Abstracts of video presentations
Abstracts of video presentations
0 Laparoscopically repaired vaginal evisceration after postpartum hysterectomy N. Waters, S. Chachan, K. Morton, A. Kent Royal Surrey Hospital , Guildford , UK
1 Prenatal and Gynecologic Diagnostic Center , Thessaloniki , Greece
2 Saint Luke's Hospital , Panorama, Thessaloniki , Greece
3 Laparoscopic bilateral transposition of the ovaries: demonstration of a technique and intraoperative events S. Tzitzimikas
S Protract, is possibly a safer alternative during the laparoscopic ovarian transposition, and may offer better tissue viability. Bilateral ovarian transposition is recommended. The surgical technique described above seems to simplify the procedure along with time saving. In case of intraoperative vascular incidents, a post-operative ultrasound study offers an evaluation of ovarian vascular integrity.
Aim: To present, for educational purposes, a laparoscopic
technique of ovarian transposition during surgical treatment
of cervical cancer, as well as concurrent intraoperative events.
Materials and methods: Between November 2004 and
March 2008, four cases of laparoscopic transposition of the
ovaries have been performed, in the context of surgical
staging and/or treatment of squamous cell cervical cancer in
reproductive age women. One of these cases is selected for
presentation, due to concurrent intraoperative events such as
mesosalpingian arterial bleeding, unsuccessful maneuvers of
electrocoagulation resulting in inadequate hemostasis.
Results: In all cases, surgery was completed laparoscopically,
without any conversion to laparotomy. Ovarian function was
preserved in all cases. Ultracision and EnSeal were used
during the adnexal dissection and the adnexal pedicle’s
preparation. The ovarian fixation to the paracolic spaces was
realized with the help of a pig-tailed titan nail (Protract, Tyco),
instead of suturing. The adnexal dissection and fixation to the
lateral peritoneal wall, using the mesosalpinx or the ipsilateral
oviduct instead of the ovary and /or its vascular pedicle, is
described. A correction of vascular pedicle torsion follows.
During the techniques’ demonstration there is a correction of
the under tension fixation above the cecum instead of a trans
mesenterian approach, in order to avoid a bridge defect, and
prevent post-operative ileus. An unsuccessful haemostatic
maneuver of mesosalpinx’s bleeding, using Ultracision ACE,
EnSeal and bipolar coagulation, is also described. After the
final surgical review of the abdomen, and the radiological
imaging of the fixation’s position, an ultrasound scan
confirmed the left adnexal vascular integrity.
Conclusions: The use of the mesosalpinx or the proper
oviduct for adnexal fixation to the abdominal wall using
Introduction: Vaginal vault rupture with extrusion of the
intraperitoneal contents is a rare complication following
hysterectomy. In our video we present laparoscopic findings
and demonstrate our laparoscopic repair technique. There is a
brief literature review on the incidence of evisceration and
mode of hysterectomy. The first case of evisceration was
described by Hyernaux in 1864. To date the highest incidence
is associated with total laparoscopic hysterectomy. The
technique to close the vaginal cuff is not different from
traditional closure and usage of thermal energy is thought to
be the predisposing factor (Walsh et al. 2007; Nezhat et al.
1996). Interestingly, this is the only case report of this
complication associated with postpartum hysterectomy with
the first postoperative intercourse as a trigger event.
Case: A 34-year-old G4P3 lady underwent emergency
postpartum hysterectomy to control the postpartum
haemorrhage on day 10 after vaginal delivery at 34 weeks. The
postoperative recovery was uneventful and the patient was
discharged on day 5. She was asymptomatic until 3 months
postpartum when there was sudden protrusion of the mass
from the introitus. This was associated with abdominal pain
and mild nausea, however speculum examination was not
remarkable. The protrusion occurred straight after the first
intercourse since the time of delivery. An EUA and
laparoscopy was performed 48 h after admission and a
complete dehiscence of vaginal vault was noted. The bowel
and omentum was adherent to the vaginal vault. There was
no haematoma or pelvic collection. The vaginal edges did
not look necrotic. Laparoscopic adhesiolysis was performed,
the edges were trimmed and closed with 2.0 Vicryl using
intracorporeal suturing technique. The patient recovered well
and advised to abstain from sexual intercourse until vaginal
vault is healed and a gynaecologist has given “clearance”.
