Navigating Complex Surgical Scenarios: It’S All About Options

43rd AAGL GLOBAL CONGRESS ON MINIMALLY INVASIVE GYNECOLOGY NOV. 17-21, 2014 | Vancouver, British Columbia

Didactic: Navigating Complex Surgical Scenarios: It’s All about Options

PROGRAM CHAIR Ted T.M. Lee, MD PROGRAM CO-CHAIR Arnaud Wattiez, MD

Matthew T. Siedhoff, MD

Sponsored by

Advancing MinimallyAAGL Invasive Gynecology Worldwide

Professional Education Information

Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology.

Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The AAGL designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.

Table of Contents

Course Description ...... 1

Disclosure ...... 2

Before the Game Begins: Entry Challenges, Port Placement, and Lysis Abdominal Wall Adhesions M.T. Siedhoff ...... 3

Laparoscopy in the Obese Patient: Strategies for Success from Start to Finish M.T. Siedhoff ...... 10

Optimizing Exposure in Challenging Surgical Scenarios in Gynecologic Laparoscopy A. Wattiez ...... 15

Methodical Approach to the Obliterated Anterior Cul‐de‐Sac in the Aftermath of Prior Cesarean Section T.T.M. Lee ...... 23

Interactive Case Presentation 1 M.T. Siedhoff ...... 27

Unfreeze the Frozen Pelvis A. Wattiez ...... 28

Location Is Everything – The Challenges of Broad Ligament and Cervical Fibroids T.T.M. Lee ...... 46

Laparoscopic Repair of GI and GU Injuries – A Game Changer A. Wattiez ...... 50

Ovarian Remnant – Prevention and Management T.T.M. Lee ...... 61

Cultural and Linguistics Competency ...... 65

COMPLX-714 Didactic: Navigating Complex Surgical Scenarios: It’s All about Options

Ted T.M. Lee, Chair Arnaud Wattiez, Co-Chair

Faculty: Matthew T. Siedhoff

Although anatomy and exposure are pillars of pelvic surgery, so is the ability to quickly formulate various strategic approaches when confronted with anticipated, as well as unexpected, surgical obstacles. The obliterated anterior cul-de-sac from previous cesarean deliveries and a frozen pelvis as a result of advanced endometriosis can both present very perplexing clinical conundrums. Similarly, broad ligament or cervical fibroids and ovarian remnants can present similar difficulties. In these challenging surgical scenarios, familiarity with several approaches to dissection and various strategies to optimize exposure will be necessary to ensure safe and effective outcome. Abundant surgical video footage will be used to illustrate the strategies and techniques necessary to overcome the difficulties associated with various anatomy-distorting pathologies. Participants of this course will apply safe and effective approaches to these challenging surgical scenarios that are evidence and experience based.

Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) Articulate techniques to achieve peritoneal access in patients with extensive anterior abdominal wall adhesions as well as techniques necessary to overcome difficulties associated with laparoscopy in obese patients; 2) formulate anatomy-based strategies when confronting various challenging surgical scenarios such as frozen pelvis, cervical fibroids and dense uterine adhesions; and 3) integrate various techniques to optimize exposure during complex pelvic surgeries.

Course Outline

12:30 Welcome, Introductions and Course Overview T.T.M. Lee 12:35 Before the Game Begins: Entry Challenges, Port Placement, and Lysis Abdominal Wall Adhesions M.T. Siedhoff 12:55 Laparoscopy in the Obese Patient: Strategies for Success from Start to Finish M.T. Siedhoff 1:15 Optimizing Exposure in Challenging Surgical Scenarios in Gynecologic Laparoscopy A. Wattiez 1:35 Methodical Approach to the Obliterated Anterior Cul-de-Sac in the Aftermath of Prior Cesarean Section T.T.M. Lee 1:55 Interactive Case Presentation 1 M.T. Siedhoff Moderated by A. Wattiez, T.T.M. Lee 2:15 Questions & Answers All Faculty 2:25 Break 2:40 Unfreeze the Frozen Pelvis A. Wattiez 3:00 Location Is Everything – The Challenges of Broad Ligament and Cervical Fibroids T.T.M. Lee 3:20 Laparoscopic Repair of GI and GU Injuries – A Game Changer A. Wattiez 3:40 Ovarian Remnant – Prevention and Management T.T.M. Lee 4:00 Interactive Case Presentation 2 T.T.M. Lee Moderated by M.T. Siedhoff, A. Wattiez 4:20 Questions & Answers All Faculty 4:30 Adjourn

Page 1 PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Viviane F. Connor* Kimberly A. Kho* Frank D. Loffer, Medical Director, AAGL* Linda Michels, Executive Director, AAGL* M. Jonathon Solnik* Johnny Yi*

SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: Blue Endo, Intuitive Surgical, SurgiQuest Other: Royalties: CooperSurgical William M. Burke* Rosanne M. Kho* Ted T.M. Lee Consultant: Ethicon Endo-Surgery Javier F. Magrina* Ceana H. Nezhat Consultant: Karl Storz Other: Medical Advisor: Plasma Surgical Other: Scientific Advisory Board: SurgiQuest Kevin J.E. Stepp Consultant: CONMED Corporation, Teleflex Other: Stock Ownership: Titan Medical Robert K. Zurawin Consultant: Bayer Healthcare Corp., CONMED Corporation, Ethicon Endo-Surgery, Hologic, Intuitive Surgical

FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Ted T.M. Lee Consultant: Ethicon Endo-Surgery Matthew T. Siedhoff* Arnaud Wattiez Consultant: Karl Storz

Asterisk (*) denotes no financial relationships to disclose.

Page 2 Disclosure

I have no relevant financial relationships with the manufacturers of any commercial products and/or providers of commercial services discussed in this CME activity. Before the game begins: Neither I nor any member of my immediate family has a financial relationship or interest Entry challenges, port placement, and lysis of with any proprietary entity producing health care goods or services related to the abdominal wall adhesions content of this CME activity. My content will include reference to commercial products; however, generic and alternative products will be discussed whenever possible.

