian or uterine arteries.

SUCCESS AND FAILURE IN INTENTION TO TREAT OF ESSURE® METHOD FOR PATIENTS WITH IUD

Diagnostic & Operative Office Hysteroscopy

Poster

Pierre Panel*, Bouquier Pariente Julie , Heckel Sergine, Engrand Jean Bernard, Hsiung Remy, Agostini Aubert, Villefranque Vincent, Kutnahorsky Richard, Lopes Patrice, Martigny Hugo, Marchand Fabienne, Chis Carmen, Coudray Jean, Dhainaut Caroline, Fernandez Hervé

Centre hospitalier de Versailles

Summary (4 lines): Patients using a IUD as contraceptive method may keep it until to Essure® placement or even till 3 month control test. We report and analyse prospectively those cases.

Introduction: This is part of a French multicentre cohort study about hysteroscopic tubal sterilisation conducted in 13 facilities from September 2008 through Mars 2011, including 2567 patients. The aim of this study was to analyse modalities and results of hysteroscopic tubal sterilisation by Essure® done for patients with any type of intra uterine device (IUD).

Material and Methods Standard control protocol is based on X ray for normal insert placement procedure or hysterosalpingography (HSG) in case of difficulties during Essure® placement. When X ray didn’t reach acceptable criteria, HSG was recommended but 2D ultrasound could also be done. This study included 346 patients. In 114 cases, IUD was remove just before hysteroscopy. In 232 cases Essure placement attempt was done IUD in place.

Results: In 4 (1,7 %) cases, IUD was remove during the Essure® procedure. When IUD was removed, placement was successful in 99/114 (87%) patients instead in 216/232 (93,1%) when not. 91,7 % of patients had control at three month. In 1 case, we concluded to a protocol failure.

Discussion: Success rate and VAS score > 7 were significantly different to disadvantage of IUD ablation before procedure. Moreover, results for patients with IUD were comparable to standard bilateral placement. No complication was reported related to concomitant situation or to IUD ablation after 3 month.

ULTRASOUND ENDOMETRIAL THICKNESS AND HYSTEROSCOPIC FINDINGS IN PATIENTS WITH INFERTILITY

Infertility and Reproductive Medicine

Poster

Celia Navejar*, Rivera Selene , Sordia Luis, Morales Felipe, Vidal Oscar, Saldivar Donato, Avila Axdruval

Hospital Universitario Dr Jose E Gonzalez

Summary (4 lines): The intrauterine pathologies are found up to 25% of infertile patients. This may affect the outcome of reproduction by interfering with implantation or causing spontaneous abortion.

Introduction: Ultrasound evaluation of endometrial thickness is a standard procedure during the infertility workup. Despite the widespread use of high resolution ultrasound equipment, the clinical significance of differences in endometrial thickness and appearance has remained controversial. Although hysteroscopy is considered the gold standard, there are still disputes between transvaginal sonography and hysteroscopy in the diagnosis of these anomalies.

Material and Methods patients with infertility diagnosis who attended the University Center for Reproductive Medicine, Hospital "Dr. Jose E. Gonzalez " Depending on the endometrial thickness the patients were divided in 3 groups: less than 4 mm, 5-9 mm and over 10 mm endometrial thickness by transvaginal ultrasound on day 7 of the menstrual cycle.

Results: %. 44% belonged to group 2 and 50% of these present normal hysteroscopy, 31% had polyps and 19% arcuate uterus.

Discussion: The relationship between endometrial thickness and hysteroscopy, there was no statistical significance with p=0.475.

SURGICAL TECHNIQUE OF LAPAROSCOPIC TRANSABDOMINAL CERCLAGE

Case reports

Video

Osorio Filipa*, Rodrigues Andreia, Costa Teresa, Centeno Mónica, Calhaz Jorge Carlos

Hospital Santa Maria - CHLN; Hospital da Luz

Summary (4 lines): The authors report a case of a laparoscopic transabdominal cerclage in a pregnant patient with residual cervix after conization for cervical cancer.

Introduction: Most cerclage operations for cervical insufficiency are performed transvaginally. The transabdominal route is beneficial in treating patients with cervices that are either extremely short, congenitally deformed, deeply lacerated, or markedly scarred because of previously failed transvaginal cerclage procedures. The laparoscopic cervicoisthmic cerclage has real benefits comparing to transabdominal surgery concerning operative time, days of hospitalization and morbidity.

Material and Methods Video presentation of an assisted laparoscopic cervicoisthmic cerclage.

Results: 34-year-old patient, with previous cervical cancer treated with conization before pregnancy, with no residual cervix visualized by vaginal route. At 14 weeks of gestation, the patient underwent a laparoscopic cervicoisthmic cerclage. The gestational course was uneventful with a cesarean section performed at 37 weeks.

Discussion: Laparoscopic transabdominal cerclage should be considered in selected patients. It ought to be performed by skilled surgeons, with experience on classical cerclage technique and endoscopic surgery.

THE EFFECT OF LAPAROSCOPIC SURGERY FOR ENDOMETRIOMAS ON AMH

Infertility and Reproductive Medicine

Oral

Amer Raza*, Richardson Robert , Phelps david, Duffy J

Chelsea and westminster hospital

Summary (4 lines): To investigate the effect of laparoscopic excision of ovarian endometrioma on ovarian reserve by monitoring serum anti mullerian hormones.

Introduction: This is a prospective study in a tertiary NHS hospital to see the impact of endometrioma excision on the AMH levels. There are number of studies which has shown the effect of different techniques of endometrioma excision on the AMH levels. We have used the standardised techniques of endometrioma stripping with KTp laser and observed its effect over 6 weeks and then 6 months on AMH levels.

Material and Methods All patients (n=39) underwent laparoscopic stripping of ovarian endometrioma followed by KTP laser ablation of ovarian edges and serosal surface effected by endometriosis. Serum AMH and FSH were measured preoperatively, at 6 weeks and 6 months postoperatively. The primary endpoint was to assess the ovarian reserve damage based on AMH alterations. Statistical analysis were done by using non parametric Wilcoxon test.

Results: The serum AMH levels are very low in endometrioma patients. Laparoscopic ovarian cystectomy causes a significant and progressive decline in serum AMH levels which is worse in patient undergoing surgery for recurrent disease

Discussion: Patients with recurrent endometriomas (n=5)had preoperatively lower AMH level than patients who had a primary endometrioma (n=32)(Mean AMH 6.7 pmol/L Vs 8.37 pmol/L) The decline in AMH level in this recurrent surgery group was much larger than after previous surgery (6.75 fall to 2.06 Vs 8.37 fall to 6.55)

LAPAROSCOPIC URETERONEOCISTOSTOMY WITH PSOAS HITCH IN A DUPLEX URINARY UNIT FOR TREATMENT OF URETEROVAGINAL FISTULA

Complications

Video

Osorio Filipa*, Barata Sónia, Guerra Adalgisa, Leitão Tito

Hospital Santa Maria - CHLN; Hospital da Luz

Summary (4 lines): The authors report a case of laparoscopic treatment of a ureterovaginal fistula after abdominal hysterectomy

Introduction: Although laparoscopy is established in Urologic ablative procedures, for reconstructive procedures it is less developed. In this case report, we present a patient with an ureterovaginal fistula after an abdominal histerectomy, associated with a congenital double ureter, corrected with a laparoscopic double ureteroneocistostomy with psoas hitch.

Material and Methods Video presentation of laparoscopic double ureteroneocistostomy with psoas hitch for the treatment of ureterovaginal fistula

Results: A 42 year-old patient presented with continuous involuntary urine loss from the vagina after an abdominal histerectomy. We describe the procedure for the identification of the fistulous tract and the ureteral duplication, as well as the correction of the fistula with a laparoscopic double ureteroneocistostomy with psoas hitch.

Discussion: A laparoscopic ureteroneocistostomy with psoas hitch for the treatment of lesions of the distal ureter is a possible approach, allowing the resolution of a complex urologic situation, through a miniminally invasive procedure, which is safe and effective, that should become the standard approach to urologic pelvic reconstruction procedures.

VERESS NEEDLE ENTRY – TIPS AND TRICKS

Tips & Tricks in Surgery

Video

Cátia Lourenço*, Maia Susana, Oliveira Mário

CHVNG/E

Summary (4 lines): Veress needle entry – Tips and tricks for safe entry presented in a video

Introduction: Despite several techniques and instruments that have been introduced to minimize entry-related injuries during last century, around 50% of major complications in laparoscopy occur in this step of the surgery. According to the surgeon’s experience and interdisciplinary variability, each of the methods of entry enjoy a certain degree of popularity. Veress needle is the most ancient and used entry technique in laparoscopy. This video presents tips and tricks for a safe Veress needle entry.

Material and Methods The video focus on the following subjects: patient positioning, instruments knowledge and checking, insertion sites, skin incision, angle of insertion, abdominal wall lifting, direction of insertion, safety tests, adequate penumoperitoneum, primary trocar entry, secondary trocars entry, trocars removal and particular situations.

Results: Tips and tricks are presented in a video

Discussion: Although surgeons should perform the technique with which they have the most experience, they should be familiar with alternative. The keystones to safe access and prevention of complications during laparoscopic surgery are proper evaluation of the patient, surgical skills and good knowledge of the instrumentation.

MORE ENDOMETRIAL CANCERS ARE TREATED SUCCESSFULLY LAPAROSCOPIC SURGERY: 5 YEARS’ EXPERIENCE IN A CANCER UNIT

Oncology

Video

Jaydip Raut*, Geary Graham, Abdul Summi

Centre for Gynaecological Cancers and Laparoscopic Surgery, Royal Derby Hospital

Summary (4 lines): We audited all the 450 endometrial cancer we treated in last 5 years. Year by year we are doing more case laparoscopically successfully with lesser hospital stay and lesser complications.

Introduction: Endometrial cancer is the commonest Gynaecological Cancer in UK and trend is increasing. However, this can be picked up early and cured. Mainstay treatment is Hysterectomy. These patients are often old, obese and hypertensive, making the surgery difficult. Laparoscopy is a safer approach with same efficacy. In 2008, we started Laparoscopic Hysterectomy in our centre. Since, we have treated 439 endometrial cancer cases. We audited each case against National Institute for Clinical Excellence (NICE) standards

Material and Methods We reviewed retrospectively, identified from MDT data-base. 4 audit members hand-searched our robust electronic-data-systems. We identified clinical questions and national auditable standards. We piloted several times before auditing cancer presentation; histology types, use of ultrasound; method of sampling; operative technique especially laparoscopy; operative time; estimate blood loss; rates of lymph node excision; length of stay, complications, rates of conversion to laparotomy, readmission rates. The data was analysed, also in sub-groups.

Results: Mean Operative time: Open-procedure- 98.6 minutes; Laparoscopy– 107.8 minutes, p=0.0014*. Mean Hospital stay: Open- 5.1 days, Laparoscopy- 2.0 days, p

Conversion to laparotomy: 7.2%

Overall complication: Open- 21.3%, Laparoscopy-20.0%. p 0.2856* (no significant difference). Re-admission rate is 7% and 10% respectively. p=0.3421 (not significant)

Discussion: We are treating more laparoscopically involving shorter hospital stays, lower blood losses and lower complication. In our unit we have changed our policy, that, Endometrial Cancer should be treated laparoscopically per say, unless there is exception. However, is this safer option is available to every patient in UK?

TAKING LAPAROSCOPY SKILLS WORKSHOP TO DEVELOPING COUNTRY PAKISTAN

Teaching & Training

Poster

Amer Raza*, Richardson Robert , Mahmud Ghazala

Chelsea and westminster hospital

Summary (4 lines): Laparoscopic surgery is making its way to the developing countries. Its benefits are being realised among the gynaecologists and patients. Therefore it is vital to take the training programmes to developing countries for safe laparoscopy.

Introduction: We worked in collaboration with Pakistan Institute of medical sciences to develop a running training programme for all the gynaecologist who had access to laparoscopy equipment in their hospitals. Our aim is to train all the established gynaecologist in laparoscopic surgery to change the attitude towards laparoscopy

Material and Methods Introduction of laparoscopic training boxes with cheap , easy to make models. Precourse assessment of laparoscopic skills. Training over three days with the same curriculum as in european centres. Post course followup for the change in attitude and behaviour of clinicians.

Results: Increase in number of laparoscopic management of ectopic pregnancies in Northern pakistan Training of 40 Gynaecologist in northern pakistan which has assisted in changing the culture of lap training. Increase collaboration with their surgical colleagues to learn the basic skills.

Discussion: We worked in collaboration with pakistan institute and designed a training in laparoscopy skills so to improve the standards of laparoscopic surgery in the gynaecologist. Gynaecologist remained behind in this field due to lack of training facilities and support. This programme has trained 40 gynaecologists.

THE MANAGEMENT OF EARLY STAGE ENDOMETRIAL CANCER

Complications

Poster

Jatinder Kaur*

West Middlesex University Hospital

Summary (4 lines): The surgical management of early stage endometrial cancer was assessed in a local nhs unit.

Introduction: The National Institute for Health and Care Excellence (NICE) issued guidance recommending that early stage endometrial cancers can be managed in local units rather than referral to tertiary cancer centres. It was suggested that the preferential surgical procedure in these select few cases is laparoscopic hysterectomy. We assessed the practice in one local unit over one year

Material and Methods The cancer database at the hospital was analysed and combined with histology and and multi-disciplinary team meeting outcomes. The cases of endometrial carcinoma over one year were included in the study. The medical notes, including the operative procedure, and histopathology for the Figo stage 1 carcinomas were collected and analysed,

Results: There were 26 cases of endometrial carcinoma, eight were early stage. One patient was deemed unsuitable for laparoscopy as she had had previous surgery. Six patients were treated with total laparoscopic hysterectomy. One patient had a conversion to total abdominal hysterectomy due to an enlarged uterus.

Discussion: Of seven suitable patients, 86% were treated according to national guidance. This suggests that it is practical and achievable for local units to treat early stage endometrial carcinoma, whilst more complicated cases can be managed in cancer centres.

HYSTEROSCOPIC DIAGNOSIS AND FOLLOW UP OF ATYPICAL ENDOMETRIAL HYPERPLASIA IN INFERTILE PATIENTS

Diagnostic & Operative Office Hysteroscopy

Poster

Graciela Keklikian*, Hermida Marcelo, Marendazzo Patricia, Rubal Agustín, Antunez Geronimo, Ilarramendi Alvaro, Capurro Ana

Tornu hospital

Summary (4 lines): We analyze the role of hysteroscopy in diagnosis and follow up of five patients with atypical endometrial hyperplasia undergoing IVF treatment.

Introduction: Atypical endometrial hyperplasia (AEH) is the least common type of hyperplasia, but it is the most likely to progress to endometrial carcinoma. (23% of untreated patients). Oral or intrauterine progestin treatment is associated with disease regression in 90% of women with AEH. Management of atypical endometrial hyperplasia is a challenge in infertile women. In this study, we present five cases of conservative treatment followed by in vitro fertilization and embryo transfer.

Material and Methods This prospective multicenter study was carried out in 2009-2013 at two institutions in Uruguay and Argentina. Atypical endometrial hyperplasia was diagnosed in 5 patients during their infertility treatment . All of them received progestin therapy :oral medroxyprogesterone (two patients) or levonorgestrel intrauterine devices (three patients). Hysteroscopy and biopsy were performed monthly until regression was proved.

Results: The median time to complete regression during surveillance was 6 months. All patients finally underwent IVF treatment. Two of them became pregnant and delivered full term infants. The follow up continued after the delivery. One of them showed a recurrence 9 months after cesarean section and hysterectomy was performed.

Discussion: It is concluded that conservative hormonal treatment for atypical endometrial hyperplasia followed by assisted reproductive technologies is an appropriate behavior for achieving pregnancy. A close follow up must be performed .Office hysteroscopy and endometrial sampling in an outpatient setting are the best option.

PRE-SACRAL ABSCESS AFTER LAPAROSCOPIC SACROHYSTEROPEXY FOR GENITAL PROLAPSE

Complications

Oral

Susana Coutinho*, Fernandes Elia, Guerra Adalgisa, Raimundo Pedro

Hospital da Luz

Summary (4 lines): A 41-year-old patient with a trans-vaginal mesh in place and recurrent prolapse underwent laparoscopic hysterosacropexy. Postoperatively a multiresistent pre-sacral abscess occurred and the prosthesis was removed by laparoscopy.

Introduction: The ideal biomaterial for use in Pelvic Floor Reconstruction is yet to be determined. To improve outcome and despite lack of data, surgeons have integrated implants in PFR. Unfortunately this can interfere with the efficacy of secondary procedures on recurrences following a primary mesh surgery. Enhanced inflammatory response may play a role in the pathogenesis of mesh complications, as well as infection. This type of complications has an increased incidence with trans-vaginal root mesh use.

Material and Methods The authors report the case of a woman with grade 2 recurrent prolapse and mesh contraction, which they decided to operate by removing the trans-vaginal mesh and do a sacrohysteropexy by laparoscopy. She had two previous vaginal surgeries done for cystocele: first at age 34 with an anterior polypropylene kit that recurred after five years, and a second in which the surgeon “repositioned” the prosthesis. This surgery wasn’t successful and the patient started having dyspareunia.

Results: The TransVaginal-Mesh body revealed sclerosis and was removed. Perioperative course seemed normal but three weeks later pre-sacral abscess was diagnosed and was resistant to standard antibiotics. Laparoscopic removal of the sacropexy prosthesis was done, under linezolid. One year after, prolapse reoccurred and the remaining two arms of TVM are displaced.

Discussion: The origin of the pelvic abscess remains uncertain, although the most probable cause is the intraoperative contamination of the mesh. It seems that mesh inflammation or infection requires multiple operations until the implant is fully removed and only then can the prolapse be solved, in this case using native tissue.

LAPAROSCOPIC APPROACH TO ESSURE IMPLANT REMOVAL

Innovation in Instrumentation and Surgical Techniques

Video

Jon Ivar Einarsson*, Janelle Moulder

Summary (4 lines): Pelvic pain is a known complication of Essure sterilization, particularly with malposition or perforation of the micro-inserts. Herein we describe a laparoscopic approach to Essure implant removal.

Introduction: We present a case of a 35-year-old woman with intermittent pelvic pain and development of symptomatic nickel allergy following Essure sterilization. She desired continued sterilization with complete removal of Essure micro-inserts. Given the placement of the Essure micro-inserts across the uterotubal junction, we performed a cornual resection and salpingectomy bilaterally to assure complete micro-insert removal and continued sterilization.

Material and Methods Careful inspection revealed no micro-insert perforation. Dissection of the pelvic sidewall was performed to identify the uterine artery at its origin. In order to minimize blood loss, temporary bilateral occlusion of the uterine arteries was performed using vascular clips, prior to cornual resection. The uterine cornua were infiltrated with dilute vasopressin to further minimize blood loss. Complete cornual resection was performed bilaterally, and the hysterotomy sites were closed using 0 PDO Quill suture.