Conclusion: Sudden occurrence of vaginal prolapse and
abdominal pain in a young lady associated with intercourse
with of recent history of hysterectomy should alert a clinician
to consider vaginal evisceration. The advantages of
laparoscopic repair are the ability to visualise the condition of the
viscera and vaginal vault and easiness of repair.
Laparoscopic resection of the mesh sacrocolpopexy—
videodemonstration of case report
Na Homolce Hospital Dept of Operative Gynaecology and
Minimally Invasive Surgery, Prague, Czech Republic
Introduction: The surgery of pelvic organ prolapse is
associated with development of new techniques, approaches
and especially of mesh implants in prosthesis surgery. The
laparoscopic mesh repair of urogenital prolapse belongs to
the advanced laparoscopic surgery with commonly low
complications rate. Mesh protrusion approximately in 2%,
postoperative urinary urgence in 4% and severe hemorrhage
in ca. 1%.
Methods: We present a case report of 48-year-old woman
who underwent 2 years ago the laparoscopic
multicompartmental mesh repair for urogenital prolapse after LAVH
hystesrectomy performed in 1995. The indication for the
resection of sacrocolpopexy was the presacral and pelvic
pain due to periapical tissue retraction.
The sequentional video demostrates initial intraabdominal
finding,the terapeutic plan and surgery scheme. Following
part shows the surgery with resection of the mesh presacraly
and from the apex of vagina. The surgery was without any
complication and the patient without any problems.
Discussion: Our approach demonstrates the possibilities
and advantages of laparoscopic approach in solving of this
We present a Video on laparoscopic ureteroneocystostomy
with psoas hitch for the treatment of infiltrative ureteral
After eradication of deep endometriosis and resection of
terminal part of the right ureter, mobilization of the bladder
and psoas hitch were performed to obtain a non refluxing
tension free ureter anastomosis. For performing this
extravesical transperitoneal ureteral reimplantation intracorporeal
suturing techniques were used.
We treated 15 patients with this technique without
intraoperative or postoperative severe complications.
Transperitoneal laparoscopic extravesical ureteroneocystostomy
with vesicopsoas hitch seems to be safe and feasible
operation for distal ureteral stricture due to endometriosis.
We describe a laparoscopic approach as a new way of
excising rectal endometriosis that can be used without
opening any part of the rectum intraabdominally. The video
showed that the ureters were stented prior to laparoscopic
surgery. This was followed by bilateral ureterolysis and
radical resection of the pelvic endometriosis. The rectum
was reflected off the back of cervix before dissection of the
mesorectum off the rectum using a Harmonic Scalpel was
carried out. The bowel was divided below the level of the
disease using laparoscopic stapling device EndoGIA 60.
The proximal end of the diseased bowel was exteriorised
through the anterior abdominal wall through a 3 cm
suprapubic incision. It was carefully resected above the diseased
level and the anvil of the CEEA 31 was inserted and secured
with sutures. This segment was then reinserted into the pelvis.
Closure of the 3 cm incision performed prior to the next step
of the operation to ensure pneumoperitoneum. The distal
end of the rectal stump was reanastomosed with the using
the CEEA device anally. The anvil was inserted into the
distal end under direct laparoscopic vision. Testing of bowel
anastomosis was carried out with air test.
Laparoscopic ureteroneocystostomy with psoas hitch
L. Minelli1, L. Mereu1, P. Pomini1, G. Grosso2
1Ospedale Sacro Cuore, Negrar, Verona, Italy, 2Ospedale
Pederzoli, Peschiera, Italy
Laparoscopic extravesical ureteroneocystostomy is an
infrequently described technique.
Introduction: The presentation is aimed to show the
workup and treatment of bladder endometriosis.