Matthew Siedhoff, MD MSCR I do not intend to discuss any unapproved or investigative use of commercial products University of North Carolina at Chapel Hill or devices. Department of Obstetrics & Gynecology Division of Advanced Laparoscopy & Pelvic Pain, Director AAGL/SRS Fellowship in Minimally In Minimally Invasive Gynecologic Surgery, Director

Objective Entry techniques

Review various entry techniques and value of various approaches for different Laparoscopic entry techniques (Review) clinical scenarios

Learn strategies for port placement, when to use what configuration Ahmad G, O’Flynn H, Duffy JMN, PhillipsK, Watson A Address methods for addressing prior surgery, abdominal wall adhesions

Entry techniques Veress entry

Systematic review: appropriate for rare outcomes Principles 28 RCTs, 4860 subjects • Have the patient flat No advantage to any one technique in terms of preventing major vascular or visceral complications • Be mindful of distance to great vessels Open-entry outperformed Veress with failed entry • Test the needle before entry Direct-trocar entry outperformed Veress with failed entry, extraperitoneal • Connect insufflation tubing before entry insufflation, omental injury • Listen / feel the cadence of the needle through layers Radially expanding access trocars: less trocar site bleeding • Confirmation: aspirate, “drop” test, pressure Very small odds ratios, not serious complications, many studies excluded • Settings: 15-20mm Hg for entry subjects w prior surgery, elevated BMI • Insufflation: time, volume, pressure Choose your technique and become proficient

Page 3 Veress entry Direct entry

Port Placement Port Placement

Page 4 Port Placement

Palmer’s point

Port Placement

Port Placement Port Placement

Page 5 Port Placement Port Placement

Port Placement

Port Placement Port Placement

Page 6 Port Placement Port Placement

Port Placement Port Placement

Angled telescope Angled telescope

Page 7 Adominal wall adhesions / prior surgery Abdominal wall adhesions / prior surgery

Slide-by test Visceral ultrasound “slide-by” test Alternate entry site Omental adhesions Uterine adhesions Open retroperitoneal spaces before addressing adherent area Small bowel adhesions Err on the side of the abdominal wall Start retroperitoneal if possible Low threshold to oversew small bowel serosa: LSC or minilap at umbilicus Triangulate

Abdominal wall adhesions / prior surgery Abdominal wall adhesions / prior surgery

Visceral ultrasound “slide-by” test: Negative test (“good slide”) Visceral ultrasound “slide-by” test • Visceral slide < 1cm to predict adhesions – Sensitivity 86% – Specificity 91% – PPV 55% – NPV 98% • Works better awake in-office than under GETA

Abdominal wall adhesions / prior surgery Abdominal wall adhesions / prior surgery

Visceral ultrasound “slide-by” test: Positive test (“bad slide”)

Page 8 Abdominal wall adhesions / prior surgery Abdominal wall adhesions / prior surgery

References

Ahmad G, et al. Laparoscopic entry techniques. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD006583 Teoh B et al. An evaluation of four tests used to ascertain Veress needle placement at closed laparoscopy. JMIG 2005; 12 (2): 153-158 Thomson A et al. Standardizing Pneumoperitoneum for Laparoscopic Entry. Time, Volume, or Pressure: Which Is Best? JMIG 2012; 19(2): 196-200 Tu F et al. Preoperative ultrasound to predict infraumbilical adhesions: A study of diagnostic accuracy. Am J Obstet Gynecol. (2005) 192, 74-9 Nezhat CH, Dun EC, Katz A, Wieser FA. Office visceral slide test compared with two perioperative tests for predicting periumbilical adhesions. Obstet Gynecol. 2014 May;123(5):1049-56

Page 9 Disclosure

I have no relevant financial relationships with the manufacturers of any commercial products and/or providers of commercial services discussed in this CME activity.

Laparoscopy in the obese: Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary entity producing health care goods or services related to the Strategies for success from start to finish content of this CME activity.

My content will include reference to commercial products; however, generic and alternative products will be discussed whenever possible.

Objective

Understand the relationship of BMI to outcomes in GYN laparoscopy Learn techniques to overcome challenges of operating laparoscopically in the obese

Background Methods

Laparoscopic hysterectomy in the obese • Prior studies: no significant differences in outcomes Retrospective cohort study Conclusions are correct Abstracted surgical data 2007 - 2011 for all LH in subspecialty division at UNC • Safe and effective procedure for obese patients Outcomes Limitations • Surgical time • Weighted toward normal-weight patients • Total OR time • Categorize obesity at BMI of 30 • EBL • Complications • Composite outcome index

Page 10 Methods Results

Composite index Result Mean Median Range • Laparoscopy generally affords good outcomes with low complication rates BMI (kg / m2) 31.4 30 18 – 70 • Little things add up (time = $) • Some complications are worse than others Uterine weight (g) 344 180 25 – 4750 • Statistically more powerful, greater precision Surgery time (min) 152 141 41 – 474

Results Results

Composite Index EBL

Results Results

Surgery time Non-surgery OR time

Page 11 Results Obesity

Total OR time

Obesity Obesity

1998 Surg Endosc (2009) 23:1995–2000

Obesity Umbilical insufflation, alternate entry site

LUQ entry Umbilical insufflation, alternative first puncture trocar site Advanced fixation / balloon-tipped trocars Hook and weight Port placement

Trendelenberg “rests” (flatten patient, let out CO2) Defer request for steep Trendelenberg until deeper steps (e.g. colpotomy, cuff closure) Score posterior colpotomy first

Page 12 Advanced fixation trocars Advanced fixation trocars

Advanced fixation trocars “Hook and weight”

