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Surgical Technology International XXVIII contains peer-reviewed articles featuring the latest advances in surgical techniques and technologies.

 

April, 2016- ISSN:1090-3941

 

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Gynecology

 

An Update on the Use of Barbed Suture in Minimally Invasive Gynecological Surgery (MIGS)
James Dana Kondrup, MD, Assistant Clinical Professor of OB/GYN, Department of OB/GYN, Our Lady of Lourdes Memorial Hospital, Binghamton, NY, Frances R. Anderson, PhD, RN, Research Coordinator, Our Lady of Lourdes Memorial Hospital, Binghamton, NY

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Abstract


The use of barbed suture has enabled general and minimally invasive gynecological surgery (MIGS) surgeons to close surgical wounds more efficiently with minimal complications. This article reviews developments in barbed (knotless) sutures and related devices.

 

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Patient Outcomes Following Injury from Hysteroscopic Sterilization
E Scott Sills, MD, PHD, Medical Director, Reproductive Research Section, Center for Advanced Genetics, Carlsbad, California, Molecular and Applied, Biosciences Department, Doctoral Researcher, Faculty of Science and Technology, University of Westminster, London, UK, Marie M Dalton, BSN, Graduate Assistant, Department of Political Science, Howard H. Baker, Jr. Center for Public Policy, University of Tennessee, Knoxville, Tennessee

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Abstract


Objective: We present clinical data on two patients who underwent hysteroscopic sterilization (HS) 11 years apart using the Essure® (Bayer Inc., Whippany, NJ) device. Materials and Methods: Symptoms and resolution are described for symptomatic Essure® patients.
Results: Case 1 (G3P1) underwent HS in 2004 at age 21. Performed in a physician’s office without anesthesia, HS involved placement of >2 Essure® devices which was followed by severe, unrelenting pelvic pain. Confirmatory hysterosalpingogram (HSG) three months after HS revealed five devices. Surgical costs for laparoscopic assisted vaginal hysterectomy (LAVH) were fully reimbursed by the device manufacturer seven months later. Case 2 (G8P4) underwent HS in 2015 at age 32. One year earlier, the patient’s right fallopian tube was removed due to ectopic pregnancy. Essure® devices were placed bilaterally in a physician’s office without anesthesia; HS was accompanied by sharp pelvic pain. The patient obtained HSG three weeks after HS due to constant discomfort. Bilateral tubal occlusion was verified, but abnormal device loop configuration suggesting myometrial penetration was noted on the right. At laparoscopy, the left Essure® device was excised intact but the right coil could not be located. Thus far, there has been no offer in Case 2 from the device manufacturer to offset medical expenses.
Conclusions: While HS has been FDA approved for use in the United States since 2002, this is the first description of clinical sequela when FDA labeling for the Essure® procedure is ignored. These cases illustrate the importance of proper physician training in HS and underscore the need for improved tracking of Essure® associated symptoms.

 

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Laparoscopic Psoas Hitch Double Ureteral Re-implantation in the Duplex Urinary System for Treatment of Ureterovaginal Fistula
Tito Palmela Leitão, MD, FEBU, Head of Minimally Invasive Surgery Unit, Urology Department, Centro Hospitalar Lisboa Norte , Faculdade de Medicina de Lisboa, CAML, Centro Académico de Medicina de Lisboa, Lisboa, Portugal, Ricardo Pereira e Silva, MD, Chief Resident, Urology Department, Centro Hospitalar Lisboa Norte, Lisboa, Portugal, Sónia Barata, MD, Clinical Assistant, Obstetrics and Gynecology Department, Centro Hospitalar Lisboa Norte, Hospital Santa Maria, Lisboa, Portugal, Adalgisa Guerra, MD, Head of  Unit, Radiology Department, Hospital da Luz, Lisboa, Portugal, Filipa Osório, MD, Head of Minimally Invasive Surgery Unit, Obstetrics and Gynecology Department , Hospital da Luz, Faculdade de Medicina de Lisboa, CAML, Centro Académico de Medicina de Lisboa, Lisboa, Portugal

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Introduction: Although laparoscopy is widely established for ablative urologic procedures, pelvic reconstructive procedures are still mostly performed by open-surgery. As urologists continue to introduce advanced laparoscopic skills to reconstructive urologic procedures, we present our experience with a laparoscopic psoas hitch double ureteral re-implantation in a patient with an ureterovaginal fistula and an ipsilateral duplex urinary system.
Materials and Methods: A 42-year-old patient presented with continuous involuntary urine loss from the vagina after an abdominal hysterectomy. A double modified Lich-Gregoir ureteral re-implantation with a psoas hitch was performed, using a 4-port laparoscopic approach.
Results: There were no post-operative complications and the cystography at post-operative day 14 revealed good positioning of the psoas hitch, with no leak or reflux. At three-months follow-up, the patient is completely dry and asymptomatic.
Conclusion: Laparoscopic ureteroneocystostomy with psoas hitch for the treatment of lesions of the distal ureter is a possible, safe, and effective way to resolve a complex urologic situation with minimally invasive surgery. Laparoscopy is becoming the standard approach to urologic pelvic reconstructive procedures, even in the most complex cases.

