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Isthmocele repair: Simultaneous hysteroscopy and robotic-assisted laparoscopy
An isthmocele is a pouch-like anterior uterine wall defect at the site of a previous cesarean scar. The incidence is not well known, but it is estimated in the literature to be between 19% and 88%.1 Issues arising from an isthmocele may include abnormal uterine bleeding; abdominal pain; diminished fertility; ectopic pregnancy; or obstetric complications, such as uterine rupture. Repair of an isthmocele may be indicated for symptomatic relief and preservation of fertility. Multiple surgical approaches have been described in the literature, including laparoscopic, hysteroscopic, and vaginal approaches.
The objective of this video is to illustrate the use of robotic-assisted laparoscopy with simultaneous hysteroscopy as a feasible and safe approach for the repair of an isthmocele. Here we illustrate the key surgical steps of this approach, including:
- presurgical planning with magnetic resonance imaging
- diagnostic hysteroscopy for confirmation of isthmocele
- simultaneous laparoscopy for identification of borders
- strategic hysterotomy
- excision of scar tissue
- imbricated, tension-free closure.
We hope that you find this video useful to your clinical practice.
>> Dr. Arnold P. Advincula, and colleagues
- Tower AM, Frishman GN. Cesarean scar defects: an underrecognized cause of abnormal uterine bleeding and other gynecologic complications. J Minim Invasive Gynecol. 2013;20:562-572. doi: 10.1016/j.jmig.2013.03.008.
An isthmocele is a pouch-like anterior uterine wall defect at the site of a previous cesarean scar. The incidence is not well known, but it is estimated in the literature to be between 19% and 88%.1 Issues arising from an isthmocele may include abnormal uterine bleeding; abdominal pain; diminished fertility; ectopic pregnancy; or obstetric complications, such as uterine rupture. Repair of an isthmocele may be indicated for symptomatic relief and preservation of fertility. Multiple surgical approaches have been described in the literature, including laparoscopic, hysteroscopic, and vaginal approaches.
The objective of this video is to illustrate the use of robotic-assisted laparoscopy with simultaneous hysteroscopy as a feasible and safe approach for the repair of an isthmocele. Here we illustrate the key surgical steps of this approach, including:
- presurgical planning with magnetic resonance imaging
- diagnostic hysteroscopy for confirmation of isthmocele
- simultaneous laparoscopy for identification of borders
- strategic hysterotomy
- excision of scar tissue
- imbricated, tension-free closure.
We hope that you find this video useful to your clinical practice.
>> Dr. Arnold P. Advincula, and colleagues
An isthmocele is a pouch-like anterior uterine wall defect at the site of a previous cesarean scar. The incidence is not well known, but it is estimated in the literature to be between 19% and 88%.1 Issues arising from an isthmocele may include abnormal uterine bleeding; abdominal pain; diminished fertility; ectopic pregnancy; or obstetric complications, such as uterine rupture. Repair of an isthmocele may be indicated for symptomatic relief and preservation of fertility. Multiple surgical approaches have been described in the literature, including laparoscopic, hysteroscopic, and vaginal approaches.
The objective of this video is to illustrate the use of robotic-assisted laparoscopy with simultaneous hysteroscopy as a feasible and safe approach for the repair of an isthmocele. Here we illustrate the key surgical steps of this approach, including:
- presurgical planning with magnetic resonance imaging
- diagnostic hysteroscopy for confirmation of isthmocele
- simultaneous laparoscopy for identification of borders
- strategic hysterotomy
- excision of scar tissue
- imbricated, tension-free closure.
We hope that you find this video useful to your clinical practice.
>> Dr. Arnold P. Advincula, and colleagues
- Tower AM, Frishman GN. Cesarean scar defects: an underrecognized cause of abnormal uterine bleeding and other gynecologic complications. J Minim Invasive Gynecol. 2013;20:562-572. doi: 10.1016/j.jmig.2013.03.008.
