Principles of port placement in laparoscopic surgery involve triangulation of the surgical focal point while minimizing restricted motion due to collision of instruments. Some gynecologic surgeons prefer to operate through two ipsilateral ports, while others use their dominant hand in a suprapubic port and non-dominant in a lateral port. Alternative port placement may be necessary in patients with altered anatomy, requiring creative surgical planning. We demonstrate proper prepping and draping with a colostomy in place and display a novel port configuration to maximize triangulation and visibility around the colostomy and adhesive disease.

Suppl Fig S4. Complement and non-target siRNA

Suppl Table S2. Top five canonical pathways from different group comparisons, identified via Ingenuity Pathway Analyses

Suppl Table S1. Differentially expressed genes from different group comparisons

Supplementary Materials and Methods

Study Objective: Identify and discuss the specific challenges faced by lefthanded medical students and beginner surgeons, and review tips for success.

This educational video addresses identification and mobilization of the ureter in complex gynecologic cases by reviewing pertinent anatomy, demonstrating techniques for retroperitoneal access, and discussing strategies for visualization and mobilization of the ureter. Identification and mobilization of the ureter is essential in complex gynecologic surgery. Knowledge of the retroperitoneal anatomy is paramount to accomplish difficult cases and to avoid injury to vital structures during ureteral mobilization. We explore the important structures in the retroperitoneum and discuss the relevance to ureteral dissection. We then discuss two surgical approaches to entering the retroperitoneum which we refer to as the lateral and posterior approaches. The choice of approach is determined by visualization as anatomic distortion may occur with pathology such as broad ligament and cervical fibroids, or obliterative endometriosis. We discuss and display how ureteral stents are helpful both in identification and mobilization of the ureter, as well as allowing for more effective ureterolysis. Finally, we demonstrate how these techniques can be used for the dissection of the parametria. Adequate mobilization of the ureter relies on knowledge of retroperitoneal anatomy, safe and effective retroperitoneal entry, and proper visualization of the ureter. These elements are essential to address complex pathology and avoid injury.

PDF file - 36K, Supplementary Table 1. Demographic and clinical characteristics of the study cohort. Supplementary Table 2. List of the 24 miRNAs identified by genome-wide plasma miRNA expression profiling from healthy controls (n=6), endometriosis patients (n=7), and EAOC patients (n=7). Supplementary Table 3. The 10 most differentially expressed miRNAs in pair-wise comparisons between SOC patients and healthy controls, endometriosis, or EAOC samples.

Suppl Table S3. Top five networks from different group comparisons, identified via Ingenuity Pathway Analyses

Suppl Fig S1. Venn diagram of DE genes from 3 group comparisons

Suppl Fig S2. Kras and Pten pathways in relationship to complement gene expression

Suppl Fig S3. Antibody-mediated, complement-induced cytotoxicity

PDF file - 488K, Supplementary Figure 1: Experimental design. Supplementary Figure 2. Reliability of RNA extraction and reproducibility of RTqPCR techniques. Supplementary Figure 3. Reliability of RT-qPCR assays. Supplementary Figure 4. miR-132 demonstrates consistent CT values (ranging from 27 to 29.5.) across all categories of plasma samples (healthy 0=Normal Healthy Endo1=mEnedtoriosis 2 = SSOerCous 3E=EAAOOCC controls, n=20; endometriosis, n=33; EAOC, n=14; and SOC, n=21), and was used for normalization of RT-qPCR results in this study. Supplementary Figure 5. Unsupervised hierarchical clustering analysis of samples based on the 23-miRNA expression profiles. Supplementary Figure 6. Box plots of top three differentially expressed miRNAs in pair-wise comparisons. Supplementary Figure 7. Lack of correlation for miRNA expression between matching tumor tissue and plasma samples from five tumor-bearing LSLKrasG12D/+/ Ptenloxp/loxp mice.

A 40-year-old gravida 3 para 1 female presented with heavy menstrual bleeding due to a large myoma uterus. She elected to proceed with total laparoscopic hysterectomy with bilateral salpingectomy. During the procedure, the patient's abdomen was entered using the open Hasson technique. After this, routine examination of the abdominal contents revealed an approximately 2 × 4 cm blind-ending outpouching from the ileum, consistent with a Meckel's diverticulum (Fig. 1, Fig. 2). The remainder of the surgery was performed without complication. The patient was informed of this finding and was referred to general surgery. She ultimately reported long-standing constipation that was felt to be unrelated to the Meckel's diverticulum but was otherwise asymptomatic. She elected to proceed with expectant management. Fig. 2Meckel's diverticulum being thoroughly examined during a laparoscopic procedure. View Large Image Figure Viewer Download Hi-res image

