Surgical Tutorial 6: Surgical Management of Fibroids - … safeguards in assuring that a CME...

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Surgical Tutorial 6: Surgical Management of Fibroids

PROGRAM CHAIR

Malcolm G. Munro, MD

Keith B. Isaacson, MD Olav Istre, MD, PhD Charles E. Miller, MD

Professional Education Information Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.

Table of Contents

Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 2 Conserving the Uterus: Options, Evaluation, and Patient Selection M.G. Munro .................................................................................................................................................. 3 Hysteroscopic Management – The Most Minimally Invasive Surgical Approach K.B. Isaacson ................................................................................................................................................. 9 Abdominal Management – Laparoscopic Management Techniques C.E. Miller ................................................................................................................................................... 14 Abdominal Management – The Very Large Uterus O. Istre ........................................................................................................................................................ 17 Cultural and Linguistics Competency ......................................................................................................... 21

Surgical Tutorial 6: Surgical Management of Fibroids

Malcolm G. Munro, Chair

Faculty: Keith B. Isaacson, Olav Istre, Charles E. Miller This session provides an opportunity for attendees to gain insight into the contemporary issues around myomectomy and to discover “pearls” that will help them provide safer, more effective surgical management of women afflicted with leiomyomas. The faculty participating in this surgical tutorial all have extensive experience with such patients and their operative management via the hysteroscopic, laparoscopic, and laparotomic approaches. The essential steps in patient assessment will be reviewed, with a particular emphasis on uterine imaging and the features that help determine the most appropriate route of removal. Hysteroscopic morcellators have been positioned as replacements for the uterine resectoscope – the advantages and limitations of each of these devices will be discussed and demonstrated. The preferred abdominal approach to myomectomy is laparoscopic, but there are a number of instances where laparotomy still has a major role. Identification of which patients are most appropriate for which technique will be covered, and, for each approach, key surgical techniques will be covered by the faculty using presentation graphics and videos. Such techniques include laparoscopic port selection, management of multiple leiomyomas, and laparoscopic extraction options. Attendees will have an opportunity to ask questions at the end of the session. Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) Evaluate patients for the appropriate route of myomectomy, and describe key elements in the performance of hysteroscopic, laparoscopic, and laparotomic removal of uterine leiomyomas.

Course Outline 2:15 Welcome, Introductions and Course Overview M.G. Munro

2:20 Conserving the Uterus: Options, Evaluation, and Patient Selection M.G. Munro • Description of the Spectrum of Options • Identification of Patient Goals • Evaluation – Imaging, Imaging, Imaging (FIGO-‐based Evaluation) • Creating the Menu of Options

2:30 Hysteroscopic Management – The Most Minimally Invasive K.B. Isaacson Surgical Approach • Resectoscope or Electromechanical Morcellator?

2:40 Abdominal Management – Laparoscopic Management Techniques C.E. Miller • Port Placement • Techniques for Enucleation and Multiple Myomectomy • Uterine Wound Closure • Extraction of Leiomyomas from the Peritoneal Cavity

2:50 Abdominal Management – The Very Large Uterus O. Istre • Factors That Make Laparotomy the Preferred Approach • Ancillary Techniques to Facilitate Surgery on the Very Large Uterus • Techniques for Laparoscopic Approach to the Very Large Uterus