 

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“See-and-Treat” Hysteroscopy in the Management of Endometrial Polyps
Morris Wortman, MD, Clinical Associate Professor , Gynecology and Obstetrics Department, University of Rochester Medical Center, Rochester, NY, Director, Center for Menstrual Disorders, Rochester, NY

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Endometrial polyps (EPs) are a common cause of abnormal uterine bleeding (AUB) in perimenopausal and postmenopausal women and are typically suggested by a screening transvaginal ultrasound. In addition, the increasing use of pelvic imaging often discloses asymptomatic EPs. In the past, saline infusion sonography (SIS) has been advocated in order to triage patients to undergo a blind curettage or a diagnostic or operative hysteroscopy. The introduction of small diameter hysteroscopes and resectoscopes—often no larger than a SIS catheter—now allows most women with abnormal ultrasound findings to undergo a single-stage “see-and-treat” hysteroscopy for the management of endometrial polyps. In order to provide optimal management of endometrial polyps, however, a variety of known and unknown factors must be considered prior to “see-and-treat” hysteroscopy. For a woman wishing to preserve or enhance her fertility, hysteroscopic polypectomy—with care to avoid collateral endometrial damage—remains the standard of care. However, the literature reveals three issues that are important to address. First, that many premalignant and malignant lesions are found at the polyp base. Second, that there is a significant recurrence risk following simple polypectomy; this is especially true in tamoxifen-treated women. Third, that polypectomy alone is often insufficient for the satisfactory management of AUB. By offering a variety of options to women undergoing hysteroscopic polypectomy—including partial or total endomyometrial resection—the author addresses many of the limitations of traditional polypectomy. Moreover, the use of small diameter hysteroscopes and resectoscopes allow these procedures to be performed as a single stage “see-and-treat” hysteroscopy in the comfort and safety of an office-based setting.

 

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Barbed Sutures in Minimally Invasive Gynecologic Surgery

Emad Mikhail, MBChB, MD, FACOG, Fellow of Minimally Invasive Gynecologic Surgery, Allison Wyman, MD, Fellow of Female Pelvic Medicine and Reconstructive Surgery, Lindsey Hahn, MD, Fellow of Female Pelvic Medicine, Stuart Hart, MD, MBA, MS, FACOG, FACS, Associate Professor

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The introduction of knotless barbed suture into the surgical market has decreased the challenges of laparoscopic suturing. Since its introduction, barbed suture has gained popularity in the field of minimally invasive gynecologic surgery and is now commonly used to close the vaginal cuff in total laparoscopic hysterectomy, to re-approximate the myometrium after laparoscopic myomectomy, and to shorten the procedure time during a laparoscopic sacrocolpopexy. Barbed sutures facilitate rapid and consistent wound closure, allowing for equal distribution of tissue tension across the suture line, and thereby providing a more secure wound closure. The most commonly encountered complication after the use of barbed sutures is postoperative bowel obstruction. Proposed methods to decrease the likelihood of this complication include ensuring that the ends of the barbed suture are either buried, over-sewn, or cut flush with the tissue.

 

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Laparoscopic Modified Vecchietti Technique for Mayer-Rokitansky-Küster-Hauser (MRKH) Syndrome: Report of Two Cases
Joseph Nassif, MD, Assistant Professor, Joe Eid, MD, Research Fellow, Pierre Akiki, Medical Student, Ali Khalil, MD, Professor, Ghina Ghazeeri, MD, Associate Professor, Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon

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Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a congenital disorder characterized by uterine aplasia and aplasia of the upper part of the vagina. It presents with primary amenorrhea in a 46, XX individual. In this paper, we report the cases of two patients with MRKH syndrome treated with the laparoscopic modified Vecchietti technique using the optimized new instruments. A neovagina was successfully created in these two patients. This minimally invasive technique offers improvements in terms of operative time, complications, and functionality.

 

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Abdominal Wall Endometriosis Excision with Mesh Closure – Report of Two Cases
Carolina Vaz-de-Macedo, MD, Resident, Ana Gomes-da-Costa, MD, Resident, Sofia Mendes, MD, Resident, Sónia Barata, MD, Clinical Assistant, Minimally Invasive Surgery, Conceição Alho, MD, Clinical Assistant, Carlos Calhaz Jorge, PhD, MD, Chief Gynecology, Filipa Osório, MD, Clinical Assistant, Head of Minimally Invasive Surgery, Obstetrics and Gynecology Department, Faculdade de Medicina de Lisboa, CAML, Centro Académico de Medicina de Lisboa, Hospital da Luz, Lisboa, Portugal

 

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Abdominal wall endometriosis (AWE) is a rare condition included in the differential diagnosis of an abdominal wall mass and/or pelvic pain in women of reproductive age. It usually occurs after pelvic surgery, most commonly caesarean section. Given the variable clinical presentation, diagnosis can be challenging if a high index of suspicion for AWE does not exist. Consequently, the correct diagnosis is often missed in the preoperative assessment. The presence of endometriosis in other locations can aid in the diagnosis, but other endometriotic lesions do not always exist. Image studies, particularly ultrasound and magnetic resonance imaging, can also be of help in the differential diagnosis. Even though new management techniques such as ultrasound-guided percutaneous cryoablation seem to be promising, surgical excision is still the mainstay of treatment. When the aponeurosis is involved, lesion excision might need to be followed by wall closure with the use of a mesh to lessen tissue tension. We present two typical cases of AWE after caesarean section, one of them recurrent, in patients with concurrent endometriosis of other locations. Total lesion excision followed by polypropylene mesh closure has been performed, with very good post-operative outcomes. We aim to raise awareness towards this diagnosis and to highlight the importance of complete lesion excision and adequate closure of the abdominal wall.

 

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