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Walker Z, Gargiulo A. Near-infrared and hysteroscopy-guided robotic excision of uterine isthmocele with laser fiber: a novel high-precision technique. Fertil Steril 2023; 120:1081-1083. [PMID: 37567494 DOI: 10.1016/j.fertnstert.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 08/02/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVE To describe a novel high-precision technique for robotic excision of uterine isthmocele, employing a carbon dioxide laser fiber, under hysteroscopic guidance, and near-infrared guidance. DESIGN Video article. PATIENT(S) A 36-year-old multipara with 3 prior cesarean sections presented to our infertility clinic with secondary infertility. The patient had been trying to conceive for 6 months without success. The patient underwent a hystero-salpingo contrast sonography that identified a large cesarean scar defect with a 1.4-mm residual myometrial thickness (RMT). The patient was counseled on surgical management with robotic approach because of RMT <3 mm precluding her from hysteroscopic resection and the potential risk for a cesarean scar ectopic or abnormal placentation if she were to become pregnant in the future. She elected to undergo excision and repair and informed consent was obtained from the patient. INTERVENTION(S) The robot was docked for traditional gynecologic robotic surgery. The uterus was injected with 5 units of vasopressin. We used a carbon dioxide laser fiber (Lumenis FIberLase) at a power of 5 watts as the sole energy source for dissection. The bladder was dissected off the uterus to identify the general area of the isthmocele. At that point, diagnostic hysteroscopy was performed using a 30-degree 5-mm hysteroscope (Karl Storz) to identify and enter the isthmocele. Near-infrared vision (da Vinci Firefly, Intuitive USA) was activated to precisely outline the extent of the isthmocele, which was not visible with simple transillumination from the hysteroscope. We proceeded with laser excision in infrared/gray scale using the laser at a power of 20 watts removing the entire area that was highlighted by the Firefly. After full excision of the isthmocele, the hysteroscope was removed and was eventually replaced by a uterine manipulator (ConMed VCare DX). The hysterotomy was closed with a 2-layer closure: 4 mattress sutures of 2-0 Vicryl (Ethicon) followed by a running 2-0 PDS Stratafix (Ethicon). The peritoneal layer was closed over these 2 layers with 2-0 PDS Stratafix (Ethicon) in a running fashion. The uterine manipulator was removed and a 14 French Malecot catheter (Bard) was placed in the uterine cavity to allow the healing to proceed with minimal risk of cervical stenosis. The bladder was backfilled to ensure integrity of the bladder wall. Interceed adhesion barrier (Gynecare) was then placed over the area of the repair and the procedure was concluded. The patient included in this video gave consent for publication of the video and posting of the video online including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, etc.), and other applicable sites. MAIN OUTCOME MEASURE(S) Completion of excision and repair of cesarean scar defect without surgical complications. RESULT(S) Robotic excision and repair of a sizable uterine isthmocele with carbon dioxide laser fiber and da Vinci Firefly was completed successfully without any surgical complications. Diagnostic hysteroscopy was used to positively identify the isthmocele and provide transillumination. However, the thickness of the cervical myometrium only allows the hysteroscopic light to shine through the thinnest portion of myometrium at the apex of the isthmocele, whereas the near-infrared vision allowed by the da Vinci Firefly technology was used to precisely identify the borders of the defect. The carbon dioxide laser was used to completely remove the defect while avoiding damage to delicate reproductive tissue and over-excision. No complications were identified during the postoperative visit. Magnetic resonance imaging 3 months after the surgery revealed an RMT of 10 mm at the location of excision compared with the initial RMT of 1.4 mm. CONCLUSION(S) Currently, there is no gold-standard technique for surgical management of isthmocele. This is the first description of the combined use of hysteroscopy, near-infrared vision, and laser fiber for the robotic excision of isthmocele. This specific setup proves to be a useful technical improvement. The use of near-infrared vision combined with precise hysteroscopic targeting allows much clearer definition of he isthmocele borders, and the flexible laser fiber allows millimetric xcision in the absence of appreciable lateral thermal spread. Further investigation is warranted to identify a gold-standard surgical technique for patients with cesarean scar defect.
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Affiliation(s)
- Zachary Walker
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Antonio Gargiulo
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Gargiulo AR, Bhagavath B. Reproductive surgery: decreasing skills and advancing technology-an existential conundrum. Fertil Steril 2019; 112:211-218. [PMID: 31352960 DOI: 10.1016/j.fertnstert.2019.06.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 06/28/2019] [Indexed: 01/18/2023]
Abstract
Our article endeavors to be both a review of the recent past and a preview of the future of reproductive surgery. By reflecting on the rate of technological advancement over the past decade, we attempt to predict the trajectory of the next. We also delve into the changing nature and practical challenges of the practice of gynecologic surgery for the reproductive endocrinology and infertility subspecialist. We will explain how technological advances may alter our perception and expectations regarding the indications, timing and extent of surgical intervention in the infertile patient and in the patient seeking preservation of fertility. This review does not aim to be comprehensive, choosing instead to focus on those innovations that hold, in our view, true potential to shape the future of surgical practice. Ours is primarily a technology review. As such, it does not focus on novel surgical techniques, including uterine transplantation and ovarian tissue transplantation.
