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Surgical Technology International XXIII contains 44 articles with color illustrations.

 

Universal Medical Press, Inc.

San Francisco, September, 2013

ISBN: 1-890131-19-9

 

1 year Institutional Subscription 

both electronic and print versions.

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Sections

Gynecology

 

Stryker
  • Stryker Stryker

 

 

 

 

McCarus Cosmetic Hysterectomy™ - A Patient-Centric Approach

Steven D. McCarus, MD, FACOG, Chief, Division of Gynecologic Surgery, Florida Hospital Celebration Health, Assistant Professor, Department of Obstetrics and Gynecology, University of Central Florida, Founder and Director, McCarus Surgical Specialists for Women, Orlando, Florida

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PMID: 23686798

Abstract

As patients are diagnosed with a health condition that requires a hysterectomy, surgical recommendations are generally discussed. Surgical options for a variety of procedures have expanded greatly in the past decade because of the development of innovations including, but not limited to, robots, advanced bipolar energy systems, HD cameras, single-site access systems, minilaparoscopic instruments, and novel uterine manipulators. These advances allow the surgeon to consider an expanded variety of procedures that may not only improve patient outcomes but also accommodate patient preferences. However, inherent bias directly related to the surgeon's specific view may influence decisions limiting hysterectomy options offered to patients. As general gynecological surgeons, we are not only empowered but also obligated to provide patients with expanded hysterectomy options that fit the indications and clinical needs of our patients.

- Cosmetic minimally invasive surgery improved cosmesis compared with standard trocars.
- Cosmetic minimally invasive surgery needs no skin or fascial closure.
- McCarus Cosmetic Hysterectomy™ affords benefits of minimally invasive surgery.
- Cosmetic minimally invasive surgery represents the next evolution in minimally invasive surgery.
- Cosmetic minimally invasive surgery allows expansion of hysterectomy options for benign disease

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The Use of Barbed Suture in Hysterectomy and Myomectomy

Elmira Manoucheri, MD, Clinical Fellow, Minimally Invasive Gynecology, Brigham and Women’s Hospital, Boston, Massachusetts, Jon I. Einarsson, MD, PhD, MPH, Director, Division of Minimally Invasive Gynecology, Associate Professor, Harvard Medical School, Brigham and Women’s Hospital, Boston, Massachusetts

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PMID:23975449

Abstract

Standard sutures used in vaginal cuff reapproximation in total laparoscopic hysterectomies and hysterotomy closure in myomectomies require knot placement and tensioning of the suture throughout the closure. This may contribute to wound dehiscence, increased blood loss, and ischemia of tissue surrounding the knots. In 2004, the United States Food and Drug Administration approved the Quill™ bidirectional barbed suture (Angiotech Pharmaceuticals, Inc., Vancouver, BC, Canada)(Fig. 1). In January 2007, the suture was introduced in the United States. The emergence of the bidirectional barbed suture has significantly affected minimally invasive surgery. Initially used by orthopaedic and plastic surgeons, barbed suture has allowed for the tedious task of knot tying to fade away. Following the introduction of the bidirectional barbed suture, the FDA approved the V-Loc™ unidirectional suture (Covidien, Mansfield, MA)(Fig. 2). The utility of the barbed suture has been instrumental in laparoscopic myomectomy and total laparoscopic hysterectomy. As barbed suture is easily utilized using the same laparoscopic ports, needle drivers, and graspers, the surgeon does not require a third hand to facilitate laparoscopic suturing. The barbs minimize tissue recoil and do so with accurate soft tissue approximation, achieving hemostasis without the use of locking and figure eight sutures. Barbed suture allows for a shorter operative time, as there is an ease of suturing without the complication of knot tying. Barbed sutures are essential tools in the modern laparoscopist’s toolbox.

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Endometrial Ablation as a Treatment for Heavy Menstrual Bleeding

Larry R. Glazerman, MD, MBA, FACOG, Faculty Preceptor, Main Line Health System, Wynnewood, Pennsylvania

