Gynecol Surg (2014) 11 (Suppl 1):S1–S358 DOI 10.1007/s10397-014-0857-1 ABSTRACTS Abstracts of the 23rd Annual congress of the European Society European Society (ESGE), 24th – 27th September 2014, SQUARE, BRUSSELS Selected Videos (20) * ES23-0217 Video Session 1: Other Benign Gynaecology LAPAROSCOPIC MANAGEMENT OF AN 11-WEEK RUDIMENTARY UTERINE HORN PREGNANCY USING EXTRA-CORPOREAL ROEDER KNOTS TO SECURE DILATED VASCULAR PEDICLES V. Minas1, L. Shaw1, T. Aust1 1Obstetrics & Gynaecology, Wirral University Teaching Hospital, Wirral, United Kingdom OBJECTIVES Pregnancy in a uterine rudimentary horn presents with an incidence of 1:100,000 pregnancies and carries a high risk of uterine rupture with severe and potentially lethal intra-abdominal haemorrhage. Accurate pre-operative diagnosis can be difficult. Limited published evidence suggests that such cases may be managed successfully by laparoscopy. A number of authors have used destructive techniques to the fetus following excision of the rudimentary horn, to extract the tissues laparoscopically. Pre-operative feticide is recommended in cases where morcellation of the fetus is planned. We encountered a live unruptured 11-week rudimentary horn pregnancy in a woman with one previous normal delivery at term. We aimed to excise the pregnant rudimentary horn laparoscopically and avoid destructive techniques to ease the patient's concerns. At laparoscopy a particularly dilated vascular infundibulopelvic ligament was seen at the side of the pregnant horn. METHODS We demonstrate the laparoscopic management of the case with the use of extracorporeal Roeder knots to secure the unusually dilated left infundibulopelvic ligament. We have performed a literature review using PubMed, Embase and Cochrane Database of Systematic Reviews to identify relevant cases and draw conclusions with regards to their management. RESULTS The procedure was completed successfully by laparoscopy. The pregnant rudimentary horn was excised and haemostasis was secured by using a combination of LigaSure™ and extracorporeal Roeder knots. We extended our suprapubic port to 3 cm to extract the fetus and thus avoided the use of destructive techniques. The estimated blood loss was minimal. The patient's recovery period was uneventful and she was discharged home on day 1 post-operatively. At the time this abstract was written the woman was pregnant following natural conception, with an estimated delivery date 16 May 2014. CONLCUSIONS There exists a growing body of evidence of rudimentary horn pregnancies successfully managed by laparoscopy (20 cases in total, including the present case). These include second trimester pregnancies as well as a case of a ruptured horn. We suggest that when encountered with large dilated vascular pedicles, securing them by extracorporeal Roeder knots is a safe alternative. In advanced gestations, patients must be counselled pre-operatively about the potential need for destructive techniques. In such cases, feticide may need to be performed. We found that the patient's anxiety was alleviated by the knowledge that the fetus was extracted intact and for this purpose we recommend a small extension to the suprapubic port. The possibility of uncommon presentations such as duplicated or absent ureter should be taken into account pre-operatively, and the ureter must be identified intra-operatively. When the expertise is available, laparoscopy appears to be at least as safe as and potentially superior to laparotomy for the management of rudimentary horn pregnancies. http://player.vimeo.com/video/104201316?autoplay=1 *** 1 ES23-0326 Video Session 1: Other Benign Gynaecology REVERSE ROBOTIC HYSTERECTOMY WITH PARADOXICAL CAMERA PLACEMENT M. Orady1, C. Salazar1 1Women's Health Institute, Cleveland Clinic, Rocky River, USA Objectives: This video will demonstrate a novel approach to robotic assisted laparoscopic hysterectomy for a large uterus. After having utilized this approach several times, it has been further refined to allow for simplified access to uterine and utero-ovarian vasculature utilizing a paradoxical camera placement below the uterine fundus and a reverse approach to the hysterectomy procedure. This allows for safe control of vasculature to prevent bleeding during the procedure utilizing and umbilical site for camera placement. Methods: This versatile approach was utilized in a 40 year old African American patient with a history of menorrhagia, pelvic pain, dysmenorrhea, and two prior cesarean sections who was found to have a 22 week sized fibroid uterus. She desired definitive management with a minimally invasive approach to hysterectomy. Results: Large uteri often pose a challenge for the gynecologic surgeon performing a hysterectomy whether approached laparoscopically or via