3:00 Questions & Answers All Faculty

3:15 Adjourn

1

PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Amber Bradshaw Speakers Bureau: Myriad Genetics Lab Other: Proctor: Intuitive Surgical Erica Dun* Frank D. Loffer, Medical Director, AAGL* Linda Michels, Executive Director, AAGL* Johnny Yi* SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: Intuitive Royalty: CooperSurgical Sarah L. Cohen* Jon I. Einarsson* Stuart Hart Consultant: Covidien Speakers Bureau: Boston Scientific, Covidien Kimberly A. Kho Contracted/Research: Applied Medical Other: Pivotal Protocol Advisor: Actamax Matthew T. Siedhoff Other: Payment for Training Sales Representatives: Teleflex M. Jonathon Solnik Consultant: Z Microsystems Other: Faculty for PACE Surgical Courses: Covidien FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Keith B. Isaacson* Olav Istre* Charles E. Miller Contracted/Research: AbbVie, Actavis, Aegea Medical, Bayer Healthcare Corp., Covidien, Gynesonics, Intuitive Surgical Consultant: AbbVie, Covidien, Ethicon Endo-‐Surgery, Gynesonics, Halt Medical, Intuitive Surgical, Pacira Pharrmaceuticals Speakers Bureau: Ethicon Endo-‐Surgery, intuitive Surgical, Smith & Nephew Endoscopy Royalty: Thomas Medical Malcolm G. Munro Consultant: Aegea Medical, Bayer Healthcare Corp., Boston Scientific, Gynesonics, Hologic, Idoman Teoranta Asterisk (*) denotes no financial relationships to disclose.

2

Malcolm G. Munro MD, FRCS(c), FACOGProfessor, Department of Obstetrics & Gynecology

David Geffen School of Medicine at UCLADirector of Gynecologic Services

Kaiser Permanente, Los Angeles Medical CenterLos Angeles, CA, USA

Malcolm G. Munro MDDisclosures

Consultant:Aegea MedicalBayer Healthcare Corp.Boston ScientificGynesonicsHologicIdoman Teoranta

Conserving the Uterus with Fibroids:Options, Evaluation & Patient Selection

Objectives

• Describe the surgical alternatives to hysterectomy for symptoms associated with uterine leiomyomas

• Discuss the approach to evaluation of patients with uterine leiomyomas

• Counsel women with symptoms thought to be related to leiomyomas considering their reproductive, cosmetic and economic goals

• Leiomyoma manifestations

• The spectrum of options

• Identification of patient goals

• Evaluation

• Creating the menu of options


Agenda


• The spectrum of options


• Evaluation



Agenda

Manifestation

• Asymptomatic

• Abnormal Uterine Bleeding

• Bulk/pressure symptoms

• Infertility

• Recurrent Pregnancy Loss

• Other

Conserving the Uterus: Options, Evaluation & Patient Selection-Leiomyoma Manifestations

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• The spectrum of surgical options


• Evaluation



Agenda

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Conserving the Uterus: Options, Evaluation & Patient Selection

Options for Leiomyoma-Associated Symptoms

• AUB

• Bulk Symptoms

Medical Therapy

• AUB

• Bulk Symptoms

• Infertility


Myomectomy

• AUB

• Bulk Symptoms

• Infertility?

• Recurrent Pregnancy Loss?

Image Guided Therapy

• AUB

Endometrial Ablation

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Options for Leiomyoma-Associated Symptoms

• AUB

• Bulk Symptoms

Medical Therapy

• AUB

• Bulk Symptoms

• Infertility


Myomectomy

• AUB

• Bulk Symptoms

• Infertility?

• Recurrent Pregnancy Loss?

Image Guided Therapy

• AUB

Endometrial Ablation

Procedural Options00

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Procedural Options

• Myomectomy

• Leiomyoma ablation

• Endometrial ablation

• Myomectomy– Laparoscopic

– Laparotomic

• Uterine Artery Occlusion

• Leiomyoma Ablation

• Uterine Artery Embolization

• MR-guided Focused Ultrasound

Intrauterine

Abdominal

Interventional Radiology

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• Myomectomy




– Laparotomic





Intrauterine

Abdominal



Procedural Options

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• Myomectomy




– Laparotomic





Intrauterine

Abdominal



Procedural Options

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• Myomectomy




– Laparotomic





Intrauterine

Abdominal



Procedural Options




• Evaluation


Conserving the Uterus:Options, Evaluation & Patient Selection

Agenda

Manifestation

• AUB

• Bulk/pressure symptoms

• Infertility


• Other

Goal(s)

• Symptom control

• Fertility– Preserve or enhance

– No desire for future fertility

• Cosmetic result

• Minimizing economic impact of intervention

Conserving the Uterus: Options, Evaluation & Patient Selection-Identification of Patient Goals

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• Evaluation



Agenda

• Are the symptoms related to the leiomyomas?