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PMID: 24081840

Abstract

Until the 1980s, the only available definitive treatment for heavy menstrual bleeding (HMB) was hysterectomy, usually performed abdominally, and sometimes vaginally. Historically, multiple attempts to effect ablation of the endometrium were developed, including using steam and toxic chemicals, such as chloriquine. The advent of Nd-YAG laser endometrial ablation in the mid-1980s offered the first minimally invasive alternative to hysterectomy for the treatment of HMB. Nd-YAG ablation, however, was expensive, cumbersome, and difficult to learn; rollerball resectoscopic ablation was initially described by DeCherney in 1987, and soon overtook laser as the main method of ablation, although adoption continued to be limited because of the hysteroscopic skills necessary to perform the technique were not widely available. In 1994, the first “global” endometrial ablation, the Thermachoice™ (Ethicon Women’s Health and Urology, Somerville, NJ) balloon was introduced in the U.S. Soon thereafter, four other techniques were introduced, namely microwave (MEA™, Microsulis, Hampshire, UK), circulating hot water (HTA™, Boston Scientific, Boston, MA), cryo-ablation (HerOption™, CooperSurgical, Trumbull, CT), and bipolar radiofrequency (Novasure™, Hologic, Bedford, MA). All of these techniques are done in an outpatient setting, often office-based, with little or no anesthesia, and success rates ranging from 50% to 70% amenorrhea, and 80% to 95% patient satisfaction. Although there have been few head-to-head comparisons of various techniques, current data suggests that they are all relatively effective, quite safe, and well-tolerated.
This article describes the history and development of various ablation technologies, and explores each technique in depth, including published data, indications, risks, and benefits.

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Comparison Between Unidirectional Barbed and Polyglactin 910 Suture in Vaginal Cuff Closure in Patients Undergoing Total Laparoscopic Hysterectomy

Fred Morgan-Ortiz, PhD, Chair Professor, Laparoscopic Diploma Course Program Coordinator, Investigation and Teaching Center for Health Sciences, Autonomous University of Sinaloa, Culiacan Civil Hospital, Sinaloa, Mexico , Juan Omar Contreras-Soto, MD, Fellowship in Obstetrics and Gynecology , Investigation and Teaching Center for Health Sciences, Autonomous University of Sinaloa, Culiacan Civil Hospital, Sinaloa, Mexico , Juan M. Soto-Pineda, MD, Assistant Professor in Gynecologic Laparoscopy, Investigation and Teaching Center for Health Sciences, Autonomous University of Sinaloa, Culiacan Civil Hospital, Sinaloa, Mexico, Marco A. López Zepeda, MD, Chair Professor, Gynecological Endoscopic Institute A.C., Guadalajara, Jalisco, Mexico, Felipe J. Peraza-Garay, PhD, Head of the Department of Probability and Statistics, Investigation and Teaching Center for Health Sciences, Autonomous University of Sinaloa, Hospital Civil de Culiacan, Culiacan, Sinaloa, Mexico,

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PMID: 23860935

Abstract

The aim of the study was to compare the efficacy and safety of barbed unidirectional vs. polyglactin 910 suture in vaginal cuff closure on patients submitted to total laparoscopic hysterectomy. From November 2011 until March 2012, a prolective, comparative, longitudinal, non-randomized study was performed on patients submitted to total laparoscopic hysterectomy (TLH). On entry, patients were assigned to two different groups, Group 1: Vaginal cuff closure with unidirectional #00 (n = 25) barbed suture, and Group 2: Vaginal cuff closure with polyglactin 910 #1 suture. The length of closure time and the frequency of dehiscence in vaginal vault were measured on the 14th postoperative day. We did not find significant differences between the groups on the general characteristic analysis. However, significant differences were found (P = .029) in the average vaginal cuff closure time (12.7 ± 3.1 min. for barbed suture group vs. 20.4 ± 7.1 min. for polyglactin 910 group). No dehiscence case was found in any group.
Based on the results of this study, we can conclude that unidirectional barbed suture reduces the surgical time for vaginal cuff closure during total laparoscopic hysterectomy and doesn’t increase the vaginal cuff dehiscence risk.

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Factors Contributing to Failure of Laparoscopic Myomectomy

Ayman Al-Talib, MD, Assistant Professor, Department of Obstetrics and Gynecology, University of Dammam, Dammam, Saudi Arabia

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PMID: 23975446

Abstract

Laparoscopic myomectomy is one of the best treatment options for women with symptomatic fibroids who wish to maintain their fertility. Compared with myomectomy by laparotomy, the laparoscopic approach is associated with shorter hospital stay, faster recovery, less postoperative pain, and reduced adhesion formation. Laparoscopic myomectomy is technically challenging, and occasionally the procedure needs to be completed by laparotomy.
In this review, I will describe my team’s experience with laparoscopic myomectomy and discuss factors contributing to failure. The most important factors affecting conversion of a laparoscopic myomectomy to laparotomy are patient selection and the laparoscopic expertise of the surgeon. Each surgeon should determine his or her criteria for laparoscopic myomectomy. Other factors include posterior intramural location, soft consistency associated with the use of gonadotropin releasing hormone agonist (GnRHa), the diameter of the dominant myoma, and the weight of the myoma. The use of robot-assisted technology may provide a means to overcome the challenges encountered with enucleation, extraction, and repair that are seen with conventional laparoscopic myomectomy.