- Tower AM, Frishman GN. Cesarean scar defects: an underrecognized cause of abnormal uterine bleeding and other gynecologic complications. J Minim Invasive Gynecol. 2013;20:562-572. doi: 10.1016/j.jmig.2013.03.008.
Excision of abdominal wall endometriosis
Endometriosis, defined by the ectopic growth of functioning endometrial glands and stroma,1,2 usually affects the peritoneal cavity. However, endometriosis has been identified in the pneumothorax, brain, and within the extraperitoneum, such as the abdominal wall.1-3 Incidence of abdominal wall endometriosis can be up to 12%.3-5 If patients report symptoms, they can include abdominal pain, a palpable mass, pelvic pain consistent with endometriosis, and bleeding from involvement of the overlying skin. Abdominal wall endometriosis can be surgically resected, with complete resolution and a low rate of recurrence.
In the following video, we review the diagnosis of abdominal wall endometriosis, including our imaging of choice, and treatment options. In addition, we illustrate a surgical technique for the excision of abdominal wall endometriosis in a 38-year-old patient with symptomatic disease. We conclude with a review of key surgical steps.
We hope that you find this video useful to your clinical practice.
>> Dr. Arnold P. Advincula, and colleagues
- Burney RO, Giudice LC. Pathogenesis and pathophysiology of endometriosis. Fertil Steril. 2012;98:511-519.
- Ecker AM, Donnellan NM, Shepherd JP, et al. Abdominal wall endometriosis: 12 years of experience at a large academic institution. Am J Obstet Gynecol. 2014;211:363.e1-e5.
- Horton JD, Dezee KJ, Ahnfeldt EP, et al. Abdominal wall endometriosis: a surgeon’s perspective and review of 445 cases. Am J Surg. 2008;196:207-212.
- Ding Y, Zhu J. A retrospective review of abdominal wall endometriosis in Shanghai, China. Int J Gynaecol Obstet. 2013;121:41-44.
- Chang Y, Tsai EM, Long CY, et al. Abdominal wall endometriosis. J Reproductive Med. 2009;54:155-159.
Endometriosis, defined by the ectopic growth of functioning endometrial glands and stroma,1,2 usually affects the peritoneal cavity. However, endometriosis has been identified in the pneumothorax, brain, and within the extraperitoneum, such as the abdominal wall.1-3 Incidence of abdominal wall endometriosis can be up to 12%.3-5 If patients report symptoms, they can include abdominal pain, a palpable mass, pelvic pain consistent with endometriosis, and bleeding from involvement of the overlying skin. Abdominal wall endometriosis can be surgically resected, with complete resolution and a low rate of recurrence.
In the following video, we review the diagnosis of abdominal wall endometriosis, including our imaging of choice, and treatment options. In addition, we illustrate a surgical technique for the excision of abdominal wall endometriosis in a 38-year-old patient with symptomatic disease. We conclude with a review of key surgical steps.
We hope that you find this video useful to your clinical practice.
>> Dr. Arnold P. Advincula, and colleagues
Endometriosis, defined by the ectopic growth of functioning endometrial glands and stroma,1,2 usually affects the peritoneal cavity. However, endometriosis has been identified in the pneumothorax, brain, and within the extraperitoneum, such as the abdominal wall.1-3 Incidence of abdominal wall endometriosis can be up to 12%.3-5 If patients report symptoms, they can include abdominal pain, a palpable mass, pelvic pain consistent with endometriosis, and bleeding from involvement of the overlying skin. Abdominal wall endometriosis can be surgically resected, with complete resolution and a low rate of recurrence.
In the following video, we review the diagnosis of abdominal wall endometriosis, including our imaging of choice, and treatment options. In addition, we illustrate a surgical technique for the excision of abdominal wall endometriosis in a 38-year-old patient with symptomatic disease. We conclude with a review of key surgical steps.
We hope that you find this video useful to your clinical practice.
>> Dr. Arnold P. Advincula, and colleagues
- Burney RO, Giudice LC. Pathogenesis and pathophysiology of endometriosis. Fertil Steril. 2012;98:511-519.