• Is surgery the most appropriate intervention?

• Determination of: – FIGO Type(s)

– Location (anterior, posterior, fundal, lower segment)

– Size or volume

– Number

• List of options compatible with patient goals

Conserving the Uterus: Options, Evaluation & Patient Selection-Evaluation of Patients with Leiomyomas

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Polyp

Adenomyosis

Leiomyoma

Malignancy & Hyperplasia

Coagulopathy

Ovulatory Dysfunction

Endometrial

Iatrogenic

Not Yet Classified

FIGO Classification System for Causes of Abnormal Uterine Bleeding in the Reproductive Years

Munro et al Int J Gynaecol Obstet. 2011;113:3-13.

5

Leiomyoma Subclassification System

S M‐ Submucous 0 Pedunculated Intracavitary

1 <50% Intramural

2 ≥ 50% Intramural

O ‐ Other 3 Contacts endometrium; 100% Intramural

4 Intramural

5 Subserous ≥50% Intramural

6 Subserous < 50% Intramural

7 Subserous Pedunculated

8 Other (specify eg. cervical, parasitic)

Hybrid

Leiomyomas (impact both

endometrium and

serosa)

Two numbers are listed separated by a dash. By convention, the first

refers to the relationship with the endometrium while the second refers to

the relationship to the serosa. One example is below

2‐5 Submucosal and subserosal, each with less

than half the diameter in the endometrial

and peritoneal cavities respectively.

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Polyp

Adenomyosis

Leiomyoma

Malignancy & Hyperplasia

Coagulopathy

Ovulatory Dysfunction

Endometrial

Iatrogenic

Not Otherwise Classified

Submucous

Other

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Classification, Size, Myoma free Margin:

Uterine Imaging Options

• Ultrasound– Transvaginal 2D

– Contrast sonography 2D

– 3-D

• MRI– No contrast

– Limited series

• Hysteroscopy

1 Transvaginal ultrasound

2 Contrast sonography

Evaluation of Women with Leiomyomas

Evaluation of Endometrial Cavity Structure

• Do it yourself !• Contrast options

Normal saline Lidocaine solution Gel (2% Lidocaine)

• Do it yourself !• Contrast options

Normal saline Lidocaine solution Gel (2% Lidocaine)

Bij de Vaate et al. Ultrasound Obstet Gynecol. 2010;35:486-9.

Evaluation of Women with AUB

Evaluation of Endometrial Cavity Structure

1 Transvaginal ultrasound

2 Infusion sonography

3 Hysteroscopy

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Evaluation of the Myometrium1. Sonography

2. MRI Goals of Myometrial Assessment

1. Identify and characterize leiomyomasa. FIGO typeb. Dimensionsc. Locationd. Margin between myoma and serosa

2. Identify and characterize adenomyosis

3. Distinguish adenomyomas from leiomyomas


Evaluation of the Myometrium1. Sonography

2. MRI MRI often superior to TVUS…. Large uteri Determining myometrial

involvement of leiomyoma Relationship to serosal margin Perhaps when adenomyosis and

leiomyomas coexist

Dueholm et al. Am J Obstet Gynecol.2002;186:409-15.