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Affiliation(s)
- Antonio R Gargiulo
- Department of Obstetrics & Gynecology, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Bala Bhagavath
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Rochester, Rochester, New York
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Menezes AQ, Cardoso PFG, Nagao CK, Minamoto H, Bibas BJ, de Faria Soares Rodrigues I, Otoch JP, Dolhnikoff M, Canzian M, Mancini MW, Pêgo-Fernandes PM. Posterior laryngofissure using a surgical contact diode laser: an experimental feasibility study. Lasers Med Sci 2019; 34:1441-1448. [PMID: 30762192 DOI: 10.1007/s10103-019-02729-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 01/21/2019] [Indexed: 11/27/2022]
Abstract
To evaluate the feasibility of a 980-nm contact diode laser (CDL) as a method for creating a posterior laryngofissure in live pigs. Twenty-eight Landrace pigs (15-20 kg) were anesthetized, intubated, ventilated, and submitted to a cervical tracheostomy. An anterior and posterior midline longitudinal laryngofissure incision was created according to randomization-control (n = 4), posterior laryngofissure with a scalpel blade; electrocautery (n = 12), posterior laryngofissure by electrocautery (10, 15, 20, 25 W powers); CDL (n = 12), posterior laryngofissure by the CDL (10, 15, 20, 25 W peak powers in pulsed mode). Larynx and proximal trachea were excised, prepared for histopathology, and digital morphometric analysis. Measurements in and within each group were analyzed (Kruskal-Wallis and Dunn test) with a level of significance of p < 0.05. Incision width was not different between the groups, as well as in the powers used in CDL (p = 0.161) and electrocautery group (p = 0.319). The depth of the incisions was smaller in the Laser group compared to control (p = 0.007), and in the electrocautery compared to control (p = 0.026). Incision area was smaller in CDL compared with the control (p = 0.027), and not different between laser and electrocautery groups (p = 0.199). The lateral thermal damage produced by electrocautery was the largest, with a significant difference between laser and electrocautery (p = 0.018), and between electrocautery and control (p = 0.004), whereas the comparison between laser and control showed no significant differences (p = 0.588). The posterior laryngofissure incision using a 980-nm CDL is feasible resulting in smaller incisional area and less lateral thermal damage.
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Affiliation(s)
- Arteiro Queiroz Menezes
- Division of Thoracic Surgery, Thoracic Surgery Research Laboratory (LIM-61), Heart Institute (InCor) do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Rua Dr. Eneas de Carvalho Aguiar 44, Bloco I, 7° andar, São Paulo, SP, 05403-000, Brazil.,Department of Surgery, Universidade do Estado do Amazonas, Manaus, Brazil.,Universidade Federal do Amazonas, Manaus, Brazil
| | - Paulo Francisco Guerreiro Cardoso
- Division of Thoracic Surgery, Thoracic Surgery Research Laboratory (LIM-61), Heart Institute (InCor) do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Rua Dr. Eneas de Carvalho Aguiar 44, Bloco I, 7° andar, São Paulo, SP, 05403-000, Brazil.
