Laparoscopic Access with Optical Gasless Trocar: A Single-center Experience of 7431 Procedures

Study Objective: To analyze the complications experienced and describe laparoscopic surgery using a gasless optical trocar.Design: A retrospective study.Setting: A department of obstetrics and gynecology in a tertiary center in Italy.Patients: Seven thousand four hundred thirty-one surgical procedures were performed.Interventions: From the hospital database, data were evaluated regarding major complications of laparoscopy with the ENDOPATH XCEL Bladeless Trocar (Ethicon, Johnson & Johnson, Somerville, NJ) performed between 2000 and 2017 by different laparoscopic surgeons.Measurements and Main Results: The mean age of the patients was 40.66 +/- 12.06 years (range, 13-91 years). The mean body mass index was 22.12 +/- 3.64 kg/m(2) (range, 15.74-41.51 kg/m(2)). The overall complication rate was 0.31% (23/7431 cases). Major complications included stomach perforation in 1 procedure (0.014%), ileal perforation in 2 procedures (0.028%), and blood vessel perforation in 1 procedure (0.014%). Twelve procedures were completed with initial access through the omentum and 2 through an ovarian cyst. In 5 procedures (0.067%), conversion to laparotomy was required because the optical trocar failed to reach the abdominal cavity. With regard to complications requiring further intervention (n = 9), the rate of complications was 0.12%.Conclusions: The optical gasless trocar is a feasible laparoscopic entry technique. The complication rate is lower than those reported previously. (C) 2019 AAGL. All rights reserved

Parametrial endometriosis with ureteral involvement: A case report of a conservative approach without ureteral resection

Introduction: Parametrial endometriosis could often involve the ureter and periureteral tissue causing hydronephrosis and distortion of the normal ureteral course and position. The treatment in the case of hydronephrosis could be ureterolysis (with or without the positioning of a stent) or a ureteral resection. Materials and methods: This is the case of left parametrial endometriosis with hydronephrosis in a young woman. The preoperative work-up showed a deep infiltrating endometriosis of the left parametria, the left uterosacral ligament, and the left ureter which caused hydronephrosis. The patient was symptomatic (dysmenorrhea, dysuria, and pelvic pain). In this video, we focused on ureterolysis: all the endometriotic tissues were removed, the ureter was completely released, and the decision was to place a stent in the ureter without ureteral resection. Results: The post-operative course was normal, the stent was changed after 1 week (from mono-J to double-J) and removed 1 month after surgery. Follow-up at 3 and 8 months after stent removal was normal, and renal function was normal. The last follow-up, after 13 months, showed no hydronephrosis, no signs of deep infiltrating endometriosis, and normal renal function. The patient continues with oral contraception. Conclusion: Ureterolysis could be an effective alternative to ureteral resection in cases of deep infiltrating endometriosis even when the ureter is involved with hydronephrosi

The Rare Extragonadal Omental Teratoma: A Case Report

Teratomas of extragonadal origin are extremely rare, and the most common extragonadal site to find teratomas is the omentum. Teratomas are typically found in women of reproductive age, but they are also seen in young girls and postmenopausal women. Generally, teratomas arise from germ cells that may induce different cells to originate from the 3 primitive embryonic layers. Three main theories have been proposed to explain their location. The present report summarizes these theories as well as describes a case of a mature cystic teratoma of the omentum that was managed by laparoscopic resection. © 2017 AAG

Laparoscopic management of a large urethral leiomyoma

Introduction and hypothesis: A 42-year-old female presented with a 12-cm mass bulging the anterior vaginal wall and causing urgency urinary incontinence and bulk symptoms. Methods: Imaging showed a tumor originating from the dorsal and cranial part of the urethra and developing in the vesicouterine space and vesicovaginal septum, dislocating the bladder ventrally and the uterus cranial-dorsally. Results: Tranvaginal biopsy showed a benign leiomyoma. A laparoscopic approach with development of the vesicouterine space permitted a safe partial morcellation of the myoma. After the bladder and vaginal wall had been completely freed, further caudal dissection was conducted with isolation of the distal cranio-dorsal portion of the urethra. The dissection plane with the vaginal wall was developed up to the caudal margin of the urethral myoma almost corresponding to the vulvar plane, and total excision of the lesion was performed. Conclusion: Laparoscopic management of urethral leiomyomas that develop into the vesicouterine space and vesicovaginal septum is feasible and safe also for very large lesions. © 2019, The International Urogynecological Association

HPV vaccination acceptability in young boys

The aim of this study was to evaluate the comprehension and acceptance of HPV vaccination in parents of adolescent boys aged 11 to 15 years

How often are endometrial polyps malignant in asymptomatic postmenopausal women? A multicenter study

Objective. The objective of the study was to evaluate the prevalence of cancer and premalignant lesions in polyps on atrophic endometrium in asymptomatic postmenopausal women to compare these findings with a similar cohort of patients with abnormal uterine bleeding. Study Design. One thousand one hundred fifty-two asymptomatic and 770 consecutive postmenopausal women with abnormal uterine bleeding were included in a retrospective multicenter study. Recruited patients underwent hysteroscopic polypectomy based on a sonohysterographic or hysteroscopic diagnosis. The pathologic report was the main outcome measure. Results. One single case of stage 1 grade 1 endometrial carcinoma on a polyp with a mean diameter of 40 mm (0.1%) was observed in asymptomatic women. This prevalence was 10 times lower than in symptomatic patients (P &lt; .0001). The prevalence of atypical hyperplastic polyps was 1.2% in asymptomatic women (2.2% in symptomatic patients; P &lt; .005). At multivariate analysis, polyps' diameter was the only variable significantly associated to an abnormal histology (cancer, polypoid cancer, and atypical hyperplasia) in asymptomatic women (odds ratio for polyps with mean diameter &gt; 18 mm, 6.9; confidence interval, 2.2-21.4). Conclusion. Follow-up and/or treatment of endometrial polyps incidentally diagnosed in asymptomatic postmenopausal patients could be safely restricted to few selected cases based on polyp diameter.<br/