6

00

22

11000

2

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Submucous Myomectomy: Issues to Consider

FIGO Myoma

Type

Diameter/Volume

Location NumberMyoma

Free Margin

0 − − −

1 −

2

Myoma Free Margin



Myomectomy Route

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Superficial Type 2Superficial Type 2 Deep Type 2Deep Type 2 Type 2-5Type 2-5

Hysteroscopic/Resectoscopic

Hysteroscopic/Resectoscopic

Hysteroscopic/Resectoscopic or

Laparoscopic/Laparotomic

Hysteroscopic/Resectoscopic or

Laparoscopic/Laparotomic

Laparoscopic or Laparotomic

Laparoscopic or Laparotomic


00

22

110002

10


Uterine Imaging

11




• Evaluation



Agenda

Manifestation

• AUB

• Bulk symptoms

• Infertility


• Other

Goal(s)

• Symptom control

• Fertility– Preserve or enhance

– No desire for future fertility

• Cosmetic result

• Minimizing economic impact of intervention

Conserving the Uterus: Options, Evaluation & Patient Selection-Counseling Considering Patient Goals

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0011

55

000 1

5

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11

442-52-5

1

42-5

2-52-5

33 44

66

2-62-6

2-5

3 4

6

2-6

2244

66

24

6

Submucous LeiomyomasInfertility, RPL or wishes to retain fertility

Resectoscopicc

Laparoscopic OR LaparotomiccLaparoscopic OR Laparotomic

AND Resectoscopicc

Laparoscopic OR Resectoscopicc

Myomectomy

7

0011

55

000 1

5

0

11

44

66

2-52-5

1

4

6

2-5

2-52-5

33 44

66

2-62-6

2-5

3 4

6

2-6

2244

66

24

6

Submucous LeiomyomasDoes not wish to retain fertility

Resectoscopicc

Laparoscopic OR LaparotomiccLaparoscopic OR Laparotomic

AND Resectoscopicc

Laparoscopic OR Resectoscopicc

Endometrial Ablation ± Myoma ResectionEndometrial Ablation ± Myoma Resection

…provided endometrial cavity within limitsHachman – Nielsen et al. J. Min Invasive Gynecol 2012;19:212-6Loffer FD. J. Min Invasive Gynecol 2012;12:254-60

Multiple and/or Large LeiomyomasInfertility, RPL or wishes to retain fertility

2-52-5

33 44

55

2-52-5

2-5

3 4

5

2-5

4

6 • Myomectomy• Laparotomic• Laparoscopic?

• UAE?

• Myomectomy• Laparotomic• Laparoscopic?

• UAE?

Multiple and/or Large LeiomyomasDoes NOT wish to retain fertility

2-52-5

33 44

55

2-52-5

2-5

3 4

5

2-5

4

6 • Myomectomy• Laparotomic• Laparoscopic?

• UAE• RF Laparoscopic

Leiomyoma Ablation

• Hysterectomy

• Myomectomy• Laparotomic• Laparoscopic?

• UAE• RF Laparoscopic

Leiomyoma Ablation

• Hysterectomy

• Gupta JK, et al. Uterine artery embolization for symptomatic uterine fibroids. CochraneDatabase of Systematic Reviews 2012, Issue 5.

• Berman et al. J Minim Invasive Gynecol. 2014;21:767-74

Berman et al. J Minim Invasive Gynecol. 2014;21:767-74.

Hachman – Nielsen et al. J. Min Invasive Gynecol 2012;19:212-6

Loffer FD. J. Min Invasive Gynecol 2012;12:254-60

Dueholm et al. Am J Obstet Gynecol.2002;186:409-15.

Munro et al Int J Gynaecol Obstet. 2011;113:3-13.

Bij de Vaate et al. Ultrasound Obstet Gynecol. 2010;35:486-9.

Gupta JK, et al. Uterine artery embolization for symptomatic uterine fibroids. CochraneDatabase of Systematic Reviews 2012, Issue 5.

