Study Objective This video describes various techniques to successfully perform a hysterectomy with a large cervical fibroid in a minimally invasive fashion. Design Case studies of two patients with large cervical fibroids who underwent definitive surgical management with total laparoscopic hysterectomy (TLH). Setting The video clips were taken in the operating room during planned procedures for two separate cases of patients undergoing TLH with cervical fibroids. Both patients were positioned in dorsal lithotomy with arms tucked. Patients or Participants The two patients each had 8-9 cm symptomatic cervical fibroids for which they desired definitive surgical management with hysterectomy. Their exams differed in length and accessibility of the cervix and in BMIs, as one patient had a shortened cervix with BMI of 28 and the other had an effaced and deviated cervix and BMI of 32. Interventions A set of techniques were employed to mitigate the challenge of TLH with a large cervical fibroid. This included pretreatment with Lupron, ureteral stent placement, ligation of uterine arteries at their origin, and different methods for completing colpotomy. Measurements and Main Results The cases exemplified how these techniques can be successful and how to use alternate approaches when unsuccessful. Both hysterectomies were successfully completed laparoscopically. Conclusion Cervical fibroids can present a challenge to accomplishing hysterectomy in a minimally invasive fashion. Successful laparoscopic hysterectomy can be performed with use of various techniques to reduce risk of bleeding and injury to nearby structures. More research is needed to help determine predictors for successful and unsuccessful applications of such techniques. This video describes various techniques to successfully perform a hysterectomy with a large cervical fibroid in a minimally invasive fashion. Case studies of two patients with large cervical fibroids who underwent definitive surgical management with total laparoscopic hysterectomy (TLH). The video clips were taken in the operating room during planned procedures for two separate cases of patients undergoing TLH with cervical fibroids. Both patients were positioned in dorsal lithotomy with arms tucked. The two patients each had 8-9 cm symptomatic cervical fibroids for which they desired definitive surgical management with hysterectomy. Their exams differed in length and accessibility of the cervix and in BMIs, as one patient had a shortened cervix with BMI of 28 and the other had an effaced and deviated cervix and BMI of 32. A set of techniques were employed to mitigate the challenge of TLH with a large cervical fibroid. This included pretreatment with Lupron, ureteral stent placement, ligation of uterine arteries at their origin, and different methods for completing colpotomy. The cases exemplified how these techniques can be successful and how to use alternate approaches when unsuccessful. Both hysterectomies were successfully completed laparoscopically. Cervical fibroids can present a challenge to accomplishing hysterectomy in a minimally invasive fashion. Successful laparoscopic hysterectomy can be performed with use of various techniques to reduce risk of bleeding and injury to nearby structures. More research is needed to help determine predictors for successful and unsuccessful applications of such techniques.

The primary goal is to demonstrate the difference in tissue healing and adhesion formation over weeks to months after a laparotomy and to understand its impact on the feasibility of surgery. Our video is a case study of a patient's elective laparoscopic surgeries following a classical cesarean delivery. The patient, a 32-year-old G4P0130, was referred to MIS faculty by MFM for placement of a laparoscopic cerclage after classical cesarean section at 23 weeks due to cervical insufficiency. The video clips were taken in the operating room during planned procedures: laparoscopic cerclage placement at 7 weeks and 7 months following classical cesarean section. Laparoscopic cerclage was initially attempted at 7 weeks postoperative from classical cesarean section but was aborted due to dense, edematous pelvic adhesions and extreme tissue friability with ultimate concern for creating a cystotomy if the surgery had been completed. Laparoscopic cerclage was then planned for 7 months postoperative from classical cesarean section. The adhesive disease during the laparoscopic cerclage placement at 7 months postoperative from classical cesarean section was significantly improved. Findings were notable for resolved prior bowel adhesions and a well-healed classical cesarean hysterotomy defect. There were minor bladder adhesions to the uterus that were safely dissected using the Harmonic scalpel, and the laparoscopic cerclage was able to be placed in standard fashion in an overall uncomplicated procedure. Although more research is needed to study the ideal time for reoperation in setting of elective surgery after a laparotomy, our case study demonstrates the significant difference in tissue adhesions and feasibility of surgery when performing an elective surgery after a longer time interval.

Objective This study evaluates penicillin allergy during pregnancy to estimate the proportion that could benefit from penicillin allergy testing. Study Design Retrospective cohort study of women with penicillin allergy that delivered from January 1, 2018 to December 31, 2018. Results Among 6,321 deliveries, 446 (7%) were identified with penicillin allergy. Nine percent (41/446) had no documentation of allergy severity. Allergies associated with intolerance, low, moderate, or high risk of anaphylaxis were reported in 6% (25/446), 40% (177/446), 32% (142/446), and 14% (61/446), respectively. Nearly 74% (330/446) received an antibiotic either antepartum, at delivery, or within 6 weeks of postpartum. The majority of women, 81% (360/446) (i.e., undocumented reactions, low, or moderate risk of anaphylaxis) would have been eligible for penicillin allergy testing. Greater appropriate utilization of antibiotics occurred in women with a high 80% (39/49) or moderate risk of anaphylaxis 70% (79/112) versus low risk of anaphylaxis 55% (64/117), history of intolerance 40% (8/20), or undocumented reaction 19% (6/32), p ≤ 0.01. Conclusion Most women who report a penicillin allergy during pregnancy would be candidates for penicillin allergy testing. With the high rate of antibiotic interventions in pregnant women who report a penicillin allergy, consideration should be given for penicillin allergy assessment.