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Ethicon
  • Ethicon Ethicon

 

 

 

 

 

 

The Use of Barbed Suture in Bladder and Bowel Surgery

Dina Chamsy, MD, Fellow, Minimally Invasive Gynecologic Surgery, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania, Ted Lee, MD, Director, Minimally Invasive Gynecologic Surgery, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh Pittsburgh, Pennsylvania

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PMID: 23965906

Abstract

A new class of suturing material, barbed suture, was recently added to the surgeon’s armamentarium. It was initially used in open surgery for soft tissue approximation. Its applications in laparoscopic surgery quickly flourished because it eliminates the time-consuming process of extracorporeal and intracorporeal knot tying. Data supporting the use of barbed suture for the repair of bladder and bowel injuries is still scarce. As a matter of fact, many surgeons still use conventional sutures, secured with knots, when facing a cystotomy or an enterotomy. Choosing the best suture material for a specific surgical procedure lies in a thorough understanding of the suture properties. In this article, we shed light on the characteristics that make barbed suture attractive for bladder and bowel repair and illustrate our surgical approach for cystotomy and enterotomy repair using this novel suture material. Based on our experience at Magee-Womens Hospital, barbed suture provides adequate tension-free repairs and improves the efficiency of laparoscopic suturing when closing bladder or bowel defects. As we have so far not encountered any complications, we conclude that repairing cystotomies and enterotomies with barbed suture is feasible and safe.

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Covidien
  • Covidien Covidien

 

 

 

 

 

 

The Benefits of Using Barbed Sutures with Automated Suturing Devices in Gynecologic Endoscopic Surgeries

Stuart Hart, MD, FACOG, FACS, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Director, Tampa Bay Research and Innovation Center (TBRIC), Director, USF Center for the Advancement of Minimally Invasive Pelvic Surgery, USF Health Center for Advanced Medical Learning and Simulation (CAMLS), University of South Florida Morsani College of Medicine, Tampa Bay, Florida, Craig J. Sobolewski, MD, FACOG, Chief, Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina

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PMID: 24081852

Abstract

Laparoscopic suturing and knot tying are some of the most difficult surgical skills to acquire, and are oftentimes regarded as a rate-limiting step in the performance of advanced gynecologic endoscopic procedures. Automated suturing devices can significantly decrease the steep learning curve of this task but still require laparoscopic knot tying. Barbed sutures offer several advantages including rapid consistent wound closure with even distribution of tension across the wound, the suture holds tension on its own, the need for knot tying with associated issues related to suture tensile strength and knot security is eliminated, and suturing time is decreased. Use of a barbed suture with an automated suturing device can offer many advantages to both the novice and the experienced surgeon, including increased efficiency, more uniform wound closure, and the ability to perform a laparoscopic continuous running stitch without the need for intracorporeal knot tying.

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Stepwise Approach to Laparoscopic Hysterectomy: Evaluation of Technique and Cost Benefit

Jessica Shepherd, MD, MBA, Assistant Professor, Director of Minimally Invasive Gynecology, Department of Obstetrics and Gynecology, University of Illinois at Chicago College of Medicine, Chicago, Illinois, Joseph L. Hudgens, MD, Owensboro Health Women’s Center, Owensboro, Kentucky, Gratis Faculty, University of Louisville, Owensboro, Kentucky, Marvin A. Yussman, MD, Professor, Department of Obstetrics, Gynecology, and Women’s Health, University of Louisville School of Medicine, Louisville, Kentucky, Shan M. Biscette, MD, Assistant Professor, Department of Obstetrics, Gynecology, and Women’s Health, University of Louisville School of Medicine, Louisville, Kentucky, Resad Pasic, MD, PhD, Professor, Department of Obstetrics, Gynecology, and Women’s Health, University of Louisville School of Medicine, Louisville, Kentucky

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PMID: 24081842

Abstract

This article examines factors associated with performing a laparoscopic hysterectomy in a stepwise fashion and addresses the technique and cost effectiveness of this procedure compared with abdominal hysterectomy. We review techniques of the laparoscopic hysterectomy as well difficulties that may be encountered throughout the procedure. The hysterectomy is profiled in a method that provides a reproducible system that allows surgeons to increase their surgical numbers and comfort level. When assessing cost-benefit analysis, the cost of hysterectomy is primarily influenced by the operative time, length of hospital stay, equipment, and complications. Robotic and laparoscopic hysterectomy had the highest mean hospital charges. The laparoscopic approach to hysterectomy provides better rates of recovery, length of stay, and hospital cost. The use of the stepwise approach to hysterectomy may allow surgeons to readily perform the procedure and also identify areas and techniques that need improvement. Regardless of age, body mass index (BMI), comorbities, and other nonclinical factors, the laparoscopic hysterectomy compared with abdominal hysterectomy and vaginal hysterectomy has been shown to be better for the patient’s recovery and quality of life.

