Accepted Manuscript Emergency Peri-Partum Laparoscopic Subtotal Hysterectomy With Transcervical Extraction Fabio Ghezzi, M.D. Jvan Casarin, M.D. Giorgio Bogani, M.D. Stefano Uccella, Ph.D. Maurizio Serati, M.D. Antonella Cromi, Ph.D. PII:
S1553-4650(14)00058-2
DOI:
10.1016/j.jmig.2014.02.002
Reference:
JMIG 2250
To appear in:
The Journal of Minimally Invasive Gynecology
Received Date: 23 January 2014 Accepted Date: 1 February 2014
Please cite this article as: Ghezzi F, Casarin J, Bogani G, Uccella S, Serati M, Cromi A, Emergency Peri-Partum Laparoscopic Subtotal Hysterectomy With Transcervical Extraction, The Journal of Minimally Invasive Gynecology (2014), doi: 10.1016/j.jmig.2014.02.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Ghezzi
1
EMERGENCY PERI-PARTUM LAPAROSCOPIC SUBTOTAL HYSTERECTOMY
2
WITH TRANSCERVICAL EXTRACTION
3
Fabio GHEZZI, M.D.; Jvan CASARIN, M.D.; Giorgio BOGANI, M.D.; Stefano
5
UCCELLA, Ph.D.; Maurizio SERATI, M.D.; Antonella CROMI, Ph.D.
RI PT
4
6
The study was conducted in Varese, ITALY
SC
7 8
10
AFFILIATION: Dept. of Obstetrics and Gynecology, University of Insubria, Del Ponte
M AN U
9
Hospital, Varese, Italy
11 12 13
Address correspondence and reprint requests to:
Giorgio BOGANI, M.D
TE D
14
Dept. Obstetrics and Gynecology - University of Insubria
15
Piazza Biroldi, 1 - Varese, 21100, Italy
16
Tel.
19 20 21 22
Fax
+39-0332-299-309
+39-0332-299-307
E-mail : [email protected]
AC C
18
EP
17
Abstract word count: 61; Text word count: 435;
23 24
CONFLICT OF INTEREST DISCLOSURE: The authors have no conflict of interest to
25
disclose. No funding source supported the present investigation.
26 1
ACCEPTED MANUSCRIPT Ghezzi
ABSTRACT:
2
We here present a technique for minimally invasive management of peripartum subtotal
3
hysterectomy. A video of peripartum emergency subtotal hysterectomy in a patient with
4
retained placenta and suspicion of accretism is presented. The procedure has been
5
accomplished totally by laparoscopy, with transcervical extraction of the specimen. To date
6
this represents the first description of a peripartum subtotal hysterectomy performed via
7
laparoscopy.
SC
RI PT
1
8
10
Keywords: Laparoscopy; Subtotal hysterectomy; Emergency hysterectomy; Peri-partum hysterectomy; Transcervical extraction.
11
TE D
12
13
17
18
AC C
16
EP
14
15
M AN U
9
19
20
21 2
ACCEPTED MANUSCRIPT Ghezzi
Although the role of minimally invasive hysterectomy continues to emerge [1-4], the usual
2
technique for peripartum hysterectomy, even after vaginal delivery, includes open
3
abdominal hysterectomy [5]. Here, we present a case of peripartum subtotal hysterectomy
4
performed via laparoscopy (Video 1).
5
A thirty-six year-old woman, gravida 1, who had a term pregnancy following in vitro
6
fertilization was transferred to our clinic from a general hospital of our geographic area 6
7
hours after vaginal delivery with diagnosis of retained placenta and suspicion of placenta
8
accreta. An intra-uterine Bakri balloon had been placed immediately after delivery to avoid
9
excessive bleeding. At the moment of admission at our Department the patient was
10
hemodynamically stable. After the removal of the intra-uterine balloon moderate vaginal
11
bleeding was observed; trans-abdominal ultrasound revealed a very thin myometrial
12
thickness at the level of placental bed. After discussion with the patient and considering the
13
high hemorrhagic risk, a decision was made to perform subtotal laparoscopic hysterectomy.
14
A skilled laparoscopic surgeon (FG) performed the operation, helped by two assistants.
15
Once general anesthesia was established, the patient was placed in Trendelembourg position
16
and a valve was introduced through the vagina to cranially push the uterus and to expose the
17
fornices. Pneumoperitoneum was created using the Verress needle and a 5-mm 0-degrees
18
telescope was placed transumbilically. Three 5-mm ancillary trocars were then inserted
19
suprapubically under direct vision. The right round ligament was grasped and sectioned with
20
bipolar cautery and the two leaves of the broad ligament were separated. The vesico-uterine
21
fold was incised and the bladder flap was developed. After the ureter was identified, the
22
right uterine vessels were skeletonized, coagulated and divided. The same steps were
23
accomplished controlaterally. Hysterotomy was performed at the level of the inferior uterine
24
segment using a monopolar hook. To avoid enlargement of the abdominal incisions we
25
decided to extract the specimen transcervically: first the uterus was divided into two halves
AC C
EP
TE D
M AN U
SC
RI PT
1
3
ACCEPTED MANUSCRIPT Ghezzi
with a laparoscopic scalpel, then the two resulting parts were extracted with an endobag
2
inserted through the cervical way. Finally, closure of the cervical stump was performed
3
laparoscopically using interrupted stitches. No complications occurred and the patient was
4
discharged the second postoperative day.