Port placement Port placement

Page 13 Port placement References

Siedhoff MT, Carey ET, Findley AD, Riggins LE, Garrett JM, Steege JF. Effect of extreme obesity on outcomes in laparoscopic hysterectomy. J Minim Invasive Gynecol. 2012 Nov- Dec;19(6):701-7. Chopin et al. Total laparoscopic hysterectomy for benign uterine pathologies: obesity does not increase the risk of complications. Hum Reprod 2009. Brezina et al. Does route of hysterectomy in obese and nonobese women? JSLS 2009. O’Hanlan et al. Total laparoscopic hysterectomy: body mass index and outcomes. Obstet Gynecol. 2003

Page 14 Disclosure Optimizing Exposure in Challenging Surgical Scenarios in Gynecologic Laparoscopy

Consultant: Karl Storz Pr. Arnaud Wattiez

M. Puga, E. Faller, J. Albornoz, A. Wattiez

Pr. Arnaud Wattiez Strasbourg University Hospital – France “Exposure is the key factor of the success of the procedure” Director of Advanced courses in Gynecological Surgery IRCAD – FRANCE

A. Wattiez

University of Strasbourg, France

Why

When

Laparoscopy is a complex and time consuming How procedure

Page 15 Emphasize the advantages and minimize The Solution the inconvenients

❖ Improve vision Why ❖ Keep your assistant

❖ Retraction is restriction

Why? ❖ Comfort and confidence When

❖ Improve surgical performance

❖ Save time and energy

How

When? Before Surgery Bowel preparation During Surgery Before Surgery •5 days low residue diet •Low Enema Bowel preparation Strategy of Exposure Patient’s positioning Patient’s positioning Arms along the body Moderate flexion of the legs Coccyx at the edge of the table

Page 16 Why

Strategy of Exposure

When “We must elaborate the surgical strategy, which will influence the strategy of exposure”

How

A. Wattiez

Strategy of Exposure

1.Inspection 2.Trendelemburg 3.Uterine manipulator RESTORE THE NORMAL 4.Sigmoid attachment ANATOMY Strategy of Exposure “We must elaborate the surgical strategy, which will influence the strategy of exposure” 5.Organ suspension

A. Wattiez

1. Inspection of the abdominal cavity 1. Inspection of the abdominal cavity

University of Strasbourg, France

Page 17 2. The Trendelenburg sequence: 2. Trendelenburg

❖ Pressure 15 mmHg ❖ Trendelenburg 30º ❖ Free the pelvis ❖ Pressure 12 mmHg ❖ Trendelenburg 15º

University of Strasbourg, France

2. Trendelenburg 3. Uterine Manipulator

helps to:

Expose the pelvis by moving the uterus in any direction Identify structure & anatomical landmarks:vaginal fornices for culdotomy Reduce ureteral injuries by pulling it away from the operative field

Avoid CO2 leakage at the vaginal opening

Retrieve the surgical specimen

University of Strasbourg, France Nassif J, Wattiez A. Clermont-Ferrand uterine manipulator. Surg Technol Int. 2010

3. Uterine manipulator Reduce ureteral injuries by pulling the ureter away

Expose the pelvis by moving the uterus in any direction

University of Strasbourg, France University of Strasbourg, France

Page 18 3. Uterine manipulator 3. Uterine manipulator

Reduce ureteral injuries by pulling the ureter away University of Strasbourg, France Identify structures as the vaginal fornices forUniversity culdotomy of Strasbourg, France

Tintara model Uterine Manipulator 4. Free lateral attachments of sigmoid colon

DYE TEST

University of Strasbourg, France

4. Free lateral attachments of sigmoid colon 5. Organ Suspension

 Allows bowel retraction

 Allows access to:  Left adnexa  Left ureter  Left pararectal fossa

University of Strasbourg, France

Page 19 Ovarian suspension: straight needle ...... But not always easy

University of Strasbourg, France

Bowel suspension Suspension of ovaries: T-Lift

Sacrocolpopexy

Endometriosis

Obese patients

University of Strasbourg, France University of Strasbourg, France

Sacrocolpopexy bowel supension: Endometriosis

Page 20 Obese patients Suspension of small bowel

University of Strasbourg, France

Uterine suspension Uterine suspension: Endometriosis

 Endometriosis

 Myomectomy: Posterior myomas

 Promontofixation with subtotal hysterectomy

University of Strasbourg, France

Uterine suspension: Myomectomy Uterine suspension: Promontofixation

University of Strasbourg, France University of Strasbourg, France

Page 21 others Help in complex procedure

Conclusion

University of Strasbourg, France

Thank you for your attention

Page 22 Disclosure

Methodical Approach to the Consultant: Ethicon Endo-Surgery Obliterated Anterior Cul‐de‐Sac ‐ Aftermath of Prior Cesarean Section

Ted Lee, M.D. Director, Minimally Invasive Gynecologic Surgery Magee Womens Hospital University of Pittsburgh Medical Center

Objectives

• Describe common challenges associated with obliteration of anterior cul de sac.

• Describe anatomic based strategies, techniques and the necessary tools to address unique challenges associated dense uterine adhesions from c-sec.

Dense Uterine Adhesion to Anterior Abdominal Wall and Bladder Challenges with Uterine Adhesions

• Distortion of anatomy. Umb Trocar • Inability to place uterine manipulator in case of severe anterior abdominal wall adhesions. • Difficulty in dissecting in the right tissue plane in case of dense uterine adhesions. • Risk of bladder injury • Risk of bleeding from ascending branch of uterine artery, bleeding from bladder or abdominal wall.

Page 23 Meeting the Challenges General Surgical Strategies

• Work from known to unknown. • Perform the easy and accessible task. • Strategies • Define your anatomy and reestablish your • Techniques landmark and perspective. • Tools • Find the gateways. •Avoid direct confrontation with pathology without going through the above.