Results: Examination of the specimens revealed complete removal of the Essure micro-inserts. Continued permanent sterilization was achieved.

Discussion: Pelvic pain can occur despite proper placement of Essure implants. Given the uterotubal location of the micro-insert, cornual resection allows for complete, intact retrieval of the implant. Minimizing blood loss during resection of this vascular tissue is essential, and can be achieved with use of vasopressin and temporary vascular clips.

APPLICATION OF THUNDERBEAT IN TOTAL LAPAROSCOPIC HYSTERECTOMY

Innovation in Instrumentation and Surgical Techniques

Video

Susana Maia*, Oliveira Nuno, Lourenço Cátia, Oliveira Mário

Centro Hospitalar Baixo Vouga, Hospital CUF Porto

Summary (4 lines): The authors intend to demonstrate the use of Thunderbeat in the dissection of tissues and sealing vessels while performing a total laparoscopic hysterectomy.

Introduction: Thunderbeat is a unique multifunctional instrument that combines advanced bipolar and ultrasonic energies, allowing to simultaneously seal and cut vessels up to and including 7mm in size with minimal thermal spread.

Material and Methods We present the case of a 54 year-old patient presenting menometrorrhagia unresponsive to medical treatment that underwent total laparoscopic hysterectomy.

Results: The postoperative period was without complications and histological examination of the uterus revealed interstitial myomas.

Discussion: Thunderbeat is an effective and safe alternative to the bipolar energy to perform laparoscopic hysterectomy. Its fast cutting capacity associated with reduced exchange of instruments results in reduction of surgical time.

SURGERY OF ENDOMETRIOSIS AND OVARIAN RESERVE

Endometriosis: Surgery

Poster

Cristina Redondo*, Faller Emilie, Murtada Rouba, Puga Marco, Fernandes Rodrigo, Alves Joao, Wattiez Arnaud

IRCAD

Summary (4 lines): In this study we assess the impact of endometriosis surgery on the ovarian reserve, by measuring the antimullerian hormone (AMH) before and after endometriosis surgery. We measure the levels of antimullerian hormone before and after the surgery.

Introduction: Among the various markers that reflect the ovarian reserve, the AMH has the advantage of being independent of the hormonal ambiance of the patient. The effect of the surgery of ovarian endometriosis cysts on the ovarian reserve has been studied by a number of authors, however the impact of the removal of deep infiltrating (DIE) lesions on the ovarian reserve has not been assessed and is not fully understood.

Material and Methods Single center observational study conducted in the Universitary Hospitals of Strasbourg, including 26 consecutive patients who underwent surgery for endometriosis from January 2012 to February 2013. Inclusion criteria: symptomatic endometriosis, 40 years old or less, endometriosis confirmed visually by laparoscopy, regardless of the stage and confirmed hystologycally, obtention of informed consent. Surgical acts: cystectomy, adhesyolysis, resection of DIE lesions.

Results: Despite a tendance to postoperative diminishment of AMH, there was no significative difference, regardless the type of surgery (p=0.073). Neither did we find it in case of cystectomy(p=0.06) [unilateral (p=0.27), bilateral (p=0.25)] or not (p=0.57). The percentage of diminishment was not superior in patients undergoing cystectomy compared to others (p=0,24)

Discussion: In our experience, the inoquity of the surgery for DIE is unlikely, and the absence of ovarian endometriomas is not completely reassuring. The surgeon's experience is a key factor, and an evaluation of the ovarian reserve should be performed in all young patients with childbearing desire.

PUNKTUELLE GEWEBEVERKLEBUNG ZUR MINIMIERUNG DER SEROMBILDUNG BEI GROßEN RESEKTIONSFLäCHEN IN DER MAMMACHIRURGIE

Oncology

Poster

Stefan Paepke*

Klinikum rechts der Isar

Summary (4 lines): Die Ausbildung von Seromen führt zu erheblichen Problemen in der postoperativen Versorgung nach Brustoperationen. Durch den Einsatz des Adhesivmaterials TissuGlu® lässt sich bei großen Resektionsflächen durch punktuelle Gewebeverklebung die Serombildung minimieren.

Introduction: Die Ausbildung von Seromen gehört zu den häufigsten Komplikationen nach Brustoperationen. Das Adhesivmaterial TissuGlu® besteht aus einem lysinbasierten Urethan, das seine Klebeintensität in feuchtem Milieu entfaltet und eine punktuelle feste Klebefläche zwischen Gewebeschichten formt.

Material and Methods TissuGlu fand in unserem Kollektiv zuerst Einsatz bei Folgeoperationen nach exzessiver Serombildung mit Folgekomplikationen (n= 3). Bei nachgewiesenem Erfolg mit problemarmer Wundheilung ohne weitere Serombildung indizierten wir den primären Einsatz bei zu mastektomierenden Patientinnen (n= 10).

Results: Es wurden 13 Patientinnen im mittleren Alter von 70, mit einem BMI von 25 untersucht. Das mittlere Resektatgewicht betrug 652g, die Resektionsfläche im Mittel 342 cm². Bei 3 Patientinnen wurde nach der Mastektomie eine komplette axilläre Dissektion, bei 3 eine SLNB vorgenommen. Eine Drainierung wurde nicht vorgenommen.

Discussion: Unsere an wenigen Mastektomiepatientinnen analysierten Ergebnisse zeigen einen absoluten Benefit in der klinischen Routine. Damit ist gezeigt, dass das Grundprinzip der Wunddrainierung neu zu hinterfragen ist. Dies an einem größeren Kollektiv zu prüfen ist eine deutschlandweite No-Drain-Multicentrer-Studie initiiert. Prospektiv erhobene Daten werden Verwendung und pharmakoökonomische Rentabilität klären.

DISSECTING THE ANTERIOR TRUNK OF THE HYPOGASTRIC ARTERY: AN APPLIED VISION OF THE ANATOMY

Teaching & Training

Video

Rodrigo Fernandes*, Puga Marco, Alves João, Redondo Cristina, Wattiez Arnaud

IRCAD

Summary (4 lines): The anatomy of the anterior trunk of the hypogastric artery is demonstrated in a didactical way, in an attempt to put into practice the theoretical knowledge.

Introduction: The anterior trunk of the hypogastric artery (ATHA) spread out into multiple branches witch are the main source of irrigation of pelvic organs. These vessels are frequently dissected, clamped or divided during different procedures. The knowledge of vascular anatomy is a key point to safe surgery; nevertheless its application in the surgical practice is not always easy. We present the anatomy of the ATHA in a schematic and didactical way useful to apply during surgery.

Material and Methods Review and compilation of laparoscopic surgical videos where the anatomy of the ATHA is demonstrated. Surgeries were performed at the Department of Obstetrics & Gynecology of the University Hospitals of Strasbourg and IRCAD, Strasbourg, France. Video edition and montage used Final Cut Pro X, Apple Inc. Several schematic designs using Adobe Photoshop CS6 are integrated in the video demonstration.

Results: The anterior trunk of the hypogastric artery and its branches are shown progressively from proximal to distal. The relationship and landmarks are demonstrated. The location of these structures during different laparoscopic procedures are highlighted

Discussion: The quality of vision in laparoscopy allows the surgeon to identify several structures distinguish from laparotomy. This fact gives accuracy and possibly safety during surgery. This advantage can be translated to the learning process, using the magnified vision of laparoscopy to show the anatomy form a didactical point of view.

DEEP ENDOMETRIOSIS OF THE RECTO-VAGINAL SEPTUM: KEY POINTS OF THE SURGICAL STRATEGY

Endometriosis: Surgery

Video

Cristina Redondo*, Puga Marco, Alves Joao, Fernandes Rodrigo, Wattiez Arnaud

IRCAD

Summary (4 lines): Surgery of deep infiltrating endometriosis may become safe and reproducible. A stepwise surgical strategy and following standardized surgical rules are mandatory.

Introduction: Surgical management of deep infiltrating endometriosis (DIE) of the recto-vaginal septum is a challenging procedure. The severe anatomical distortion produced by the disease is associated with the risk of complications and the possibility of an incomplete surgery. A defined surgical strategy is mandatory in order to make this surgery feasible, safe and reproducible. The objective is to present the key surgical steps, as well as the main anatomical landmarks.

Material and Methods Review and selected compilation of cases of DIE of recto-vaginal septum are included. All surgeries were performed at the Department of Obstetrics & Gynecology of the University Hospitals of Strasbourg & IRCAD, France. Video edition and montage using Final Cut Pro X (Apple INC) and schematic designs created with Adobe Photoshop CX6 are used.

Results: The technique is presented in a step-by-step fashion. Key points of anatomy are highlighted. The dissection techniques are thoroughly analyzed.

Discussion: Strategy is fundamental in surgery to achieve a good and safe result. In addition, the relevance of a stepwise technique increases with the complexity of the surgery. The systematization of the steps in the management of DIE makes surgery more reproducible and facilitates the learning process.

LAPAROSCOPIC HYSTERECTOMY DOSE NOT SUBSTITUTE VAGINAL HYSTERECTOMY, SHOWN BY RESULTS FROM TWO DIFFERENT CROATIAN INSTITUTIONS

Hysterectomy

Poster

Ingrid Marton*, Kopjar Miroslav, Maricic Igor, Marton Ingrid

University hospital

Summary (4 lines): Vaginal hysterectomy is historically considered as first step of minimally invasive surgery. Laparoscopic hysterectomy is alternative to abdominal, but not to vaginal hysterectomy, which should be performed when ever indicated.

Introduction: We compared results from two institutions, one with almost twenty years experience in laparoscopic hysterectomies (Zabok), and other with only five years experience (Sv.Duh). Indications for operation were benign and similar in both hospitals: fibroid uterus or lower abdominal pain, abnormal uterine bleeding, adnexal mass, stress urinary incontinence, endometriosis and chronic pelvic pain, benign neoplastic conditions.

Material and Methods In Zabok, 1994-2005, 1127 hysterectomies were performed: 332 (29.47%) TLH, 26 (2.30%) LAVH, 12 (1.06%) LH, 507 (44.99%) abdominal, 250 (22.18%) VH. In Sv. Duh, 2008-2012, 843 procedures were performed: 65 (7.71%) TLH, 62 (7.35%) LAVH, 11 (1.30%) LH, 554 (65.72%) abdominal, 151 (17.91%) VH. For laparoscopic hysterectomies four abdominal entry ports were used with obligatory use of uterus manipulator. Haemostasis was achieved with bipolar coagulation. Vaginal vault was closed either laparoscopically or vaginally.

Results: Major complications in both institutions were quite similar and included injuries of baldder, urether and intestines, vaginal vault dehiscence and one case of vesicovaginal fistula. Conversion rate was in acceptable terms. Vaginal hysterectomies contributed with approximately of 20% of total number of operations in both centers, with no recorded complications.

Discussion: Our experience shows that the learning curve of laparoscopic hysterectomy is long, and that the number of major complications is directly connected with it. Both procedures are safe and beneficial for patient. In experienced hands, laparoscopic hysterectomy is an alternative to abdominal hysterectomy, but, it does not substitute vaginal hysterectomy.

DETECTION OF ENDOMETRIOSIS IN GYNECOLOGIC DEPARTMENTS OF BAKU, AZERBAIJAN IN 2006 – 2007

Endometriosis: Diagnosis

Poster

Islam Magalov*, Baghirova Hicran, Ebert Andreas

Azerbaijan Medical University

Summary (4 lines): Retrospective analyses of surgery records for 2006-2007 received from 6 gynecologic clinics located in Baku, Azerbaijan was performed to detect the prevalence of endometriosis and its various forms.In the clinics with endoscopic facilities the prevalence of endometriosis was almost twice as high. The highest results were shown in the group of patients with adnexal pathology who were operated laparoscopically.

Introduction: The study of epidemiology of endometriosis has its own special features. In spite of generally acknowledged statement of wide spread occurrence of the disease among female population, the scientific data concerning its prevalence is discrepant. Marked variation in the results of different researches depends first of all on their design and focus group.

Material and Methods Retrospective analyses of surgery records for 2006-2007 received from 6 gynecologic clinics located in Baku, Azerbaijan was performed to detect the prevalence of endometriosis and its various forms. 5 of them were state and one -private institution. 3 clinics were fit out with endoscopic. The total amount of surgical interventions for the mentioned time was equal to 2796. 1714 of them were “open” and 689 – laparoscopic.

Results: Endometriosis was detected altogether in 3,76+0,36% of cases. In the clinics with endoscopic facilities the prevalence of endometriosis was almost twice as high – 5,65+0,64% vs 2,88+0,50% (OR=2,02, 95% CI, p

Discussion: The results of our study are indicative rather of low rate of endometriosis detection than of its low prevalence. This could be explained by the fact that gynecologic surgery in Azerbaijan is performed mainly for ‘life threatening” conditions, whereas “quality of life issues remain overshadowed.

LAPAROSCOPIC HYSTERECTOMY FOR LARGE UTERUS: WORLD'S FIRST CASE WITH ARTICULATING ENSEAL

Innovation in Instrumentation and Surgical Techniques

Video

James Kondrup*

Lourdes

Summary (4 lines): This video shows the world's first laparoscopic hysterectomy performed with the new Enseal Lap G-2 Articulating device. The uterus had over a dozen fibroids present.

Introduction: Surgeons are always interested in new innovations in surgical equipment especially if it can give better access and angle of approach to blood vessel sealing. This is very first surgical case utilizing the new Enseal Lap G-2 Articulating energy device device to perform a total laparoscopic hysterectomy on a difficult fibroid uterus. The biggest challenge was the low anterior segment large fibroid. The Articulation was essential in access to the vessels.

Material and Methods 3 - 5mm trocars and 1 - 12mm trocar, Enseal Lap G-2 Articulating device, The new Sigma morcellator

Results: Surgery took about 90 minutes and blood loss was less than 50cc. The patient did quite well and was ambulating two hours post operatively.

Discussion: Articulating Energy devices will be invaluable for difficult laparoscopic GYN surgeries, single site surgeries as well as other appropriate laparoscopic general surgery cases. The device performed as well as if not better than the regular Enseal Lap G-2 device.

3D TRANSABDOMINAL ULTRASOUND. A NEW RELIABLE APPROACH TO LOCALIZE ESSURE® MICROINSERTS AFTER HYSTEROSCOPIC AMBULATORY STERILIZATION

Surgical Hysteroscopy

Poster

Georges BADER*, Amel MAHDHI, Philippe BOUHANNA, Arnaud FAUCONNIER

POISSY UNIVERSITY HOSPITAL

Summary (4 lines): the main recommendation to confirm the position of the Essure® micro-insert device after hysteroscopic sterilization is by pelvic X-ray or HSG 3 months after the procedure. Previous studies have demonstrated that 3D transvaginal US is a reliable confirmation test for Essure® micro-inserts localization.

Introduction: The aim of the study is to evaluate transabdominal 3D US as a less invasive confirmation test to localize Essure® micro-inserts 3 months after ambulatory hysteroscopic sterilization.

Material and Methods single center prospective cohort study concerning patients who underwent hysteroscopic Essure® sterilization. 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 controls were done by an expert who ignores the operative data.

Results: 55 patients (83%) were easily evaluated by 3D transabdominal US and 62 by 3D transvaginal US (94%). The non-visualization of implants by abdominal approach was observed in case of retroverted uterus and BMI > 30. Laparoscopy was proposed in 5 cases : 2 non visualized microinserts and 3 inadequate position.

Discussion: Transabdominal 3D US is an interesting alternative to confirm proper placement of the Essure® microinserts. Despite of retroverted uterus and BMI > 30, it offers a better imaging of uterine fundus. It’s an easy and reproducible technique and could replace the 3D transvaginal ultrasound in most cases.

LAPAROSCOPIC HYSTEROTOMY AT 18 WEEKS GESTATIONAL AGE FOR A FAILED TERMINATION OF PREGNANCY (TOP)

Case reports

Video

Jan Bosteels*, Jan Baekelandt, Lore Lannoo, Carine De Rop

Imeldaziekenhuis Bonheiden

Summary (4 lines): We describe a case treated by a laparoscopic hysterotomy at 18 weeks for a failed termination of pregnancy for a chromosomal abnormality (trisomy 21). The technique is demonstrated in a video presentation. To the best of our knowledge, this may be the first published case report of a laparoscopic hysterotomy for a failed TOP.

Introduction: A 39 year primigravida was counseled to undergo an amniocentesis for an increased risk of fetal aneuploidy (1/218). Chromosome analysis confirmed a diagnosis of trisomy 21. On ultrasound scanning associated fetal structural abnormalities were present. The couple opted for a TOP at 18 weeks’ gestational age after additional counseling. We installed medical treatment according to the standard protocol of TOP of the department; there was however no successful expulsion of the fetus after one full week.

Material and Methods We used a disposable 10 mm trocar in Palmer’s point for the introduction of the laparoscope. We used four ancillary ports:three 5 mm disposable ports in the umbilicus, the left iliac fossa and suprapubiclally and one 10 mm disposable port in the right iliac fossa. We made a median incision on the posterior uterine wall with a monopolar hook over a distance of 5 cm.

Results: The dead fetus was gently extracted from the cavity using toothed forceps. The placenta was successfully removed from the uterus. Both were inserted in an endobag. We closed the uterine incision in two layers by a continuous locking technique using one single vicryl-1 suture.

Discussion: This is the first published case report of a laparoscopic hysterotomy for the removal of a dead fetus and placenta after a failed TOP. This approach can only be recommended if the surgeons have the skills for suturing the uterine wall adequately.

PREGNANCY RATE AND OVARIAN ENDOMETRIOMA RECURRENCE AFTER ABLATION USING PLASMA ENERGY

Endometriosis: Surgery

Poster

Lucian Puscasiu*, Horace Roman, Horace Roman, Marpeau Loic, Bourdel Nicolas, Auber Mathieu, Martin Cecile

University of Medicine and Pharmacy Targu Mures

Summary (4 lines): Plasma energy may have an important role in the management of ovarian endometrioma in women seeking to conceive. Patients in need of surgical procedures that can spare ovarian parenchyma, may benefit from ablation using plasma energy.

Introduction: Recent data have suggested that excision of endometriomas via cystectomy does not prevent inadvertent removal of ovarian parenchyma surrounding the cyst.This loss of ovarian cortex may lead to fertility impairment. The PlasmaJet system uses the high thermal and kinetic energies of a jet of pure argon plasma. The objective of the present study was to retrospectively assess, after a minimum of 12 months after surgery, the recurrence and pregnancy rates in women who underwent endometrioma ablation using plasma energy.

Material and Methods Retrospective non-comparative pilot study including 55 patients treated during 28 months. Ovarian endometriomas were managed solely via ablation using plasma energy. The minimum follow-up was 1 year. Information was obtained from the database of the North-West Inter Regional Female Cohort for Patients with Endometriosis, based on self-questionnaires completed before surgery, surgical and histologic data, and systematic recording of recurrences, pregnancy, and symptoms. Recurrences were assessed using pelvic ultrasound examination.