5
In conclusion the present case showed a technique to reduce invasiveness of conventional
6
open abdominal peripartum hysterectomy. To date, this represents the first report of
7
laparoscopic subtotal hysterectomy performed via laparoscopy. Laparoscopic approach
8
upholds the outcomes of abdominal procedure, but it minimizes morbidity. We point out that
9
the use of transvaginal extraction technique (with an endobag) instead to a laparoscopic
10
morcellator [6] allows avoiding the enlargement of the abdominal incisions and reducing the
11
loss of potentially dangerous placental debris.
M AN U
SC
RI PT
1
12
REFERENCES:
14
1- Ridgeway B, Falcone T. Innovations in Minimally Invasive Hysterectomy. Clin Obstet
15
Gynecol. 2013 Oct 18. [Epub ahead of print]
16
2- Bogani G, Uccella S, Cromi A, et al. Low vs. standard pneumoperitoneum pressure
17
during laparoscopic hysterectomy: a prospective randomized trial. J Minim Invasive
18
Gynecol 2013. doi: 10.1016/j.jmig.2013.12.091. [Epub ahead of print]
19
3- Falcone T, Walters MD. Hysterectomy for benign disease. Obstet Gynecol 2008;111:753-
20
67.
21
4- Garibaldi S, Perutelli A, Baldacci C, Gargini A, Basile S, Salerno MG. Laparoscopic
22
approach for peripartum hysterectomy. J Minim Invasive Gynecol 2013;20:112-4.
23
5- Grace Tan SE, Jobling TW, Wallace EM, McNeilage LJ, Manolitsas T, Hodges RJ.
24
Surgical management of placenta accreta: a 10-year experience. Acta Obstet Gynecol Scand
AC C
EP
TE D
13
4
ACCEPTED MANUSCRIPT Ghezzi
1
2013;92:445-50.
2
6- Milad MP, Milad EA. Laparoscopic Morcellator-Related Complications. J Minim
3
Invasive Gynecol 2013. doi: 10.1016/j.jmig.2013.12.003. [Epub ahead of print]
AC C
EP
TE D
M AN U
SC
RI PT
4
5
ACCEPTED MANUSCRIPT
Précis: Description of technique for peri-partum laparoscopic subtotal hysterectomy, with transcervical
AC C
EP
TE D
M AN U
SC
RI PT
extraction of the uterine corpus, is presented.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S1553-4650(14)00058-2
DOI:
10.1016/j.jmig.2014.02.002
Reference:
JMIG 2250
To appear in:
The Journal of Minimally Invasive Gynecology
Received Date: 23 January 2014 Accepted Date: 1 February 2014
Please cite this article as: Ghezzi F, Casarin J, Bogani G, Uccella S, Serati M, Cromi A, Emergency Peri-Partum Laparoscopic Subtotal Hysterectomy With Transcervical Extraction, The Journal of Minimally Invasive Gynecology (2014), doi: 10.1016/j.jmig.2014.02.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Ghezzi
1
EMERGENCY PERI-PARTUM LAPAROSCOPIC SUBTOTAL HYSTERECTOMY
2
WITH TRANSCERVICAL EXTRACTION
3
Fabio GHEZZI, M.D.; Jvan CASARIN, M.D.; Giorgio BOGANI, M.D.; Stefano
5
UCCELLA, Ph.D.; Maurizio SERATI, M.D.; Antonella CROMI, Ph.D.
RI PT
4
6
The study was conducted in Varese, ITALY
SC
7 8
10
AFFILIATION: Dept. of Obstetrics and Gynecology, University of Insubria, Del Ponte
M AN U
9
Hospital, Varese, Italy
11 12 13
Address correspondence and reprint requests to:
Giorgio BOGANI, M.D
TE D
14
Dept. Obstetrics and Gynecology - University of Insubria
15
Piazza Biroldi, 1 - Varese, 21100, Italy
16
Tel.
19 20 21 22
Fax
+39-0332-299-309
+39-0332-299-307
E-mail : [email protected]
AC C
18
EP
17
Abstract word count: 61; Text word count: 435;
23 24
CONFLICT OF INTEREST DISCLOSURE: The authors have no conflict of interest to
25
disclose. No funding source supported the present investigation.
26 1
ACCEPTED MANUSCRIPT Ghezzi
ABSTRACT:
2
We here present a technique for minimally invasive management of peripartum subtotal
3
hysterectomy. A video of peripartum emergency subtotal hysterectomy in a patient with
4
retained placenta and suspicion of accretism is presented. The procedure has been
5
accomplished totally by laparoscopy, with transcervical extraction of the specimen. To date
6
this represents the first description of a peripartum subtotal hysterectomy performed via
7
laparoscopy.
