scientific program • symposia - American Society for Reproductive ...

conversion to dihydrotestosterone. As the risk of
testicular neoplasms in AIS patients may be up to 22%,
a gonadectomy is often recommended to prevent
malignancies in adulthood.
DESIGN: We describe a case of a 16-year-old phenotypic
female with complete AIS who decided to undergo a
laparoscopic gonadectomy for bilateral intra-abdominal
testes. Anatomically, the testicular tissues were attached
inferiorly by the gubernaculums and superiorly via the
suspensory ligaments that contained the testicular
vasculature. After placement of an umbilical camera
port and 3 lower abdominal accessory ports, the testes,
suspensory ligaments and the gubernaculums were
skeletonized and transected using the LigaSure device. The
retroperitoneum surrounding the testes was also dissected
in an event that the intra-operative pathology revealed
malignancy and warranted a lymph node dissection for full
staging. After a routine post-operative course, the patient
was started on estrogen replacement therapy to prevent
osteoporosis and to further induce secondary sexual
characteristics.
MATERIALS AND METHODS: Although gonadectomies
are widely performed to avoid future malignancies, it is
important to emphasize that the optimal timing of the
surgery remains controversial. Some advocate removal
of the testes upon its discovery whereas others choose to
delay the operation until adolescence. As pre-pubertal
risk of neoplasms is low, we believe that awaiting puberty
not only allows for the development of female secondary
characteristics, but also provides an opportunity for the
patient to be involved in a decision that may have longterm
health and psychological impact.
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V-15 4:59 PM
LAPAROSCOPIC MANAGEMENT OF CERVICAL AGENESIS.
R. Flyckt, M. Attaran, T. Falcone. Obstetrics and
Gynecology/Reproductive Endocrinology and Infertility,
Cleveland Clinic, Cleveland, OH.
OBJECTIVE: Presented here is the laparoscopic
management of a patient with cervical agenesis, partial
vaginal agenesis, and recurrent hematometra. Our first
objective is to review the classification and embryology
of these types of Mullerian anomalies with accompanying
animations. In addition, multiple variations of cervical
agenesis are illustrated and associated malformations such
as ureteral and renal anomalies are discussed. Second,
typical signs and symptoms as well as physical exam findings
of cervical agenesis are presented. Suggestions are made
for appropriate pre-operative imaging. Finally, a video of
the patient’s surgery highlights useful tips and techniques
for managing cervical agenesis laparoscopically.
Treatment options are summarized and controversies and
complications are addressed.
DESIGN: Surgical video with accompanying illustrations and
animations.
MATERIALS AND METHODS: Cervical agenesis is a
rare Mullerian anomaly which often requires surgical
management. Preoperative diagnosis requires thorough
work-up and imaging. A minimally invasive approach is safe
and practical and should be the preferred route of surgery.
However, the optimal surgical procedure for treatment of
cervical agenesis remains controversial. When performing
laparoscopy for these types of anomalies, a systematic
approach is essential. Patients undergoing surgery for
VIDEO PROGRAM
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cervical agenesis must be counseled preoperatively
regarding options for future fertility.
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V-16 5:07 PM
ROBOT-ASSISTED LAPAROSCOPIC TRACHELECTOMY FOR
ADENOMYOSIS.
A. R. Gargiulo1, O. Istre2, D. Shah1, S. S. Srouji1. 1Center for
Infertility and Reproductive Surgery, Brigham and Women’s
Hospital/Harvard Medical School, Boston, MA; 2Division
of Minimally Invasive Gynecologic Surgery, Brigham and
Women’s Hospital/Harvard Medical School, Boston, MA.
OBJECTIVE: To describe our technique of robot-assisted
laparoscopic trachelectomy in a case of adenomyosis of
the cervical stump.
DESIGN: A disposable uterine manipulator was secured in
place by standard technique. The robotic set-up (da Vinci
S) involved two instrument arms. Monopolar Hot Shears
set at 80 watts pure cutting power and bipolar Maryland
Forceps set at 30 watts were employed. The procedure
began with the dissection of the space between the lower
anterior aspect of the cervix and the urinary bladder. Bipolar
coagulation of residual cervical vessels was then carried
out. Excision of the stump was rapidly completed following
the edge of the uterine manipulator’s cervical cup. A
bidirectional barbed suture was employed to securely close
the vaginal cuff. The stumps of the uterosacral ligaments
were included in this stitch, for vaginal cuff support.
At final inspection, a 2 cm solid nodule was found in
association with an appendix epiploica of the sigmoid. This
was excised and recovered intact through a specimen
pouch. The pathological diagnosis for both the cervical
growth and the nodule was adenomyisis. The procedure
lasted less than one hour. The patient was discharged home
on the day of surgery and had an uneventful recovery.
The console operator was a high-volume robotic surgeon
with no prior experience with trachelectomy who
was guided through the procedure by a non-robotic
consultant with high expertise in trachelectomy. Effective
communication was allowed by Telestration, a feature by
which images drawn on a dedicated screen overlap with
the live image at the robotic console.
MATERIALS AND METHODS: Robot-assisted laparoscopic
trachelectomy is a safe and simple procedure that should
be part of the armamentarium of the gynecologist and
the reproductive surgeon at a time when the supracervical
hysterectomy is gaining popularity.
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V-17 5:20 PM
ROBOT-ASSISTED TOTAL LAPAROSCOPIC HEMI-HYSTERECTOMY
AND VAGINECTOMY OF A DIDELPHYIC UTERUS IN A PATIENT
WITH OBSTRUCTED HEMIVAGINA AND IPSILATERAL RENAL
AGENESIS (OHVIRA).
S. Berger-Chen1, J. H. Kim1, J. Ritch1, J. Evanko1, T. Hensle1.
1Obstetrics and Gynecology, Columbia University, New York,
NY; 2Pediatric Urology, Columbia University, New York, NY.
OBJECTIVE: To describe the diagnosis and management of
an anomaly of the female genitourinary tract.
DESIGN: Case report.
Setting: Metropolitan academic medical center.
Patient: A 10 year old menarchal girl with uterine didelphys,
pelvic pain and a retrovesicular mass.
Intervention: Septum resection, Robotic hemihysterectomy.
Main Outcome Measures: Symptomatic Reproductive tract
anomalies and management.