Strategies for Dense Uterine Adhesions Posterior Approach

 Secure the blood supply first before • Ligation of ascending branch of uterine artery addressing the adhesion. without developing bladder flap.  Secure cornual pedicles (uteroovarian or IP) first.  Take the ascending uterine artery from the • Excellent in patients with extensive and dense “posterior approach” uterine adhesions to the bladder and anterior  Or taking uterine from its origin from internal abdominal wall. iliac.  Find normal tissue plane at the level of cervix • Technique usually not available during open and vagina. surgery, unique to laparoscopic or robotic approach.  Stay close to the uterus becomes easier when the uterus is devasculariezed.

Port Placement Creating Landmark

• The use of uterine manipulator with • If uterine adhesion extend above ½ way colpotimizer to accentuate vaginal fornices. point between symphysis pubis and Identify vesicovaginal plane below the level umbilicus, use subxiphoid port as the of dense adhesion. visual trocar initially.

Page 24 Creating Landmark Foley Catheter Guide as Bladder Probe • Briesky Navaratil retractor can be used whenever uterine manipulator with colpotomizer can not be placed due to displacement of cervix or any other reason

Lee TM, Hur HC. New Bladder Probe Technique: A Novel Use of the Rigid Foley Catheter Guide. J Pelvic Med & Surgery. 12(5):277-279, 2006

Identification of Bladder Posterior Approach to Uterine Artery 1

• Back filled the bladder. • The use of Foley catheter guide

Posterior Approach to Uterine Artery 2 Lateral Approach to Uterine Artery

Page 25 Vesicovaginal Dissection Diagnosing Bladder Injury

• Foley bag filled with air.

• Backfill the bladder or cystoscopy.

Page 26 Disclosure

I have no relevant financial relationships with the manufacturers of any commercial Navigating complex surgical scenarios: products and/or providers of commercial services discussed in this CME activity. Neither I nor any member of my immediate family has a financial relationship or interest It’s all about options with any proprietary entity producing health care goods or services related to the content of this CME activity. Interactive Case #1 My content will include reference to commercial products; however, generic and alternative products will be discussed whenever possible.

Case one Case one

30yo g2p0 underwent fetal meninomyelocele at 25w6d Pfannenstiel laparotomy, posterior hysterotomy (anterior placenta) POD7 – new abd pain U/s: oligohydramnios, nl BPP, visible fetal bladder, pPROM ruled out At 27w4d, plan made for laparoscopy Diagnostic at least, possibly therapeutic U/s-guided amnioinfusion of dyed saline LUQ entry 4 additional ports – on either side of the umbilicus and sub-xiphoid Interrupted box sutures of 2-0 delayed absorbable suture Imbricating layer with barbed suture and fibrin sealant Discharged to Chicago POD1 Delivered at 34w with signs of preterm labor – 2012 grams

Case One

Page 27 Pr. Arnaud Wattiez Unfreeze Strasbourg University Hospital – France the Director of Advanced courses in Gynecological Surgery Frozen Pelvis IRCAD – FRANCE

R Fernandes, C Redondo, M Puga, J Alves I have the following conflicts of interest to disclose : Consultant: Karl Storz

AWattiez

Pelvis Frozen

Adhesive situation that distort the anatomy

Danger & Risks Frozen Pelvis

Danger Risks “L' Absence du Renoncement”

bowel Fistula

vascular PO Failure “Along with the the right to start, comes the obligation to ureter Conversion finish” Incomplete treatment ovarian function hemorrhage

Page 28 The Point of no return

Laparoscopy inspection Requirements Frozen Pelvis Dissection Frozen Pelvis

Start dissection Stop

requirements

Requirements Frozen Pelvis

Knowledge of… Anatomic Anatomy Follow up Keypoints Frozen Pelvis Exposure Manage emergency situations

Energy Check tests

Principles of Dissection Transversal competences Ureter Vessels Bowel

Disease

Techniques of haemostasis

Surgical Intuition

Anatomy Wall Frozen Pelvis Ureter

Ureter Adventitia Vascularization - innervation

circular - external Muscular longitudinal - internal Position

Vascularization Mucosal

Rules of dissection

Page 29 Path Wall Ureter Ureter

Ureteric arteries

superior - renal T arteries accessory - ovarian

median - common iliac Anastomotical inferior - uterine

ParietalUreter

RetroligamentorUretery

Page 30 IntraligamentoryUreter

RetrovesicalUreter Yabuki’s4th Space

Intravesic al Ureter

Page 31 AnatomyFrozen Pelvis

Vessels Dangerous areas

Vascular Anatomy

Vascular Vascular Anatomy Anatomy

Vital risk group Impaired vision group

external iliac vessels complication at level of IP ligament Sacral vessels posterior trunk of the uterine vessels hypogastric middle rectal artery inferior mesenteric artery

Page 32 Anatomy Vessels

Vital risk group Impaired vision group complication

PARAVESICAL PARAVESICAL FOSSA FOSSA external iliac vessels Sacral vessels at level of IP ligament

posterior trunk of the uterine vessels hypogastric PARARECTAL PARARECTAL middle rectal artery FOSSA FOSSA inferior mesenteric artery

Anatom Anatom y Vessels y Vessels External iliac vessels at level of IP ligament posterior trunk of the hypogastric artery

ilio lumbar sacral lateral superior gluteal

Anatomy Anatomy Vessels Vessels

inferior mesenteric artery Sacral vessels

Page 33 Anatom Anatom y Vessels y Vessels

Uterine vessels

uterine vessels

AnatomyFrozen Pelvis

Bowel vascularization Energy Superior rectal artery - inferior mesenteric Knowledge

Middle rectal artery - anterior trunk internal iliac artery

Inferior rectal artery - posterior trunk internal iliac artery

Middle sacral artery

EnergyKnowledge

energy delivered to small area

high power density cutting wave non modulated low voltage ultrassound wave cut cavitation coagulation wave oscilation between compression modulated and rarefaction high voltage