SC
RI PT
1
8
10
Keywords: Laparoscopy; Subtotal hysterectomy; Emergency hysterectomy; Peri-partum hysterectomy; Transcervical extraction.
11
TE D
12
13
17
18
AC C
16
EP
14
15
M AN U
9
19
20
21 2
ACCEPTED MANUSCRIPT Ghezzi
Although the role of minimally invasive hysterectomy continues to emerge [1-4], the usual
2
technique for peripartum hysterectomy, even after vaginal delivery, includes open
3
abdominal hysterectomy [5]. Here, we present a case of peripartum subtotal hysterectomy
4
performed via laparoscopy (Video 1).
5
A thirty-six year-old woman, gravida 1, who had a term pregnancy following in vitro
6
fertilization was transferred to our clinic from a general hospital of our geographic area 6
7
hours after vaginal delivery with diagnosis of retained placenta and suspicion of placenta
8
accreta. An intra-uterine Bakri balloon had been placed immediately after delivery to avoid
9
excessive bleeding. At the moment of admission at our Department the patient was
10
hemodynamically stable. After the removal of the intra-uterine balloon moderate vaginal
11
bleeding was observed; trans-abdominal ultrasound revealed a very thin myometrial
12
thickness at the level of placental bed. After discussion with the patient and considering the
13
high hemorrhagic risk, a decision was made to perform subtotal laparoscopic hysterectomy.
14
A skilled laparoscopic surgeon (FG) performed the operation, helped by two assistants.
15
Once general anesthesia was established, the patient was placed in Trendelembourg position
16
and a valve was introduced through the vagina to cranially push the uterus and to expose the
17
fornices. Pneumoperitoneum was created using the Verress needle and a 5-mm 0-degrees
18
telescope was placed transumbilically. Three 5-mm ancillary trocars were then inserted
19
suprapubically under direct vision. The right round ligament was grasped and sectioned with
20
bipolar cautery and the two leaves of the broad ligament were separated. The vesico-uterine
21
fold was incised and the bladder flap was developed. After the ureter was identified, the
22
right uterine vessels were skeletonized, coagulated and divided. The same steps were
23
accomplished controlaterally. Hysterotomy was performed at the level of the inferior uterine
24
segment using a monopolar hook. To avoid enlargement of the abdominal incisions we
25
decided to extract the specimen transcervically: first the uterus was divided into two halves
AC C
EP
TE D
M AN U
SC
RI PT
1
3
ACCEPTED MANUSCRIPT Ghezzi
with a laparoscopic scalpel, then the two resulting parts were extracted with an endobag
2
inserted through the cervical way. Finally, closure of the cervical stump was performed
3
laparoscopically using interrupted stitches. No complications occurred and the patient was
4
discharged the second postoperative day.
5
In conclusion the present case showed a technique to reduce invasiveness of conventional
6
open abdominal peripartum hysterectomy. To date, this represents the first report of
7
laparoscopic subtotal hysterectomy performed via laparoscopy. Laparoscopic approach
8
upholds the outcomes of abdominal procedure, but it minimizes morbidity. We point out that
9
the use of transvaginal extraction technique (with an endobag) instead to a laparoscopic
10
morcellator [6] allows avoiding the enlargement of the abdominal incisions and reducing the
11
loss of potentially dangerous placental debris.
M AN U
SC
RI PT
1
12
REFERENCES:
14
1- Ridgeway B, Falcone T. Innovations in Minimally Invasive Hysterectomy. Clin Obstet
15
Gynecol. 2013 Oct 18. [Epub ahead of print]
16
2- Bogani G, Uccella S, Cromi A, et al. Low vs. standard pneumoperitoneum pressure
17
during laparoscopic hysterectomy: a prospective randomized trial. J Minim Invasive
18
Gynecol 2013. doi: 10.1016/j.jmig.2013.12.091. [Epub ahead of print]
19
3- Falcone T, Walters MD. Hysterectomy for benign disease. Obstet Gynecol 2008;111:753-
20
67.
21
4- Garibaldi S, Perutelli A, Baldacci C, Gargini A, Basile S, Salerno MG. Laparoscopic
22
approach for peripartum hysterectomy. J Minim Invasive Gynecol 2013;20:112-4.
23
5- Grace Tan SE, Jobling TW, Wallace EM, McNeilage LJ, Manolitsas T, Hodges RJ.
24
Surgical management of placenta accreta: a 10-year experience. Acta Obstet Gynecol Scand
AC C
EP
TE D
13
4
ACCEPTED MANUSCRIPT Ghezzi
1
2013;92:445-50.
2
6- Milad MP, Milad EA. Laparoscopic Morcellator-Related Complications. J Minim
3
Invasive Gynecol 2013. doi: 10.1016/j.jmig.2013.12.003. [Epub ahead of print]
AC C
EP
TE D
M AN U
SC
RI PT
4
5
ACCEPTED MANUSCRIPT
Précis: Description of technique for peri-partum laparoscopic subtotal hysterectomy, with transcervical
AC C
EP
TE D
M AN U
SC
RI PT
extraction of the uterine corpus, is presented.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
