Laparoscopic Adenomyomectomy Under Transient Occlusion of Uterine Arteries with an Endoscopic Vascular Clip

Laparoscopically assisted Adenomyomectomy Using the Double/Multiple-Flap Method with Temporary Occlusion of the Bilateral Uterine Artery and Utero-Ovarian Vessels in Comparison with the Double/Multiple-Flap Only Method

Introduction Adenomyomectomy is the most conservative surgical treatment for adenomyosis. However, the surgical efficacy of this treatment and the best approach to use are still debated. We aimed to evaluate the efficacy of laparoscopic adenomyomectomy using the double/multiple-flap method combined with temporary occlusion of the bilateral uterine artery and the utero-ovarian vessels to treat symptomatic adenomyosis.

Patients We recruited 155 patients with symptomatic adenomyosis and divided them into group A (n = 76) and group B (n = 79), with each group treated using a different surgical approach. All eligible women were informed of the potential complications, benefits, and alternatives of each approach before they were assigned into one of the two groups. In group A, we performed laparoscopic adenomyomectomy with the double/multiple-flap method while in group B, we performed a double/multiple-flap adenomyomectomy combined with temporary occlusion of the bilateral uterine artery and utero-ovarian vessels. Over a 24-month follow-up period, we evaluated operating time, intraoperative blood loss, visual analog scale (VAS) scores, anti-Mullerian hormone levels, uterine volume, and relief of menorrhagia.

Results There were no significant differences between groups A and B with respect to VAS scores, relief of menorrhagia and uterine volume at 3 months, 6 months, 12 months and 24 months after surgery (p > 0.05). Both groups showed significant improvement of these parameters after surgery compared with preoperative values (p < 0.05). Blood loss in group B was significantly lower than in group A (p < 0.001) while there was no significant difference in operating times (p > 0.05). Levels of AMH did not differ significantly between the groups throughout the follow-up period (p > 0.05).

Conclusion Laparoscopic adenomyomectomy with temporary occlusion of the bilateral uterine artery and the utero-ovarian vessels offers a feasible surgical option to treat symptomatic adenomyoma.

A comparison of surgical outcomes between robot and laparoscopy-assisted adenomyomectomy

We aimed to investigate the feasibility of robotic adenomyomectomy and compared surgical outcomes between laparoscopic and robotic approaches for adenomyomectomy.We retrospectively reviewed the data of women who were diagnosed with adenomyosis and underwent adenomyomectomy through a minimally invasive approach between January 2014 and March 2018 at the CHA Gangnam Medical Center, Seoul, Republic of Korea. Patient demographics and operation-related outcomes were compared between the robotic and laparoscopic surgery groups.We evaluated 43 women who underwent adenomyomectomy through a minimally invasive approach (21 underwent a laparoscopic and 22 underwent a robotic adenomyomectomy). All 22 women who had originally been scheduled to undergo robotic adenomyomectomy could successfully undergo the robotic surgery without requiring conversion to laparotomy and/or serious complications. No statistically significant differences in patient demographics were observed between the robotic and the laparoscopic surgery groups. No significant intergroup difference was observed in the operative time, estimated blood loss, weight of the resected nodule, and length of hospitalization (160.0 vs 212.5 min, P = .106; 500.0 vs 300.0 mL, P = .309; 60.0 vs 70.0 g, P = .932; and 5.0 vs 6.0 days, P = .277). No serious perioperative complications were observed in either group.Robotic adenomyomectomy is feasible for women with adenomyosis. Surgical outcomes of robotic adenomyomectomy were comparable to those of a laparoscopic approach. There was, however, no superiority of robotic adenomyomectomy in terms of surgical outcomes. Further multicenter prospective studies using standardized surgical procedures are needed to confirm the conclusion of this study.

Transient Occlusion of Uterine Arteries in Procedures with High Risk of Uterine Bleeding

Introduction:

Uterine-conservative surgery via laparoscopy is a challengeable and high risk because of heavy intra-operative bleeding events in reproductive women with highly vascular uterine benign disease. There are three reported cases of women with highly vascular uterine benign diseases and high risk of intra-operative heavy bleeding, but were treated successfully to control intra-operative heavy bleeding risk by transient occlusion of the uterine artery (TOUA) through laparoscopy and resulted in safe conservation of the uterus.

Case Presentation:

The cases of women with high risk of heavy bleeding during therapeutic procedure included cesarean scar pregnancy, hydatid form mole on cesarean scar, and cervical pregnancy. All these women had the strong desire to presere their fertility and uterus. In all the three cases, we used the method of TOUA and performed therapeutic surgeries successfully, with less bleeding and safe conservation of the uterus through laparoscopy.

Conclusion:

Laparoscopic TOUA could be a therapeutic option to manage heavy intra-operative bleeding during conservative uterine surgeries associated with the risk of heavy bleeding.

A sandwich technique (N&H variation technique) to reduce blood loss during cesarean delivery for complete placenta previa: a randomized controlled trial

Objective: To investigate the effect of A sandwich technique Nahla & Hany variation (N&H) technique versus stepwise uterine devascularization on blood loss during cesarean section (CS) in patients with complete placenta previa. Methods: The study was single-blind randomized controlled trial carried out in a tertiary University Hospital between March 2015 to March 2018. We included patients scheduled for CS due to complete placenta previa. They were randomly allocated to group (I) managed by stepwise uterine devascularization, group (II) managed by double transverse compression suture at the lower uterine segment plus intrauterine inflated Foley's catheter Balloon (H&N variation sandwich) at the lower uterine segment. The primary outcome was the amount of total estimated blood loss both intra- and post-operative. Results: One hundred and six patients were enrolled (n = 53 in each group). There was a great reduction in intraoperative blood loss in group II 570 (400-1300) compared with Group I 1030 (500-1540) (p = .0001), or blood in the intraabdominal drain in group II than group I (p = .0001) Also, there was no significant reduction in postoperative vaginal bleeding. Hence, the total estimated blood loss in group II 750 (550-1580) showed significant reduction compared with group I 1350 (780-1800) (p = .0001). Conclusions: N&H variation sandwich technique in the management of complete placenta previa is a simple technique, safe and effective to decrease blood loss.