- Ecker AM, Donnellan NM, Shepherd JP, et al. Abdominal wall endometriosis: 12 years of experience at a large academic institution. Am J Obstet Gynecol. 2014;211:363.e1-e5.
- Horton JD, Dezee KJ, Ahnfeldt EP, et al. Abdominal wall endometriosis: a surgeon’s perspective and review of 445 cases. Am J Surg. 2008;196:207-212.
- Ding Y, Zhu J. A retrospective review of abdominal wall endometriosis in Shanghai, China. Int J Gynaecol Obstet. 2013;121:41-44.
- Chang Y, Tsai EM, Long CY, et al. Abdominal wall endometriosis. J Reproductive Med. 2009;54:155-159.
- Burney RO, Giudice LC. Pathogenesis and pathophysiology of endometriosis. Fertil Steril. 2012;98:511-519.
- Ecker AM, Donnellan NM, Shepherd JP, et al. Abdominal wall endometriosis: 12 years of experience at a large academic institution. Am J Obstet Gynecol. 2014;211:363.e1-e5.
- Horton JD, Dezee KJ, Ahnfeldt EP, et al. Abdominal wall endometriosis: a surgeon’s perspective and review of 445 cases. Am J Surg. 2008;196:207-212.
- Ding Y, Zhu J. A retrospective review of abdominal wall endometriosis in Shanghai, China. Int J Gynaecol Obstet. 2013;121:41-44.
- Chang Y, Tsai EM, Long CY, et al. Abdominal wall endometriosis. J Reproductive Med. 2009;54:155-159.
Laparoscopic bilateral salpingo-oophorectomy via minilaparotomy assistance for the massively enlarged adnexal mass
Large adnexal masses traditionally are removed surgically via laparotomy through a midline vertical incision to achieve adequate exposure and to avoid spillage of cyst contents. However, large laparotomies carry significant morbidity compared with minimally invasive techniques. Minilaparotomy is a minimally invasive approach that is associated with shorter operating times and lower estimated blood loss compared with laparoscopy in gynecologic surgery.1 The procedure also provides adequate exposure and can be used for carefully selected patients with a large adnexal mass.2,3 Preoperative assessment for the risk of malignancy typically includes an evaluation of risk factors, physical examination, imaging, and tumor markers.4
In this video, we illustrate a minimally invasive technique for the removal of a massively enlarged adnexal mass through laparoscopic bilateral salpingo-oophorectomy with minilaparotomy assistance. We conclude that this procedure is a safe and feasible option for women with a large benign adnexal mass, such as the highlighted patient whose final pathology resulted in a mucinous cystadenoma. Careful patient selection and preoperative assessment of malignancy risk is critical.5,6
We hope that you find this innovative approach useful in your clinical practice.
>> Dr. Arnold P. Advincula and colleagues
- Kumar A, Pearl M. Mini-laparotomy versus laparoscopy for gynecologic conditions. J Minim Invasive Gynecol. 2014;21:109-114.
- Pelosi MA. A novel minilaparotomy approach for large ovarian cysts. OBG Manag. 2004;16(2):17-30.
- Rhode JM, Advincula AP, Reynolds RK, et al. A minimally invasive technique for management of the large adnexal mass. J Minim Invasive Gynecol. 2006;13:476-479.
- American College of Obstetricians and Gynecologists' Committee on Practice Bulletins--Gynecology. Practice Bulletin No. 174: evaluation and management of adnexal masses. Obstet Gynecol. 2016;128:e210-e226.
- Roman LD, Muderspach LI, Stein SM, et al. Pelvic examination, tumor marker level, and gray-scale and Doppler sonography in the prediction of pelvic cancer. Obstet Gynecol. 1997;89:493-500.
- Dodge JE, Covens AL, Lacchetti C, et al; Gynecology Cancer Disease Site Group. Preoperative identification of a suspicious adnexal mass: a systematic review and meta-analysis. Gynecol Oncol. 2012:126:157-166.