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A New Minimally Invasive Treatment Option for Stress Urinary Incontinence in Women

Labib Riachi, MD, FACOG, Chairman of Obstetrics and Gynecology, Trinitas Regional Medical Center, Elizabeth, New Jersey, Karli Provost, DO, Resident, Department of Obstetrics and Gynecology, Lenox Hill Hospital, New York, New York

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PMID: 23860932

Abstract

The aim of this article is to present a new, modified shorter obturator sling with an inside-out transobturator trajectory for the treatment of female stress urinary incontinence (SUI). It is a method that proves efficient, is reproducible, and is associated with less postoperative pain when compared with the conventional method.
The modified procedure involves the use of less tape and reduced dissection in the obturator space, while pursuing a more medial approach. Tape length was shortened, with placement of non-absorbable suture loops at either end to adjust the sling. At the mid-portion of the sling, a removable loop suture ensures equidistance. This is the only mini-sling that can be adjusted allowing one to modify terminal placement along an anterior/posterior axis.
The incidence of immediate postoperative groin pain was reduced by 35% in the modified technique as compared with the original inside-out transobturator approach. There was also reduction of immediate pain severity by +/– 50%. In addition, the modified approach required less analgesics, less time in the operating room, and a shortened time until discharge home.

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Sonographically Guided Hysteroscopic Myomectomy (SGHM): Minimizing the Risks and Maximizing Efficiency
Morris Wortman, MD, FACOG, Director, Center for Menstrual Disorders and Reproductive Choice, Rochester, New York

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PMID: 24081849

Abstract

Hysteroscopic myomectomy (HM), first described by Neuwirth and Amin in 1976,1 is an important technique in the management of selected women presenting with infertility, abnormal uterine bleeding (AUB), or both. The complications of HM include excessive bleeding, uterine perforation, prolonged operative times, and excessive intravasation of distention media.
The author describes his technique of sonographically guided hysteroscopic myomectomy (SGHM). SGHM allows one to continuously monitor the progress of resectoscopic surgery while minimizing the risk of uterine perforation and permitting one to incorporate non-resectoscopic morcellation. The combination of both resectoscopic and non-resectoscopic techniques enable one to safely and efficiently remove submucous leiomyomas without the risk of excessive fluid absorption.

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Olympus
  • Olympus Olympus

 

 

Use of the ENSEAL® G2 Tissue Sealer in Gynecologic Surgery
James Dana Kondrup, MD, FACOG, Minimally Invasive Surgeon, Broome Obstetrics and Gynecology, Binghamton, New York, Assistant Clinical Professor, Department of Obstetrics and Gynecology, Upstate Medical Center , Syracuse, New York, Fran Anderson, PhD, RN, Research Coordinator, Our Lady of Lourdes Hospital, Binghamton, New York, Becky Quick, MSN, RN, CNOR, Surgical Education Coordinator, Our Lady of Lourdes Hospital, Binghamton, New York,

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PMID: 24081850

Abstract

Minimally invasive surgery (MIS) has become the standard of care for a variety of surgical conditions, and reliable vessel sealing and precise cutting are essential. A variety of tissue-sealing devices have been used successfully to decrease operating time and control bleeding during hysterectomy and other MIS gynecologic procedures. One development involves the next generation of advanced bipolar devices by ETHICON (Ethicon Endo-Surgery Inc., Cincinnati, OH), called ENSEAL® G2 Tissue Sealers. Tip improvements to the ENSEAL® have included stronger jaws and a welded positive electrode in the stationary jaw, thus enabling the new ENSEAL® G2 Tissue Sealer to provide reliable vessel sealing and precise cutting all in the same instrument. The patented I-BLADE® forces the jaws of the device together as it advances, resulting in high, uniform compression along the entire length of the jaws. The temperature-regulating Positive Temperature Coefficient (PTC) material in the jaws is designed to minimize sticking, and the offset electrode configuration is designed to minimize thermal spread. The ergonomics provided by the ENSEAL® G2 Tissue Sealer offer significant improvement over previous devices and may make this a much more cost-effective choice for benign gynecologic procedures.

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Stryker
OLYMPUS
Covidien
Baxter
Covidien
Karl Storz