Laparoscopic vs transvaginal cuff closure after total laparoscopic hysterectomy: a randomized trial by the Italian Society of Gynecologic Endoscopy

BACKGROUND: Vaginal cuff dehiscence following hysterectomy is considered an infrequent but potentially devastating complication. Different possible techniques for cuff closure have been proposed to reduce this threatening adverse event.OBJECTIVE: The aim of the present randomized study was to compare laparoscopic and transvaginal suture of the vaginal vault at the end of a total laparoscopic hysterectomy, in terms of incidence of vaginal dehiscence and vaginal cuff complications. Factors associated with vaginal dehiscence were also analyzed. This article presents the results of the interim analysis of the trial.STUDY DESIGN: Patients undergoing total laparoscopic hysterectomy for benign indications were randomized at the time of colpotomy to receive vaginal closure through transvaginal vs laparoscopic approach using a 1:1 ratio. Allocation concealment was obtained using a password-protected randomization database. Monopolar energy for colpotomy was set at 60W. Vaginal closure was performed with a single-layer running braided and coated 0-polyglactin suture. In all cases an attempt was performed to include the posterior peritoneum in the suture. Laparoscopic knots were tied intracorporeally. All patients were scheduled for a postoperative follow-up visit 3 months after surgery, to detect possible vaginal cuff complications. Univariate and multivariable analyses were performed to identify independent predictors of vaginal cuff dehiscence after total laparoscopic hysterectomy.RESULTS: After enrollment of 1408 patients, a prespecified interim analysis was conducted. Thirteen (0.9%) women did not undergo the postoperative assessment and were excluded. Baseline characteristics of the 1395 patients included (695 in the transvaginal group and 700 in the laparoscopic group) were similar between groups. Patients in the transvaginal group had a significantly higher incidence of vaginal dehiscence (2.7% vs 1%; odds ratio, 2.78; 95% confidence interval, 1.16-6.63; P = .01) and of any cuff complication (9.8% vs 4.7%; odds ratio, 2.19; 95% confidence interval, 1.43-3.37; P = .0003). Based on these findings, the data monitoring committee recommended that the trial be terminated early. After multivariable analysis, transvaginal closure of the vault was independently associated with a higher incidence of vaginal dehiscence and any vaginal complication; premenopausal status and smoking habit were independently associated with a higher risk of dehiscence.CONCLUSION: Laparoscopic closure of the vaginal cuff at the end of total laparoscopic hysterectomy is associated with a significant reduction of vaginal dehiscence, any cuff complication, vaginal bleeding, vaginal cuff hematoma, postoperative infection, need for vaginal resuture, and reintervention

Laparoscopic vs Transvaginal Cuff Closure after Total Laparoscopic Hysterectomy: A Randomized Trial by the Italian Society of Gynecologic Endoscopy

BACKGROUND: Vaginal cuff dehiscence following hysterectomy is considered an infrequent but potentially devastating complication. Different possible techniques for cuff closure have been proposed to reduce this threatening adverse event.OBJECTIVE: The aim of the present randomized study was to compare laparoscopic and transvaginal suture of the vaginal vault at the end of a total laparoscopic hysterectomy, in terms of incidence of vaginal dehiscence and vaginal cuff complications. Factors associated with vaginal dehiscence were also analyzed. This article presents the results of the interim analysis of the trial.STUDY DESIGN: Patients undergoing total laparoscopic hysterectomy for benign indications were randomized at the time of colpotomy to receive vaginal closure through transvaginal vs laparoscopic approach using a 1:1 ratio. Allocation concealment was obtained using a password-protected randomization database. Monopolar energy for colpotomy was set at 60W. Vaginal closure was performed with a single-layer running braided and coated 0-polyglactin suture. In all cases an attempt was performed to include the posterior peritoneum in the suture. Laparoscopic knots were tied intracorporeally. All patients were scheduled for a postoperative follow-up visit 3 months after surgery, to detect possible vaginal cuff complications. Univariate and multivariable analyses were performed to identify independent predictors of vaginal cuff dehiscence after total laparoscopic hysterectomy.RESULTS: After enrollment of 1408 patients, a prespecified interim analysis was conducted. Thirteen (0.9%) women did not undergo the postoperative assessment and were excluded. Baseline characteristics of the 1395 patients included (695 in the transvaginal group and 700 in the laparoscopic group) were similar between groups. Patients in the transvaginal group had a significantly higher incidence of vaginal dehiscence (2.7% vs 1%; odds ratio, 2.78; 95% confidence interval, 1.16-6.63; P = .01) and of any cuff complication (9.8% vs 4.7%; odds ratio, 2.19; 95% confidence interval, 1.43-3.37; P = .0003). Based on these findings, the data monitoring committee recommended that the trial be terminated early. After multivariable analysis, transvaginal closure of the vault was independently associated with a higher incidence of vaginal dehiscence and any vaginal complication; premenopausal status and smoking habit were independently associated with a higher risk of dehiscence.CONCLUSION: Laparoscopic closure of the vaginal cuff at the end of total laparoscopic hysterectomy is associated with a significant reduction of vaginal dehiscence, any cuff complication, vaginal bleeding, vaginal cuff hematoma, postoperative infection, need for vaginal resuture, and reintervention