Results: The rate of recurrence was 10.9%. Of 33 women who wished to conceive, 67% became pregnant, spontaneously in 59%. Time from surgery to the first pregnancy was 7.6 months. After discontinuation of hormone therapy, the probability of not conceiving at 12 months was 0.36, and at 24 months was 0.27.

Discussion: Recurrence and pregnancy rates are comparable to the best reported results after endometrioma cystectomy. The mean time from surgery to first pregnancy was 6 months. Considering that the median time from surgery to recurrence was 14 months, the first 6 to 9 months after surgery represents a key phase for conception.

DIGESTIVE FUNCTION AFTER RADICAL VERSUS CONSERVATIVE SURGICAL APPROACH FOR DEEP ENDOMETRIOSIS INFILTRATING THE RECTUM

Endometriosis: Surgery

Oral

Lucian Puscasiu*, Roman Horace, Marpeau Loic, Vassilieff Maud, Tuech Jean-Jacques, Huet Emmanuel

University of Medicine and Pharmacy Targu Mures

Summary (4 lines): The results of the present study strongly suggest that using the symptom-guided approach may improve postoperative digestive functional outcomes in women with deep rectal endometriosis.

Introduction: Surgical management of colorectal endometriosis has increasingly become a topic of interest in gynecologic surgery, leading to much debate.Studies show that two surgical philosophies or approaches are usually used:the radical philosophy mainly based on colorectal resection, and the conservative philosophy or symptom-guided approach prioritizing conservation of the rectum.The objective of the study was to compare delayed digestive outcomes in women managed by the two different surgical philosophies.

Material and Methods “Before and after” comparative retrospective study of twenty-four women managed during a period when surgeons pursued a radical philosophy toward treatment, and 51 women managed during a period when a conservative philosophy was adopted.Preoperative patient characteristics, rectal nodule features, and associated localizations of the disease were comparable between the two groups. Standardized gastrointestinal questionnaires were used to compare the postoperative results.

Results: During the radical period, colorectal resection was carried out in 67% of patients, whereas during the second period only 20% of women underwent colorectal resection. Women managed conservative had significantly improved results on the KESS Questionnaire, GIQLI and FIQL, and significantly improved values for items related to postoperative constipation.

Discussion: The results do not imply that endometriosis surgeons should abandon colorectal resection, because treatment of large nodules does not always allow rectal conservation. A 10%–20% colorectal resection rate would bear witness to surgical wisdom and prudence, whereas performing mandatory colorectal resection in all women with rectal endometriosis seems excessive and insufficiently supported by evidence.

OPERATIVE HYSTEROSCOPY FOR PLACENTAL SITE TROPHOBLASTIC TUMOR

Surgical Hysteroscopy

Video

Susana Coutinho*, Gaspar Augusto, Oliveira Pedro

Hospital da Luz

Summary (4 lines): The video reports a case of Placental site trophoblastic tumor in a 33 year-old woman with local disease, in which a hysteroscopic resection was performed for tumor excision.

Introduction: Placental Site Trophoblastic Tumors (PSTT) are rare slowly growing malignant tumors, accounting for less than 0.2% of all cases of gestational trophoblastic disease. These tumors are derived from intermediate cytotrophoblast cells that are present in the placenta. PSTT can occur after any kind of gestation, and generally becomes symptomatic months to years after. More than 30% of patients already have metastases when diagnosed. Management involves surgical removal, as PSTT are highly resistant to chemotherapy.

Material and Methods A Para 2 woman with amenorrhea since last delivery 16 months ago and intra-uterine formation was referred for office hysteroscopy. The samples revealed intermediate trophoblastic tissue but were not conclusive: placental remnants or PSTT. βHCG was 7,8 UI/L and progesterone 9,36 ng/mL. A staging with tomographic and magnetic resonance studies showed local disease in uterine fundus with 3 cm largest diameter.

Results: Hysteroscopy with bipolar loop resection under saline distension was performed but was interrupted near completion because of overload. After PSTT pathology, the hysterectomy revealed a 5x3 mm residual tumor. A video showing the diagnostic pictures and the endoscopic resection is presented. After five years the patient is disease-free.

Discussion: The conservative treatment of this rare condition by hysteroscopy has been described in women that want to preserve their fertility. A previous image study is mandatory for the selection of cases, namely for characterization of vascularization that can be problematic. The role of lymphadenectomy in stage I is not defined.

EFFECTIVENESS OF A SYNTHETIC CYANOACRYLATE GLUE ON THE ONSET OF POSTOPERATIVE LYMPHOCELE AFTER PELVIC LYMPHADENECTOMY

Oncology

Oral

Pierluigi Giampaolino*, Bifulco Giuseppe, Morra Ilaria, Tommaselli Giovanni Antonio, Simioli Stefania, Piccegna Mirko, Schiattarella Antonio, Nappi Carmine

Department of Gynaecology and Obstetrics, and Path

Summary (4 lines): We evaluated the cyanoacrylic glue in preventing lymphoceles in patients undergoing pelvic lymphadenectomy . Our data show that the cyanoacrylic glue is useful for the prevention of pelvic lymphocele.

Introduction: lymphoceles are among the most common postoperative complications of pelvic lymphadenectomy , with a reported incidence of 1% to 29% in gynecology oncology. Several studies evaluated the effectiveness of biological glues on reducing lymphoceles,but no data on gynecological patients are available.We evaluated the effectiveness of cyanoacrylic glues (n-butyl cyanoacrylate) ( glubran 2-gem s.r.l, italy) in preventing lymphocele on 30 patients underwent pelvic lymphadenectomy for endometrial or cervical cancer.

Material and Methods prospective case-control study.Patients were divided into 2 groups: pelvic lymphadenectomy plus n-butyl cyanoacrylate ( treatment group : 15 patients) and pelvic lymphadenectomy without n-butyl cyanoacrylate ( control group : 15 patients). The amount of lymph in the two intraperitoneal drainage was assessed 36,48,72,96 hours after surgery (primary endpoint); moreover patients underwent abdominal and pelvic ultrasound examination on postoperative 15 days for evaluation of pelvic lymphocele (second endpoint).

Results: the amount lymph was significantly lower in the treatment group ( pe control group (presence of lymphocele at ultrasound.

Discussion: Intraoperative application of n-butyl cyanoacrylate seems to reduce lymph production after pelvic lymphadenectomy, providing a useful additional treatment option for reducing drainage volumse and preventing lymphocele development after pelvic lymphadenectomy.

SEVERE POSTLAPAROSCOPIC LEIOMYOMATOSIS PERITONEALIS DISSEMINATA – A CASE REPORT AND REVIEW OF THE LITERATURE

Complications

Poster

Stefan Heuer*, Schwab Michael, Firnschild Andreas, Häusler Sebastian, Hönig Arnd, Dietl Johannes, Bernar Thomas, Kircher Stefan

Universitäts-Frauenklinik

Summary (4 lines): Fragmented myomas which occur during laparoscopic morcellation seem to cause leiomyomatosis peritonealis disseminata (LPD) in rare cases. This uncommon side effect should be explained to patients before such laparoscopic precedures.

Introduction: Leiomyomas represent the most common gynecologic and uterine neoplasms. LPD is characterized by multiple subperitoneal or peritoneal nodules of varying sizes on the omentum and peritoneal surfaces, grossly mimicking peritoneal carcinosis. LPD is a rare disease and usually follows a benign course. Its pathophysiology remains unclear. In susceptible women, leaving fragments of myoma in the abdominal cavity might cause the development of LPD. We here present a case which supports this hypothesis.

Material and Methods A 29-year-old woman presented with firm pelvic masses. Medical History revealed laparoscopic myomectomy with tissue morcellation for uterine myoma six years before. Under laparoscopic observation, multiple firm tumors were detected. The biggest lesion (20x18x10cm) almost completely filled the douglas pouch and caused ventral displacement of the uterus. Multiple other lesions from 3x2x2mm to 8x7x7cm were attached to rectosigmoideum and dorsal pelvic peritoneum. In contrary the ventral peritoneum and upper abdomen were unremarkable.

Results: These findings suggested a peritoneal spreading pattern due to morcellation. In order to avoid another spreading of fragmented myomas we converted to transverse Pfannenstiel laparotomy. All lesions were completely resected. Pathological examination demonstrated that these tumors were leiomyomas very similar to the myoma tissue excised earlier.

Discussion: The growing knowledge about postlaparoscopic LPD should lead to improved patient information. This possible adverse effect has to be explained before every laposcopic procedure in which morcellation is planned. Further evaluation of appropriate surveillance and risk factors, which can be revised preoperatively, needs to be done.

AN OVERVIEW OF OUTPATIENT HYSTEROSCOPY IN WOMEN WITH POSTMENOPAUSAL BLEEDING

Diagnostic & Operative Office Hysteroscopy

Poster

Burke Cathy*

Cork University Maternity Hospital, Ireland

Summary (4 lines): Outpatient Hysteroscopy (OPH) is highly acceptable to an older patient cohort often having multiple medical morbidities.

Introduction: Postmenopausal bleeding (PMB) accounts for around 70% of postmenopausal referrals to gynaecology outpatient clinics. OPH is gaining prominence in the investigation of this symptom due to fewer complications, shorter recovery time and reduced costs. We aim to explore the demographics of patients attending our clinic and determine pain scores, patient satisfaction, acceptability and common pathologies found in women being investigated for PMB via OPH.

Material and Methods A retrospective review of PMB patients assessed in the OPH clinic at Cork University Maternity Hospital over the 3-year period January 2010-December 2012 was conducted. OPH clinic reports were electronically retrieved and data securely recorded on an Excel spreadsheet. Study number was 124. Median age was 55 years (45-84). 31% of patients were overweight (BMI 25.0-29.9) and 50% of patients were obese (BMI >30).

Results: Of 124 patients, median age was 55 years (45-84). Most patients had multiple medical disorders. Commonest hysteroscopic findings were normal or atrophic cavity (61%) and endometrial polyp(s) in 27%. Procedure failure rate was 3%. Ninety percent of patients indicated that they would undergo OPH again.

Discussion: OPH is acceptable for the vast majority of PMB women attending our clinic. Even amongst those with higher pain scores, most were satisfied and willing to undergo the procedure again, possibly due to a shorter procedural time and fewer side effects associated with general anaesthesia use.

HYSTERECTOMY VIA TRANSVAGINAL NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY (NOTES): FEASIBILITY OF AN INNOVATIVE APPROACH

Innovation in Instrumentation and Surgical Techniques

Poster

KAI-YUN WU*, Lee Chyi-Long, Yen Chih-Feng, Su Hsuan, Han Chien-Min

CHANG GUNG MEMORIAL HOSPITAL

Summary (4 lines): Hysterectomy for the treatment of benign diseases can be feasibly carried out via transvaginal NOTES. However, prospective studies are needed to determine its full clinical applications.

Introduction: To evaluate the feasibility and safety of performing a hysterectomy using the transvaginal natural orifice transluminal endoscopic surgery (NOTES).

Material and Methods From May through December 2010, 16 patients with benign uterine diseases who were eligible for laparoscopic hysterectomy were recruited to undergo transvaginal NOTES at a tertiary referral medical center. Intraoperative and postoperative surgical outcomes were measured.

Results: All of the included hysterectomies were completed via transvaginal NOTES. The mean uterine weight was 538.8g, the mean operative time was 122.7minutes, and the mean blood loss was 379.4mL. The mean postoperative hospital stay was 2.8 days. No intraoperative or postoperative complications were noted in this series.

Discussion: To the best of our knowledge, the present study is the first report on the use of transvaginal NOTES for performing hysterectomy that has appeared in the literature.

URETHROVAGINALE FISTELN - URSACHEN, MANAGEMENT, OUTCOME

Urogynaecology

Oral

Sabine Hahn*, Markus Huebner, Markus Hahn, Diethelm Wallwiener, Christl Reisenauer

University Hospital Tuebingen, Department OB/GYN

Summary (4 lines): UVF sind seltene Komplikationen, die ein diagnostisches und therapeutisches Gesamtkonzept zur erfolgreichen Behandlung erfordern.

Introduction: Während in den Entwicklungsländern die häufigste Ursache für UVF Geburtstraumata darstellen, sind die Mehrzahl dieser Komplikation in der westlichen Welt iatrogen verursacht. Die Schwierigkeit besteht in dem Erkennen einer UVF sowie in der operativen Versorgung, die einer entsprechenden Erfahrung in der vaginal-rekonstruktiven Chirurgie bedarf. Weitere Risikofaktoren zur Ausbildung urethrovaginaler Fisteln sind neben den suburethralen Bändern und Urethradivertikeln eine mangelnde lokale Östrogenisierung, vorangegangene vaginale Deszensusoperationen mit Narbenbildung sowie Z.n. Strahlentherapie.

Material and Methods Es wurden 71 genitale Fisteln, davon 8 UVF, operativ versorgt. In 87.5 % wurde vorausgehend eine suburethrale Bandanlage durchgeführt. Kleine UVF wurden durch eine spannungsfreie doppelschichtige Naht gedeckt. In 3 Fällen musste ein Martiusflap verwandt werden. In drei weiteren Fällen wurde aufgrund der unmittelbaren Nähe zum Ostium urethrae externum ein invers U-förmiger Schwenklappen aus der oberen Vaginalhaut benutzt und die dorsale Urethrawand rekonstruiert und eine Reformierung des Ostium urethrae externum erzielt.

Results: Bei 7/8 Patientinnen zeigte sich eine extraurethrale Kontinenz. Bei 75% bestand eine persistierende Belastungsinkontinenz, die teilweise konservativ durch Duloxetin, Applikation von Vaginaltampons und Beckenbodengymnastik ausreichend therapiert werden konnte. Bei zwei Patientinnen wurde eine suburethrale Bandanlage zur Behebung einer ausgeprägten residualen Belastungsinkontinenz durchgeführt.

Discussion: Das Risiko einer UVF sollte insbesondere bei suburethraler Bandanlage und Urethradivertikelabtragung dem Operateur bewusst sein. Die Art der operativen Defektdeckung richtet sich nach der Größe und Lokalisation der UVF. Der Martiusflap sowie der invers U-förmige vaginale Schwenklappen ermöglichen bei ausreichender operativer Erfahrung gute Ergebnisse bzgl. des langfristigen und rezidivfreien Fistelverschlusses.

FACTORS RELATED TO PAIN DURING OFFICE DIAGNOSTIC AND OPERATIVE HYSTEROSCOPY

Diagnostic & Operative Office Hysteroscopy

Poster

Silvia Von Wunster*, Lombardi Claudio, Imbruglia Laura, Colonna Laura, Dinatale Angela, Persiani Paolo, Mantegazza Priscilla, Pavoni Chiara

Ospedale di Alzano Lombardo (BG)

Summary (4 lines): Parity, menopausal status and operator experience were significantly related to pain perception during office hysteroscopy. No correlation has been found with the type of the procedure, diagnostic or operative.

Introduction: Outpatient services of office diagnostic and operative hysteroscopy are gaining prominence as a standard of care, but the experience of pain can be a limiting factor. Previous studies failed to identify factors significantly related to pain during hysteroscopy. Identification of patient subgroups where special pain management considerations should be done, could avoid the perception of elevated levels of discomfort.

Material and Methods We retrospectively analyzed 1253 office operative and diagnostic hysteroscopic procedures performed from april 2007 to december 2013 at the center for abnormal uterine bleeding of Alzano Lombardo (BG, Italy). All the procedures were performed under paracervical block and with vaginoscopic approach. Pain evaluation was made immediatly after the end of the procedure with a verbal numeric pain scale. Fisher tests and t-tests were used to study the significativity of covariates, testing differences between means.

Results: The main pain scores were: postmenopausal 3.72, premenopausal 3.18, nulliparous 3.76, parous 3.19, diagnostic 3.26, operative 3.45, experienced operator 3.07, not experienced 3.48. One-way ANOVA produced evidence that postmenopausal status is related to higher pain scores (p -.0001) while parity (p -.0001) and operator experience (p=0014)to lower scores"

Discussion: Menopausal status, parity and experience of the operator are significantly related to pain experience during office hysteroscopy, while no signicantly difference was seen between diagnostic and operative procedures. Regardless the programmed procedure, the subgroups of postmenopausal nulliparous women may require a special attention to control of pain during hysteroscopy.

EFFECT OF LAPAROSCOPIC E NDOMETRIOTIC CYST EXCISION ON OVARIAN RESERVE IN INFERTILE WOMEN

Complications

Poster

Meenu Agarwal*, Joshi Namita , Joshi Namita , Joshi Namita , Joshi Namita

Morpheus Bliss Fertility Centre

Summary (4 lines): In a study of 50 women with endometriotic cysts undergoing ART for infertility it was observed that women who had cyst excision had lower values of AMH and AFC as compared to the women of the same age.

Introduction: Endometriosis is an established cause of infertility. Laparoscopy is the gold standard for the diagnosis.Laparoscopic endometriotic cyst excision for infertility in patients going in for IVF/ICSI is a matter of debate.The aim of this study is to share our experience of effect of cyst excision on the ovarian reserve and ovarian response in a stimulated cycle as compared to the women of the same age.

Material and Methods A retrospective study that included 25 pts of infertility with endometriomas who underwent laparoscopic cyst excision and 25 patients who had endometriotic cyst on USG but did not undergo cyst excision.Inclusion Criterion- Age 28-31 years.Endometrial cyst 3-5 cms.Pt underwent IVF within 3 months of surgery.Post op AMH values/AFC count and No of Oocyts retrieved were taken as a measure to evaluate the ovarian response.

Results: There was a marked reduction in the volume of the operated volume with low AFC on the operated ovary.The AMH values were lower in the operated group.Ovarian response to ovulation induction was significantly low in operated group.

Discussion: Laparoscopic excision of endometriomas adversly affects the ovarian reserve.In an already diseased ovary a little loss of of healthy ovarian tissue makes a large difference in the ovarian reserve.

HYSTEROSCOPIC RESECTION OF SMALL SUBSEPTUM IN UTERUS IMPROVES FERTILITY OUTCOME

Surgical Hysteroscopy

Oral

Meenu Agarwal*

Mrpheus Bliss Fertility Centre

Summary (4 lines): In the present stud ypatients with unexplained primary or secondary infertility that included patients with previous normal hysteroscopic findings were found to have improved fertility outcome after resection of small sub septum at fundus.

Introduction: Uterine septum is the most common congenital anomaly of the female reproductive tract.The incidence of uterine septum is about2-3%.They are associated with spontaneous abortions,preterm delivery and primary infertility.While it is a known fact that septal resection improves the fertility outcome sometimes very small uterine subseptums are left untouched at hysteroscopy.We share our experience of treating these small subseptums and the improved fertility outcome thereafter.

Material and Methods This was a retrospectine study .150 patients in the age group of 25-35 years with unexplained primary or secondary infertility of more than 3 years were evaluated. They included patients with previous normal hysteroscopic findings.They were divided in two groups one with primary infertility and the other with 1 or more previous spontaneous abortion. All patients with a small subseptum underwent septal resection using hysteroscopic scissors.All patients were analyzed in terms of their reproductive outcome.

