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Chorionic villus sampling
Published in Hung N. Winn, Frank A. Chervenak, Roberto Romero, Clinical Maternal-Fetal Medicine Online, 2021
Giovanni Monni, Maria Angelica Zoppi, Carolina Axiana
For the transcervical procedure, the woman is set in the lithotomy position with comfortable leg supports. The woman’s vulva, perineum, and vagina are cleansed with an antiseptic solution. A sterile speculum (or valve) is inserted into the vagina and opened, and the cervix is swabbed with the same solution. With the speculum in situ, the course of the cervical canal and a more detailed location in the sagittal and transverse view of the uterus is achieved. During the procedure, the assistant (or the operator himself) takes care to establish the placental site and its relation to the cervical canal, so as to guide the instrument toward the site of sampling. Sometimes it is necessary to use a tenaculum or a vulsellum for steadying the cervix and passing through the cervical canal.
Robot-Assisted Myomectomy
Published in Rooma Sinha, Arnold P. Advincula, Kurian Joseph, FIBROID UTERUS Surgical Challenges in Minimal Access Surgery, 2020
Arnold P. Advincula, Chetna Arora
Once the desired hemostatic approach has been employed, the surgeon must thoughtfully dissect out the intramural leiomyoma by first incising the serosa and myometrium to the level of the pseudocapsule in one plane. Transverse incisions allow the surgeon to ergonomically close the hysterotomy, but awareness of the proximity to the uterine vessels is essential. Another benefit of robotics is the capacity to more feasibly adapt to the creation and subsequent rapid closure of oblique or vertical incisions where necessary. The instruments used to complete the enucleation are largely surgeon preference but can be accomplished with a variety of robotic devices such as the monopolar scissors and bipolar forceps [11, 20, 21]. Another significant advantage of the robotic technology is the use of the robotic tenaculum. When this is placed in the fourth arm, static and consistent tension can be more fluidly applied while maintaining the ability to dissect and retract for oneself. Alternatively, this can be provided with a bedside assist using either a standard laparoscopic tenaculum or a corkscrew [21]. As with all routes, careful attention to the dissection planes allows the leiomyomas to be circumferentially enucleated and dissected from their fibrous attachments to the surrounding myometrium. When the number of incisions is intentionally minimized, blood loss is reduced from exposed myometrium, less serosa is disrupted (thus decreasing the formation of adhesions), and the overall integrity of the uterus can be maintained [21, 30] (Figure 9.4.).
Laparoscopic and Robotic-Assisted Myomectomy
Published in Botros R.M.B. Rizk, Yakoub Khalaf, Mostafa A. Borahay, Fibroids and Reproduction, 2020
Harold Wu, Anja Frost, Mostafa A. Borahay
The standard laparoscopy instrument set contains most of the instruments required for LM. Few studies have assessed various energy sources used for LM. The harmonic scalpel has been found to have a lower total operative time (mean 17 minutes) and EBL (mean 47 cc) when compared to conventional electrosurgery [29]. Also, the pulsed bipolar system has been associated with a lower EBL (mean 53 cc) compared to conventional electrosurgery [30]. Ultimately, the surgeon's preference and comfort level with the various energy sources should take precedence in choosing the instrumentation for the case. Additional instruments that should be prepared include a laparoscopic tenaculum to aid in providing tissue traction and countertraction for enucleation of the fibroids, a laparoscopic injection needle for vasopressin, and endoscopic bags or morcellators (see further discussion in next section) for tissue extraction. It is critical to have an operating room setup that includes all necessary instruments and devices and allows for efficient team movement (Figure 11.1).
Use of low dose vaginal misoprostol in office hysteroscopy: a pre–post interventional study
Published in Journal of Obstetrics and Gynaecology, 2021
Erika P. New, Papri Sarkar, Emad Mikhail, Shayne Plosker, Anthony N. Imudia
In our study, there was a significant improvement in patient’s self-reported pain following office hysteroscopy when patients were pre-treated with low dose (50 mcg) vaginal misoprostol the evening prior to the procedure. The same patients were less likely to require a tenaculum to straighten the cervical angle during the procedure. The observed pain reduction with low dose vaginal misoprostol in the office hysteroscopy alone group was not evident when office hysteroscopy was combined with endometrial biopsy. This may partially be explained by the increased need for tenaculum utilisation in the latter group in the presence or absence of misoprostol priming. It has previously been shown that pain scores are often higher in patients who require a tenaculum (Kucukgoz Gulec et al. 2014). When considering why the patients undergoing hysteroscopy alone who were pre-treated with vaginal misoprostol had a lower rate of tenaculum use, it is important to consider that misoprostol does not change the angle of the cervical canal but instead works by softening the cervix allowing for easier passage. Therefore, misoprostol is likely one of many factors leading to the reduced tenaculum utilisation in this group.
Office hysteroscopy in pre- and post-menopausal women: a predictive model
Published in Gynecological Endocrinology, 2021
Flavia Sorbi, Massimiliano Fambrini, Srdjan Saso, Ersilia Lucenteforte, Federica Lisi, Luigi Piciocchi, Riccardo Cioni, Felice Petraglia
All OH were performed in the outpatient setting. Neither analgesia nor local anesthesia was administered. Pre-operative cervical ripening was not performed. All hysteroscopes were rigid, using a 30 degree lens (Karl Storz, Tuttlingen, Germany). Depending on each patient’s characteristics, hysteroscopes with both a 3.5 and 5 mm outer diameter were used. The uterine cavity was distended with carbon dioxide (CO2), at a flow rate ≤50 ml/h and with intrauterine pressure <100 mmHg, or with saline solution at a pressure <60mmHg, controlled by an electronic irrigation pump. For the operative procedures, the following semirigid 5 Fr instruments were used: scissors, a grasper, and a tenaculum. Patients were divided in three groups according to the type of hysteroscopy performed: 3.5 mm hysteroscope with CO2, 3.5 mm hysteroscope with saline solution, 5 mm hysteroscope with saline solution. Four senior operators performed all procedures.
Modified Extraperitoneal Uterosacral Ligament Suspension in Preventing Cuff Prolapse Risk after Vaginal Hysterectomy; 4 Clamp Method
Published in Journal of Investigative Surgery, 2020
Pınar Kadiroğulları, Kerem Doga Seckin
The upper and lower lips of the cervix were tractioned after being held with a tenaculum. With the help of the metal probe placed in the bladder, the boundary between the bladder and the cervix was determined. Anterior cul de sac boundary was determined at the place that metal probe’s edge was finished where the skipping sensation occurs with finger. Half centimeter below this limit a 1.5–2 cm long transverse incision was made through the pubocervical fascia with the help of a cautery. A transverse incision was also performed in the posterior vaginal wall. After both ends of the anterior wall was held with the alice clamps, the vaginal tissue was tractioned upwards. The anterior vaginal wall and bladder boundary were made visible. With this maneuver, the peritoneal fold was observed and the anterior peritoneum was opened by blunt or sharp dissection with the help of scissors and fingers and intraabdominal cavity has been reached from anterior. The same procedure was also performed in the posterior wall and intraabdominal cavity has been reached from posterior also. The anterior and posterior incisions on the cervix were also assembled from the side wall. Long thin retractors were inserted into the opened peritoneal cavities and the surgical area made visible with the help of an assistant (Figure 1a).