References

Malcolm G. Munro MD, FRCS(c), FACOGProfessor, Department of Obstetrics & Gynecology

David Geffen School of Medicine at UCLADirector of Gynecologic Services

Kaiser Permanente, Los Angeles Medical CenterLos Angeles, CA, USA

8

Hysteroscopic Management – The Most Minimally Invasive

Keith Isaacson MD

Associate Professor OB/GYN

Harvard Medical School

Boston, MA

[email protected]

Disclosures

• I have no financial relationships to disclose

Objective

Discuss Hysteroscopic Management – The Most Minimally Invasive

Hysteroscopic Energy

• Laser

• Radiofrequency– Monopolar

– Bipolar

• Morcellation

• Morcellation with bipolar energy

1970 – 1995Monopolar Hysteroscopy

Electrosurgery =Secondary Thermodynamic Change

Na+ Cl-

Na+

Na+ Cl-Cl-

9

Non-conductive media Ω = ∞

TissueTissue Impedance = 100

Conventional Monopolar Electrosurgeryrequires non-conductive media and adequate current density

Current flows through

the tissue

concentrated

• 3% Sorbitol

• 1.5% Glycine

• 5% Mannitol

• 3% Sorbitol

• 1.5% Glycine

• 5% Mannitol

Non-Electrolyte, Non-Conductive Solutions for Monopolar Resectoscopic Surgery

Non-Electrolyte, Non-Conductive Solutions for Monopolar Resectoscopic Surgery

Changes in amino acids, ammonium, and coagulation factors after transcervical resection of the endometrium with a glycine solution used for uterine irrigation.Istre O, Jellum E, Skajaa K, Forman A.Am J Obstet Gynecol. 1995 Mar;172

Potential Risks of Monopolar Electrosurgery

• Direct Coupling

• Capacitive Coupling

• Insulation Failure

• Surgical Fires

• Alternate Site Burn (Injury)

• Grounding / Return Pad Failure

Saline Impedance = 25

TissueTissue Impedance = 100

Conventional Monopolar Electrosurgery- In Normal Saline -

Current flows through saline

following path of least resistance to return electrode

10

Current HysteroscopicBipolar Technology

Myoma Resection With VERSAPOINT ElectrodeMyoma Resection With VERSAPOINT Electrode

VideoTo view, click on picture with left mouse button.

Bipolar resection type II

Monitoring Venous Air Embolism

• Doppler, TE echo 0.1 - 0.25

• End title CO2 or 025-0.5

• Nitrogen tension

• CVP and Pulmonary 05-0.75artery P increase

• Mean Art P decrease 0.75 - 1.25

• Ventricular dysrhythmias 1.25

• Mill-wheel murmur 1.5

• Cardiovascular collapse 2.0

Sensitivity

mL/Kg/min air entrapment Hysteroscopic Mechanical

Morcellation

11

The TRUCLEAR ™ 5.0 System* offers many benefits

19

205mm working length provides access to entire uterus

J-snap locking mechanism for one handed control of sheath

Patented dual outflow allows clear visualization

2.9 mm close cutting edge resects pathology down to base

Distal marking ideal for blade orientation

Proximal marking indicates blade has reached distal end of scope

5.0 Scope and 5.6 Sheath allows procedure with limited to no dilation

Inflow from Fluid Mgmt.Systemor Pressurized Saline Bag

Gravity Outflow

3.1mm diameter working channel allows 9 Frinstruments

* Pending FDA clearance

MyoSure® Tissue Removal System

FDA Clearance October-2009; Commercial Launch- November 2009

Pathology Removal with MyoSure®

Tissue Removal System is Fast and Effective

Historical perspective

1869

Pantaleoni credited with 1st

hysteroscopic procedure in uterine

cavity

Rubin utilized C02 to distend the uterine

cavity

1925

Source(s): Valle, R, Glob. libr. women's med., (ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10087Cohen, S. et. al., Hysteroscopic Morcellation for Treating Intrauterine Pathology, Obstet Gynecol. 2011 Summer; 4(2): 73-80