Page 34 energy delivered to large area

low power density

coagulation

energy delivered to tip of bipolar tissue between jaws energy delivered to large area

low power density high power density calculation of tissue impedance coagulation cut sound signal

blade activated by surgeon

Dissection Techniques

Principles of Restore the anatomy Individualization of structures Dissection Laparoscopic Dissection Techniques Reducing the amount of uncertainty

Better decisions - intuition Better managing of emergency situations Individualization of haemostasis

Individualized use of energy

Page 35 Dissection Techniques Divergent ForcesBubbles No irrigation

Dissection Dissectio Techniques n Techniques

Dissectio Dissectio n Techniques n Techniques The White The Divergent Line Forces

Page 36 Transversal Competences How to repair

The ureter The bowel

suturing reimplantation handsew Transversal discoid Competences circular JJ placement

Segmental resection reanastomosis

Ileostomy

vessel clamping The vessels vessel repair

when to call

1# Bowel Detachment left adnexa left ureter left pararectal fossa

Surgical strategy Frozen pelvis

1# Bowel 2# Ovaries Detachment Suspension access ovarian fossa access ureters

Page 37 2# Ovaries 3# Left Suspension Pararectal fossa left pararectal fossa

3# Left Pararectal fossa 4# RightPararectal fossa

right pararectal fossa

4# Right 5# Rectovaginal Pararectal fossa Nodule

Repeated dissection 1# surrounding the nodule

2# Attack the nodule

Page 38 5# Rectovaginal Nodule Techniques Bowelsurgery

Techniques Bowel

Superficial resection

Limited to the lesion Shaving

Mucosal skinning Nerves and vascular preservation

Avoid surrounding Bowel resection damage

Discoid resection

Segmental resection

Techniques Bowel - Mucosal Skinning

Shaving Bowelresection

MucosalSkinning

Page 39 Techniques Bowel - When

Choosing the resection Segmentary obstruction - stenosis full thickness involvement Bowelresection large - multiple lesions

significant injury

large hole

complete division

devascularization

Techniques Techniques Bowel - Segmentar Bowel - Segmentar

1 - Division of the mesentery 1- Division of the mesentery

2 - Division of the bowel Limited to the lesion Nerves and vascular preservation

3 - Extraction

abdominal

transvaginal

transrectal

Page 40 Techniques Techniques Bowel Bowel - Segmentar

2- Division of the bowel Abdominal extraction

Cranial and caudal to the lesion Enlargement of a port site incision

complications - pain, infection, incisional hernia

Techniques Techniques Bowel - Segmentar Bowel - Segmentar

Abdominal extraction Transvaginal - Transanal extraction

NOSE - Natural Orifice Specimen Extraction Sistematic review of 23 130 articles patients 46,15% of cases of deep endo showed feasibility and benefits

Diana M, et al; Colorectal Disease 2011

Techniques Techniques Bowel - Segmentar Transvaginal extraction Bowel - Segmentar

Transanal extraction

Page 41 Techniques Bowel - Discoid

Discoid Bowelresection

Techniques Techniques Bowel - Discoid Bowel - Discoid

Techniques Conservative - discoid

aim - reduce the volume of the nodule before the discoid resection

volume of nodule to extract before shaving

volume of nodule to extract after shaving

Page 42 BladderNodule

access paravesical fossa

surround the nodule

aim for mucosal Techniques skinning BladderNodule

Safety Tests Bowel Bladder Ureter

Gas Blue Test Test

Page 43 Gas Double J Test - failure Stent

Bladder Test

Followup Frozen pelvis

Followup

Thank you for your attention! Follow upFollow up

VIDEO Challenge uneventful winnersproject.com propension to normality

daily evolution

easy second look See you in Greece!!!

Page 44 the rectovaginal nodule

Deep Endometriosisthe rectovaginal nodule Deep Endometriosis

the rectovaginal nodule the rectovaginal nodule

Page 45 Disclosure

Location Is Everything – The Consultant: Ethicon Endo-Surgery Challenges of Broad Ligament, Cervical Fibroids and other Low Lying Fibroid

Ted Lee, M.D. Director, Minimally Invasive Gynecologic Surgery Magee Womens Hospital University of Pittsburgh Medical Center

Objectives Challenges of Low Lying Fibroids

• Describe common challenges associated with broad ligament fibroid, cervical fibroid and other low lying fibroid. • Difficulty with fitting uterine manipulator • Lack of mobility. Lack of space • Describe anatomic based strategies, techniques and the necessary tools to address unique • Difficulty with exposure challenges associated with low lying fibroids. • Distortion of anatomy. • Increased vascularity

Meeting the Challenges General Surgical Strategies

Page 46 Absolute Principle on Operating on General Strategies for Hysterectomy Large Fibroid

• Maintain a hemostatic operative field especially in  Always Take the Easier Pedicles the beginning.  Do not tackle the hard pedicle without • Bleeding is the biggest enemy of laparoscopy. securing the easier pedicles • Visualization is quickly impaired even with small  Can always take the uterovarian and go back amount of bleeding. for the IP. • Poor visualization leads to more bleeding and more  Can always take one IP (sacrifice one ovary) if uterovarian is difficult complications.

Page 47 Ureter at Risk Topics to cover

• Not knowing the location of ureter halts the • Uterine artery ligation from origin progression of surgery for the careful and invites • Uterine artery ligation from ascending branch/anterior disaster for the careless. approach/modified anterior approach • Easy pedicles first • Ureteral stents let you know the course of the • Use of scheiden. ureter so you can zip along when you are away • Port placement. from the ureter and refine your dissection as you • Use of angle scope get closer • Use of ureteral stent • Amputation of cervix • Bleeding is the enemy

Creating Landmark Port Placement for Hysterectomy for Large Fibroid

• Briesky Navaratil retractor can be uses whenever uterine • Higher (subxiphoid) visual port placement is used manipulator with mostly to facilitate access to upper pedicles (IP or colpotomizer can not Uterovarian) and for ease of morcellation when the be placed due to fibroid uterus is close to umbilicus or above. displacement of cervix or obstruction from • Uterine artery location is unchanged (still low) fibroid. regardless of the size of fibroid uterus.