Methods: A monozygotic pair of twin sisters presented
with an almost identical spread of endometriosis involving
deep infiltration in the bladder. The work-up existing of
ultrasound, IntraVenous Pyelography, MRI-scan and
diagnostic cystoscopy with laparoscopy is presented. Next the
laparoscopic excision of the lesions was identical for both
sisters and is summarized in a 7.5 min video.
Results: Genetic factors may play an important role in the
expression and presentation of endometriosis. Bladder
endometriosis is rare, estimated to occur in about one percent of the
patient population. In monozygotic twins endometriosis often
show resemblance but the almost identical presentation of
bladder endometriosis as shown here, have not been reported
before. The harmonic scalpel gave the opportunity to excise
laparoscopically the lesions almost bloodless in both sisters
with short hospitalization and complete recovery of the
micturation pain during menstruation.
Discussion: Deep endometriosis of the bladder is a rare
but distressing presentation of endometriosis that can be
treated by laparoscopic excision in the hands of
experienced laparoscopic surgeon.
A truly keyhole colposuspension
A. Kent, P. Barton-Smith, N. Waters
Royal Surrey County Hospital, Guildford, Surrey, UK
Laparoscopic colposuspension has been shown to be at least
equivalent to open colposuspension in terms of success in
treating stress incontinence (Kitchener et al., BJOG 113
(9):1007–1013, 2006). It is still criticised in terms of operating
time and hospital stay.
We would like to demonstrate a truly keyhole approach
to laparoscopic colposuspension which dramatically reduces
the operating time allowing operations to be carried out as a
daycase or extended daycase procedures. The sutures and
suturing techniques are similar to those used in the open
operation for which there is comprehensive long term data.
There is the added advantage in the reduction of anterior wall
This video demonstrates the key steps of the procedure. A
transperitoneal approach is utilised and two small windows
(keyholes) opened directly onto the ileopectineal ligaments
using the Harmonic ACE, with subsequent dissection
of the paravaginal space to the ‘white’ of the vagina.
Complete dissection of the Cave of Retzius is not required.
It is important to open the thin fascial membrane covering
the ligament which allows entry into the correct layer
and blunt dissection of the space, aided by the
intraabdominal pressure (18 mmHg) and a10 mm cherry
dissector. It is helpful for the surgeon to palpate the
lateral fornices but this can be achieved by the assistant
using a probe.
Two ethibond sutures are then placed on each side
between the ileopectineal ligaments and paravaginal tissues.
These are tied in turn using external throws and tensioned
using a knot pusher or Babcock type forceps. The
peritoneal openings are then closed with a figure of 8 vicryl
1. Kitchener HC, Dunn G et al. Laparoscopic versus open
colposuspension—results of a prospective randomised
controlled trial. BJOG 2006; 113(9): 1007–13.
Laparoscopic cornuotomy using a temporary
tourniquet suture and diluted vasopressin injection
in interstitial pregnancy
D.-S. Eun, Y.-S. Choi, K.-S. Shin, J. Choi
Eun Hospital, Kwang-Ju, Korea, Republic of
Objective: This study evaluated the efficiency of
laparoscopic cornuotomy in interstitial pregnancy and its effects
on anatomical reproductive capacity.
Design and method: This was an uncontrolled
retrospective case review of eight patients with interstitial pregnancy
who had undergone laparoscopic cornuotomy.
Laparoscopic cornuotomy was performed using a temporary tourniquet
suture and the injection of diluted vasopressin around the
cornual mass. The tourniquet suture was removed
completely after repairing the cornu. The uterotubal patency and
cornual integrity were evaluated using a
hysterosalpingogram (HSG) and magnetic resonance imaging (MRI),
Results: The estimated blood loss was 50 ±22 ml (mean ±
SD) and the operating time was 58±16 min. The serum
βhCG level returned to normal range about 4 weeks or so
postoperatively in all patients. There were no major
postoperative complications, such as hemorrhage. Four of six
patients had excellent uterotubal patency on the affected side,
while HSG revealed tubal occlusion of the affected proximal
cornu in two patients. There was no significant difference in
cornual thickness compared with the unaffected cornu in each
patient and there were no remarkable defects in the cornual
contour on MRI, although there was no statistical significance
owing to the small sample size (p=0.49, paired t test).