Von Mikulicz-Radecki & Freund introduced electro-

coagulation of intramural portion of

tubes

1927

Silander introduced a hysteroscope with a latex balloon for

distention

1962

Edstrom & Fernstrom used

dextran for distention

1970

Distention & Visualization Visualization & Intervention

Neuwirth & Amin first resectoscope

hysteroscpic resection of

submucous myoma

1976

Smith & Nephew’s Truclear™ System

Introduced(mechanical cutting)

2005

Hologic’s MyoSure™ System

Introduced(mechanical cutting)

2009

Boston Scientific’s Symphion™ System

Introduced(closed-loop, RF bipolar resection)

2014

Monopolar and Bipolar resection

RF Bi-Polar Resection Process

• Tissue hydraulically drawninto resecting window

• Reciprocating RF electrode delivers bipolar plasma

• Minimal collateral effect

• Bipolar current switches to internal path

• Vaporized tissue & fluid trapped in the tip of the device

Phase I

• Vaporized tissue & fluid help to remove resected fragments

• Cleans electrodes surface to eliminate tissue sticking to electrode surface

Phase II Phase III

Hysteroscopic Morcellation Patient Selection

12

Follow-up after incomplete hysteroscopicremoval of uterine fibroids

Van Dongen H, Emanuel MH, Smeets J, Trimbos, B and Jansen FW

• 528 Hysteroscopic myomectomies• 91 Incomplete resections (17%)

• 37 repeated immediately for fertility• 41 observed for menorrhagia

Incomplete myomaresection

55% required additional surgery within 3 years

13

Abdominal Management – Laparoscopic Management Techniques

Charles E. Miller, MD, FACOG

Past President, AAGL (2007 – 2008)

Past President, International Society for Gynecologic Endoscopy – ISGE (2011 – 2013)

Treasurer, International Society for Gynecologic Endoscopy (ISGE)

Clinical Associate Professor, Department OB/GYN, University of IL at Chicago, Chicago, IL USA

Director of Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital, Park Ridge, IL USA

Director, AAGL/SRS Fellowship in Minimally Invasive Gynecologic Surgery, Advocate LutheranGeneral Hospital, Park Ridge, IL USA

Contracted/Research:AbbVie, Actavis, Aegea Medical, Bayer Healthcare Corp., Covidien, Gynesonics, IntuitiveSurgical

Consultant: AbbVie, Covidien, Ethicon Endo--‐Surgery, Gynesonics, Halt Medical, IntuitiveSurgical, Pacira Pharrmaceuticals

Speakers Bureau: Ethicon Endo--‐Surgery, intuitive Surgical, Smith & Nephew Endoscopy

Royalty: Thomas Medical


At the end of this discussion, the physician will be able to:

1. List two different energy sources for fibroid enucleation.

2. List two advantages of barbed vs. monofilament suture.

3. Explain how morcellation in a bag minimizes the risk of tissue spread at time of myomectomy.

• Parker, WH, 2010. Risk factors for uterine rupture after laparoscopic myomectomy. J Minim Invasive Gynecol, Sep-Oct;17(5), 551-4.

• Pelosi, MA, 1997. Spontaneous uterine rupture at thirty-three weeks subsequent to previous superficial laparoscopic myomectomy. Am J Obstet Gynecol, Dec;177(6), 1547-9.

• Dubuisson, JB, 1995. Uterine rupture during pregnancy after laparoscopic myomectomy. Hum Reprod, Jun;10(6), 1475-7


Strategies in the Laparoscopic Management of the Large Myomatous Uterus

Surgery Preparation

• Cycle timing – early follicular phase– Day# 6-12

• OCP’s– Anytime

• GNRH agonists– Anytime

– Fibroid degeneration can cause loss of myoma planes

– Try to avoid unless severely anemic



Surgery Preparation

• General endotracheal anesthesia

• Place Foley catheter

• Perform hysteroscopy to identify and treat submucosal fibroids, polyps, intrauterine adhesions

• Place uterine manipulator that enables anterior-posterior and lateral mobility— Valchev