Introduction: Simulation and coaching have become increasingly important in laparoscopic skills acquisition. This study was designed to evaluate if access to the recorded audio and video feedback after a single proctored session improves the acquisition of laparoscopic suturing skills in obstetrics and gynecology (OB/GYN) residents. Methods: Twenty OB/GYN residents received a single face-to-face coaching session on a laparoscopic vaginal cuff closure model. The session was recorded and residents were randomized to access either the video-only or the audio and video recording of the proctored session. The primary outcome measure was comparison of Global Operative Assessment of Laparoscopic Skills plus Vaginal Cuff Metrics (GOALS+) scores of the vaginal cuff closure prior to and following the proctored session. Results: Only 30% of residents accessed the recorded sessions with junior residents most likely to access the recording. Baseline GOALS+ scores were significantly higher in senior residents (mean 21.7, SD 3.9) as compared to junior residents (mean 14.7, SD 3.2) (p<.001). While all learners' GOALS+ scores significantly improved after proctoring the intervention (p<.001), the senior residents continued to have significantly higher GOALS+ scores at the final assessment (mean 28.3, SD 4.2, p=.01) when compared to their junior residents (mean 24.0, SD 3.1). Conclusion: Due to the low uptake of the review of recorded proctored sessions among OB/GYN residents across skill and year levels, we were unable to assess the effect of recorded audio and video feedback on resident performance. However, the intervention of a single proctored session of simulated laparoscopic vaginal cuff closure significantly improved resident performance as assessed with GOALS+ scores.

w?>A 45-year-old woman, gravida 3 para 2-0-1-2, with 2 previous cesarean sections and a total laparoscopic hysterectomy for endometriosis, presented to the hospital with severe focal abdominal pain, fever, and skin erythema. She had a known history of abdominal wall endometriosis treated with norethindrone and declined excision of the abdominal wall endometrioma at the time of her hysterectomy. She discontinued her norethindrone 5 days before presentation. On examination, she had an 8-cm tender subcutaneous nodule and a 10.0 × 20.0-cm area of induration, erythema, and tenderness consistent with cellulitis (Figs. 1 and 2). An abdominal ultrasound and a computed tomography showed a left rectus muscle endometrioma measuring 4.6 × 3.0 × 9.1 cm (Figs. 3 and 4). She was admitted to the hospital for 3 days of intravenous antibiotics and discharged on sulfamethoxazole / trimethoprim and norethindrone. She was scheduled for a bilateral salpingo-oophorectomy, endometriosis resection, and abdominal wall reconstruction in combination with plastic surgery once her infection resolved (given the high likelihood of requiring mesh for the reconstruction). Fig. 2Patient's abdomen on presentation with the area of cellulitis outlined. View Large Image Figure Viewer Download Hi-res image Fig. 3Abdominal wall ultrasound showing the endometrioma. View Large Image Figure Viewer Download Hi-res image Fig. 4CT scan showing abdominal wall endometrioma with overlying cellulitis in the sagittal and axial planes. CT = computed tomography. View Large Image Figure Viewer Download Hi-res image

A 33-year-old woman (gravida 3 para 3) complained of new onset pelvic pain that was constant and sharp during her annual examination. Surgical history included a laparoscopic bilateral salpingectomy 3 years before, with no abnormal findings. Transvaginal ultrasound showed the rectovaginal pouch filled with a poorly circumscribed multicystic mass measuring approximately 9.6 × 5.2 × 8.6 cm with multiple grape-like cysts and no vascular flow (Fig. 1A). MRI was obtained before her referral to assist with characterizing the cysts. It showed moderate ascites with multiple closely opposed rounded cystic lesions with thin intervening septations posterior and anterior to the uterus but not specifically surrounding either ovary, which is typical of peritoneal inclusion cysts (Fig. 1B). Although likely a benign process favoring benign multicystic mesothelioma due to the imaging features noted above, these findings were reviewed with general surgery because of the possibility of malignant mesothelial cysts. Decision was made to proceed with a laparoscopic excision of pelvic cystic mass with possible need for hysterectomy or oophorectomy on the basis of intraoperative findings for treatment and definitive diagnosis.

OBJECTIVE: To explore whether two-layer laparoscopic vaginal cuff closure at the time of laparoscopic hysterectomy is associated with a lower rate of postoperative complications compared with a standard one-layer cuff closure. METHODS: A retrospective cohort study of total laparoscopic hysterectomies performed by fellowship-trained minimally invasive gynecologic surgeons between 2011 and 2017 was performed. Surgeons sutured the vaginal cuff laparoscopically, either in a two- or one-layer closure. The primary outcome was a composite of total postoperative complications, including all medical and surgical complications within 30 days and vaginal cuff complications within 180 days. Factors known to influence laparoscopic vaginal cuff complications including age, postmenopausal status, body mass index, tobacco use, and immunosuppressant medications were examined and controlled for, while surgeon skill, colpotomy technique, and suture material remained standardized. We conducted statistical analyses including χ2, Fisher exact test, logistic regression, and post hoc power calculations. RESULTS: Of the 2,973 women who underwent total laparoscopic hysterectomies, 40.8% (n=1,213) of vaginal cuffs were closed with a two-layer closure and 59.2% (n=1,760) with a one-layer technique. Two-layer vaginal cuff closure was associated with decreased numbers of total postoperative complications (3.5% vs 5.7%; P<.01). The primary difference stemmed from lower vaginal cuff complications within 180 days (0.9% vs 2.6%; P<.01); no differences in 30-day medical and surgical postoperative complications were observed between the two groups (2.6% vs 3.1%; P=.77). No patients in the two-layer vaginal cuff closure cohort experienced a vaginal cuff dehiscence or mucosal separation compared with 1.0% in the one-layer group (P<.01). Compared with a one-layer closure, a two-layer closure was protective from postoperative complications (adjusted odds ratio 0.38, 95% CI 0.19–0.74). CONCLUSION: Although postoperative complications with laparoscopic hysterectomies are rare, two-layer laparoscopic vaginal cuff closure is associated with lower total postoperative complications compared with a one-layer closure. The difference was primary driven by cuff complications.