Purpose of reviewThoracic endometriosis is a rare disease that can lead to a variety of clinical manifestations. There are currently no guidelines for optimal diagnosis and management of the disease. The purpose of this review is to provide an overview of the diagnosis and surgical treatment of thoracic endometriosis.
Recent findingsVarious imaging modalities, including computed tomography (CT), MRI and ultrasound, have been reported in the detection of thoracic endometriosis. MRI is the most sensitive imaging study and may aid in preoperative planning. Histopathology of a biopsied lesion remains the gold standard for diagnosis. Surgical management of thoracic endometriosis may involve laparoscopy and/or thoracoscopy, and surgical planning should include preparation for single ventilation capability. A multidisciplinary approach involving a gynaecologic surgeon and thoracic surgeon may be considered. Repairing diaphragm defects and pleurodesis are shown to decrease recurrent symptoms.
The laparoscopic, or ''straight-stick'' approach to hysterectomy accounts for *30% of hysterectomies performed. Enhanced magnification and visualization, decreased blood loss, and fewer complications have made laparoscopic hysterectomy a preferred approach and the modality recommended by the American College of Obstetricians and Gynecologists and the American Association of Gynecologic Laparoscopists when vaginal hysterectomy is not possible. Laparoscopic hysterectomy is ideal for managing fibroids, adnexal masses, and endometriosis by providing excellent visualization of the pelvis while offering the benefits of minimally invasive surgery. Large pathologies, such as fibroids or adnexal masses, can be navigated safely using an angled laparoscope. In patients undergoing surgery for pelvic pain, laparoscopy allows the surgeon to inspect the abdomen fully to determine if anatomical abnormalities or pathology are present. The laparoscopic approach is useful for patients who desire supracervical hysterectomy and for those having concomitant pelvic support procedures such as sacrocolpopexy. Advantages of laparoscopic hysterectomy include the ability to allow same-day discharge with no increase in intraoperative or postoperative complications, readmission rates, or 30-day morbidity, compared with patients admitted to the hospital. Patients are able to return to normal activities sooner and experience decreased postoperative pain, compared to patients who undergo abdominal hysterectomy. Shorter hospitalization and decreased complications have also enabled the laparoscopic approach to become more costeffective than the abdominal approach. To facilitate a safe and effective laparoscopic hysterectomy regardless of surgical complexity, the surgeon must be comfortable with adhesiolysis, retroperiteoneal dissection, and suturing. There are several limitations to laparoscopy, including numerous prior surgeries, extensive pathology, comorbidities, and concern for malignancy. In these cases, an alternative route to hysterectomy may be preferred. Many of these challenges may be overcome with alternative entry points, modifications to trocar placement, an angled lens, and appropriate instrument selection. Surgeons who perform laparoscopic hysterectomy must anticipate potential concerns and consider patient-specific characteristics carefully when choosing this route of surgery. Surgeon skillset and expertise is essential to performance of straight-stick hysterectomy ( J GYNECOL SURG 37:107
The objective of this video is to illustrate how to incorporate the use of vascular bulldog clamps for reducing blood loss during robotic-assisted laparoscopic myomectomy. DESCRIPTION: This video provides technical details on the use of robotic bulldog clamps and shows their placement and removal during a robotic myomectomy case. CONCLUSION: For experienced surgeons comfortable with retroperitoneal dissection, the use of vascular bulldog clamps may be easily incorporated into surgical technique for robotic myomectomy.
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