Conclusions: The temporary tourniquet suture is a safe and
effective method for hemostasis and the suture enabled the
performance of laparoscopic cornuotomy in interstitial
pregnancy. We believe that cornuotomy has the advantage
Objective: Ovarian pregnancy is a rare event. It accounts
for about 1–3%of all ectopic pregnancies. Risk factors
include previous pelvic inflammatory disease ‘IUCD use’
endometriosis and assisted reproductive technologies.
Treatment of ovarian pregnancy usually requires
oopherectomy or wedge resection.
Design and methods: A 32-year-old female who used
IUCD for contraception, her second pregnancy proved to be
ovarian ectopic pregnancy’ her B-HCG level was 2322, and
ultrasonographic imaging helped to put the definite
diagnosis. Laparoscopic ectopic pregnancy extirpation was
done by using single laparoscopic trochar entry.
Results: After 1 week of the operation B-HCG level was
<10’ and the patient was discharged at first postoperative day.
Conclusion: Ovarian ectopic pregnancy can be treated
laparoscopically with single trochar entry, and medical
management with methotrexate may be an option if there is
persistent trophoplastic tissue after laparoscopy. If future
fertility is desired wedge resection considered.
Oopherectomy should be reserved for cases of advanced gestations.
Genital prolapse presents a challenge in nowadays surgery.
With the introduction of new and costly techniques the old
ones demand a reappraisal. The data from retrospective
analysis of 15 laparoscopic promontofixations (PMF) were
studied. The indications for the operation were: uterine
myoma + genital prolapse (nine), genital prolapse and
prolapse of cervical stump (four), prolapse of vaginal stump
(two). The mean age was 57.8±7.93, from 45 to 69 years.
Reproductive function: all patients had deliveries: 1–3
(27.3%), 2–8 (72.2%). All patients had abortions from 2 to
8, mean 4.5±2.1. Three (27.3%) patients had missed abortions
from 1 to 3. The duration of postmenopause was from 1 till
23 years, mean 9.4±7.8. The duration of prolapse—1.5–
10 years, mean 4.5±2.1. As a first step of the operation eight
patients suffered panhysterectomy, three cervical stump
extirpation, three bilateral adnexectomy (patient suffered
vaginal hysterectomy previously). Mesh was fixed to cervical
stump in one patient. In all other patients mesh was sutured
typically to levator muscles and vagina. PMF followed all
operations as a second step. The duration of the operation
varied from 120 to 180 min, mean 151±23.74 min. Mean
blood loss 200 ml. Cervical stump extirpation was the most
challenging part of the whole operation (105 min). Eight
patients were cardiovascularily compromised. There were no
intraoperative complications. Patients were discharge on
seventh postoperative day. After 6 months of observation
two erosions of vagina was revealed with small bleeding in
one patient. This patient demanded mesh excision. One
patient after cervical stump fixation required second operation
because of relapse. After 6 month 12 patients estimated the
postoperative results as excellent, two as satisfactory, one as
Conclusion: Laparoscopic promontofixation presents
technical challenge for the surgeon but gives excellent results.
Laparoscopic myomectomy and abdominal cerclage
Brigham and Women’s Hospital, Boston, MA, USA
We present a case of a concurrent laparoscopic
myomectomy and laparoscopic abdominal cerclage in a patient with
a history of cervical incompetence and a previously failed
vaginal cerclage. We present the usage of a novel bidirectional
barbed suture for the myometrial closure. The monofilament
suture slides easily through tissue, but the barbs prevent any
backward slippage, thereby preventing a secure closure and
excellent hemostasis. We routinely use this suture for
myometrial closure as well as vaginal cuff closure during a
total laparoscopic hysterectomy.
Pelvic and/or paraaortic lymphadenectomy is considered
the standard procedure to perform surgical staging of
gynaecology cancer and evaluate the extent of the disease.
It permits to adjust the radiotherapy and evaluate the need
of chemotherapy with the minimal morbidity.