Dr. Cui is Resident, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York.
Dr. Dubin is Fellow, Minimally Invasive Gynecologic Surgery, Columbia University Irving Medical Center.
Dr. Advincula
Dr. Advincula is Levine Family Professor of Women's Health; Vice-Chair, Department of Obstetrics & Gynecology; Chief of Gynecology, Sloane Hospital for Women; and Medical Director, Mary & Michael Jaharis Simulation Center, Columbia University Irving Medical Center, New York-Presbyterian Hospital. He serves on the OBG Management Board of Editors.
Dr. Advincula reports serving as a consultant to ConMed, CooperSurgical, Intuitive Surgical, and Titan Medical and receiving royalties from CooperSurgical. The other authors report no financial relationships relevant to this article.
Dr. Cui is Resident, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York.
Dr. Dubin is Fellow, Minimally Invasive Gynecologic Surgery, Columbia University Irving Medical Center.
Dr. Advincula
Dr. Advincula is Levine Family Professor of Women's Health; Vice-Chair, Department of Obstetrics & Gynecology; Chief of Gynecology, Sloane Hospital for Women; and Medical Director, Mary & Michael Jaharis Simulation Center, Columbia University Irving Medical Center, New York-Presbyterian Hospital. He serves on the OBG Management Board of Editors.
Dr. Advincula reports serving as a consultant to ConMed, CooperSurgical, Intuitive Surgical, and Titan Medical and receiving royalties from CooperSurgical. The other authors report no financial relationships relevant to this article.
Dr. Cui is Resident, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York.
Dr. Dubin is Fellow, Minimally Invasive Gynecologic Surgery, Columbia University Irving Medical Center.
Dr. Advincula
Dr. Advincula is Levine Family Professor of Women's Health; Vice-Chair, Department of Obstetrics & Gynecology; Chief of Gynecology, Sloane Hospital for Women; and Medical Director, Mary & Michael Jaharis Simulation Center, Columbia University Irving Medical Center, New York-Presbyterian Hospital. He serves on the OBG Management Board of Editors.
Dr. Advincula reports serving as a consultant to ConMed, CooperSurgical, Intuitive Surgical, and Titan Medical and receiving royalties from CooperSurgical. The other authors report no financial relationships relevant to this article.
Large adnexal masses traditionally are removed surgically via laparotomy through a midline vertical incision to achieve adequate exposure and to avoid spillage of cyst contents. However, large laparotomies carry significant morbidity compared with minimally invasive techniques. Minilaparotomy is a minimally invasive approach that is associated with shorter operating times and lower estimated blood loss compared with laparoscopy in gynecologic surgery.1 The procedure also provides adequate exposure and can be used for carefully selected patients with a large adnexal mass.2,3 Preoperative assessment for the risk of malignancy typically includes an evaluation of risk factors, physical examination, imaging, and tumor markers.4
In this video, we illustrate a minimally invasive technique for the removal of a massively enlarged adnexal mass through laparoscopic bilateral salpingo-oophorectomy with minilaparotomy assistance. We conclude that this procedure is a safe and feasible option for women with a large benign adnexal mass, such as the highlighted patient whose final pathology resulted in a mucinous cystadenoma. Careful patient selection and preoperative assessment of malignancy risk is critical.5,6
We hope that you find this innovative approach useful in your clinical practice.
>> Dr. Arnold P. Advincula and colleagues
Large adnexal masses traditionally are removed surgically via laparotomy through a midline vertical incision to achieve adequate exposure and to avoid spillage of cyst contents. However, large laparotomies carry significant morbidity compared with minimally invasive techniques. Minilaparotomy is a minimally invasive approach that is associated with shorter operating times and lower estimated blood loss compared with laparoscopy in gynecologic surgery.1 The procedure also provides adequate exposure and can be used for carefully selected patients with a large adnexal mass.2,3 Preoperative assessment for the risk of malignancy typically includes an evaluation of risk factors, physical examination, imaging, and tumor markers.4
In this video, we illustrate a minimally invasive technique for the removal of a massively enlarged adnexal mass through laparoscopic bilateral salpingo-oophorectomy with minilaparotomy assistance. We conclude that this procedure is a safe and feasible option for women with a large benign adnexal mass, such as the highlighted patient whose final pathology resulted in a mucinous cystadenoma. Careful patient selection and preoperative assessment of malignancy risk is critical.5,6
We hope that you find this innovative approach useful in your clinical practice.