Results: After hysteroscopic septal resection 38% became pregnant within 3 months of surgery.The rate of spontaneous miscarriage decreased in patients with previous history of spontaneous abortion to 56%.The term delivery rate improved in both the groups.The rate of caesarean section was 36.6% .

Discussion: The presence of a small subseptum at fundus is a common finding noted in patients of unexplained primary and secondary infertility.Impaired vascularity at implantation site may be a cause for the same.Resection of septum may restore the normal function of the endometrium.

THE LOST SURGICAL INSTRUMENT ,A SURGEON`S NIGHTMARE AND A NOVICE METHOD TO RESOLVE THE COMPLICATION

Innovation in Instrumentation and Surgical Techniques

Video

Meenu Agarwal*

Morpheus Bliss Fertility Centre

Summary (4 lines): The aim is to report a case when while doing laparoscopic myomectomy one blade of the needle holder broke and got lost inside the patients body.It was retrieved laparoscopically with the help of a magnetic piece

Introduction: A 42 yrs old lady was undergoing laparoscopic myomectomy in a nursing home setup.All the complications associated with the myomectomy were taken care of till it was noticed that while repairing the uterine defect one blade of the needle holder broke and got lost in patients body.After futile efforts to trace is under direct vision the lost piece was finally recovered with the help of a magnetic piece laparoscopically

Material and Methods A small magnetic piece was bought.It was sterilized by keeping it in cidex solution.The piece was tested on the needle holder outside the patients body to see whether it was effective.It was held with a grasper and introduced inside patients body through the port used for morcellator.

Results: As soon as the magnetic piece held in a grasper was put inside the patients body the lost piece of the instrument came out of nowhere and got stuck to the magnetic piece.It was the removed under direct vision.

Discussion: This was an unexpected complication.It is difficult to manage such complications in a small nursing home set up where there are no facilities for C-arm,portable x-ray machine or the magnetic forceps.Quick thinking by the operating surgeon helped in managing the situation laparoscopically.

SACROCOLPOPEXY FOR VAGINAL VAULT PROLAPSE

Tips & Tricks in Surgery

Oral

Pantelis Trompoukis*, Evangelinakis Nikolaos, Grammatikakis Ioannis

University Hospital Attikon

Summary (4 lines): Vaginal vault prolapse can be a frustrating complication for patients and doctors. We present a case of laparoscopic sacrocolpopexy for vaginal vault prolapse after hysterectomy.

Introduction: Vaginal vault prolapse after total hysterectomy is often difficult to treat especially in premenopausal women.

Material and Methods Laparoscopically corrected vaginal vault using a polupropylene mesh sutured to vagina and positioned to sacral promontory. A tricky vaginal manipulator was used…

Results: The post operative results of laparoscopic sacrocolpopexy were uneventful.

Discussion: Vaginal vault prolapse can be a frustrating complication for patients and we need a standardized approach to laparoscopic sacrocolpopexy and we prefer to use the mesh sutured to vagina and anchored to sacral promontory with further burrial to right lateral peritoneum.

LAPAROSCOPIC MYOMECTOMY FOR MULTIPLE BIG FIBROIDS USING 10MM LAPAROSCOPIC SCREW

Innovation in Instrumentation and Surgical Techniques

Oral

Pantelis Trompoukis*, Evangleinakis Nikolaos, Angelopoulos Miltiadis

University Hospital Attikon

Summary (4 lines): Laparoscopic myomectomy for multiple fibroids can be a difficult and challenging operation, especially for big fibroids. we present the usefulness of 10mm screws according to our experience.

Introduction: Laparoscopic myomectomy is a quite common operation, but depending on size, shape and position of fibroids surgical dissection may be very challenging.

Material and Methods In addition to the common surgical instruments we use a 10mm laparoscopic screw for the extraction-manipulation of the fibroids from the uterus.

Results: With the use of a 10mm laparoscopic screw we gain important surgical time and we dissect effortless in contrary to classical instruments.

Discussion: A lot of instruments can be used for the surgical dissection of fibroids. We review the laparoscopic myomectomy together with the 10mm screw.

THE TRUE EFFECTIVENESS OF ENDOMETRIAL ABLATION: A RETROSPECTIVE COHORT STUDY AT THE GREAT WESTERN HOSPITAL

Hysterectomy

Poster

Karolina Mazan*

University of Bristol

Summary (4 lines): The study has shown high re-treatment rates after endometrial ablation performed for patients with menorrhagia. For higher success rates, ablation needs to be offered to a more specific patient population.

Introduction: The minimally invasive endometrial ablation (EA) has become a popular surgical alternative to hysterectomy for treatment of menorrhagia. It is associated with shorter hospital stay and fewer complications. Yet a large proportion of women eventually require further surgical treatment, such as hysterectomy, after the ablation. Here I report the rates of re-treatment following endometrial ablation in a large UK hospital and the correlation between the patient characteristics and the failure rate of the procedure.

Material and Methods All 322 patients who underwent endometrial ablation treatment in the hospital between 2005 and 2007 were eligible for the study. The primary outcome measured was any further surgical treatment related to menorrhagia. Clinical letters and surgery logs were studied, up to year 2013, to determine the primary outcome. Examination findings and any known pelvic pathologies at the time of the EA procedure were recorded to identify any specific characteristics leading to failure of the procedure.

Results: Out of 322 patients, 35% needed further surgical treatment (26% - hysterectomy). Comparing the successful ablation and re-treatment patient groups: young age (MD=1.31 years, 95%CI 0.09-2.53), presenting with both menorrhagia and dysmenorrhoea (MD=13%, 95%CI 3-23), and a large uterus with fibroids (MD=11%, 95%CI -0.5-22) were predictors of treatment failure.

Discussion: More than 1 in 3 women treated with ablation returned to the theatre with the same problem. EA needs to be offered to a more specific population of women (presenting solely with menorrhagia, with normal, small uterus) in order to achieve maximum success rate and avoid unnecessary procedures.

UTERINE MANIPULATOR WITH VAGINAL TRANSILLUMINATION OF FORNICES (SECUFIX ®) IMPROVES SURGICAL SAFETY DURING LAPAROSCOPIC HYSTERECTOMY

Innovation in Instrumentation and Surgical Techniques

Oral

Benedictus Schoot*, Hesther Vunderink , Ilham Atfane, van Vliet Huib,

Catharina Hospital

Summary (4 lines): During total laparoscopic hysterectomy, movement of the manipulator helps to find the vaginal fornices. The Secufix ® uterine manipulator can improve identification of the bladder and opening the posterior fornix.

Introduction: Opening of vaginal fornices can be a difficult step during total laparoscopic hysterectomy. Wrong identification of planes of anterior vaginal fornices can lead to bladder injury, whereas the posterior fornix at the backside of the uterus is often difficult to find. In currently used manipulators, movement of the uterine manipulators is used to indicate the precise spot to open the cuff. The Secufix ® manipulator can help to simplify and secure this procedure.

Material and Methods Women undergoing laparoscopic assisted hysterectomy, using the SecuFix® Uterus Manipulator, were included. Surgery was performed for benign uterine pathology. This novel device was evaluated as manipulator and as delineator of the vaginal fornices during surgery. Patient characteristics and results were collected during surgery and from the electronic medical patient files. Secufix® was used in combination with a separate lightsource.

Results: Patients (BMI above 32; intermittent bloodloss and large myoma). underwent laparoscopic hysterectomy using SecuFix® Uterine Manipulator. Application vacuum aspiration was as achieved. Tenaculum was used.

Discussion: This novel small light device appeared easy to manipulate. Opening the anterior and posterior fornix seems to be simplified, due of the extra visual characteristic of the manipulator. Preliminary evaluation of SecuFix® Uterus Manipulator revealed safe and good surgical results. In training hospitals it can be of value

A EUROPEAN SURVEY ON AWARENESS OF POST-SURGICAL ADHESIONS AMONG GYNAECOLOGICAL SURGEONS

Operative Risk Management

Oral

Markus Wallwiener*, Markus Wallwiener, Hans Brölmann, Philippe Robert Koninckx, Per Lundorff, Adrian Lower , Arnaud Wattiez, Michal Mara, De Wilde Rudy Leon

Dept. OB/GYN University Heidelberg

Summary (4 lines): European gynaecological surgeons are aware of the risk of post-surgical adhesions but substantial proportions of them have not yet adopted the solutions recommended to reduce this sequel of gynaecological surgery.

Introduction: Post-surgical adhesions are a frequent complication of gynaecological surgery and one of the main causes of secondary infertility. Post-surgical adhesions may also cause small bowel obstruction, chronic pain, and dyspareunia. Several measures are recommended to reduce post-surgical adhesions, including appropriate surgical techniques and the use of adhesion-reduction agents. The present survey was conducted among gynaecological surgeons from several European countries to assess the actual knowledge and practice related to post-surgical adhesions and their reduction.

Material and Methods From September 1, 2012 to February 6, 2013, gynaecological surgeons were invited to answer an 18-item online questionnaire accessible through the ESGE website. This questionnaire contained eight questions on care settings and surgical practice and ten questions on adhesion formation and adhesion reduction.

Results: 414 surgeons participated; 70,8% agreed that adhesions are a source of major morbidity. Fewer surgeons expected adhesion formation after laparoscopy (18.9%) than after laparotomy (40.8%); 60% knew the surgical techniques recommended to prevent adhesions; 44.3% used adhesion-reduction agents regularly.

Discussion: This survey gives a broad picture of adhesion awareness among European gynaecological surgeons, mainly from Germany, the UK, and Italy. The participants had a good knowledge of factors causing adhesions. Knowledge of surgical techniques recommended and use of anti-adhesion agents developed to reduce adhesions need to be improved.

TORSION OF A PARASITIC LEIOMYOMA AFTER LAPAROSCOPIC MYOMECTOMY: A CASE REPORT

Myomectomy

Video

Yu Kawasaki*, Kitade Mari, Kumakiri Jun, Takeda Satoru

Juntendo University Faculty of Medicine

Summary (4 lines): We demonstrated that a patient with acute abdominal pain because of torsion of a parasitic myoma after laparoscopic myomectomy (LM) was successfully managed using laparoscopic resection.

Introduction: LM has been widely performed to excise symptomatic uterine myomas in women desirous of fertility preservation. This procedure is popular because of a lower rate of postoperative pelvic adhesions compared with that in an open myomectomy. However, the potential risk of parasitic myoma due to incomplete removal of myoma fragments from morcellation has been reported. In this study, we demonstrate a rare case of torsion of a parasitic myoma originating from a previous LM.

Material and Methods A 29-year-old nulliparous woman underwent LM at our hospital. The patient revisited us because of severe lower abdominal pain 3 years after LM. On pelvic examination, a painful solid mass was observed in her abdomen. A magnetic resonance image showed a 6-cm solid mass in her pelvic cavity, which had low intensity on T1- and T2-weighted images. Laparoscopic surgery was performed to identify and resect the mass causing her symptoms.

Results: No abnormal findings were observed in her uterus or bilateral adnexa. However, a pedunculated tumor on the right infundibulopelvic ligament was twisted three times in a counterclockwise manner. The tumor was safely resected and histopathologically diagnosed as leiomyoma. The tumor was diagnosed a parasitic myoma originating from a previous LM.

Discussion: The results suggest that myoma fragments generated by morcellation during LM should be removed from the peritoneal cavity because parasitic myoma has potential risks for unexpected postoperative complications, and resection of the tumor may be occasionally difficult depending on the attachment site.

IMAGING TECHNIQUES VS HYSTEROSALPINGOGRAPHY IN ESSURE® DEVICE CONTROL

Diagnostic & Operative Office Hysteroscopy

Poster

Juan Antonio Solano Calvo*, del Valle Rubido Cristina, Delgado Espeja Juan José, González Hinojosa Jerónimo, Heras Sedano Irene, Marcos González Victoria, Zapico Goñi Alvaro

Hospital

Summary (4 lines): Our study demonstrates that imaging techniques are not enough to ensure that Essure® intratubal device is effective, even if it is correctly placed.

Introduction: Our objective is to establish a relation betwween the number of spirals left in the uterine cavity with the measurement of the intracavitary device by 3D sonography and the presence or absence of contrast in hysterosalpingography.

Material and Methods This is an observational prospective study of 77 patients that requested permanent contraception in gynecology clinic of Area 3 of Madrid community, Spain. The insertion of Essure® was done in an outpatient clinic with the technique described by Kerin et al. After the procedure patients were instrcted to use an alternative contraceptive method until confirmation of the device placement by vaginal sonography with GE Voluson 730 (Kretzchnik, GE Medical Systems, Zipf, Austria) and hysterosalpingography.

Results: We found 8 cases of tubal permeability in perfectly placed devices, measured by number of spirals left during insertion and 3D ultrasound control. A relation between the number of spirals and the intracavitary measurement with 3D sonography has been established, but not the criteria of selection of cases that require hysterosalpingography.

Discussion: The imaging techniques give us trustful information of the device placement but not of its effectiveness, which is given by hysterosalpingography.

LAPAROSCOPIC MANAGEMENT OF MASSIVE OVARIAN CYSTS

Innovation in Instrumentation and Surgical Techniques

Poster

Susannah Hogg*, Huppler Lucy, Vyas Sanjay

Southmead Hospital. Bristol

Summary (4 lines): A retrospective cohort study of nineteen women with massive ovarian cysts >10cms in Southmead Hospital UK, between 2009-2012, that demonstrates the benefits of a laparoscopic approach to removal.

Introduction: Ovarian cysts are a common finding in the gynaecology outpatient setting amongst women of all ages. The mainstay of surgical management for cysts less than 7cms has been with laparoscopy but cysts ≥ 10cms are more commonly managed through laparotomy. With the reduction in complication rates, reduced hospital stay and economic benefits of laparoscopy, combined with increasing laparoscopic training opportunities, we demonstrate that massive ovarian cysts can be safely managed by a laparoscopic procedure.

Material and Methods A retrospective cohort study of nineteen women with massive ovarian cysts >10cms on ultrasound who had elective laparoscopic ovarian cystectomy or salpingoophorectomy, +/- intra-operative ultrasound guided cyst aspiration, at a UK teaching hospital between April 2009 - December 2012. Inclusion criteria were simple cysts, absence of suspicious features on ultrasound and a low Risk of Malignancy Index (RMI) score. Women were not excluded for age or BMI. All procedures were performed by the same surgeon.

Results: Mean patient age was 29 years, two were antenatal, and body mass index 17-40. Cysts measured 11-36cms (80% unilateral) and drained 900-8000mls. Mean intraoperative blood loss 85mls. Mean anaesthetic time 74 minutes. 10% conversion to laparotomy, one major complication. 74% cases admitted less than 2 days. All benign histology.

Discussion: With adequate experience and training, we believe massive benign ovarian cysts > 10cms can be successfully managed by a laparoscopic approach. It is associated with a reduction in intra-operative and post-operative morbidity in addition to the economic benefits of reduced hospital stay and complication rates compared to laparotomy.

LAPAROSCOPIC TREATMENT OF OVARIAN TORSION IN ADOLESCENT PATIENTS: OUR EXPERIENCE AND REVIEW

Innovation in Instrumentation and Surgical Techniques

Poster

SERGIO SCHETTINI*, DI PIERRO GIUSEPPE, PISATURO MARIA LAURA, AMMATTATELLI OTTAVIO EUGENIO

AZIENDA OSPEDALIERA REGIONALE SAN CARLO POTENZA

Summary (4 lines): This retrospective study was to evaluate our experience and review of the literature in the treatment of ovarian torsion in adolescent patients

Introduction: To report our experience in the surgical treatment of ovarian torsion in adolescent patients and review of the literature. Represents 2-3% of cases of acute abdominal pain in adolescents and complication more frequent of an ovarian cyst; risk factors for torsion are the size and weight of the cyst, the length of its stalk and laxity of the ligaments ovary.

Material and Methods We have retrospectively evaluated 28 patients, age 8 to 18 years, treated surgically between 2000 and 2013. Out of these, 10 patients had a hemorrhagic corpus luteum, 7 showed a follicular cysts, 7 patients showed cystic teratomas and 4 patients normal ovaries. Most of these patients had clinical symptoms as the typical picture of acute abdomen.

Results: Conservative treatment was performed in 35% of cases (10 out of 28 patients) with cleansing and removal of ovarian cysts responsible for the twist. In 65% of the cases (18 out of 28 patients), due to necrosis of the annex, it was necessary to perform radical surgery with unilateral salpingo-oophorectomy.

Discussion: Literature and research has shown a 40% conservative intervention vs 60% intervention demolitive. From our study and review of literature we came to the conclusion that the treatment of ovarian torsion in adolescents should be more conservative as possible to preserve future fertility of the patient.

THE BEST HYSTERECTOMY FOR YOUR PATIENT – EVIDENCE AND COST-BASED

Hysterectomy

Oral

Bhaskar Goolab*

University of Witwatersrand

Summary (4 lines): “Vaginal Hysterectomy is the bedrock skill, and signature operation of the Gynaecological Profession” - Robert Kovac: Advances in Reconstructive Vaginal Surgery.

Introduction: ACOG Recommends Vaginal Hysterectomy as Approach of Choice (21/10/2009) In general, based on the medical evidence, vaginal hysterectomy is associated with better outcomes and fewer complications than either laparoscopic or abdominal hysterectomy. Statement on Robotic Surgery - ACOG President James T. Breeden (14/03/2013) Many women today are hearing about the claimed advantages of robotic surgery for hysterectomy, thanks to widespread marketing and advertising. THE OUTCOME OF ANY SURGERY IS DIRECTLY ASSOCIATED WITH THE SURGEON’S SKILLS

Material and Methods 1400 women underwent vaginal hysterectomy for benign pathology. Normal contra-indications of vaginal route: moderate - excessive uterine enlargement, nulliparity, previous caesarean section, minimal utero-vaginal descent. Mean age = 41.5 yrs Mean parity =3.2 Nulliparty = 68 (5%) Multiparity = 1332 (95%) Previous abdominal surgery = 240 (16.5%) Minimal uterine descent = 1308 (90%) Previous caesarean section: 208 (14.8%) Caesarean section x1 = 122(60.2%) Caesarean section x2 = 54 (25%) Caesarean section x3 = 32 (14.8%)

Results: Total cases = 1400 Abdominal Hysterectomy = 250 Conversion to TAH = 33 (2.4%) Successful vaginal hysterectomy = 1117 (79.8%) Duration of surgery (mean) = 95 min Duration of stay in hospital (mean) = 2.8 days Mean weight of uterus = 120 gm Ave. weight of patient = 77 kg

Discussion: Vaginal hysterectomy can be performed successfully in women with relative contra-indications and with enlarged uteri. It is significantly cheaper than total laparoscopic hysterectomy, with minimal complications. Hence, vaginal hysterectomy should be the choice operative procedure.