However, since some years ago, some studies conclude
with enough scientific evidence the value of the lymph
node dissection as a therapeutic weapon on gynaecological
tumors: Advanced cervical cancer, endometrial cancer
FIGO stage III C and ovarian cancer specially in those
cases with macroscopically lymph node disease.
Considering this evidence, it could be established a
group of indications of the pelvic/paraaortic debulking:
–Locally advanced cervical cancer not subsidiary of surgery
and suspicion of macroscopic lymphadenopathy.
–FIGO stage III C endometrial carcinoma
–Vulvar cancer with pelvic or inguinal lymph node
We show in the video surgical tips and strategies to face
the difficulties due to the vascular infiltration and massive
nearby tissue affectation.
Videopresentation technique of anterior, posterior
and total laparoscopic exenteration
P. Bartos, M. Skrovina, M. Trhlik
JG Mendel Cancer Centre, Novy Jicin, Czech Republic
Description of videopresentation: Pelvic exenteration is a
salvage procedure done in the effort to eliminate completely
recurrent pelvic cancer. The primary tumors are usually
those of the cervix, rectum, vagina, endometrium or urinary
bladder. The latest advances in the technique involve low
coloanal laparoscopic anastomosis and continent urinary
diversion enabling complete or modified pelvic evisceration
without the need for external appliances. The port placement
is demonstrated as well as the evaluation of operability with
dissection of paravesical and pararectal spaces. After
appropriate lymphadenectomy the dissection continues down until
the pedicle containing lateral parametrium with uterine
vessels, superior haemorrhoidal vessels and ureter. The ureter
is completely dissected from above the pelvic brim around
psoas muscle to the ureteral canal parametrial entrance. The en
bloc dissection of the neoplasm is undertaken by coagulating/
cutting instrument of laparoscopic plasmakinetic trissector.
The ureter is clipped and divided at the parametrial entrance as
distally as possible. In case of bladder removal the pelvic
fascia is incised anteriorly, urethra identified, dissected,
clipped and divided. If the colorectum must be removed the
dissection continues posteriorly in the avascular plane towards
the anal sphincter. The specimen is removed transperineally or
vaginally. Further in the video we present side to end coloanal
reanastomosis with circular stapler as well as the technique of
urinary continent pouch reconstruction.
Laparoscopic treatment of retroverted uterus associated
with chronic pelvic pain
J. Nassif1, C. Zacharopoulou1, V. Thoma2, A. Wattiez1
1IRCAD/EITS, Strasbourg, Bas Rhin, France,2Hautepierre
University Hospital, Strasbourg, Bas Rhin, France
Objective: Surgical treatment for pelvic congestion
syndrome is still controversial, and showed failure in some
data. We suggest that in patient’s selection and good surgical
techniques are important factor for treatment’s success. We
present a short video showing three operative laparoscopic
techniques for the treatment of pelvic congestive syndrome.
Design and methods: The three techniques are:
1. Simple round ligament plicature: its indication is distal atrophy of the round ligament associated with a normal proximal part and uterine retroversion.
2. Retrouterine round ligaments plicature: this technique
is used for proximal atrophy of the round ligament with
a normal distal part and for uterine retroflexion.
3. Anterior fixation of round ligaments to the aponeurosis: it is indicated in distal atrophy of the round ligament with a normal proximal part and for uterine retroversion.
Results: In a series of six patients (two patients per
technique) we found that dyspareunia and chronic pelvic
pain is dramatically reduced postoperatively, but there is no
effect on dysmenorrhea. Pain on incision sites persists
responds to minor pain killers and resolves in 10 days. No
late complications occurred at three months follow-up.
Conclusion: These techniques are easy to learn and perform.
Dyspareunia and chronic pelvic pain is dramatically reduced
postoperatively, but there is no effect on dysmenorrhea.
A three trocart technique for laparoscopic total
and subtotal hysterectomy using Ligasure® 10 mm
and the rotocut morcellator
L. Amini, M. Ketabi
Jam General Hospital, Tehran, Iran, Islamic Republic of
Objectives: Evaluation of the feasibility, safety and
morbidity of a laparoscopic subtotal and total hysterectomy
using Ligasure® 10 mm and the Rotocut morcellator.