>> Dr. Arnold P. Advincula and colleagues
- Kumar A, Pearl M. Mini-laparotomy versus laparoscopy for gynecologic conditions. J Minim Invasive Gynecol. 2014;21:109-114.
- Pelosi MA. A novel minilaparotomy approach for large ovarian cysts. OBG Manag. 2004;16(2):17-30.
- Rhode JM, Advincula AP, Reynolds RK, et al. A minimally invasive technique for management of the large adnexal mass. J Minim Invasive Gynecol. 2006;13:476-479.
- American College of Obstetricians and Gynecologists' Committee on Practice Bulletins--Gynecology. Practice Bulletin No. 174: evaluation and management of adnexal masses. Obstet Gynecol. 2016;128:e210-e226.
- Roman LD, Muderspach LI, Stein SM, et al. Pelvic examination, tumor marker level, and gray-scale and Doppler sonography in the prediction of pelvic cancer. Obstet Gynecol. 1997;89:493-500.
- Dodge JE, Covens AL, Lacchetti C, et al; Gynecology Cancer Disease Site Group. Preoperative identification of a suspicious adnexal mass: a systematic review and meta-analysis. Gynecol Oncol. 2012:126:157-166.
- Kumar A, Pearl M. Mini-laparotomy versus laparoscopy for gynecologic conditions. J Minim Invasive Gynecol. 2014;21:109-114.
- Pelosi MA. A novel minilaparotomy approach for large ovarian cysts. OBG Manag. 2004;16(2):17-30.
- Rhode JM, Advincula AP, Reynolds RK, et al. A minimally invasive technique for management of the large adnexal mass. J Minim Invasive Gynecol. 2006;13:476-479.
- American College of Obstetricians and Gynecologists' Committee on Practice Bulletins--Gynecology. Practice Bulletin No. 174: evaluation and management of adnexal masses. Obstet Gynecol. 2016;128:e210-e226.
- Roman LD, Muderspach LI, Stein SM, et al. Pelvic examination, tumor marker level, and gray-scale and Doppler sonography in the prediction of pelvic cancer. Obstet Gynecol. 1997;89:493-500.
- Dodge JE, Covens AL, Lacchetti C, et al; Gynecology Cancer Disease Site Group. Preoperative identification of a suspicious adnexal mass: a systematic review and meta-analysis. Gynecol Oncol. 2012:126:157-166.
Minilaparotomy: Minimally invasive approach to abdominal myomectomy
A minilaparotomy is loosely defined as a laparotomy measuring between 4 cm and 6 cm. For the appropriate surgical candidate, a minilaparotomy is a useful alternative to laparotomy or laparoscopy, especially for large pathology.1 Benefits of minilaparotomy include improved pain management and postoperative recovery, as well as improved cosmetic outcome, with comparable blood loss and operative time.2,3
In this video, we illustrate the key surgical steps of a minilaparotomy for the removal of large fibroids. These steps include:
- strategic vertical skin incision
- use of a self-retaining retractor
- infiltrate myometrium with dilute vasopressin
- strategic hysterotomy
- use of tenaculum for upward traction
- 10# blade scalpels for the “lemon wedge” coring technique
- layered closure.
Minilaparotomy myomectomy can be an excellent minimally invasive alternative to a traditional “full laparotomy” for women with large fibroids.
We hope that you find this video beneficial to your clinical practice.