— Pelosi

— Rumi

— Jarcho

— V-Care

— Fornisee

14



Port Placement

10-12mm trocar at umbilicus

— Even if uterine mass is 18+ weeks’ size, generally the umbilicus is the easiest option for insufflation

— Alternatively, consider left upper quadrant access

Place secondary ports lateral and cephalad to uterus/fibroid(s)

— 5-mm lateral ports are advantageous

Cosmetic

Fascia closure not required

Less risk of post-op hernia

Requires morcellation through umbilicus with lateral 5-mm port camera



Large Uterus Port Placement


Myomectomy (laparoscopic and robotic assisted)

Enucleation

Dilute Vasopressin— 30 units diluted in 100cc normal saline

— Half-life = 10-20 minutes

— 18G spinal needle with controlled syringe Inject into myometrium near fibroid aiming for myoma capsule

• Multiple areas

• “Connect the dots”

Aspirate to avoid injection intravascularly• Notify anesthesia

— Elevates blood pressure

— Loss of pulse oximetry reading



Enucleation Instrumentation

Energy options for myomectomy— Monopolar hook or scissors

— Ultrasonic scalpel Maximize cut to minimize tissue desiccation

• Risk of uterine rupture during pregnancy

Instrumentation— Toothed instruments

Single-toothed spoon

Claw

Myoma screw

— Traction/countertraction

• Parker, WH, 2010. Risk factors for uterine rupture after laparoscopic myomectomy. J Minim Invasive Gynecol, Sep-Oct;17(5), 551-4.• Pelosi, MA, 1997. Spontaneous uterine rupture at thirty-three weeks subsequent to previous superficial laparoscopic myomectomy. Am

J Obstet Gynecol, Dec;177(6), 1547-9.• Dubuisson, JB, 1995. Uterine rupture during pregnancy after laparoscopic myomectomy. Hum Reprod, Jun;10(6), 1475-7.



Enucleation



Tissue Reapproximation

Suture type— Absorbable

— Taper needle

Multi-layer closure— Hemostasis

Avoid use of energy to reduce tissue destruction

— Eliminate “dead” space

— Reduce risk of uterine rupture during pregnancy

• Parker, WH, 2010. Risk factors for uterine rupture after laparoscopic myomectomy. J Minim Invasive Gynecol, Sep-Oct;17(5), 551-4.• Pelosi, MA, 1997. Spontaneous uterine rupture at thirty-three weeks subsequent to previous superficial laparoscopic myomectomy. Am

J Obstet Gynecol, Dec;177(6), 1547-9.• Dubuisson, JB, 1995. Uterine rupture during pregnancy after laparoscopic myomectomy. Hum Reprod, Jun;10(6), 1475-7.

15



Barbed Suture

Stratafix™, Quill™, and V-Loc™ wound closure device

— The barbs grasp tissue at numerous points providing distribution of tension across the wound

— Eliminates the need for tying knots


Traditional Laparoscopic Myomectomy With Covidien V-Loc™ Advanced Wound Closure Device



Adhesion Prevention

Minimize energy

Avoid multiple surgical incisions

Serosal closure – minimize suture exposure

Adhesion barriers


Electromechanical Power Morcellation in a Bag


GelPOINT Power Morcellation in a Bag

16

Abdominal Management – The Very Large Uterus

Olav Istre, MD. PhDProfessor in MIGS

Aleris private HospitalAnd

University of Southern Denmark

• I have no financial relationships to disclose

To compare surgical approach and technique

• Discuss minimal invasive gynecological tecniques

• Describe pathology that interferes with function

• Improve the quality of life

Complication between abdominal or laparoscopic aproach

• Net difference in the incidences for complications – Adhesions +50.1% (midline double the incidence)

– hernia +10.7%

– surgical site infection +4.8%

– small bowel obstruction +2.8%

– venous thromboembolism +2%

• Audebert AJ, Gomel V. Role of microlaparoscopy in the diagnosis of peritoneal and

• visceral adhesions and in the prevention of bowel injury associated with blind trocar

• insertion. Fertil Steril 2000 Mar;73(3):631‐5.