Patients and methods: Our study is a series of 51
consecutive patients operated by this technique from September
2006 to march 2008. Twenty-two patients underwent
supra-cervical hysterectomy and 29 patients total
hysterectomy with bilateral oophorectomy. In all cases hysterectomy
was indicated for dysfunctional uterine bleeding. Twenty
seven patients had a former history of laparotomy (ten had
one caesarean section and 17 patients had two former
caesarean sections). The procedure was performed by
Ligasure® 10 mm for pedicle ligation-section and
electromechanical morcellator (Rotocut; Karl Storz) to remove
uterus from abdominal cavity in case of supra-cervical
The mean operating time was 75 min (range 50 to 220).
The mean blood loss was 105 cc (60 to 310 cc). The mean
weight of the uterus was 290 g (range 80 to 580).One
conversion to laparotomy was performed for haemorrhage
(0.019%) and one bladder injury diagnosed and treated during
surgery (0.019%). Hospital stay was 1.18 days (from 1 to
3 days). Twenty-three active patients had 1 week off work.
Conclusion: Using a ligation-section system with the same
instrument reduces time, haemorrhage and the need for
multiple trocarts in this modality and decreases the total
operating time which is admitted to be the disadvantage of
the laparoscopic route comparing to the vaginal route.
Using electromechanical rotocut morcellator allows quick
removal of enlarged uteri by laparoscopy in cases where
vaginal route is usually contra-indicated.
The Plymouth colpotomy tube and uterine manipulator
J. Frappell, D. Barclay, M. Norbrook
Derriford Hospital, Plymouth, UK
Background: We have previously reported on the use of
the Plymouth colpotomy tube for total laparoscopic
hysterectomy (TLH). We developed this as an alternative
to similar devices currently available which we felt were
unnecessarily complicated, and whose cost was a
disincentive to uptake of the TLH procedure (ESGE 15th Annual
Congress Oct 2006). We have recently developed a simple
uterine manipulator which can be used with the colpotomy
tube during TLH procedures.
Aim: To demonstrate both the Plymouth colpotomy tube
and uterine manipulator.
Method: This video presentation describes the colpotomy
tube and uterine manipulator and demonstrates their use
during a total laparoscopic hysterectomy.
Results: The Plymouth colpotomy tube (LINA UK) has
proved highly effective in the delineating of the vaginal
fornices and providing a gas-tight seal during TLH. Its use
can also be applied to other procedures involving colpotomy
such as laparoscopic excision of endometriotic nodules
involving the vaginal vault
The combined use of the Plymouth colpotomy tube and
uterine manipulator has been a significant advance in our
ability to perform the TLH more safely and with greater
efficiency. Its use with the colpotomy tube has not
significantly increased the overall cost of the device.
Conclusion: The uterine manipulator combined with
the Plymouth colpotomy tube has improved operative
Indications of the transabdominal cervicoithsmic cerclage
are the previous failure of vaginal cerclage, extremely short
cervix due to previous cervical surgery, exposition to
dietyletilbestrol or Müllerian alterations and cervical
damage caused by obstetric traumatism.
Video: We present a case of a first trimester pregnant women
with previous four second trimester miscarriage (inefectives
shydokar cerclages).We decided to perform a transabdominal
laparoscopic cervicoithsmic cerclage.
Technique: Three trocars, one of 10 mm, two of 5 mm were
used. First step is to proceed to the dissection of the
vesicouterine space and isolation of uterine vessel and ureters. A
tunnel between the vessels and he cervicoithsmic wall is then
made. A vaginal cerclage tape is placed around ithsm and
secured with monocryl stich.
At 38th week a caesarean delivery was performed and
the tape was removed
Correction the pelvic floor disorders with hybrid mesh
M. Jose Martinez-Paya
Hospital de la Ribera, Alzira–Valencia, Spain
Objective: The aim of this video is to present the technique
we are using in our center to correct pelvic floor defects in
women. We have placed 195 implants from July 2004. In this
video we will show the anterior and posterior correction with a
new hybrid mesh.