>> Arnold P. Advincula, MD
Laparoscopic bilateral salpingo-oophorectomy via minilaparotomy assistance for the massively enlarged adnexal mass
- Pelosi MA 2nd, Pelosi MA 3rd. Pelosi minilaparotomy hysterectomy: a non-endoscopic minimally invasive alternative to laparoscopy and laparotomy. Surg Technol Int. 2004;13:157-167.
- Fanafani F, Fagotti A, Longo R. Minilaparotomy in the management of benign gynecologic disease. Eur J Obstet Gynecol Reprod Biol. 2005;119:232-236.
- Glasser MH. Minilaparotomy: a minimally invasive alternative for major gynecologic abdominal surgery. Perm J. 2005;9:41-45.
A minilaparotomy is loosely defined as a laparotomy measuring between 4 cm and 6 cm. For the appropriate surgical candidate, a minilaparotomy is a useful alternative to laparotomy or laparoscopy, especially for large pathology.1 Benefits of minilaparotomy include improved pain management and postoperative recovery, as well as improved cosmetic outcome, with comparable blood loss and operative time.2,3
In this video, we illustrate the key surgical steps of a minilaparotomy for the removal of large fibroids. These steps include:
- strategic vertical skin incision
- use of a self-retaining retractor
- infiltrate myometrium with dilute vasopressin
- strategic hysterotomy
- use of tenaculum for upward traction
- 10# blade scalpels for the “lemon wedge” coring technique
- layered closure.
Minilaparotomy myomectomy can be an excellent minimally invasive alternative to a traditional “full laparotomy” for women with large fibroids.
We hope that you find this video beneficial to your clinical practice.
>> Arnold P. Advincula, MD
Laparoscopic bilateral salpingo-oophorectomy via minilaparotomy assistance for the massively enlarged adnexal mass
A minilaparotomy is loosely defined as a laparotomy measuring between 4 cm and 6 cm. For the appropriate surgical candidate, a minilaparotomy is a useful alternative to laparotomy or laparoscopy, especially for large pathology.1 Benefits of minilaparotomy include improved pain management and postoperative recovery, as well as improved cosmetic outcome, with comparable blood loss and operative time.2,3
In this video, we illustrate the key surgical steps of a minilaparotomy for the removal of large fibroids. These steps include:
- strategic vertical skin incision
- use of a self-retaining retractor
- infiltrate myometrium with dilute vasopressin
- strategic hysterotomy
- use of tenaculum for upward traction
- 10# blade scalpels for the “lemon wedge” coring technique
- layered closure.
Minilaparotomy myomectomy can be an excellent minimally invasive alternative to a traditional “full laparotomy” for women with large fibroids.
We hope that you find this video beneficial to your clinical practice.
>> Arnold P. Advincula, MD
Laparoscopic bilateral salpingo-oophorectomy via minilaparotomy assistance for the massively enlarged adnexal mass
- Pelosi MA 2nd, Pelosi MA 3rd. Pelosi minilaparotomy hysterectomy: a non-endoscopic minimally invasive alternative to laparoscopy and laparotomy. Surg Technol Int. 2004;13:157-167.
- Fanafani F, Fagotti A, Longo R. Minilaparotomy in the management of benign gynecologic disease. Eur J Obstet Gynecol Reprod Biol. 2005;119:232-236.
- Glasser MH. Minilaparotomy: a minimally invasive alternative for major gynecologic abdominal surgery. Perm J. 2005;9:41-45.
- Pelosi MA 2nd, Pelosi MA 3rd. Pelosi minilaparotomy hysterectomy: a non-endoscopic minimally invasive alternative to laparoscopy and laparotomy. Surg Technol Int. 2004;13:157-167.
- Fanafani F, Fagotti A, Longo R. Minilaparotomy in the management of benign gynecologic disease. Eur J Obstet Gynecol Reprod Biol. 2005;119:232-236.
- Glasser MH. Minilaparotomy: a minimally invasive alternative for major gynecologic abdominal surgery. Perm J. 2005;9:41-45.