QUALITY OF LIFE AT FOLLOWING EXCISION OF RECTOVAGINAL ENDOMETRIOSIS – A PROSPECTIVE COHORT STUDY

Endometriosis: Surgery

Oral

Haider Jan*, Kent Andrew, Pearson Carol, Haines Pat , Rockall Tim

Royal Surrey County Hospital NHS Foundation Trust

Summary (4 lines): We report prospective outcomes following excision of rectovaginal endometriosis after 1 year follow up demonstrating significant improvements in quality of life using validated QoL questionnaires.

Introduction: Radical surgery has been advocated for deep infiltrating rectovaginal endometriosis but the literature shows variable surgical outcomes with minimal prospective or longer-term quality of life data. Our unit manages this disease with a staged approach. Initial laparoscopy is followed by 6 months of GnRH analogues after which definitive surgery takes place. This second surgery is a combined procedure by a single senior laparoscopic gynaecological surgeon and a senior laparoscopic colorectal surgeon.

Material and Methods All patients undergoing bowel surgery had questionnaires pre operatively and at 2 months, 6 months and 12 months post operatively. All data was collected prospectively using validated questionnaires; Gastrointestinal Quality of Life Index (GIQLI), EHP 30 and EQ-5D. Additional data was collected via visual analogue scales and some nominal questions. The data was analysed with SPSS. Following a Shapiro Wilk test of normality, Friedman, Mann Whitney-U, Kruskal Wallis and Chi squared tests were done.

Results: 83 cases had 1 year follow up. All quality of life metrics in EHP 30 and GIQLI and EQ-5D and visual analogue scales show significant improvements at p %.

Discussion: Severe rectovaginal endometriosis can be treated surgically as a combined procedure with expert gynaecological and colorectal input largely resulting in significant improvement in pain, sexual function and quality of life 1-year post operatively regardless of the kind of bowel surgery performed. Pelvic clearance significantly improves pain scores over conservative surgery.

SINGLE INCISION LAPAROSCOPIC HYSTERECTOMY: A SIMPLE TECHNIQUE FOR THE MASSES??

Single Access Surgery

Video

Haider Jan*, Shakir Fevzi, Kent Andrew

Royal Surrey County Hospital NHS Foundation Trust

Summary (4 lines): We demonstrate a step-by-step reproducible technique for single incision laparoscopic hysterectomy using standard straight stick laparoscopic instruments.

Introduction: Single incision laparoscopic surgery has many potential benefits including lower blood loss, shorter time to flatus, shorter hospital stay and a potentially smaller incision with better cosmesis. We demonstrate a simple reproducible technique to allow others to practice single incision laparoscopic hysterectomy.

Material and Methods A 15-20mm incision is made at the base of the umbilicus. An Olympus Triport+ is inserted. The operation requires ACE+/bipolar or Thunderbeat, an atraumatic grasper and a 5mm 30 degree laparoscope with a right-angled light connector. The key is that after division of the adnexa, the surgeon holds the Valtchev uterine manipulator in one hand and the energy device in the other to complete the intrafascial dissection. A vaginal colporraphy with vaginal suturing is performed.

Results: This technique demonstrates an effective and reproducible method of single incision laparoscopic hysterectomy.

Discussion: Use of standard laparoscopic instruments apart from the Triport ensures this technique could gain widespread adoption. Combination with vaginal colporraphy and suturing means it is easy to perform, teach and learn. As part of an Enhanced Recovery Pathway (ERP), it provides simple, low pain, short-stay, and almost “scarless” hysterectomy technique.

DIFFERENCES IN GYNECOLOGIC SURGICAL ACTIVITY BETWEEN CLINICS WITH WND WITHOUT ENDOSCOPIC EQUIPMENT

Innovation in Instrumentation and Surgical Techniques

Poster

Islam Magalov*, Omarov Nabi, Israfilbeyli Solmaz, Ebert Andreas

Azerbaijan Medical University

Summary (4 lines): Surgical activity of gynecologic departments with and without endoscopic equipment was compared. It was revealed that surgical activity in former was concentrated on less complicated operations in the beginning and middle phase.

Introduction: Endoscopic interventions take progressively the leading place in gynecology. Nevertheless, on the way of implentation of modern technologies surgival activity may concentrate on less complicated operations.

Material and Methods Surgical activity of gynecologic departments with (1) and without(2) endoscopic equipment located in Baku, Azerbaijan was compared relying on the records taken from operations’ register 2006-2007: 1547 (1) vs 1249 operations.

Results: The most frequent operation in the first group was intervention on ovaries (21,46%) whereas hysterectomy was on the first place in the second group (32,59%). Apparent difference was observed between the ratio of diagnostic surgery for reproductive desire and myomectomies ratios: 17,97% and 9,63% vs 2,32% and 5, 44%, correspondingly.

Discussion: Less complicated operations are characteristic of the beginning and middle phase of implementation of endoscopic technologies in gynecologic departments.

AN UNUSUAL COMPLICATION OF THE MCCARTNEY TUBE AT TOTAL LAPAROSCOPIC HYSTERECTOMY

Complications

Poster

Maryam Modarres*, Sana Yasmin, Markopoulos Marios, Lee Chris

SouthLondon Healthcare Trust

Summary (4 lines): This case report describes an unusual complication of the McCartney tube during a total laparoscopic hysterectomy with bilateral salpingo-oophorectomy.

Introduction: The McCartney tube is widely used in total laparoscopic hysterectomies. It confers benefits including exposure of the cervico-vaginal junction and stretching of the vaginal fornices away from the ureters. It also functions as a conduit for exteriorizing tissue during laparoscopic pelvic surgery, and allows the maintenance of pneumoperitoneum following colpotomy. Minimal complications have been reported, the only significant one reported being that of vault haematoma

Material and Methods We performed a total laparoscopic hysterectomy on a 60 year old lady in view of a suspicious uterine polyp that could not be removed hysteroscopically, because of cervical stenosis. A McCartney tube was utilised during this procedure. As pressure was applied to the McCartney tube by the assistant to further expose the cervico-vaginal junction, the McCartney tube perforated through the right vaginal fornix into the pelvic sidewall.

Results: Right ureterolysis was performed to confirm there had been no ureteric injury, and haemostasis was secured. The hysterectomy was completed and specimens were removed through the McCartney tube. The vaginal vault was closed laparoscopically using absorbable monofilament sutures and a modified McCall Culdoplasty was used to support the vaginal vault.

Discussion: Whilst the McCartney tube is a safe, reliable instrument to use in performing laparoscopic hysterectomies, surgeons need to be aware of the potential risk in patients with atrophic tissue where there is a chance of inadvertent vaginal injury with potential damage to the ureters or vessels within the pelvic sidewall.

OUR WAY OF TRANSITION TO TOTAL LAPAROSCOPIC HYSTERECTOMY

Hysterectomy

Poster

Islam Magalov*, Omarov Nabi, Ebert Andreas

Azerbaijan Medical University

Summary (4 lines): Mode, route and number of hysterectomies performed by the same team from 2006 till present were analyized. It is possible within relatively short period of time to shift for TLH through LAVH/VALH regardless of difficulty of each individual case.

Introduction: Total laparoscopic hysterectomy is accepted to be one of the most advanced interventions in benign gynecologic surgery. Certain learning curve is required to master the technique of this operation.

Material and Methods Mode, route and number of hysterectomies performed by the same team from 2006 till present were analyized: TVH, LAVH/VALH, TLH, LASH, TAH/STAH.

Results: The use of LAVH/VALH techniques allowed to reach the following statistics within the last year of the given period of time: TLH -41,9%, LASH-33,8%, LAVH/VALH - 2,7%, TVH - 8,1%, and TAH/STAH -13,5%.

Discussion: Our experience shows that it is possible within relatively short period of time to shift for TLH through LAVH/VALH regardless of difficulty of each individual case.

FLORID CYSTIC ENDOSALPINGIOSIS AT LAPAROSCOPY : A DIAGNOSTIC CHALLENGE

Case reports

Poster

Neeraja Kuruba*, Palihawadana Thilina, Sule Medha, Raje Gautam

Norfolk and Norwich University Hospital

Summary (4 lines): Endosalpingiosis can be diagnostically challenging. Awareness of the condition and familiarity with surgical findings are necessary to avoid a misdiagnosis of malignancy.

Introduction: Endosalpingiosis is the presence of ectopic tubal-type ciliated glandular epithelium which resembles the normal endosalpinx. It is usually multicentric and can involve the peritoneum as well as other pelvic structures, including the ovarian surface and paratubal tissue, as well as pelvic and para-aortic lymph nodes. The etiology of endosalpingiosis is still debated. The most widely accepted theory is that of celomic metaplasia. Clinicians must be aware of this benignmanifestation so as to refrain from overtreatment

Material and Methods 42 yr old woman presented with a history of menorrhagia not resolved with Mirena or endometrial ablation. Pelvic ultrasound scan demonstrated a normal pelvic anatomy and the endometrial biopsy was normal. She was offered a laparoscopic assisted vaginal hysterectomy with conservation of ovaries for dysfunctional uterine bleeding

Results: At laparoscopy, widespread yellow white multicustic lesions of less than 1cm involving pelvic peritoneum were noted. The histology of these lesions revealed florid endosalpingiosis. This seemed to be an incidental finding rather than the cause of her symptoms. She had an unremarkable recovery.

Discussion: The relevance of endosalpingiosis as a cause of chronic pelvic pain is controversial. Endosalpingiosis is not a variant of endometriosis and differs histologically as it has ciliated glandular epithelium, no endometrial stroma and no inflammatory response and unlike malignancy is mitotically inactive. Paired box-8(PAX8) is helpful to confirm Mullerian origin.

THE IMPACT OF ENDOMETRIOSIS ON OOCYTES AND EMBRYOS IN IVF CYCLES

Endometriosis: Surgery

Oral

Andrej Vogler*, Merlo Sebastjan, Virant-Klun Irma

University Medical Centre Ljubljana

Summary (4 lines): Hypothesis that oocyte and embryo quality may be altered in patients with endometriosis, who underwent IVF programme, was not confirmed by our work.

Introduction: Most women with endometriosis present with chronic pelvic pain, dysmenorrhoea and infertility. In infertile patients with endometriosis treatment options are laparoscopic surgery and assisted reproduction. Impact of endometriosis on in vitro fertilisation (IVF) remains still controversial and is a matter of debate. The present study was designed to try to clarify if endometriosis whether or not affects oocytes and embryos in IVF procedures.

Material and Methods In 202 patients who underwent IVF program the only cause of infertility was endometriosis which had been previously laparoscopically treated. Minimal or mild disease was diagnosed in 138 patients whereas 64 had moderate or severe stage of endometriosis. The control group represented 305 patients with tubo-peritoneal infertility. IVF cycle outcome parameters were compared between the study and control group of patients as well as between both groups with endometriosis.

Results: In none of the compared parameters statistically significance was observed. Birth rate per embryo transfer was similar in all groups of patients: the lowest rate (40.0 %) was in the control group of patients, whereas the highest was in the group with moderate or severe endometriosis (42.6 %).

Discussion: According to our work, endometriosis does not impair oocyte and embryo quality and has no negative influence on IVF outcome. Live birth rate per ET is even slightly higher in the study group, yet statistically not significant, than in patients with tubo-peritoneal cause of infertility.

ENDOSCOPIC TEACHING DURING RESIDENCY – RESULTS OF A SURVEY AMONG GERMAN RESIDENTS

Teaching & Training

Poster

Lena Luisa Gabriel*, Schimmelpfennig Lisa, Winkelmann Hannah, Solomayer Erich-Franz, Juhasz-Böss Ingolf

Universitätsfrauenklinik des Saarlandes

Summary (4 lines): First results of a Germany-wide survey to the importance of and the expectations on endoscopic teaching during their residency of german residents.

Introduction: The role of endoscopic teaching becomes more and more important when it comes to adequate medical education and qualification. At this point not much is known about the wishes and expectations of young german residents concerning their endoscopic training during their residency. For this reason we contacted residents country-wide to ask for their personal level of endoscopic training as well as their personal opinion which aspects endoscopic teaching ideally should involve.

Material and Methods As methods we used standarised surveys, which anonymously assessed the following information: personal consideration of the importance of teaching endoscopy, willingness to participate in training courses, financial aspects, expectations on teachers and hospitals, self-assessment of the required number of operations as operating assistant as well as operating surgeon to optimize endoscopic training.

Results: First results will be presented on the ESGE-meeting in October 2013

Discussion: Considering the increasing role of endoscopic surgery standarised education and training becomes more and more essential. To improve endoscopic teaching it is inevitable to know about the expectations of the residents. For the first time we will present Germany-wide data concerning these aspects

DEVELOPMENT OF AN ADHESION RISK SCORE IN GYNAECOLOGICAL SURGERY

Operative Risk Management

Oral

Per Lundorff*

Private Hospital Molholm

Summary (4 lines): An Adhesion Risk Score is being developed to help gynaecological surgeons quantify the risk of post-surgical adhesions in individual patients.

Introduction: Risk factors for post-surgical adhesions following gynaecological surgery have been identified, but their relative importance has not been precisely determined. No practical tool exists to help gynaecological surgeons quantify the risk of adhesions in individual patients.

Material and Methods An extensive review of the literature was done by a group of European gynaecological surgeons (ANGEL group) to identify the risk factors and the surgical operations reported as carrying a risk of post-surgical adhesions. A 4-point scale was then used by each expert to attribute a specific weight to each of these items. Agreement between experts was reached by consensus during conferences and face-to-face meetings.

Results: A first version of the Adhesion Risk Score is presented .

Discussion: This is the first example of an Adhesion Risk Score intended for gynaecological surgeons. Assessment of its predictive value in a large cohort of women is warranted.

CESA AND VASA – A NEW SURGICAL METHOD FOR THE TREATMENT OF FEMALE GENITAL PROLAPSE

Urogynaecology

Poster

Sebastian Ludwig*, Mohamed Abudabbous

Universitätsfrauenklinik Köln

Summary (4 lines): By cesa and vasa the uterosacralligaments (USL) are replaced by PVDF tapes. This standardized procedure effectively restores uterine and vaginal prolapse. After repair of the anatomy also incontinence was improved

Introduction: Prolapse of the uterus or vaginal vault is caused by a dysfunction of the USL. We therefore developed a surgical method to replace the USL in a standardized manner. We present the results of 25 patients with uterine and 13 patients with vaginal vault prolapse after cesa or vasa respectively

Material and Methods Patients were categorized according to the POP-Quantification Scoring System as proposed by the ICS. Only patients with stage 2, 3 and 4 prolapse were evaluated. Measurements were performed before, during and 16 weeks after cesa and vasa. Clinical symptoms such as urgency and stress incontinence were defined according to ICS criteria. During cesa and vasa operations the USL were replaced by PVDF tapes as described previously (www.cesa-vasa.com)

Results: All 38 patients demonstrated a normal anatomical position (stage 0) of cervix or vaginal vault 16 weeks after surgery. 12 out of 14 patients with a cystocele did not need any further colporrhaphy after the operation. Out of the group of 22 patients with postvoid residuals 20 (91%) were cured

Discussion: Cesa and vasa is a standardized surgery which restores the pelvic anatomy. It also was effective for the treatment of cystocele. Beside the restoration of postvoid residuals positive effects on stress and urgency incontinence were observed in a considerable number of patients

LAPAROSCOPIC MYOMECTOMY – ABOUT UTERINE CAVITY DISRUPTION

Myomectomy

Poster

Inês Martins*, Mendes Sofia, Barata Sónia, Osório Filipa, Alho Conceição, Calhaz-Jorge Carlos

Departamento/Clínica Universitária de Obstetrícia e Ginecologia, CHLN-Hospital Universitário de Santa Maria, Faculdade de Medicina da Universidade de Lisboa, CAM-Centro Académico de Medicina de Lisboa

Summary (4 lines): Uterine cavity disruption during laparoscopic myomectomy is unusual, relates with myoma location and not its weight and does not imply increased blood loss.

Introduction: Uterine myomas are the most common benign tumors of the female genital tract. Myomectomy is a recognized surgical treatment, avoiding hysterectomy and preserving fertility. Laparoscopic surgery has known medical advantages. However, myoma size and location limit the use of this approach, taken in consideration the risks of bleeding and inadequate closure of the uterine wall. Our objective was to explore the relationship between endometrial disruption during surgery, myoma characteristics and blood loss.

Material and Methods A retrospective review of the 73 laparoscopic myomectomies performed at our Unit, from January 2009 to July 2013. Data concerning demographics, symptoms, myoma number/location/weight, endometrial exposure, hemoglobin loss and complications were collected. Population was stratified by entrance (group A, n=7) or not (group B, n=63) in the uterine cavity. Mann-Whitney test was used to compare myoma weight. Fisher exact test was used to compare myoma location and blood loss.

Results: Mean patient age 33±5 years; 41% with multiples myomas. In group A, 57% of myomas were transmural vs 12% in group B. There was no difference between groups concerning myoma weight (A/B: 261 vs 155g, p=0.386) or hemoglobin loss (A/B group: 1 vs 2g, p=0.058). No major complications were registered.

Discussion: Frequency of entrance in uterine cavity during laparoscopic myomectomy is low and not related to myoma weight. Occasional disruption seems to relate to myoma location within the uterine wall. Blood loss was not increased in cases of opening of the cavity. Laparoscopic myomectomy appears safe even when implies endometrial disruption.

SURGICAL REPLACEMENT OF THE UTEROSACRAL LIGAMENTS SUCCESSFULLY TREATS URGE URINARY INCONTINENCE – 2 CASE REPORTS

Case reports

Poster

Burghard Abendstein*, Schwamberger Andrea

LKH Hall in Tirol

Summary (4 lines): We demonstrate the successful treatment of two cases of otherwise incurable urge and urge urinary incontinence by replacing the uterosacral ligaments with an alloplastic tape.

Introduction: The etiology of urge urinary incontinence is unknown. Petros in the so called Integral Theory postulated that incompetent pelvic ligaments may play a role for he development of urge and urge urinary incontinence. In 2012 Jäger reportet a 77% cure rate for urge urinary incontinence after replacement of the uterosacral ligaments by an alloplastic tape. We want to demonstrate the effectiveness of this method in 2 similar cases of pure urge urinary incontinence.

Material and Methods 2 Patients: age 65 (66) years, para 0 (1), hysterectomy 1990 (1987), history of urge and urge urinary incontinence since 14 (12) years. Anatomy: minimal enterocele (entero-rectocele) Urodynamic studies (both): overactive bladder, urethra closing pressure normal. Treatment: reconstruction of the uterosacral ligaments using an alloplastic tape by laparotomy.

Results: Both patients reported immediate cure of urge and urge urinary incontinence after removal of the catheder and remained cured until today (62 days case 1 and 38 days case 2)

Discussion: Pelvic ligament defects have theoretically been viewed as a possible cause of urge and urge urinary incontinence. Although the anatomic defect was not pronounced in both cases uterosacral ligament reconstruction by an alloplastic tape was successful. We think that this method could be an effective treatment for otherwise incurable urge.