Methods: The technique, after urodynamic study with a
pessary in order to avoid possible masked SUI, will start
repairing the anterior compartment and afterwards the
posterior one. The repair of the anterior compartment will
start with a longitudinal incision on the vaginal anterior wall
from the fold of the periurethral promontory, due in this case
there is no additional incontinence correction technique, to
1 cm. of the reflection with the uterine neck or of the scar in
the vaginal vault.
Later, bilateral dissection in paravesical spaces until
reaching the tendineous arc of the endopelvic fascia and the
ischial spine. Prepared the paravesical spaces, we proceed
to prepare incisions over the obturator fossa.
The anterior and posterior edges of the obturator foramen
are identified and in order to start with anterior incisions nest
to genitocrural fold, being in line at the level of the clitoris.
Posterior incisions would be at the level of posterior edge of
the obturator foramen which varies according to patient
anatomy, but it is approximately 2 cm outside and 3 cm
downwards. The space between the four incisions is really
important in order to extend the mesh properly.
Needles with Hook shape and with a snare extension are
introduced. After passing the vaginal incision the snare
extension must be deployed in order to catch the leg of the
mesh, to traction it and to assure it in the needle and to
traction towards the superficial incision. We must repeat
same procedure with the four arms of the implant. The
mesh is manufactured with two layers one of lightweight
polypropylene and the other of cross-linked dermis porcine
collagen. In the anterior compartment we place the collagen
facing the bladder in order to preserve it, and posterior
compartment we place the collagen facing the vagina in
order to preserve it (we could chose to change it to preserve
the vagina or the bladder or the rectum)
The mesh is fixed to the bladder neck and to the vaginal
vault or to the uterine isthmus. The vaginal incision is closed
with continuous suture.
Afterwards we proceed to repair posterior compartment.
We perform a longitudinal incision at the posterior vaginal
wall from 1 cm. of the vaginal vault or up to one cm. above
the perineal body. Pararectal dissections in order to reach
both ischial spines (both sides). Perineal incisions should be
performed at 3 cm lateral and posterior to the anus. Needles
with bow-shaped and with a loop extension are introduced.
We guide Needle through ischiorectal space parallel to the
rectum. We drive needle to 1 cm from ischial spine and
then deploy extension loop to the vaginal incision in order
to catch the arm of the hybrid mesh, first superior ones, the
ones which reaches ischial spine and afterwards inferior
ones which are driven to the perineal body, leaving this way
a completed extended mesh, reinforcing rectovaginal fascia.
Then we perform traction of the arms, superior and inferior
fixation of the mesh, and we finish closing the vaginal
incision with continuous suture. We leave a Foley catheter and
a vaginal packing is placed in the vagina for 12–24 h. We
finish the procedure with a systematic rectal tact.
Results: We have placed 195 implants, which 16 of them
where us this new hybrid mesh with good immediate results
pre and postoperative and a 3 months follow-up.
Conclusion: The use of these kind of implants seems to
be and effective, safe and comfortable which can give
good results. Our experience with biological meshes is
good and it seems that with this new hybrid mesh we will
be able to obtain the benefits of the biological and synthetic
Treatment and diagnosis of non-tubal ectopic pregnancies
O. Istre, R. Svenningsen
Department of Obstetrics and Gynecology, Oslo, Norway
Objective: Management of non-tubal ectopic gestations
remains an inadequately explored clinical field due to the
rarity of the presentations. A major disadvantage of
twodimensional pelvic ultrasonography is its inability to
reconstruct the uterine coronal axis.
Method: Cases presented are interstitial, and C-section scar
Result: The advances in minimal access techniques and
imaging modalities have resulted in novel fertility
preserving endoscopic procedures. The patients received
methotrexate and surgical treatment either initially or delayed
surgery with laparoscopy or hysteroscopy.
Conclusion: Treatment with the least invasive method,
either by minimal access techniques, non-invasive
radiological procedures or medical treatment should be encouraged.