Page 48 Colpotomy Facilitated with Amputation of Cervix to Facilate Colpotomy Vaginal Retractor

Anterior Approach to Uterine Artery 1 Anterior Approach to Uterine Artery 2

Lateral Approach to Uterine Artery 1 Lateral Approach to Uterine Artery 2

Page 49 Laparoscopic Repair of GI and Disclosure GU Injuries A Game Changer

• Consultant: Karl Storz A Wattiez

G. Centini, J Castellano, C Meza, K Afors, R Murtada,

Bowel Complications Bowel Complications Generalities Generalities

Lack of Information: few report on mechanism of injury Vascular & Bowel : more than 70% of all the complications few report on localization of injury

Incidence: overall rate 0,36% (105 / 29532) Probably Underestimate: unreported near miss events

perforation 0,22% (66 / 29532) injury without consequences

van der Voort M Br J Surg 2004

Misdiagnosis: 10 -50% within he first 24h Chapron at al. Hum Rep, 1999 … 3,6% mortality

Bhoyrul S, et al., 2001

Bowel Complications Bowel Complications Localization Mechanisms: When and How They Occur

• Setting-up Injury: … 32.1 - 41.8% Entry Techniques Second Trocar Insertion

• Operative Injury: …more than 50% Tissues Manipulation Thermal Injury

van der Voort M Br J Surg 2004 Chapron at al. Hum Rep, 1999 Dissection Opposite trend comparing general and gynecological surgery

Gynaecological General Surgery Surgery

Small Bowel 55% 34%

Large Bowel 38% 48%

Chapron at al. Hum Rep, 1999 van der Voort M Br J Surg 2004

Page 50 Bowel Complications Bowel Complications Risk Factors Sometimes The Surgeon Have To Deal With Bowel Previous Surgery

• Increase the risk of bowel injury X 10

• Leading cause… adhesions

• Mainly related with the insertion of the first trocar

Bowel Complications Bowel Complications How Can we Decrease the Incidence? Risk Factors Advanced Surgery Experience Endometriosis, Frozen Pelvis, PID, Oncology The rate increase according with the complexity of the procedure

Bummer at al. Hum Repro, 2008

Cut-off in Laparoscopic Hysterectomy Endometriosis Intra-operative Post-operative < 30 > 30 < 30 > 30 The risk Increase with: radicality of surgery Major Complication 1.3 % 0.5 % Bowel Complication 1.7 % 0.2 % Minor Complication 11.7 % 6.5 % number of organs involved Overall Rate 4.2 % 0.5 % Overall Rate 12.9 % 7.0 % bowel treatment Surgeon without experience x 2 - 8 Algassen at al. Obstet Gynecol 20

Bowel Complications Bowel Complications Prevention: Mechanical Injury Prevention Entry … 30 - 40 % • Taylor the way to enter Assess of previous surgery…

• Instrumentation knowledge and selection Adhesions High Risk No Surgery 0.68% 0.42 % • The power of vision Laparoscopy 1.6% 0.8 % Pfannenstiel 19.8 6.47 % • Electricity Midline Incision 51.7 31.86 % Audebert at al. Fertil Steril 2000

• Safety Test … in case of midline incision don’t choose the umbilicus

Taylor the way to Enter

Page 51 Bowel Complications Bowel Complications Prevention: Mechanical Injury Prevention: Mechanical Injury

Dissection … 46% The P wer of Vision

Bowel Complications Bowel Complications Prevention: Mechanical Injury Prevention: Mechanical Injury Grasping Forceps … 1.1% Laparoscopic Grasper = Less Feedback Instrument Selection Handle with care

Way to Be Applied Laparoscopic Grasper = Less Feedback

Bowel Complications Bowel Complications Prevention: Thermal Prevention: Thermal

Electrosurgery … 10.7 % of bowel complications Causes … 2 - 5 per 1000 of all the complications Accidental Activation … 0.6 - 3 per 1000 leading to perforation Wu MP at al. J Am Surg, 200 Insulator Failure Direct Coupling

Page 52 Bowel Complications Bowel Complications Diagnosis Diagnosis: Time

Misdiagnosis increase the mortality rate Time of Presentation: Mean time 4 Days with a rage of 0 -23 Mechanical Injury 1.4 (0 - 4) 15 - 50% were unrecognized for at least 24h Thermal Injury 10.4 (0 - 38) mortality % mortality

Stovall T. Uptodate 2012 The risk of bowel complication decrease after 7 days time of recognition Bhoyrul S, et al., 2001

Chapron at al. Hum Rep, 1999

Bowel Complications Bowel Complications How to Increase Intraoperative Diagnosis How to Increase Intraoperative Diagnosis

Direct Visualization: If some doubt arise perform a Bowel Integrity Test … abdominal cavity exploration at the end of the procedure GAS DYE

Bowel Complications Bowel Complications How to Increase Intraoperative Diagnosis Post-operative Diagnosis

Positive Tests Clinical Evaluation:

• Excessive Pain +++

• Ileo, abdominal defense, nausea, vomit and tachycardia

• Instrument Exam: Ultrasound, Rx, CT Scan

Not diagnostic Instrumental exam …

Easy second-look laparoscopy

Page 53 Bowel Complications Bowel Complications Post-operative Diagnosis What to Do

• Expert equipe Options • Suture • Laparoscopy ? • …Yes and then laparotomy, if needed • Resection and reanastomisis