SONOHYSTEROGRAPHY AND OFFICE HYSTEROSCOPY IN PREMENOPAUSAL WOMEN-MINIMALLY INVASIVE APPROACH

Diagnostic & Operative Office Hysteroscopy

Poster

Robert Bartkowiak*, Luterek Katarzyna, Iwona Szymusik, Miroslaw Wielgos

Warsaw Medical University

Summary (4 lines): SHG and office hysteroscopy were performed in 90 premenopausal women. In 30 (33%) of them no uterine pathology was detected. It restrained us from doing office hysteroscopy.

Introduction: Although SHG does not allowe for direct observation of uterine cavity, it has ability to detect focal cavity lesions reaching sensitivity of the golden standard of hysteroscopy. When SHG does not reveal any cavity lesions we can avoid hysteroscopy lowering the risk of cervical canal injury especially in infertility patients.

Material and Methods 90 premenopausal women after conventional TV ultrasonography were estimated. SHG with saline infusion was performed using no baloon Goldstein SHG catheter. Hysteroscopy was performed using 5 mm Bettocchi hysteroscope in office manner. Indications: focal cavity anomalies and infertility.

Results: In 30 patients (33%) no uterine cavity pathology was detected. They did not go for hysteroscopy. Polyps were detected in 42%, myomas in 11%, adhesions in 4%, uterine malformations in 4%, retained products of conception in 4% of patients. SHG was compatible with hysteroscopy in 87% of cases.

Discussion: Introduction of rigid instrument into cervical canal may cause injury even in office manner. This is of importance in infertility patients. SHG by destending of uterine walls can reveal no cavity lesions in many patients beeing done in experienced hands. This contributes to extremely low invasiveness.

LEARNING CURVE FOR HYSTERECTOMY IN A HIGH-VOLUME-HOSPITAL AFTER IMPLEMENTATION OF ENDOSCOPIC PROCEDURE

Hysterectomy

Oral

Russalina Mavrova*, David Bardens, Julia Radosa, Klaus Neis, Erich-Franz Solomayer, Ingolf Juhasz-Böss

University of Saarland

Summary (4 lines): Operating time for laparoscopic hysterectomy decreased significantly over time with increasing total number of cases after implementation of endoscopic procedure overnight.

Introduction: The role of laparoscopic surgery in the gynecology is rising. The aim of the presented study was to characterize the learning curve for laparoscopic hysterectomy including total hysterectomy and supracervical hysterectomy and to identify factors that influence this learning curve. An interesting fact is that the operating technique for hysterectomy was completely changed from non-laparoscopic to laparoscopic procedure overnight in our high-volume-hospital in October 2009.

Material and Methods We retrospectivly analyzed the medical records of 200 women who underwent either total laparoscopic hysterectomy (TLH) or laparoscopic supracervical hysterectomy (LASH) at the Department of Gynecology and Obstetrics at the University Hospital Homburg/Saar. We compared patient characteristics, intraoperative findings and the operating time. The duration of the operations was evaluated among 3 time periods over 6 months: group A = 10/2009-03/2010, group B = 04/2010-10/2010 and group C 11/2010-04/2011.

Results: 108 patients received a TLH and 92 patients underwent a LASH. The duration of the operations was as follows: in group A 161±68min; in group B 132±54min and in group C 122±44min. The time reduction between the groups was significant (p

Discussion: There was a significant reduction in operating time between the different surgeons as well as between the different methods. Significant factors for decreasing operating time were the experience of the surgeon, the experience of the assistant, the experience of the surgical nurse and the BMI of the patient.

URINARY COMPLICATIONS AND FUNCTIONAL DISORDERS AFTER TOTAL LAPAROSCOPIC RADICAL HYSTERECTOMY (TLRH): OUR EXPERIENCE

Complications

Oral

Ines Kristofic*, Haller Herman, Mamula Ozren, Klaric Marko, Vejnovic Danilo, Milanovic Maja

University Hospital Rijeka

Summary (4 lines): The objective of this retrospective study was to evaluate incidence of urinary complications and functional bladder disorders after total laparoscopic radical hysterectomy (TLRH) for cervical cancer in Rijeka, Croatia.

Introduction: Clinical hospital center Rijeka started with total laparoscopic radical hysterectomy (TLRH) for early stage cervical cancer (FIGO IB1) in 2010. Functional disorders of the lower urinary tract are the most common long-term complications following radical surgery for cancer of the uterine cervix. These disorders are associated to the interruption of the autonomic fibers innervating the bladder during the resection of of anterior, lateral and posterior parametrium and vaginal cuff.

Material and Methods The aim of this study was to retrospectively analyze all women operated by TLRH for early stage cervical cancer in our hospital. Total of 16 patients underwent laparoscopic radical hysterectomy from 2010 till June 2013 and all were included in this retrospective study. There were no conversions from laparoscopy to laparotomy.

Results: In our analysed group one (6.2%) intraoperative ureteral lesion and one (6.2%) cystotomy was encountered. Both were repaired laparoscopically. There were no postoperative fistula. Foley catheter was administered in all cases, and removed on 7.2±0.7postoperative days. After removal of Foley catether urinary retention was complained by 3 (18.7%) patients.

Discussion: In our experience a total laparoscopic radical hysterectomy (TLRH) has proved to be a safe and efficient approach in treating women with early stage cervical cancer with acceptable intraoperative and postoperative urinary complications. Additional attention and training is needed to reduce the urinary tract complications during laparoscopic radical hysterectomy .

A CASE SERIES OF LAPAROSCOPIC MANAGEMENT OF ACUTE LIFE-THREATENING INTRA-ABDOMINAL EMERGENCIES IN GYNAECOLOGY

Case reports

Poster

Carlotta Modestini*, Narvekar Nitish

Kings College Hospital

Summary (4 lines): A case series of 8 life-threatening intra-abdominal emergencies in gynaecology managed laparoscopically. Our cohort shows that laparoscopy may be the preferred method of dealing with such emergencies, avoiding unnecessary laparotomy.

Introduction: Intra-abdominal emergencies in gynaecology have traditionally been dealt with by laparotomy, because of the presumed quicker access and therefore safety. We present a case series of 8 women who presented to a tertiary hospital with intra-abdominal emergencies in gynaecology between February 2011 and July 2013 and were operated on by an experienced laparoscopic surgeon.

Material and Methods Open Hassan entry was used for pneumoperitoneum. Three patients with PID peritonitis were managed by adhesiolysis, meticulous lavage of purulent material and multiple post-operative drains. 5 patient with massive (> 2 Litre) intra-abdominal bleed (2 ruptured ectopic pregnancy, 1 vaginal hysterectomy uterine artery bleed, 1 laparoscopic myomectomy suture line bleed, 1 TOP uterine perforation) were managed by salpingectomy, pelvic side-wall uterine artery ligation and re-suturing as appropriate to the case.

Results: Seven cases (88%) were managed laparoscopically whereas 1 case with TOP uterine perforation was converted to midline laparotomy to manage intractable side-wall bleeding. The mean (sd) operating time was 110 (42) minutes. One woman underwent laparotomy hysterectomy and bilateral salpingo-oophorectomy for recurrent PID.

Discussion: Laparoscopy is safe, feasible and effective for the management of a range of acute life-threatening intra-abdominal emergencies in gynaecology, when performed by a skilled and experienced surgeon. Further evaluation is needed including comparison of outcomes with those managed by traditional laparotomy.

PALMER POINT ENTRY LAPAROSCOPIC MYOMECTOMY USING V-LOCK SUTURING

Tips & Tricks in Surgery

Video

Faruk Vanlioglu*

Camlica Medicana Hospital

Summary (4 lines): This patient is 35 year-ago and she has previous surgery two times due to ovarian cystectomy and sezarian sectio.She has 45*45mm intramural subserozal myoma and we prefer palmer point entry and laparoscopic myomectomy using v-lock suturing.

Introduction: This video has shown palmer point entry rules and laparoscopic myomectomy using v-lock suturing

Material and Methods palmer point entry and laparoscopic myomectomy using v-lock suturing

Results: Using palmer point entry especialy who has previous surgery and v-lock suturing in laparoscopic myomectomy is safe and faster surgery.

Discussion: This video has shown Laparoscopic palmer point entry rules and how to use laparoscopic myomectomy using v-lock suturing

UTERINE MANIPULATION MAKES THE DIFFICULT TOTAL LAPAROSCOPIC HYSTERECTOMY SAFE AND EASY

Hysterectomy

Oral

Prashant Mangeshikar*

Mangeshikar M.A.G.I.C. for Woman

Summary (4 lines): Ergonomics and Strategies are important to render laparoscopic surgery safe and effective. The aim in minimal access surgery is to render optimal exposure with minimal access for effective tissue dissection.

Introduction: Total Laparoscopic Hysterectomy (TLH) has now been accepted as an effective replacement of the abdominal hysterectomy with the development of better optics, camera systems and newer instrumentation. The manipulation of the uterus has been effective in providing optimal exposure within the pelvis. For rendering the difficult TLH safe and easy, I developed over a decade, the concept of uterine manipulation with the invention of the Mangeshikar Uterine Mobilisar in collaboration with Karl Storz GmBH, Germany.

Material and Methods The Mangeshikar Uterine Mobilisar (MUM) is a reusable, take-apart, lightweight steel uterine manipulator with an insert with an inbuilt tenaculum to hold the cervix and anchors intrauterine elements of varied lengths to adapt to the size of the uteri. The reusable vaginal presenting cup of varied sizes allowing circumcision of the vagina after displaying the bladder, rectum, ureters outside the ceramic rim. The cup facilitaes bladder dissection, maintains pneumoperitoneum during the rest of the TLH.

Results: The MUM allows uterine manipulation anteroposteriorly, laterally, cephalad and around the axis of the uterus. Can be used in all uteri small or large for TLH and Subtotal as well as in malignancy of the cervix or body of the uterus.

Discussion: It is truly as described by Mettler “The THIRD Hand in the Pelvis” as it provides Optimal Visualisation, Exposure and Access to the Uterus in difficult situations esp. previous surgery, Large Uteri, and in Endometriosis.

OPERATIVE MANAGEMENT OF PREMENOPAUSAL OVARIAN CYSTS

Imaging

Poster

Shmaila Siddiki*

Ninewells Hospital/ Dundee

Summary (4 lines): To investigate the assessment of premenopausal ovarian cysts requiring surgery and the operations performed.

Introduction: This is a retrospective study. All patients below the age of 57 operated upon for ovarian cysts between September 2011 and September 2012 were identified. Postmenopausal cases and incidental finding of cysts intraoperatively were excluded. The case notes of the remaining cases were assessed.

Material and Methods 39 patients were identified.13 cases had abdominal scans, 11 vaginal, 7 had both modalities. 2 cases had CT scans only and 11 had CT and ultrasound while 2 cases had MRI.26 laparoscopies were done and 14 laparotomies.Six of the laparotomies were performed for large cysts (>10cms) and 3 for suspected malignancy.

Results: 36 cases were benign, 1 malignant and 2 borderline tumours. The malignancy was a mucinous cyst adenocarcinoma which was unsuspected and had a risk of malignancy index of 75.

Discussion: Ultrasound assessment remains the cornerstone for the management of premenopausal cysts. The six cases with high risk findings on scan included the two cases of borderline tumours. Doppler studies however, have not been used consistently. Premenopausal cysts are less likely to be discussed in MDT meetings.

ROBOT-ASSISTED SURGERY: RETROSPECTIVE ANALYSIS OF CLINICAL AND ONCOLOGICAL PARAMETERS AND PERIOPERATIVE OUTCOMES OF 75 CASES

Robotics

Poster

Alexander di Liberto*, Michael Ulbricht, Kubilay Ertan

Klinik für Gyn u. Geb., Klinikum Leverkusen

Summary (4 lines): The daVinci™ surgical system (dV) is a widespread and reliable tool in performing advanced minimal invasive surgery and has some advantages over traditional laparoscopy (LSC). In malignant diseases especially endometrial (EmCa) and cervical cancer (CxCa) requiring radical hysterectomy and LND seems to be ideal for robot-assisted surgery.

Introduction: Because LSC in oncologic surgery keeps exhaustive and requires a high expertise minimal invasive surgery treatment is not standard in Germany. Robotic surgery is performed in the reporting institution with the 4 arms dV standard system. Especially pts with early stage EmCa and CxCa has been selected for robotic surgery. The main objective was to avoid laparotomy and to diminish peri- and postoperative morbidity, but to retain oncologic safety at the same time.

Material and Methods Robotic surgery has been performed between 2008 and 2013; mean age of the pts was 59,4 years; 39 pts with EmCa, 27 pts with CxCa were applied for robotic surgery; 9 pts with other gynaecological malignancies. Type of hysterectomy as well as pelvic or pelvic and paraaortic LND have been done according to the guidelines of cancer treatment. In 60 cases a radical hysterectomy was perfomed, in 51 of those pelvic/paraaortic LND.

Results: All specimen had tumour free margins. Mean number of lymph nodes for pelvic lymph nodes was 27, for paraaortic lymph nodes 8. No conversion to laparotomy took place. Major complication rate was 8%. No local recurrence in pts with EmCa or CxCa occurred in the follow-up (2-60 months).

Discussion: dV technique is suitable in gynaeco-oncology, particularly in pts with early stage EmCa/CxCa. The perioperative outcome is favourable. The proportion of abdominal procedures in EmCa and CxCa decreased significantly. The principles of oncologic surgery are achievable. 3D sight and enormous versatility of robotic instruments offer decisive advantages compared to LSC.

EFFICACY AND SAFETY OF ROBOTIC MYOMECTOMY: A RETROSPECTIVE STUDY OF 100 CASES

Robotics

Selected abstract Oral

Vasiliki Chatzirafail*, MITSIS THEODOROS, TSERKEZOGLOU ALIKI, BAKAS ARISTIDIS, KALOGEROPOULOU SOFIA, KOLESKAS DIMITRIS

Euroclinic hospital of Athens

Summary (4 lines): We performed robotic myomectomy in 100 cases between 2007-2012. Our results show the technique's safety and efficacy. It allows more complicated cases to be dealt with through minimally invasive techniques.

Introduction: Robotic myomectomy is a minimally invasive surgical method, alternative to conventional laparoscopy. Even though it has been available for some years already, it has not been applied broadly, partially because there is not enough evidence to support its cost effectiveness and other advantages over conventional laparoscopy. However, using the robotic system makes the learning curve much quicker, the suturing technique easier to apply, and the surgeon able to operate in a much more comfortable position.

Material and Methods A retrospective study of 100 cases which underwent robotic myomectomy in private hospitals in Athens, Greece. The principal Gynaecologist – Surgeon was the same in all cases. The Da Vinci standard, - S and - Si were the robotic systems used. Patients’ characteristics(BMI:27,3 mean age 40,1 y.o), myomas’ characteristics (No 229 in total, largest per case mean7,6) , procedure, indication (pain, bleeding, fertility), complications (intra and post-operative), and hospitalization duration were all recorded.

Results: Robotic myomectomy is safe (minimum intra and post-operative complications) and effective,with an impressing learning curve. It facilitates difficult cases because of the great improvement in the ability to see and remove the fibroids, without damage of endometrium, vessels, or ureter. It permits an easier 3 layer suturing, preserving fertility.

Discussion: A potential drawback of the robotic myomectomy is the bigger sized “holes”, and the damage on patient's skin compared to conventional laparoscopy. Finally, further research is needed to explore whether it is cost effective.

OVARIAN LEIOMYOMA: A CASE REPORT

Case reports

Poster

Sofia Mendes*, Martins Inês, Barata Sónia, Alho Conceição, Osório Filipa, Abesassis Manuel, Calhaz-Jorge Carlos

Centro Hospitalar de Lisboa Norte

Summary (4 lines): Ovarian leiomyoma is a rare entity and its clinical diagnosis is difficult as a result of a low incidence. We present a case of a patient with this situation.

Introduction: Ovarian leiomyoma accounts for 0.5 to 1% of all benign ovarian tumors, mostly measuring only a few millimeters, being unilateral and occurring in premenopausal women. The majority of ovarian leiomyomas (78%) are associated with uterine leiomyomas, as occurred in our patient.

Material and Methods 35-years-old asymptomatic nuliparous woman. An Ultrasound and MRI showed a polimyomatous uterus and a large right pelvic mass measuring 7cm, with an apparent relation with right ovary, suggesting a uterine fibromyoma or a solid ovarian mass. She underwent diagnostic laparoscopy with drainage of peritoneal fluid and, right laparoscopic adnexectomy for a solid hipervascularized mass followed by mini-laparotomic extraction. Extemporaneous examination of the mass revealed a leiomyoma. She remains under follow-up in our outpatient care unit.

Results: case report

Discussion: Ovarian leiomyoma should be considered in the differential diagnosis of ovarian tumors. Pre operative diagnosis between pediculated fibromyoma and solid ovarian mass is difficult, even more in this rare cases.

MULTI-LAYERED CONTINUOUS CLOSURE SUTURING TECHNIQUE @ LAPAROSCOPIC MYOMECTOMY

Tips & Tricks in Surgery

Oral

Prashant Mangeshikar*

Mangeshikar M.A.G.I.C. for Woman

Summary (4 lines): Laparoscopic Myomectomy in skilled hands is an effective technique obviating the need for a laparotomy. The closure of the myoma bed is very important during the myomectomy. It achieves complete haemostasis and should avoid any dead space and should facilitate healing to avoid rupture during pregnancy and labor.

Introduction: Suturing in the vertical zone as described by Koh employs two portals: the left lower and the left Koh point and two KOH needle holders: Right and Left to facilitate intracorporeal suturing of the myoma bed. Multilayer continuous closure using standard 20 cm Polysorb or Vicryl suture on a CT1 or GS Needle was achieved to obtain full thickness access of the myoma bed avoiding dead space and achieving excellent haemostasis.

Material and Methods Laparoscopic Myomectomy was performed on 225 women with intramural myomas between 2008 -2012. Multilayer closure of the myoma bed was performed employing Koh’s technique of suturing in the vertical zone. The layers were approximated by continuous non-locking technique ensuring no dead space formation and achieving perfect haemostasis. The final layer was performed in a baseball stitch mode, which prevents exposure of the suture and gives pressure on the myoma bed.

Results: Of the 225 women, two-layered closure was performed in 156 women, 57 had a 3-layered closure while a 4-layered closure was performed in 12 women. The avg. myoma size was 6 cms (range 3 to 12 cms). The number of fibroids: 1 (N=93); 2(N=101); 3 (N=19); 4 and more (N=12).

Discussion: Ambidexterity during laparoscopic surgery facilitates quick effective suturing of the myoma bed using two needle holders and standard suture material. The multi-layered continuous closure suturing technique achieves excellent haemostasis and minimizes blood loss. It minimizes adhesion formation avoiding exposure of the suture within the pelvis.

