Abstract


Background: Female cosmetic genital surgery is becoming increasingly sought after by women who are concerned with the appearance of their vulva. Labiaplasty for the labia minora is undoubtedly the most commonly performed female cosmetic genital surgery. However, an increasing number of patients seen in our clinics in both Brazil and the United States are presenting with clitoral hypertrophy, specifically clitoral elongation. The elongated clitoris will usually protrude beyond the labia minora and majora and from the patient’s perspective will give a less feminine appearance as they will often describe the protruding clitoris as feeling like they have a small penis.
The surgical technique described here, Batalha Clitoropexy, is a minimally invasive surgical technique for clitoral length-reduction that does not require amputation or debulking. This technique is presented in the form of the detailed sequential steps needed to achieve satisfactory results. Photos taken before and after the procedure in a representative case show that the clitoral length has been shortened from 5.0 cm to 1.5 cm without the need of an invasive amputation or debulking clitoroplasty.
Many patients with clitoromegaly or an elongated protruding clitoris do not need to undergo an invasive clitoroplasty. Specifically, patients with clitoral elongation or clitoral ptosis can be surgically treated with a less-invasive clitoropexy surgical procedure which can restore normal anatomic position to treat a protruding clitoris.

Abstract


Laparoscopy has advanced over the last three decades with residency training programs focusing on trans-abdominal laparoscopic techniques whether conventional or robotic. Despite attempts over many years to adopt vaginal surgery as the preferred method of hysterectomy, traditional vaginal surgery has largely fallen out of favor. Vaginal natural orifice transluminal endoscopic surgery (vNOTES) has gained popularity with patients and promises to provide an attractive option, but the surgical skills of many gynecologists have limited its widespread adoption. We explore the use of robot-assisted vNOTES (RA-vNOTES), which offers improved ergonomics, visualization, and wristed instruments for more precise surgery. Robotic vNOTES, was originally performed in Taiwan by Dr. Chyi-Long Lee in 2014.¹ Our center has used the robotic vaginal approach for hysterectomy, myomectomy, sacrocolpopexy, adnexal surgery, endometriosis excision, and more. We have also shown feasibility in performing surgery on patients with a completely obliterated posterior cul-de-sac, long been thought to be a contraindication for the transvaginal approach. Enhancements have been made to improve safety and efficiency, such as the use of indocyanine green to visualize the ureters. There are some limitations on instrument maneuverability and reach with the current da Vinci^® Xi (Intuitive Surgical, Sunnyvale, California) platform. However, with over 300 cases logged in our center, these limitations may be overcome with the new da Vinci^® SP (Intuitive Surgical, Sunnyvale, California). We are eager to share our experience and hope that more gynecologic surgeons will choose this innovative approach for the benefit of our patients.

Abstract


Preterm birth is the leading cause of perinatal and neonatal morbidity and mortality in the developed world. An important cause of preterm birth is cervical insufficiency, leading to membrane prolapse, premature rupture of membranes, and mid-trimester pregnancy loss. A cerclage can be placed vaginally or abdominally to treat cervical insufficiency. In cases of failed prior transvaginal cerclage (TVC), transabdominal cerclage (TAC) is the alternative. The procedure can be completed via laparoscopy or open approach. The suture is placed at the internal os giving greater structural support.¹ In this article, we review the definition of cervical incompetence, we present the indications for TAC, we discuss the outcomes of minimally invasive TAC compared to open approach, and we review surgical tips and tricks for robotic assisted (RA) TAC placement that can be used prior to pregnancy or in early gestation. The included images delineate the surgical technique for safe placement of robotic assisted laparoscopic abdominal cerclage in the management of cervical insufficiency.

Abstract


Introduction: Achieving excellent cosmetic monsplasty results consistently can be difficult. Undertreatment or overtreatment of the fatty ptotic mons pubis will yield suboptimal results. A stepwise tactical approach to the monsplasty eliminates these problems and produces excellent aesthetic results.
Materials and Methods: The surgical management of monsplasty requires individualization and careful surgical planning. The authors’ approach illustrating the steps and tactics to perform monsplasty is presented. Based on our experience with 1,200 cases, a comprehensive clinical classification of mons pubis ptosis with surgical guidelines for treatment was created.
Results: Over 1200 patients have undergone monsplasty using the authors’ stepwise tactical approach to mons rejuvenation. No complications associated with the monsplasty occurred. Patient satisfaction with the monsplasty was very high.
Conclusion: In the authors’ experience, the preoperative grading of the mons pubis ptosis and the use of guidelines produces consistently excellent aesthetic results. Monsplasty is associated with high aesthetic and functional patient satisfaction.

Abstract


Harry Reich, MD, FACOG, FRCOG, FACS is known worldwide as a pioneer in the field of laparoscopic surgery. He performed the first laparoscopic hysterectomy, the first pelvic lymphadenectomy for cancer, and the first excision of cul-de-sac endometriosis that included rectal resection. This article explores his life and contributions.
The author knew Dr. Reich from medical conferences over many years and visited Dr. Reich in Pennsylvania to observe him in the operating room. For this article, the author spoke with Dr. Reich on nearly a nightly basis over a 13-month period in 2022 and 2023. Dr. Reich’s descriptions were cross-referenced with his publications and those of his peers. The author also interviewed physicians who worked closely with Dr. Reich and reviewed the trial transcript of the February 1980 Nesbitt Memorial Hospital special ad hoc investigatory committee. The result is a comprehensive review spanning from Dr. Reich’s early life to his ultimate recognition as one of the most significant innovators of advanced laparoscopic surgery.
The author concluded that Dr. Reich’s accomplishments are rooted in his command of pelvic anatomy, his lifelong interest in surgery and his willingness to challenge existing surgical dogma. By attending medical school in Ireland, Dr. Reich benefitted from the deep study of anatomy offered there. He also had a unique background of being a Harvard-trained gynecologic surgeon practicing in Wilkes-Barre, a small Pennsylvania community that trusted him because both his parents practiced medicine there before him. Dr. Reich favored conservative surgery rather than hysterectomy for endometriosis and patiently excised deep disease, offering relief to countless women, at times without compensation. He exhibited astonishing bravery and perseverance in the face of scathing criticism. Dr. Harry Reich’s empathy for his patients and willingness to challenge the status quo were pivotal in improving the lives of many thousands of women and revolutionizing gynecologic surgery.