robotic assistance. The classic robotic camera placement in the supra-umbilical region often decreases visibility of the lower uterine segment, potentially decreasing success in the very large uterus and increasing the risk of ureteral or bladder injury and bleeding. Creative utilization of the robot can open up new venues for optimizing access and visualization to the most vital structures involved in performing a hysterectomy. By utilizing a 30 degree scope and placing the camera intra-umbilically below the level of the uterine fundus, the surgeon was able to effectively focus cephalad to secure ovarian vasculature as well as clearly visualize the region of the uterine vasculature, ureter and bladder flap by opening up the anterior and posterior leaflets of the broad ligament and dissecting the retro-peritoneal anatomy. This allowed for safe and adequate control of uterine blood supply. Once uterine vessels are sealed by then continuing the dissection upwards along the ascending uterine vessels in a reverse approach the utero-ovarian ligaments were then sealed and cut and uterus was separated from the broad and round ligaments. Culpotomy could then be easily performed thus completing the hysterectomy safely and efficiently with minimal blood loss. Conclusion: Paradoxical camera placement may be utilized for large uteri with narrow lower uterine segments and the absence of cul de sac pathology by starting the hysterectomy inferiorly and working in the caudad direction. http://player.vimeo.com/video/103299264?autoplay=1 *** ES23-0440 Video Session 2: Operative Risk Management AN UNUSUAL (AND LIFE-THREATENING) COMPLICATION DURING RTLH – UTERUS JAMMING BETWEEN RIGHT EXTERNAL ILIAC VESSELS FOLLOWING A FALSE MANOEUVRE M. Pliszkiewicz1, B. Siekierski1, G. Stokluska1 2 1Gynaecology, Centrum Medyczne Zelazna, Warszawa, Poland Surgeons: B.P.Siekierski, MD, PhD; G.Stokluska, MD; M.Pliszkiewicz, MD; Anaesthetist: M.Golebiowska; scrub nurse: K.Falkiewicz. Location: St Sophia Ob/Gyn hospital, Warsaw, Poland. This presentation is a warning against uncontrolled movements of instruments outside the visualised surgical area in laparoscopy, particularly when instruments are being switched. Their movements should be visually followed from insertion until they reach the working area. Even experienced surgeons should follow fundamental rules of manipulation in the surgical area. The patient was a 32-year-old multipara with IB cervical carcinoma, undergoing RTLH. Surgical setting included Storz laparoscopy equipment and instruments, a Hohl uterine manipulator without screw and bar, an Erbe Vio 300D electrosurgcial unit with BiClamp® and BiSect® instruments. The patient was stabilised in a 20o Trendelenburg position. The working intra-abdominal pressure was 12 mmHg. Trocar positioning: right upper abdomen trocar (10 mm, optics), umbilibal trocar (10 mm), two lateral lower abdomen trocars (5 mm). Due to the anatomy of the patient, the optical trocar was placed to the right and above the umbilical trocar to provide sufficient working space. The event presented in this video occurred following bilateral iliac and obturator lymphadenectomy, when the uterus was moved to the right for dissection of the left ureteric canal. The video helps understand why the complication occurred and shows how the problem was solved. Fundamental principles of endoscopy surgery should be observed at all times, and instruments should never be used if their movement is not sufficiently visualised. This potentially fatal incident was solved without detriment to the patient, and no major damage occurred within the vessels exposed to uncontrolled forces, apart from limited damage to vasa vasorum of the external and common iliac arteries. The postoperative course was uneventful. http://player.vimeo.com/video/103330199?autoplay=1 *** ES23-0050 Video Session 3: Urogynaecology SYSTEMATICS IN LAPAROSCOPIC SACROCOLPOPEXY H. Magg1, D. Sarlos1, G. Schaer1 1Obstetrics and Gynecology, Kantonsspital Aarau, Aarau, Switzerland Objectives Within the last few years, laparoscopic sacrocolpopexy (SCP) has established itself as gold standard in therapy of the apical pelvic floor defect. Increasingly, this procedure is performed laparoscopically (LSCP). Current data show it is safe and objective and subjective cure rates are high. Until today, no widely accepted standard how to perform LSCP exists. Which is the ideal material for the suture? What comprises the ideal mesh? How should it be composed? What points and depth are ideal for fixation? Is it possible to leave the uterus, performing a sacrohysteropexy or should a supracervical hysterectomy be performed simultaneously? To all these important questions, there are yet no evidence based answers. 3 Methods This video demonstrates