THE MORPHOLOGICAL DIVERSIFICATION OF THE UTERINE SEPTUM AND ANTI-ADHESION PREVENTION AFTER HYSTEROSCOPIC METROPLASTY

Surgical Hysteroscopy

Poster

Artur Ludwin*, Ludwin Inga, Pityński Kazimierz, Banas Tomasz, Milewicz Tomasz, Basta Antoni

Department of Gynecology and Oncology, Jagiellonian University, Medical Colege

Summary (4 lines): The width of the uterine septum determines the healing-dependent final anatomical results of hysteroscopic metroplasty. The patients who benefit most from anti-adhesion prevention are women with a wide-based uterine septum

Introduction: The effects of uterine septum morphology on the healing-dependend anatomical results (adhesions and residual septum/fundal notch) after hysteroscopic metroplasty already were not analyzed.It may be assumed that the morphological diversification of the septum can influence the formation of adhesions and may be an indication for the use of targeted anti-adhesion prevention.The aim of study was to predict the optimal healing-depended anatomical results after hysteroscopic metroplasty rates after hysteroscopic metroplasty with and without additional antiadhesion prevention

Material and Methods Women (n=93) with diagnosed septate uterus and a history of miscarriage or infertility were consecutively enrolled in a prospective observational study. Septal width, length and surface area, were determined using 3D-sonohysterography (coronal view). The hysteroscopic metroplasty was monitored using an intraoperative 3D/4D transrectal ultrasound (uncomplete resection=exclusion criterion). In part of women received ACP (n=47). 3D-SHG and second look hysteroscopy were conducted to make final assessments of the anatomical results

Results: The septal width (>4cm) and the application of the ACP were independent factors influencing the final anatomical result of hysteroscopic metroplasty (multivariate analysis of variance, p

Discussion: The fusion of previously separated surfaces is present after nearly every hysteroscopic metroplasty procedure, also after the applicaton of ACP. Healing dependend abnormal anatomical results is significantly rare when septal width

SIMPLE ANATOMICAL FACTORS (PE-SI-MA) AND STEPW-CLASSIFICATION OF SUBMUCOSAL MYOMAS IN PREDICTING ONE-STEP COMPLETE HYSTEROSCOPIC MYOMECTOMY

Surgical Hysteroscopy

Oral

Artur Ludwin*, Ludwin Inga, Pityński Kazimierz, Basta Paweł, Basta Antoni

Department of Gynecology and Oncology, Jagiellonian University, Medical Colege

Summary (4 lines): One-step resection rates can be high or average, when STEP-scoring gives little chance for one-step resection. Simple anatomical factors may be more significant predictors for complete resection of small myomas

Introduction: Leading the study, whose primary purpose was to predict the one-step complete resection rates after transrectal ultrasound-guided hysteroscopic myomectomy and to determine the utility of intraoperative transrectal ultrasonography (TRUS) in monitoring hysteroscopic electroresection of submucosal myomas we made additional observations of the predictive value of simple anatomical factors characterizing submucosal myomas Pe-Si-Ma (Penerate, Size, Margin) and STEPW classification

Material and Methods One hundred and twenty women with symptomatic submucosal myomas (≤5cm with a myometrial free margin≥ 3mm); interventions a preoperative sonohysterographical evaluation (penetrate, size, myometrial-free margin, STEPW grading; 1-3 months of aGnRH therapy in patients with myomas>3cm; hysteroscopic myomectomy under TRUS-guidance or without TRUS-guidance and a postoperative TVS, SIS or hysteroscopy

Results: One-step resection rates in enrolled 120 women: G0+G1/G2=92vs74%,STEPWI/STEPWII+III=89vs75%,Sizevariable logistic analysis: for all treated patients revealed three factors affecting the rate of one-step complete resection:TRUS[OR=2.74,p5.21,pnd the myometrial free marginp001 and one for Group without TRUS: penetration(G0+G1)[OR=3.25,p

Discussion: Importance anatomical parameters in prescribing hysteroscopic myomectomy will change in the future depending on the surgical techniques,the use of additional intraoperative visualization and surgeon experience.We believe that in the future,a real and constant factor that will limit the applicability of hysteroscopic myomectomy is the presence of a myometrial free margin.

EFFICACY OF THE NOVEL TECHNIQUE OF SENTINEL LYMPH NODE DETECTION IN ENDOMETRIAL CANCER

Oncology

Poster

Pawel Basta*, Nocun Agnieszka, Wiechec Marcin, Basta Antoni

Jagiellonian University

Summary (4 lines): The study demonstrates efficacy of the different techniques of sentinel lymph node (SLN) mapping in endometrial cancer (EC) with fusion of various devices like: ultrasound, SPECT and laparoscopy.

Introduction: Sentinel node mapping has become a standard technique in some solid neoplasms, like breast cancer, and has brought attention into gynaecological oncology now. There are on-going trials in vulva and cervical cancer with promising preliminary results, however it is disputed the feasibility of SLN detection in EC. The study presents results of novel (embryologicaly based) technique of sentinel lymph node mapping in that neoplasms underlining the role of endoscopy in its detection.

Material and Methods 23 patients with EC were randomized into 2 groups of sentinel lymph node detection. In both groups SLN was mapped with double technique: dye and radioisotope technique with subsequent SPECT imaging. Doses and times of injections of tracers were the same in both groups, also operations were performed via laparoscopy with endoscopic gamma detection probe. In the first group both tracers were injected into cervix, whereas in second into subserosal layer under ultrasound guidance.

Results: Detection of SLN in both iliac and paraaortic lymph nodes was noted with a different typical anatomical location of SLN in 7 patients who were injected with tracers into subserosal under ultrasound guidance in compare to 16 patients who were injected with tracers into cervix.

Discussion: The presented novel technique of injection of tracers in SLN mapping in EC (into subserosal layer under ultrasound guidance), representing more embryological nature of lymphatic spread of tracers, seems to be more accurate in detection of true SLN in compare to more preferable cervical route if injection.

DEMONSTRATION OF THE NOVEL ALGORITHM FOR SENTINEL LYMPH NODE DETECTION IN ENDOMETRIAL CANCER

Oncology

Video

Pawel Basta*, Nocun Agnieszka, Wiechec Marcin, Basta Antoni

Jagiellonian University

Summary (4 lines): This is a step-by-step video demonstration of a proposal of an alternative sentinel node (SLN) mapping in endometrial cancer (EC).

Introduction: Sentinel node mapping has become a standard technique in some solid neoplasms, like breast cancer, and has brought attention into gynaecological oncology now. There are on-going trials in vulva and cervical cancer with promising preliminary results. Those tumours represent a good access to the site of injection of tracers. However, it is disputed the feasibility of SLN mapping in EC. Cervical injection site does not reflect embryological development of lymphatic pathway in EC.

Material and Methods 7 patients with EC were mapped for SLN with double technique: dye and radioisotope method with subsequent SPECT imaging. Doses and times of injections of tracers were similar in all patients, and operations were performed via laparoscopy with endoscopic gamma detection probe. The way of tracers injection represented a novelty – they were injected into subserosal layer under ultrasound guidance.

Results: Injections with tracers into subserosal layer of the uterus under ultrasound guidance enable to demonstrate SLN’s both in iliac and paraaortic lymph nodes in EC during laparoscopy.

Discussion: Preoperative, subserosal injection of tracers under ultrasound guidance facilitate outflow of those tracers within lymphatic system, and more likely reflects embryological development of lymphatic pathway in EC.

RECTOVAGINAL ENDOMETRIOSIS WITH HYDROURETERONEPHROSIS AND RECTAL INFILTRATION

Endometriosis: Surgery

Video

Fasolino Luigi*, Koh Charles

Summary (4 lines): Pt. with symptomatic deep endometriosis involving rectum and bilateral hydroureteronephrosis causing pain, obstruction and hypertension

Introduction: after 2 previous laparotomy without resolution of the problem, the pt. underwent laparoscopic radical excision with fertility preservation

Material and Methods edited original videotape

Results: successful laparoscopic ureteral resection/anastomosis, bowel resection/anastomosis, endometriectomy

Discussion: advanced laparoscopic technique using simple tools can perform successful radical excision of endometriosis where laparotomy failed. conservation of reproductive capacity does not compromise success of surgery

COMPLIANCE AND ARTHRALGIA IN CLINICAL THERAPY: THE COMPACT TRIAL

Oncology

Selected abstract Oral

Hadji P*

Philipps University of Marburg

Summary (4 lines): This prospective study evaluated the relationship between arthralgia and compliance during the first year of adjuvant anastrozole therapy in postmenopausal women with hormone receptor-positive early breast cancer.

Introduction: We present the results of COMPliance and Arthralgia in Clinical Therapy (COMPACT), a prospective study evaluating the relationship between arthralgia and compliance during the first year of AI therapy in postmenopausal women with HR+ early breast cancer.

Material and Methods COMPACT was an open-label, multicenter, non-interventional study conducted in Germany. Patients had started adjuvant anastrozole 3–6 months prior to study start. The primary endpoints were arthralgia, compliance, and the relationship between compliance and arthralgia, assessed at specific time points.

Results: There was a significant association between arthralgia mean scores and non compliance at 6 months (P

Discussion: Arthralgia is important in the clinical management of women with early breast cancer, and may contribute to non-compliance and clinical outcomes. ClinicalTrials.gov identifier: NCT00857012.

CERVICAL DETACHMENT USING MONOPOLAR SUPRALOOP™ ELECTRODE VERSUS MONOPOLAR NEEDLE IN LAPAROSCOPIC SUPRACERVICAL HYSTERECTOMY (LSH)

Hysterectomy

Selected abstract Oral

Sara Brucker*

Tuebingen University Women's Hospital

Summary (4 lines): Comparison of the efficiency and safety of cervical detachment with a newly developed monopolar loop electrode (SupraLoop™) with a conventional method of cervical detachment in laparoscopic supracervical hysterectomy (LSH).

Introduction: Prospective, Interventional, Comparative Study. Our study sample included 1598 patients; 1070 patients that underwent LSH with cervical detachment using the monopolar SupraLoop™ (study group) and 528 patients that underwent LSH with cervical detachment using the monopolar needle (control group). We also assessed cervical detachment time and total device application and cutting time in a subgroup of 49 patients (23 patients from the study group and 26 patients from the control group.

Material and Methods Total operation time for LSH was significantly shorter among SupraLoop™ patients (93±41 minutes) when compared to patients in whom cervical detachment was performed with the needle (105±44 minutes) (p3±1.8 min vs 5.4±2.4 min (p

Results: There were no major or minor complications directly related to the use of the SupraLoop™ device, whereas two intraoperative complications were directly related to the application of the monopolar needle.

Discussion: The newly developed monopolar loop electrode (SupraLoop™) is both an effective and safe instrument for cervical detachment in laparoscopic supracervical hysterectomy, and performed better than the needle, offering a significantly shorter operating time and less complications for the hysterectomy compared to the conventional method.

A RETROSPECTIVE STUDY IN 76 PATIENTS

Surgical Hysteroscopy

Oral

Rothmund Ralf*, Ralf-Rainer Kurth

Tübingen

Summary (4 lines): To analyze clinical and pathologic features as well as recurrence patterns of cellular leiomyomas (CL) in women who underwent surgical therapy for symptomatic disease.

Introduction: This retrospective study was conducted at the Department of Obstetrics and Gynecology, University Women’s Clinic, Tuebingen, Germany. We identified all women who had CL on final diagnosis after surgery between January 1st, 2000 and December 31st, 2010.

Material and Methods Our study sample comprised 76 women with a diagnosis of CL.

Results: A single uterine mass was present in 51.3% of the cases; in uteri with both CL and uterine leiomyomas (UL), the CL constituted the largest uterine mass in 20 of 21 (95.2%) cases. Additionally, in 98% of the uteri, CL were either the largest or the only uterine mass.

Discussion: Over the follow-up period, 6 women who underwent uterus-conserving surgery (12.0%; 6/50) with CL had leiomyoma recurrence. Five women underwent abdominal myomectomy and one woman underwent hysteroscopic resection of the CL. One patient had recurrence of a CL 43 months after abdominal myomectomy and underwent vaginal hysterectomy; the other five women had recurrences of UL. Mean time to recurrence was 28.6 months (median 12.5; range, 4.0 – 83.0). Recurrence rates of CL in our study group resemble recurrence rates of UL.

LAPAROSCOPIC UTEROVAGINAL ANASTOMOSES FOR CONGENITAL CERVICAL AGENESIS

Innovation in Instrumentation and Surgical Techniques

Video

Padmawar Ameya*, Rizwana Syed

Rotunda,centre for human reproduction,Mumbai,India

Summary (4 lines): Laparoscopic uterovaginal anastomoses forms a minimally invasive option for patients with congenital cervical agenesis attaining significant symptomatic relief and the possibility of future fertility.

Introduction: Congenital cervical agenesis is a rare Mullerian developmental anomaly resulting in cryptomenorrhea and cyclical dysmenorrhea. Literature review suggests that most of the patients eventually undergo hysterectomy at an early age. Laparoscopic uterovaginal anastomoses is a minimally invasive surgical solution for the condition.

Material and Methods CASE REPORT: We are presenting a case of a 13 year old girl with history of primary amenorrhea and cyclical dysmenorrhea. Diagnosis of cervical agenesis was confirmed by a MRI scan of the pelvis. She underwent laparoscopic uterovaginal anastomoses with placement of a silastic NO 14 Foleys catheter as a stent till the pathway epithelizes.A four month follow up of the patient revealed that she has been having normal menstruation with complete relief of dysmenorrhea.

Results: Laparoscopic uterovaginal anastomoses with placement of the stent , resulted in spontaneous expulsion of the stent at the end of 9 weeks. Relook hysteroscopy at 10 weeks showed good epithelisation of the tract and a good uterine cavity.

Discussion: Laparoscopic uterovaginal anastomoses should be considered as the first line therapy for cervical agenesis based on: minimally invasive technique, relief of symptoms and conservation of the uterus and hence possible future fertility.

LAPAROSCOPIC LATERAL SUSPENSION USING MESHES TO TREAT VAGINAL VAULT PROLAPSE

Urogynaecology

Video

Jean-Bernard Dubuisson*

HFR Fribourg - Hôpital cantonal, Fribourg, Switzerland

Summary (4 lines): We present a video of laparoscopic management of vaginal vault prolapse after total hysterectomy using the technique of lateral colposuspension using two free meshes.

Introduction: The video concerns a postmenopausal patient with a past history of total hysterectomy for fibroids. She complained of pelvic discomfort and exteriorization of a “mass”, especially at the end of the day.

Material and Methods The patient underwent a laparoscopic lateral suspension using two meshes. The originality of the technique we present is the use of a tetanized coated mesh placed on the anterior vaginal wall and on the vault, with its two arms for lateral suspension, associated with a free patch fixed to the recto-vaginal septum.

Results: At the end of the video, the organs of the three compartments are placed in a good position without excessive tension.

Discussion: Laparoscopic lateral suspension with two free meshes may be an alternative to treat vault prolapse after total hysterectomy.

THE ILAPAROSCOPE – THE DEVELOPMENT AND IMPLEMENTATION OF A SMARTPHONE BASED LAPAROSCOPY BOX TRAINER

Teaching & Training

Selected abstract Oral

Khan Zahid*

City Hospital, Birmingham

Summary (4 lines): Using our validated, innovative trainer, one is able to utilise the features of a smartphone for acquisition of basic skills in laparoscopic surgery for a fraction of its cost implications.

Introduction: 81% of European doctors own a smartphone; this includes 75% of junior trainees, with the iPhone owning a significant 4:1 advantage. Our aim was to design a robust, reproducible, hyper-portable, wireless, laparoscopy box trainer. In the process of amalgamating those attributes, we managed to produce the world’s cheapest smartphone based box trainer, which enables not only skills acquisition anywhere in the world, but also aids across assessment platforms for a fraction of today’s costs.

Material and Methods The box is laser cut from thick, recycled plastic. It features a multi-plane adjustable shelf where the smartphone sits. The contents of the box (the exercises) are held on hyper-adjustable shelf and is lit by the led flash light off the smartphone. It features anatomically positioned port sites to allow the operator different angles of approach. For validation, 25 trainee doctors completed a psychometric scale based questionnaire after 3 different exercises with the box.

Results: The training box was then validated and evaluated thoroughly. Suitable Apps for the box were also identified. The box trainer scored a high mean 4.6/5 for training potential.

Discussion: With world class training, guidance and assessment being only a Skype®™ call away, the potential for a smartphone based laparoscopy box trainer, with established validity, seems endless, with the added possibility of provision of training by world class trainers, across borders and per pro bono.

CLINICAL CHARACTERISTICS INDICATING ADENOMYOSIS COEXISTING WITH LEIOMYOMAS: A RETROSPECTIVE, QUESTIONNAIRE-BASED STUDY

Complications

Poster

Hübner Markus*, Sara Brucker, Markus Wallwiener, Florin-Andrei Taran, Elizabeth Stewart, Sandra Ebersoll, Birgitt Schoenfisch

Summary (4 lines): To elucidate the clinical profile of a concomitant diagnosis of adenomyosis in women with leiomyomas.

Introduction: Our understanding of benign myometrial lesions, including adenomyosis and leiomyomas, lags far behind our understanding of malignant lesions of the uterus, despite the much greater prevalence of the former.

Material and Methods This retrospective, questionnaire-based study was conducted at the Department of Obstetrics and Gynecology, University Women’s Clinic, Tuebingen, Germany and compared women undergoing hysterectomy with adenomyosis and leiomyomas to women with leiomyomas alone.

Results: The study sample comprised a total of 560 women; 159 women with adenomyosis and leiomyomas and 401 women with leiomyomas alone. Women with a concomitant diagnosis of adenomyosis and leiomyomas had significantly higher scores for disease burden during the menstrual period prior to surgery: heavy bleeding episodes and passing blood clots.

Discussion: Adenomyosis is contributing to symptomatology in women with concomitant adenomyosis and leiomyomas.

FEASIBILITY AND FIRST LONG-TERM RESULTS AFTER LAPAROSCOPICALLY ASSISTED TRANSVAGINAL RECTAL SEGMENT RESECTION FOR DEEP ENDOMETRIOSIS

Endometriosis: Surgery

Oral

Hepp Phillip*, Ines Beyer, Tanja Fehm, Markus Fleisch

Dep. of Ob & Gyn, Heinrich-Heine-University Medical

Summary (4 lines): We describe our technique of laparoscopically assisted transvaginal rectal resection (LATRR) and give long term follow-up information. All 4 patients reported persistent pain relief at the end of follow-up period.

Introduction: We describe our technique of laparoscopically assisted transvaginal rectal resection (LATRR) and give long term follow-up information. All 4 patients reported persistent pain relief at the end of follow-up period.

Material and Methods Retrospective observational monocentric study on all DIE patients with rectal infiltration treated between 2008 and 2010 with LATRR at our department available for at least 3-year follow-up. Follow-up was obtained including baseline, 1-year and 3-year pain scores.