| | - Christopher Kengo Nagao
- Division of Thoracic Surgery, Thoracic Surgery Research Laboratory (LIM-61), Heart Institute (InCor) do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Rua Dr. Eneas de Carvalho Aguiar 44, Bloco I, 7° andar, São Paulo, SP, 05403-000, Brazil
| | - Helio Minamoto
- Division of Thoracic Surgery, Thoracic Surgery Research Laboratory (LIM-61), Heart Institute (InCor) do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Rua Dr. Eneas de Carvalho Aguiar 44, Bloco I, 7° andar, São Paulo, SP, 05403-000, Brazil
| | - Benoit Jacques Bibas
- Division of Thoracic Surgery, Thoracic Surgery Research Laboratory (LIM-61), Heart Institute (InCor) do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Rua Dr. Eneas de Carvalho Aguiar 44, Bloco I, 7° andar, São Paulo, SP, 05403-000, Brazil
| | - Isaac de Faria Soares Rodrigues
- Division of Thoracic Surgery, Thoracic Surgery Research Laboratory (LIM-61), Heart Institute (InCor) do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Rua Dr. Eneas de Carvalho Aguiar 44, Bloco I, 7° andar, São Paulo, SP, 05403-000, Brazil
| | - José Pinhata Otoch
- Discipline of Surgical Technique and Experimental Surgery (LIM 26), Faculdade de Medicina da Universidade de Sao Paulo, Av. Dr. Arnaldo, 455-4° andar, Sao Paulo, SP, 01246-903, Brazil
| | - Marisa Dolhnikoff
- Department of Pathology, Faculdade de Medicina da Universidade de Sao Paulo, Avenida Dr. Arnaldo 455, sala 1155, Sao Paulo, SP, 01246-903, Brazil
| | - Mauro Canzian
- LABPAC Pathology Lab, Rua Calixto da Mota 72, São Paulo, SP, 04117-100, Brazil
| | - Marilia Wellichan Mancini
- Núcleo de Pesquisa e Ensino de Fototerapia nas Ciências da Saúde-NUPEN, Rua Pedro Fernandes Alonso 766, São Carlos, SP, 13562-380, Brazil
| | - Paulo Manuel Pêgo-Fernandes
- Division of Thoracic Surgery, Thoracic Surgery Research Laboratory (LIM-61), Heart Institute (InCor) do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Rua Dr. Eneas de Carvalho Aguiar 44, Bloco I, 7° andar, São Paulo, SP, 05403-000, Brazil
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Odenthal J, Friedl P, Takes RP. Compatibility of CO 2 laser surgery and fluorescence detection in head and neck cancer cells. Head Neck 2018; 41:1253-1259. [PMID: 30549379 DOI: 10.1002/hed.25547] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 10/08/2018] [Accepted: 10/29/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Surgical treatment of cancer requires tumor excision with emphasis on function preservation which is achieved in (early stage) laryngeal cancer by transoral carbon dioxide (CO2 ) laser surgery. Whereas conventional laser surgery is restricted by the surgeon's visual recognition of tumor tissue, new approaches based on fluorescence-guided surgery (FGS) improve the detection of the tumor and its margin. However, it is unclear whether fluorophores are compatible with high-power laser application or whether precision is compromised by laser-induced bleaching of the dye. METHODS We applied topology-controlled 3D laser resection of fluorescent tumors cell in vitro and laser-induced autofluorescence analysis ex vivo. RESULTS Laser-induced bleaching of fluorescent dyes in the visible and near-infrared light spectrum (650-900 nm) ranges below the resolution range of operation microscopes. Furthermore, specific fluorescent signals in an FGS mouse model is 104 higher than laser-induced autofluorescence in mouse tissue. CONCLUSION Laser-induced lateral photobleaching is negligible indicating a path forward for fluorescence-guided laser surgery in head and neck cancer.
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Affiliation(s)
- Julia Odenthal
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Cell Biology, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Peter Friedl
- Department of Cell Biology, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands.,Genitourinary Medical Oncology - Research, UT MD Anderson Cancer Center, Houston, Texas.,Cancer Genomics Center, Utrecht, The Netherlands
| | - Robert P Takes
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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Diaz EC, Lindgren BW, Gong EM. Carbon dioxide laser for detrusor tunnel creation in robot-assisted laparoscopic extravesical ureteral reimplant. J Pediatr Urol 2014; 10:1283.e1-2. [PMID: 25168317 DOI: 10.1016/j.jpurol.2014.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 07/21/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Demonstrate and report initial results using a carbon dioxide (CO2) laser for detrusor tunnel creation in robot-assisted laparoscopic extravesical ureteral reimplant (RALUR). METHODS Retrospective chart review was performed for cases of RALUR from 2011 to 2014. Patients undergoing complex reconstruction (ureteral tailoring, dismembered reimplant, concomitant ureteroureterostomy), and those who had incomplete follow-up were excluded. Variables, including use of the CO2 laser, were collected and correlated with outcomes. RESULTS 23 patients representing 40 ureteral units were included for analysis. A CO2 laser was used in 9/23 (39%) patients and 16/40 (40%) ureteral units. Intraoperative mucosotomy was reported in 3/14 (21%) patients for the electrocautery group and 1/9 (11%) patients for the CO2 laser group. Resolution of VUR was observed in 11/14 (79%), and 9/9 (100%) of patients for the electrocautery group and the CO2 laser group, respectively. Two complications were identified in the electrocautery group of patients: ileus (Clavien 2), and transient bilateral ureteral obstruction requiring placement of ureteral stents (Clavien 3B). There were no complications in the CO2 laser group. CONCLUSIONS Creation of the detrusor tunnel with a CO2 laser is safe and effective, and is associated with a lower rate of failure and complication in this cohort.
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Affiliation(s)
- E C Diaz
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA.
| | - B W Lindgren
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA
| | - E M Gong
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA
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