SMIG Videos

Disclaimer:

SMIG is proud to present educational and informative videos for our members and colleagues across the world. Although our Video Committee has reviewed the content, we are not responsible for the information presented in the videos including any facts or claims made by the authors.

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We request that patient privacy be respected and the expectation is that all patients have provided permission to the author for use of these images on-line for educational purposes. In addition, there is to be no identifiable demographic or image data in the presentations.

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Laparoscopic BSO for Breast Cancer

Video demonstrating Laparoscopic Bilateral Salpingoophorectomy for a Patient with Estrogen Positive Breast Cancer. The patient has provided permission to share her surgery for educational purposes.

The surgery being conducted is a Laparoscopic Bilateral Salpingoophorectomy in a premenopausal woman with breast cancer that has been recently treated. The cancer was found to be estrogen receptor positive and she has elected to have her ovaries removed to decrease her estrogen exposure instead of medical suppression.

The key points from this surgery are the following:

  1. General Survey: It is important to rule other pathology through a general inspection of the abdomen, liver surface and pelvis.
  2. Retroperitoneal Dissection: In order to completely isolate the ovarian vessels, our approach involves transection of the round ligaments bilaterally followed by retroperitoneal dissection lateral to the infundibulopelvic ligaments. The ureter is identified and a peritoneal window is created above the ureter and below the IP ligaments to isolate the pedicles. This prevents injury to the ureter through thermal spread but also confirms complete excision of our ovary.
  3. Bipolar Instrument: A bipolar instrument that is a "maryland" tip is essential in gynecologic surgery. The older "kleppinger" bipolar forceps do not offer the same grasp or clinical result. There are many reusable bipolar instruments available on the market currently. The device we are using is manufactured by Storz.
  4. Complete removal of the fallopian tube: this is important in order to minimize any risk of malignancy related to the tubes since there is a correlation between breast cancer and ovarian cancer in some patients.

Please send any feedback or comments to smig@sogc.com

Novel Management of Ureteric Endometriosis

An approach to ureteric endometriosis is presented that has not been described before. The case presented is that of a 45 year old woman with left sided ureteric obstruction due to endometriosis resulting in significant renal impairment. Consent for this video was obtained and is to be used for educational purposes only. The video was also presented in November 2010 at the AAGL Meeting in Las Vegas.

Approach to the Difficult Laparoscopic Hysterectomy: Bladder Adhesions

Injuries to the bladder are the among the most common type of injuries at laparoscopic hysterectomy, with an incidence of 0.4 -1%. The increased risk of bladder injury is highlighted in a recent Cochrane review demonstrates increased risk of urinary tract injury with laparoscopic hysterectomy compare to the abdominal or vaginal approach.

Despite, these findings, good surgical technique and experience can reduce the risk of bladder injury
We highlight 6 steps to managing the difficult bladder at hysterectomy.

  • Anticipate potential difficulties preoperatively
  • Develop the paravesical spaces  
  • Dissect bladder flap lateral to medial
  • Optimize visualization & anatomic relationships
  • Consider alternatives management
  • Identify & repair injury

These 6 key steps can be carried out routinely at laparoscopic hysterectomy. With experience, these principles can allow the surgeon to proceed safely and confidently with difficult bladder adhesions.