• Ileo/Colonstomy

• Washing and drainage

How to choose: • intra or post operative diagnosis (inflammation)

• surgeon experience

• mechanisms

• patient’s characteristics

Bowel Complications Bowel Complications What to Do: Deep Injury What to Do: Superficial Injury

• Separate or figure-of-eight stitches • Separate or figure-of-eight stitches • Extramucosal?…doesn’t matter

• Extamucosal single layer • Single or double layer

• 3 - 0 resorbable monofilament • 3 - 0 resorbable monofilament

Bowel Complications Bowel Complications What to Do: Anastomosis leakage What to Do: perforation with post-op Diagnosis • Suture +/- Colostomy • Double/Single Layer Separate stitches + Ileo/Colostomy • Safety Test • Resection and anastomisis

• Extramucosal?…doesn’t matter

Page 54 Bowel Complications What to Do: postoperative care Ureteral Injuries

• Full thickness Injury Antibiotic Therapy

• Lesion < 1cm No Diet Restrictions

• Lesion > 1cm 3 days low residual diet Gradual reintroduction to normal alimentation

Development of the Paravesical Fossa Bladder Suturing

Safety tests Postoperative Cystoscopy

Page 55 Postoperative Voiding Problem

global risk 10%

The problem of urinary

retention… Postoperative Safety

• Leave catheter in place for 10-14 days if bladder opened

• Consider clamping regime just prior to removal

• Cystography: to check integrity

UreterUreter complications FactsFacts

• 70% ureteral injuries are diagnose postoperatively

UreterUreter • 90% Most ureteral injuries happen during complications gynecological procedures

• But NOT ONLY by gynecologists ureter injuries 1% • 97% are iatrogenic

Ostrzenski A1, Radolinski B, Ostrzenska KM. review of laparoscopic ureteral injury in pelvic surgery.Obstet Gynecol Surv. 2003 Dec;58(12):794-9.

Page 56 Ureteric Endometriosis Ureteric injuries

Direct • Mechanical • Thermal Indirect • Devascularization Combination

General Strategy Action: Rules of dissection Adopt a strategic approach & prevent complications

1. Awareness + understanding • Know the anatomy Superior Ureteral - 2. Adhesiolysis Renal Artery • Handle with care Accessory Ureteral - 3. Exposure Ovarian Artery

4. Consider ureterolysis • Preserve the adventitia

Median ureteral - 5. Re-evaluation - consider need for JJ stents Common Iliac Artery • Minimize the use of energy 6. Safety checks Inferior Ureteral - • Follow the ureter till the channel Uterine Artery

Ureteric Recognition Mobilization of the Sigmoid

Page 57 Dissection Don’t Forget to Complete the Ureterolysis

Ureteral Devascularization Ureter • Double J stent and suture of the adventitia

JJ Catheter Size Suture Edges Mechanical injury plasty-edges + suture Disposition end to end anastomosis Deppness re emplantation

Deepness Thermal injury JJ Stent Size Suture resection and anastomosis

UreterUreter complications Ureteral Anastomosis Ureteral Transection

• Double J stent and suture 4 stitches 5/0 monofilament (3, 6, 9, 12)

Page 58 UreterUreter complications Ureteric Resection Ureteral Laceration

• Double J stent and suture with 5/0 monofilament

Ureteric Fistula - delayed complication Intraoperative Diagnosis Enhancing

• Check for movement: A burned ureter doesn't vermiculate

• Control the color: A bluish aspect means devascularization

• Perform a cystoscopy: no outflow means obstruction

Check the Final Aspect Knowledge of Instruments: Thermal Injuries

Page 59 Postoperative Safety

• Remove double J stents after 6-8 weeks:

• In cases of ureteroneocystotomy Thanks for your attention

• Partial cystectomy close to trigone

• Ureteral anastomosis or laceration

Bowel Complications

Thanks !!

Page 60 Disclosure

Consultant: Ethicon Endo-Surgery Ovarian Remnant Syndrome: Prevention and Treatment and Treatment

Ted Lee, M.D. Director, Minimally Invasive Gynecologic Surgery Magee Womens Hospital

1 2

Ovarian Remnant : Definition Common Risk Factors

• Retention of ovarian tissue with prior • Endometriosis documentation of prior salpingoophrectomy.

• Previous surgeries

•PID

3 4

Ovarian Remnant: Initial Clinical Presentations Ovarian Remnant: Symptoms

Studies Mayo 2005 Mayo 2007 Magee 2011 Studies Mayo 2005 Magee 2011 Pelvic Pain 66% 96% (29/30) LLQ pain 55.2% (16/29) Pain 48% (89/186) 90 % (18/20) 96 % (29/30) RLQ pain 27.6% (8/29) Lower abdominal pain 17.2% (5/29) Mass 57% (105/186) 10 % (2/20) 4% (1/30) Dyspareunia 26% 56.7% (17/29) Dyschezia 6% 36.7% (11/29) Dysuria 7% 20% (6/29)

Kho RM, Magrina JF, Magtibay PM. Pathologic findings and outcomes of a minimally invasive approach to ovarian remnant syndrome. FertilSteril. 2007;87

Magtibay PM, Nyholm JL, Hernandez JL, Podraz KC. Ovarian remnant syndrome. Am J Obstet Gynecol. Magtibay PM, Nyholm JL, Hernandez JL, Podraz KC. Ovarian remnant syndrome. Am J Obstet Gynecol. 2005;193 2005;193

Arden D. Lee TM Laparoscopic Excision of Ovarian Remnants: A Retrospective Cohort Study with Long- Arden D. Lee TM Laparoscopic Excision of Ovarian Remnants: A Retrospective Cohort Study with Long- Term Follow-Up. J Min Inv Gyne 2011, 18 (2) Term Follow-Up. J Min Inv Gyne 2011, 18 (2),

