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Volume 10 Supplement 1

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

  • Abstracts
  • Open Access

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

Gynecological SurgeryEndoscopic Imaging and Allied Techniques201310:818

https://doi.org/10.1007/s10397-013-0818-0

  • Published:

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