Results: 4patients undergoing LATRR available for follow-up. DIE confirmed by histology in all cases. No intraoperative complications. 2patients had transient postoperative urinary retention, 1 patient developed recto-vaginal fistula and required transient colostomy. 1 patient suffered persistent vaginal dryness. All reported persistent pain relief also at the end of follow-up period.

Discussion: LATRR is a feasible variation of laparoscopic bowel resection for DIE with rectal infiltration. In our series it has promising results with respect to pain control. Larger series have to determine the safety of this procedure.

POST-OPERATIVE MORBIDITY FOLLOWING LAPAROSCOPIC SACROCOLPOPEXY IN WOMEN ABOVE AND UNDER 65 YEARS

Urogynaecology

Oral

Haest Kim*, Filip Claerhout, Erika Werbrouck, Jasper Verguts, Joan Veldman, Frank Van der Aa, Martha Van Hasselt, Dirk de Ridder, Jan Deprest

University Hospitals Gasthuisberg

Summary (4 lines): Outcomes of patients undergoing LSC are similar for patients above 65 years compared to those being younger. We observed 3% reoperations. There were less graft related complications in the elderly.

Introduction: Abdominal sacrocolpopexy offers better anatomical results than sacrospinous fixation (SSPF), however at the expense of increased morbidity. For that reason, vaginal SSPF rather than abdominal apical suspension is often suggested for elder or frail women. This might be reconsidered since laparoscopic sacrocolpopexy has equal efficacy yet lower morbidity. We therefore offered LSCP also topatients above 65 years. Herein we compare the immediate postoperative morbidity following laparoscopic sacrocolpopexy (LSCP) in two age groups.

Material and Methods Prospective study on 365 consecutive LSC for symptomatic vault prolapse (stage 2 or higher), n=201 > 65 years and 164 complications and anatomical outcome (Stage I or 0 at vault or any compartment)within three months. Additional outcomes were need for conversion, blood loss, occurrence and nature of postoperative complications as displayed in the table.

Results: Demographics, surgical history and intraoperative parameters were comparable, except less blood loss in > 65 years. There was 1 immediate reintervention by open surgery because mesh release from the tackers. Postoperative hospital stay was 5.1 days in both groups. The major and minor complications were comparable (Table).

Discussion: Given equal outcomes LSCP should be offered to any patient with vault prolapse who has no contraindication for laparoscopy. We observed 3% reoperations and less graft related complications in the elderly. This may be a bias as patients at elder age were less frequently sexually active and/or may complain less.

FIRST LONG TERM IN VITRO VISUALISATION OF ANTERIOR VAGINAL MESH USING PARAMAGNETIC IRON OXIDE MICROPARTICLES

Innovation in Instrumentation and Surgical Techniques

Oral

Jan Deprest*, Dirk de Ridder, Endo Masayuki, Hans-Christian Kolberg, Frederik de Keyzer, Nikhil Sindwani, Filip Claus

University Hospitals Leuven

Summary (4 lines): We demonstrate the feasibility of in vivo clinical mesh visualization. High resolution images can be made, demonstrating the location and conformation of the mesh.

Introduction: Knowledge about the in vivo behaviour of meshes as well as their actual anatomical location may help to understand, manage and prevent failures and graft related complications following the use of mesh. Non-invasive medical imaging methods are preferable to surgical exploration. However, ultrasound is limited by the depth of vision and tissue contrast and, while contrast can be enhanced by coating the mesh with barium, computed tomography requires radiation.

Material and Methods Case report on use of Dynamesh Visible mesh for anterior repair. A patient with symptomatic cystocele underwent repair with PR4 soft-1B 4-arms PVDF mesh (FEG Textiltechnik, Aachen, Germany; pore size 1.3 *2.3 mm; effective porosity 61.1%), with passage of mesh arms through the obturator membrane and sacrospinous ligament. It contains paramagnetic 1 mg/g Fe3O4 micro particles into polyvinylidene fluoride-polymer filaments. Fe3O4 particles generate susceptibility effects causing signal voids on magnetic resonance imaging.

Results: We used routine T2-weighted Turbo-Spin-Echo (TSE)-sequences complemented with axial, sagittal and coronal TrueFisp sequences and high-resolution non-contrast-enhanced 3D-Fast-Field-Echo (FFE)-sequence (voxel resolution 1.0x0.7x0.7 mm) on 3T Ingenia scanner (Philips) for

Discussion: We made a 3D-reconstruction based on region growing with one central see point, demonstrating the porous structure and location of the mesh. This approach may be used for studying the concepts behind surgical techniques, correlation between anatomical and functional results, or documenting complications rather than invasive surgical exploration.

DOCUMENTATION BY MRI OF THE IN VIVO BEHAVIOR OF MESHES LOADED WITH FE3O4 MICRO-PARTICLES IN RABBITS

Innovation in Instrumentation and Surgical Techniques

Oral

Urbankova Iva*, Andrew Feola, Nikhil Sindhwani, Stefano Manodoro, Filip Claus, Jarek Vlacil, Thomas Deprest, Alexander Engels, Godelieve Verbist, Endo Masayuki, Jan Deprest

Pelvic Floor Unit, University Hospitals Leuven, Leuven, Belgium

Summary (4 lines): Meshes or sutures can be visualized in vivo using PVDF constituting fibers with paramagnetic Fe3O4 micro particles. This allows non-invasive measurement of changes of the apparent surface area of implants.

Introduction: In vivo visualization of implants may help understand the tissue response as well as the occurrence of graft related complications. We set up an experimental study to document mesh contraction following primary overlay repair of a full thickness abdominal wall defect in rabbits. Fixation sutures or meshes, with paramagnetic 1 mg/g Fe3O4 micro particles embedded in constituting fibers allow visualization on magnetic resonance images (MRI). Outcomes were mesh contraction and biomechanical properties of explants.

Material and Methods 9 New-Zealand rabbits underwent overlayepair of two full-thickness 25*30 mm midline defects in the upper and lower anterior abdominal wall, by 30*40mm implants of polyvinylidinefluoride(PVDF)-mesh (Dynamesh, n=6), or pure or hybrid polypropylene (Ultrapro Ethicon, n=6 or Marlex; Bard, n=6). To fix and identify edges 3/0 PVDF sutures with paramagnetic particles were used. Outcome measures were apparent surface area by high-resolution 3 Tesla T2 images at 2, 30 and 90 days.

Results: Fe3O4 particles visualize sutures and meshes with maximum detail of textile structure for PVDF-mesh when constituting fibers run transversely to body axis. In 83.3% surface area measurements can be made. Dynamesh and Marlex show initial contraction of roughly 17% each by day 2 (p

Discussion: Meshes or sutures can be visualized in vivo using PVDF constituting fibers with paramagnetic Fe3O4 micro particles. Surface calculation fails in case of large collections or high local deformation. Software development may make measurements of surface and deformation more usable. There is an apparent contraction of mesh immediately after implantation.

ABDOMINAL VERSUS VAGINAL MESH INSERTION: EXPERIMENTAL EVIDENCE THAT IT DOES MAKE A DIFFERENCE

Urogynaecology

Oral

Urbankova Iva*, Andrew Feola, Stefano Manodoro, Jaromil Vlacil, Endo Masayuki, Pieter Uvin, Jan Deprest

Pelvic Floor Unit, University Hospitals Leuven, Leuven, Belgium

Summary (4 lines): In sheep, the location of mesh implantation significantly influences contraction and passive biomechanics, though not between mesh types. Compared to native tissue, mesh affects the passive and active properties.

Introduction: The Food and Drug Administration has issued a health notification that, next to material choice, vaginal, as opposed to abdominal mesh use is associated with a higher number of Graft Related Complications (GRC). We tested the hypothesis that the route of implantation affects the contraction rate, occurrence of GRC, active and passive biomechanical properties of the vaginal and abdominal wall following implantation with lightweight polypropylene (PP) meshes with or without collagen coverage.

Material and Methods 24 Texel sheep were divided into 1) non-operated controls 2) Avaulta Solo (Bard, Belgium); 3) Avaulta Plus (Bard; =Solo+acellular collagen); 4) Ugytex (Sofradim, France; coating with atelocollagen, polyethyleneglycol and glycerol). Abdominal implant was 50x50 mm, rectovaginal implant was 35x35mm. Explants were removed after 180d for macroscopy, passive bi-axial (Zwicki tensiometer Ulm, Germany) and active biomechanics by contractility testing. Parametric data are displayed as mean □SD and non-parametric as median (interquartile range).

Results: Native vagina has 34% longer comfort zone length (p(p=0.001). Implantation decreases comfort zone length by 23% (p=0.001), increases comfort and stress zone stiffness by 56% (p=0.002) and 38% (p=0.004) without group differences. Active properties were 75% higher for Solo versus collagen-coated (p=0.02).

Discussion: This is experimental evidence that implantation of any material changes tissue biomechanics. Also location changes the response of the host. Vaginal meshes contract twice more than abdominal (p=0.01) and biomechanics are also altered. Collagen coverage additionally compromises vaginal wall contractility.

SHORT TERM OUTCOMES FOLLOWING LAPAROSCOPIC SACROCOLPOPEXY WITH PARTIALLY RESORBABLE ULTRA-LIGHTWEIGHT VERSUS LIGHTWEIGHT POLYPROPYLENE MESH

Urogynaecology

Oral

Haest Kim*, Filip Claerhout, Jasper Verguts, Erika Werbrouck, Joan Veldman, George Coremans, Dirk de Ridder, Jan Deprest

Pelvic Floor Unit, University Hospital Gasthuisberg, Leuven, Belgium

Summary (4 lines): Material choice may influence outcomes. We could not observe relevant differences in short-term outcomes after laparoscopic sacrocolpopexy (LSCP) with ultra- or lightweight meshes.

Introduction: LSCP is the standard of care for level I defects. We earlier reported a 4.6 % exposure rate and 2.4% mesh revision rate. These graft related complications (GRC) may, in part, be due to material choice. Herein we report short term outcomes of LSCP in 159 consecutive patients, using either light weight polypropylene (PP) (Gynemesh, Ethicon; 50 g/m²; n=1-60) or a ultra-lightweight hybrid mesh of PP and resorbable polyglecaprone (Ultrapro, Ethicon, 28 g/m²; n=99; 61-159).

Material and Methods Prospective study in patients undergoing LSC for symptomatic stage≥2 prolapse at pointC. Short term (≤12 wks) outcomes were anatomical cure (C≥-1 cm) or elsewhere, need for conversion, minor (infection treated medically, hemorrhage requiring blood transfusion without reintervention, urinary retention, …), or major (any reintervention or re-admission within 6 weeks, thromboembolism, spondylodiscitis) complications, graft related complications leading to early reintervention. . Student t-test and Pearson chi square were used to compare continuous and categorical data.

Results: Demographics were similar. In the Ultrapro group, blood loss (134.1±76.2 vs. 179.4±115.8 mL) and hospital stay (3.6±0.45 vs. 4.9±0.38 postoperative days) was less (Table). There was one conversion for adhesions, 5 reinterventions (2 mesh exposures, one bleeding, one ureteral lesion, and one early release at the promontory on vomiting.

Discussion: There were no relevant differences in short-term outcomes in patients undergoing laparoscopic sacrocolpopexy (LSCP) with ultra- or lightweight meshes, except for shorter hospital stay. Short term graft-related-complications occured in

VAGINAL CUFF DEHISCENCE AFTER HYSTERECTOMY

Hysterectomy

Poster

Susana Maia*, Manuel Rodrigues, Jose Luis Silva Carvalho

Centro Hospitalar Baixo Vouga, Hospital CUF Porto

Summary (4 lines): Vaginal cuff dehiscence after total laparoscopic hysterectomy presents an incidence between 0.3 and 3.1%. Possible causes may be the electrosurgical colpotomy, the technique used for vaginal vault closure and an early resumption of regular activities after surgery.

Introduction: Vaginal cuff dehiscence after total laparoscopic hysterectomy presents an incidence between 0.3 and 3.1%. Possible causes may be the electrosurgical colpotomy, the technique used for vaginal vault closure and an early resumption of regular activities after surgery.

Material and Methods We present the case of a 46 year-old patient complaining with dysmenorrhea, dyspareunia and hypermenorrhea due to uterine fibroids, adenomyosis and rectovaginal septum endometriosis. She underwent a total laparoscopic hysterectomy with rectovaginal endometriotic nodule excision. Eighty-three days after the surgery the patient complained of acute abdominal pain triggered by sexual intercourse. At examination she presented a vaginal cuff dehiscence around 5mm with no vaginal blood loss, haematoma or evisceration that has been managed by laparoscopy.

Results: In this patient several factors contributed to the vaginal cuff dehiscence, including weakness of the tissue by the endometriosis, thinning of the vaginal wall caused by the surgery, suture technique and increased tension on the suture.

Discussion: In this patient several factors contributed to the vaginal cuff dehiscence, including weakness of the tissue by the endometriosis, thinning of the vaginal wall caused by the surgery, suture technique and increased tension on the suture.

REPORT OF 1428 CONSECUTIVE HYSTEROSCOPIES IN AN OUTPATIENT SETTING

Surgical Hysteroscopy

Oral

van de Water Marije*, Bart De Vree, Marc Francx

UZ Gent – Dept Ob/Gyn – Gent/Belgium

Summary (4 lines): Since June 2001 we conducted 1428 hysteroscopies diagnostic and operative in an outpatient setting. Main indication was abnormal uterine bleeding (AUB). In more than 96% of our patients the ambulatory hysteroscopy was possible and well tolerated.

Introduction: Hysteroscopy and D & C under general anaesthesia has long been the gold standard in evaluation of abnormal uterine bleeding. Due to the development of small diameter hysteroscopes nowadays ambulatory hysteroscopy without anaesthesia is the evaluation method of choice for AUB. The development of specific auxilliary instruments even permits to perform small operative procedures in the outpatient. We will discuss our experiences in ambulatory hysteroscopy from June 2001.

Material and Methods From June 2001 until June 2013 we collected data of the outpatiënt hysteroscopy unit of the ZNA Middelheim Hospital – Antwerp/Belgium. Hysteroscopies were performed by 2 senior staff members, using the vaginoscopic approach and without anesthesia, using a rigid 30° minihysteroscope and saline distention. In selected patients small operative procedures (polypectomy, adhesiolysis) were performed using mechanical instruments or 5 Fr bipolar instruments.We documented patient characteristics, indication, succes rate, diagnosis, operative procedures, complications and pain score.

Results: We performed 1428 hysteroscopies, mainly for AUB. In 96% of our patients the ambulatory hysteroscopy was possible and well tolerated with a median pain score of 3/10. Complication rate (vasovagal syncope) was 1,5%. Hysteroscopy was abnormal in 48%. Abnormal findings include atrofy, polyps, fibroids, adhesions, uterine anomalies, placental remnants, endometrial hyperplasia and dislocated intra-uterine devices. When a polyp was diagnosed we could perform adequate polypectomy in 27% of cases.

Discussion: Our data comfirm that ambulatory hysteroscopy, using the vaginoscopic approach and without anesthesia, is a well established technique. In experienced hands and due to the development of specific auxilliary instruments (5Fr bipolar instruments) a small range of operative procedures can also be performed in the outpatiënt setting.

LAPAROSCOPIC REPAIR OF CAESAREAN SCAR DEFECTS USING CAPIO® SUTURE CAPTURING DEVICE

Innovation in Instrumentation and Surgical Techniques

Video

Deidre Meulenbroeks*, Kuijsters Nienke, Kortenhorst Madeleine

Catharina hospital

Summary (4 lines): In this video we show that the Capio® is of significant aid in the laparoscopic repair of a severe scar defect in a 23-year old patient.

Introduction: Three to six percent of women undergoing a caesarean section develops a uterine scar defect, leading to post-menstrual spotting and infertility. To solve these problems, scar tissue is resected and repaired.

Material and Methods When the residual myometrium is less than 3mm, a laparoscopic approach is chosen. Use of conventional laparoscopic suturing results in difficulties with correct placement of the sutures. Furthermore, intra-corporal knotting is needed.

Results: The Capio® Suture Capturing Device solves these problems. After resection of the caesarean scar tissue, the Capio® took full-thickness bites of both sides of the resulting wound. Extra-corporal knotting of the sutures was performed after all sutures were placed.

Discussion: Six weeks post-operative, the patient complaints were resolved and a control hysteroscopy showed a successful repair.

OBSTETRIC OUTCOMES OF PATIENTS UNDERGOING TOTAL LAPAROSCOPIC RADICAL TRACHELECTOMY

Oncology

Oral

Keiko Ebisawa*, Andou Masaaki

Kurashiki Medical Center

Summary (4 lines): We performed total laparoscopic radical trachelectomy in 61 patients. Fifty-seven patients’ fertility was preserved without requiring post-operative adjuvant treatment. Twenty-seven women attempted to conceive. Of these, 14 succeeded for a total of 22 pregnancies (pregnancy rate, 52%).

Introduction: We introduced our total laparoscopic radical trachelectomy (TLRT), a technique in which resection of the cardinal ligament was modified to type III in December 2001. Therefore we reviewed our experiences using this surgical technique and analyzed the outcomes of our patients.

Material and Methods A total of 61 patients who underwent TLRT between December 2001 and July 2013 were reviewed retrospectively using clinicopathological, surgical, and follow-up data from patients’ medical records.

Results: The median operating time was 338 min (range,215-640min) and the mean estimated blood loss was 300 ml (range, 75-1540ml). Twenty-eight women attempted to conceive after TLRT. Of these, 15 succeeded for a total of 23 pregnancies (pregnancy rate, 53%).

Discussion: TLRT is a useful technique associated with an excellent pregnancy rate in fertility-preserving surgery to treat early stage cervical cancer.

HYSTEROSCOPIC MANAGEMENT OF UTERINE ISTHMOCELE

Surgical Hysteroscopy

Video

Jaime Albornoz*, Fernandez Carlos, Fernandez Emilio

Clinica Las Condes

Summary (4 lines): Uterine Isthmocele is a sacular cavity secondary to cesarean-section scar defect. It can cause abnormal uterine bleeding and secondary infertility and can be managed easily by hysteroscopy.

Introduction: Uterine Isthmocele is a sacular cavity located at the anterior wall of the uterine isthmus. It is secondary to cesarean-section scar defect, and can be a cause of postmenstrual abnormal uterine bleeding and secondary infertility due to the presence of blood stained cervical mucus that affect sperm quality and fluid-reflux into the uterine cavity that impairs endometrial implantation. Diagnosis can be made with Transvaginal Ultrasound and Sonohysterography.

Material and Methods We present a case of uterine isthmocele managed by hysteroscopy. Surgical strategy consists in the resection of the lower margin of the isthmocele, which lead to an increase in the diameter of the cervical canal.

Results: After removal of the lower border of the uterine isthmocele, we show a significant increase in the diameter of the cervical canal, thus facilitating blood drainage during the menstrual period.

Discussion: Hysteroscopic management of symptomatic uterine isthmocele is a minimally invasive procedure that can solve postmenstrual abnormal uterine bleeding and increase spontaneous conception rate in infertile patients.