Advanced Laparoscopic and Hysteroscopic Skills: Techniques to make - PowerPoint PPT Presentation

Advanced Laparoscopic and Hysteroscopic Skills: Techniques to make hard cases easier No disclosures Alison Jacoby, MD ! Director, Comprehensive Fibroid Center Keys to success Learning Objectives ¥ Laparoscopic entry: port placement, cosmetic incisions ! ¥ Incorporate new surgical ¥ Share strategies for ¥ Visualization: seeing around corners ! techniques into your contained morcellaltion ! ¥ Uterine manipulation: delineate vaginal fornices, practice ! ¥ Maximize success in displace ureters ! ¥ Review anatomical hysteroscopic ¥ LSH: cervical transection made easy, Þnd those ureters ! landmarks for the myomectomy ureters and PalmerÕs ¥ Specimen removal: the most challenging part of point ! surgery today ! ¥ Hysteroscopic myomectomy: enucleation or bust ! !

Left Upper Quadrant Trocar Entry: Laparoscopic entry: PalmerÕs Point Port Placement Indications: ! ¥ Prior midline incision ! ¥ Known pelvic adhesions ! ¥ Large pelvic mass ! ¥ Pregnancy ! ¥ Failed umbilical port placement Always have your scope higher than the fundus ! (with maximum cephalad displacement) Left Upper Quadrant Trocar Entry: PalmerÕs Point Relative Contraindications: ! ¥ Prior LUQ surgery ! ¥ Ascites ! ¥ Hepatomegaly ! ¥ Spenomegaly

Laparoscopic entry: Cosmetic incisions Umbilicus ! ¥ Incision types: Vertical and Omega ! ¥ Cosmetically appealing ! ¥ Minimize # of incisions ! ! Omega Umbilical Incision

Visualization: Visualization: Uterine manipulation Seeing around corners Angled scopes: ! ¥ 0¡, 30¡ & 45¡ ! ¥ Places tissue on ¥ Invaluable for seeing over and around tension ! large Þbroids ¥ Separates ureter and uterine artery ! ¥ Delineates vaginal fornix Visualization: Identifying the Bladder ¥ Controlled insufßation of the bladder with CO2

Visualization: Find the ureters ¥ Practice ureterolysis on your easy cases Tools for Cervical Amputation ¥ Electrosurgical loop- monopolar or bipolar ! ¥ Fast but potentially dangerous

Specimen Removal: Before Nov 2013 Iatrogneic complications from Specimen Removal: dissemination tissue fragments The Controversy ¥ Peritonitis, abscess, obstruction (Lieng, J Minim Invasive Gynecol 2006) ! Power Morcellation: ! ¥ Case reports of iatrogenic myomas on bladder, ¥ November 2013- News story about dissemination appendix and retroperitoneally (Kho, Obstet Gynecol 2009) of unsuspected sarcoma ! ¥ April 2014-FDA safety warning ! ¥ May 2014- J&J suspends sale of morcellator ! ¥ Nov 2014- FDA requires Òblack boxÓ warning ! ¥ 2015- Some insurers refuse to reimburse for cases in which the power morcellator is used

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Specimen Removal: Specimen Removal: Options for L/S myo & LSH Supra-pubic mini-lap ! ¥ Colpotomy ! ¥ Addition incision ! Text ¥ Uncontained power morcellation (with ¥ Cosmetically less appealing ! informed consent) ! ¥ Increased pain ! ¥ Contained scalpel morcellation ! ! ¥ Contained power morcellation ! ! Contained Power Morcellaltion

Hysteroscopic Myomectomy Pearls Hysteroscopic Myomectomy: Types of Submucosal Fibroids Pearls ¥ Success is complete enucleation ! ¥ Choose cases wisely ! ¥ Probe technique ! ¥ Minimize intravasation ! ¥ Set infusion pressure as low as possible ! ¥ Vasopressin injection ! ¥ Pause to let the uterus contract

` Learning Objectives ¥ Incorporate new surgical ¥ Share strategies for techniques into your contained morcellaltion ! practice ! ¥ Maximize success in ¥ Review anatomical hysteroscopic landmarks for the myomectomy ureters and PalmerÕs Thank you point ! ! ! UCSF Comprehensive Fibroid Center: 415-885-7788 ! Questions: jacobya@obgyn. ucsf.edu