5 6

Page 61 Ovarian Remnant: Patient Characteristics Ovarian Remnant after Unilateral Salpingoophrectomy

Studies Mayo 2005 Nezhat 2005 Mayo 2007 Magee 2011 Age (years) 37.6 38.7 48 38.6 Previous 1.4 2 2.7 2.5 Studies Nezhat 2005 Magee 2011 Laparotomy Previous 0.77 2 1.4 1.9 Laparoscopy 30% (19/64) 20% (6/30) Previous 35% 15.6% 0% 17% Surgical Attempts

Kho RM, Magrina JF, Magtibay PM. Pathologic findings and outcomes of a minimally invasive approach to ovarian remnant syndrome. FertilSteril. 2007;87

Magtibay PM, Nyholm JL, Hernandez JL, Podraz KC. Ovarian remnant syndrome. Am J Obstet Gynecol. Arden D. Lee TM Laparoscopic Excision of Ovarian Remnants: A Retrospective Cohort Study with Long- 2005;193 Term Follow-Up. J Min Inv Gyne 2011, 18 (2),

Arden D. Lee TM Laparoscopic Excision of Ovarian Remnants: A Retrospective Cohort Study with Long- Nezhat C, Kearney S, Malik S, Nezhat C, Nezhat F. Laparoscopic Term Follow-Up. J Min Inv Gyne 2011, 18 (2) management of ovarian remnant. Fertil Steril. 2005;83

Nezhat C, Kearney S, Malik S, Nezhat C, Nezhat F. Laparoscopic management of ovarian remnant. Fertil Steril. 2005;83

7 8

Ovarian Remnant: Diagnosis Location of Ovarian Remnant

Studies Mayo 2005 Nezhat 2005 Magee 2011

Ultrasound 93% 80.4% (US &CT) 89.6% Location Magee 2011

Left 60% (18/30) Premenopausal 69% NA 59.1% FSH (<30 IU/dL) Right 23.3% (7/30) Premenopausal E2 63% NA 70.6% Bilateral 16.7% (5/30) (>35 pg/mL)

Magtibay PM, Nyholm JL, Hernandez JL, Podraz KC. Ovarian remnant syndrome. Am J Obstet Gynecol. 2005;193

Arden D. Lee TM Laparoscopic Excision of Ovarian Remnants: A Retrospective Cohort Study with Long- Term Follow-Up. J Min Inv Gyne 2011, 18 (2), Arden D. Lee TM Laparoscopic Excision of Ovarian Remnants: A Retrospective Cohort Study with Long-Term Follow-Up. J Min Inv Gyne 2011, 18 (2), Nezhat C, Kearney S, Malik S, Nezhat C, Nezhat F. Laparoscopic management of ovarian remnant. Fertil Steril. 2005;83

9 10

Location of Ovarian Remnant Complexities of Ovarian Remnant Surgeries

Studies Nezhat 2005 Magee 2011

Enterolysis 90.6 % (58/64) 90.0% (27/30)

Uretolysis 73.4% (47/64) 93.3 % (28/30)

Arden D. Lee TM Laparoscopic Excision of Ovarian Remnants: A Retrospective Cohort Study with Long- Term Follow-Up. J Min Inv Gyne 2011, 18 (2),

Nezhat C, Kearney S, Malik S, Nezhat C, Nezhat F. Laparoscopic management of ovarian remnant. Fertil Steril. 2005;83

11 12

Page 62 Intraop Complications/Complexities of ORS Surgeries Post-op Complications of ORS Surgeries

Studies Mayo 2005 Nezhat 2005 Magee 2011 Studies Mayo 2005 Nezhat 2005 Magee 2011 Bowel injury with primary 5% 13.3% (4/30) Vesicovaginal 0 1.6% (1/64) 0 repair Fistula Bowle injury with primary 7.8% (5/64) 10% (3/30) Ureteral 2% 0 0 resection Obstruction Bladder Injury with primary 2% 1.6%(1/64) 6.7%(2/30) DVT or PE 2% 0 0 repair Ileus or partial SBO 8% 0 0 Ureteral injury/repair 1% 1.6 (1/64) 0 Transfusion 12% 0 0 Transfusion 12% 0 0 Conversion NA 3.1% (2/64) 0 Conversion NA 3.1% (2/64) 0 Recurrences/ 1% 12.5% (8/64) 0 Persistence Recurrences/ Persistence 1% 12.5% (8/64) 0 Reoperation for 9% 7.8 %(5/64) 6.6% (2/30) Pain or Remnant

13 14

Finding and Dissecting the Ureter Finding and Dissecting the Ureter

Preventing Ovarian Remnant Preventing Ovarian Remnant

Page 63 Videos on Ovarian Remnant Prevention Videos of Laparoscopic Resection of Ovarian Remnant

19 20

Conclusion

• High index suspicion is essential for the diagnosis of ovarian remnant in patients with high risk factors. • Imaging and/or premenopausal hormones will detect close to 100% of ovarian remnant. • Ovarian remnant is a surgically challenging condition even in the best of hands. • Risk of visceral injury and its associated repair is high. Discussion of the specific risks should be carefully documented in the inform consent process. • Adherence to the anatomic approach to salpingoophrectomy will minimize the risk of ovarian remnant. • Laparoscopic resection of ovarian remnant is safe and feasible in the majority of cases.

Page 64 CULTURAL AND LINGUISTIC COMPETENCY

Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians (researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

US Population California Language Spoken at Home Language Spoken at Home

Spanish English Spanish

Indo-Euro English Indo-Euro Asian Other Asian

Other 19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the program, the importance of the services, and the resources available to the recipient, including the mix of oral and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies, including those which provide federal financial assistance, to examine the services they provide, identify any need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every California state agency which either provides information to, or has contact with, the public to provide bilingual interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills. A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

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