Laparoscopic Surgery for Focal Adenomyosis

BACKGROUND AND OBJECTIVES

For conservative surgical treatment of focal uterine adenomyosis, laparoscopic adenomyomectomy has been increasingly performed, so that reassessment to determine the safety and efficacy of the laparoscopic surgical technique in a larger number of cases and reevaluation for reproducibility for laparoscopic adenomyomectomy is needed. We evaluate the clinical outcomes of laparoscopic adenomyomectomy with transient occlusion of uterine arteries (TOUA) for focal uterine adenomyosis performed by a single surgeon at a single institute.

METHODS

Patients (N = 105) with symptomatic focal uterine adenomyosis underwent laparoscopic adenomyomectomy with TOUA by a single surgeon at Ulsan University Hospital from May 1, 2011, through September 30, 2016. Surgical outcomes included operative time; intraoperative injury to blood vessels, nerves, and pelvic organs; and intraoperative blood loss. We assessed the degree of improvement in dysmenorrhea and menorrhagia and relapsing or remnant adenomyosis lesion by ultrasonography at the 7-momth follow-up after the operation. Then, all patients were followed up at 6-month intervals at the outpatient clinic.

RESULTS

The mean patient age was 41.98 ± 4.73 years. The mean TOUA and operative times were 4.46 ± 2.68 and 75.14 ± 20.56 min, respectively. The mean estimated blood loss was 148.19 ± 101.69 mL. No conversion to laparotomy or major complications occurred. At the 7-month follow-up, complete remission of dysmenorrhea and menorrhagia had occurred in 93.02% and 76.92% of patients, respectively.

CONCLUSIONS

Laparoscopic adenomyomectomy with TOUA is a safe and effective surgical treatment modality for women with symptomatic focal uterine adenomyosis who want to preserve fertility.

Conservative surgery of diffuse adenomyosis with TOUA: Single surgeon experience of one hundred sixteen cases and report of fertility outcomes

The aim of this study is to evaluate the clinical outcomes of conservative adenomyomectomy with TOUA for diffuse uterine adenomyosis and to determine the feasibility and safety. One hundred and sixteen patients with symptomatic diffuse uterine adenomyosis underwent adenomyomectomy with TOUA by a single surgeon at Ulsan University Hospital between May 2011 and March 2016. Surgical outcomes included operative time, intraoperative injury and operative blood loss. We assessed the degree of improvement in dysmenorrhea and menorrhagia at the 7-month follow-up visit after the operation. The mean age of patients was 37.49 years (range: 26-49). The mean total surgical time was 116.12 min (range: 60-300, SD: 37.27). The mean estimated blood loss was 207.22 mL (range: 30-1200, SD: 161.08) and there were no cases of injury to the uterine arteries or pelvic nerves. The mean duration of hospital stay was 5.05 days (range: 4-7, SD: 0.68) and the mean follow-up period of 16.67 months (range: 6-49, SD: 12.77). At the 7-month follow-up after adenomyomectomy with TOUA, dysmenorrhea and menorrhagia were improved in 100% and 89% of the patients, respectively. In patients with diffuse uterine adenomyosis, even when the whole uterus is involved, for relief of severe adenomyosis-related symptoms, adenomyomectomy with TOUA could be a safe and effective surgical treatment option for those who want to preserve their fertility.

Monochorionic twin delivery after conservative surgical treatment of a patient with severe diffuse uterine adenomyosis without uterine rupture

A 31-year-old nulliparous woman with severe diffuse uterine adenomyosis, which replaced nearly the whole uterine myometrium, visited our hospital due to severe dysmenorrhea, menorrhagia, and a desire to have a baby. The patient had a history of two spontaneous abortions. Laparotomic adenomyomectomy with transient occlusion of uterine arteries (TOUA) was performed safely and the patient tried in vitro fertilization and achieved a intrauterine twin pregnancy after recovery time of the operation. At 31+6 weeks of gestation, a male neonate baby weighing 1,620 g and a male neonate baby weighing 1,480 g were born by transverse lower segment cesarean delivery. There was no complication after the operation. The babies were discharged after receiving routine neonatal intensive care for neonatal respiratory distress syndrome. Adenomyomectomy with TOUA technique would be an option for conservative surgical treatment in patients with severe diffuse whole uterine adenomyosis. This is the first report of twin pregnancy after diffuse whole uterine adenomyomectomy with TOUA.

Intraoperative bleeding control during cesarean delivery of complete placenta previa with transient occlusion of uterine arteries

There are few methods to control heavy intra-operative bleeding during cesarean delivery of placenta previa. Transient occlusion of uterine arteries (TOUA) during operation has previously been reported as a quick and safe method to control intra-operative uterine bleeding. We reported 2 cases of cesarean delivery with complete placenta previa in which TOUA was performed to safely reduce intra-operative complication, especially heavy intra-operative bleeding. In the 2 cases, cesarean deliveries were safe and without any complications under the TOUA method. TOUA can be a good method to control heavy intra-operative bleeding during cesarean delivery of complete placenta previa with risk of heavy bleeding.