Introduction: From 2003 till 2007 we performed a
prospective clinical study evaluating laparoscopic sacrocolpopexy
focusing on objective anatomical results and postoperative
quality of life. Pre- and postoperative data were collected
using the prolapse quantification system (POP-Q) and the
Kings Health questionnaire.
Study results: One hundred one patients completed the
study with a median follow-up of 12 months. The subjective
cure rate was 93% the objective cure rate according to the
International Continence Society (ICS) classification of
prolapse was 98%. The most severe intraoperative
complications were four bladder and three rectal lesions. The main site
of objective recurrence was the anterior compartment with 6%
recurrences of which only 2% were symptomatic. No apical
recurrences occurred. There was a significant postoperative
improvement in overall quality of life and in sexual quality
with less than 1% de novo dyspareunia. No vaginal mesh
erosion occurred in this short time follow-up.
Video content: The video shows the intraoperative setup,
the instruments used, the position of the surgical team, the
specially designed vaginal retractor and the surgical
technique we used as a standard for the prospective study
described above. Especially the posterior dissection to the
levator any muscle where the posterior mesh was attached
and the anterior sub-vesical dissection where the anterior
mesh was attached are well illustrated. The video also
shows the technique of laparoscopic suturing in the deep
pelvis or the promontory as all fixations were performed
with laparoscopic sutures, without using any tackers or
Laparoscopic resection of rectal endometriosis: how
to prevent postoperative rectovaginal fistulae
by using fat tissue of pararectal space
H. Roman, J.J. Tuech, I. Chanavaz-Lacheray, L. Marpeau
University Hospital, Rouen, France
Introduction: Laparoscopic resection of rectal
endometriosis is usually associated with the removal of the vaginal
posterior fornix because of its frequent infiltration by the
disease. Consequently, there is a high postoperative risk of
rectovaginal fistula, due to the occurrence of an abnormal
communication between the colorectal anastomosis and the
vaginal wound. In order to prevent this postoperative
complication, surgeons use to carry out an omentoplasty,
by the section of the omentum along the inferior board of the
transversal colon followed by its placing between the two
wounds. However, the omentoplasty is a supplementary
stage of the surgical procedure and increases the operative
time. Furthermore, the section of the omentum along the
colon may require to change the placement of the surgical
team and of the endoscopic video tower, the change of the
operative field from the pelvis to the upper quadrants of the
abdomen. We suggest a safe, rapid and easier procedure to
prevent rectovaginal fistulae using the fat tissue depending
on the mesorectum and pararectal space.
Methods: The dissection of the rectal endometriosis nodule
usually requires to open the pararectal space down to the
lateral limits of the nodule. During this stage, the preparation
of a flap of fat tissue depending on the pararectal space makes
sure of preserving a posterior attachment on the mesorectum.
At the end of the procedure, the flap is placed between the
vaginal wound and the colorectal anastomosis, and fixed by
two separate stitches.
Results: Five women have benefited from this technique
from January 2008 to June 2008. All women presented with
rectal endometriosis involving the posterior fornix of the
vagina and benefited for segmental resection of the rectum
followed by immediate colorectal anastomosis. We did not
encounter any difficulty to perform the “fat tissue-plasty”
technique in less than five minutes on average. No
rectovaginal fistula was recorded.
Conclusion: Fat tissue located in the pararectal space might be
use to replace an omentoplasty during laparoscopic removal
of rectal endometriosis. This technique appears to be quick
and safe, and it could be as efficient as the omentoplasty in the
prevention of postoperative rectovaginal fistula.
We wish to show a procedure as an alternative to using a
morcellator to reduce the size of a bulky uterus found to be
too big to pass through the vagina. We performed total
laparoscopic hysterectomy for a patient with a big uterus
due to adenomyosis. We used a long bladed knife which
was passed directly through the anterior abdominal wall in
the midline of suprapubic region to cut the uterus into four
or more portions. These smaller portions of the cut uterus
were then removed through the vagina for histopathology.
We kept pneumoperitoneum throughout the procedure by
using a sanitary pad held tightly against the vulva. Our
experience has shown this can be performed without major
complications in a cost-effective manner.