• Dubuisson J, Botchorishvili R, Perrette S, Bourdel N, Jardon K, Rabischong B, et al.

• Incidence of intraabdominal adhesions in a continuous series of 1000 laparoscopic

• procedures. Am J Obstet Gynecol 2010 Aug;203(2):111 e1‐3.

• Le Huu Nho R, Mege D, Ouaissi M, Sielezneff I, Sastre B. Incidence and prevention of

• ventral incisional hernia. J Visc Surg 2012 Oct;149(5 Suppl):e3‐14.

• Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, et al. Surgical

• approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev

• 2009(3):CD003677.

• Angenete E, Jacobsson A, Gellerstedt M, Haglind E. Effect of laparoscopy on the risk of

• small‐bowel obstruction: a population‐based register study. Arch. of surg. 2012

Limitation of surgical aproach

• The goal is laparoscopic aproach

• Dependent on

– Number of fibroids

– Size of fibroid

– Previous surgery

– Patients wish

17

Open surgery with midline Incision, 1998

Open myomectomy

Multiple (57) Large fiboids >1200 g

Phannenstiel (morcelation with knife in bag, )

Sarcoma issue

• 41 patients leiomyosarcomas morcellated• Prognosis was significantly worse in these patients • 1 of these 41 patients had laparoscopic morcellation.• The other 40 patients had the specimen morcellated using a

cold knife through a minilaparotomy (n=17), transvaginally(n=19), or hysteroscopically (n=4)."

• Park JY, Park SK, Kim DY, et al. The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma. Gynecol Oncol. 2011 Aug;122(2):255–259.

• Perri T, Korach J, Sadetzki S, Oberman B, Fridman E, Ben‐Baruch G. Uterine leiomyosarcoma: does the primary surgical procedure matter? Int J Gynecol Cancer. 2009 Feb;19(2):257–260.

The fibroid/Sarcoma debate

• 42 year old women

• Prevoius 5 IVF

• Missed abortion with D&C March 2015

• Ca 125 =280, CEA =1

• Abdominal tumor 11 cm

Fibroid / sarcoma issue

• CT scan suspicion of sarcom

• PET scan = PET positiv (FDG uploading in the periferi of the tumor) with central necrosis

• FDG (deoxyglycose) is obtained in cells with increased metabolisme

18

Fibroid / sarcoma issue

• Rapid Growth

• Recommendation from Gynecology Oncology clinic and sarcoma group ( 12 doctors)

• Recomondation:

• Midline incision, Removal of tumor including Hysterectomy

Fibroid / Sarcoma issue

• She has seen at 3 different University Hospitals

• She wants second opinion

• She wants to be sure

• She wants to keep the uterus

Fibroids natural history

• Composed of smooth muscle and varying amount of fibrous connective tissue

• As leiomyomas enlarge, they may outgrow their blood supply resulting in various types of degeneration: 2/3 shows degeneration

– Hyaline or myxoid degeneration (75%)

– Calcification (10%)

– Cystic degeneration(10%)

– Fatty degeneration

Red degenation

Ueda, Radiographics. 1999 Oct;19 Spec No:S131‐45

19

HISTOLOGY

• Histology:

• Examination number: 15SH1154‐1

• 1. Myometrium

• ‐leiomyoma ‐

• ‐necrosis ‐

• ‐bleeding

20

CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians

(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws

identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

program, the importance of the services, and the resources available to the recipient, including the mix of oral

and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English

Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

including those which provide federal financial assistance, to examine the services they provide, identify any

need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every

California state agency which either provides information to, or has contact with, the public to provide bilingual

interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

~

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsian

Indo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

21

http://www.imq.org/

http://www.usdoj.gov/crt/cor/pubs.htm

http://www.usdoj.gov/crt/cor/13166.htm

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538

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