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Papers by Ceana Nezhat

Obstetrics & Gynecology, 2019

JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons

To compare robotic-assisted laparoscopic hysterectomy (RALH) with a matched control group of stan... more To compare robotic-assisted laparoscopic hysterectomy (RALH) with a matched control group of standard laparoscopic hysterectomy (LH). A retrospective chart review of all RALH was performed. All cases were compared with a matched control group of standard LH. Comparisons were based on Fisher's exact, Mann-Whitney, and exact chi-square tests. Between January 2006 and August 2007, 26 consecutive RALH were performed (10 with bilateral salpingo-oophorectomy). These were compared with 50 matched control standard LH (22 with bilateral salpingo-oophorectomy). The 2 groups were matched by age (P=0.49), body mass index (P=0.25), gravidity (P=0.11), previous abdomino-pelvic surgery (P=0.37), and size of the excised uterus (P=0.72). Mean surgical time for RALH was 276 minutes (range, 150 to 440) compared with 206 minutes (range, 110 to 420) for standard LH (P=0.01). Blood loss, hospitalization length, and postoperative complications were not significantly different. No conversion to laparot...

JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons

Natural orifice transluminal endoscopic surgery involves the introduction of instruments through ... more Natural orifice transluminal endoscopic surgery involves the introduction of instruments through a natural orifice into the peritoneal cavity to perform diagnostic and therapeutic surgical interventions. We report the utilization of the vaginal opening at the time of laparoscopic-assisted vaginal hysterectomy or total laparoscopic hysterectomy as a natural orifice for appendectomy. We reviewed cases of 42 patients who underwent total laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy followed by appendectomy, performed by applying a stapler and removing the appendix transvaginally. By using a small-diameter laparoscope, the appendix was mobilized, especially in patients with adhesions, endometriosis, or retrocecal appendix, to facilitate transvaginal access with the stapler. All procedures were performed successfully without intraoperative or major postoperative complications. The appendectomy portion of the procedure took approximately 5 minutes to 10 minutes. ...

JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons

Laparoscopic myomectomy has recently gained wide acceptance. However, this procedure remains tech... more Laparoscopic myomectomy has recently gained wide acceptance. However, this procedure remains technically highly demanding and concerns have been raised regarding the prolonged time of anesthesia, increased blood loss, and possibly a higher risk of postoperative adhesion formation. Laparoscopic-assisted myomectomy (LAM) is advocated as a technique that may lessen these concerns regarding laparoscopic myomectomy while retaining the benefits of laparoscopic surgery, namely, short hospital stay, lower costs, and rapid recovery. By decreasing the technical demands, and thereby the operative time, LAM may be more widely offered to patients. In carefully selected cases, LAM is a safe and efficient alternative to both laparoscopic myomectomy and myomectomy by laparotomy. These cases include patients with numerous large or deep intramural myomas. LAM allows easier repair of the uterus and rapid morcellation of the myomas. In women who desire a future pregnancy, LAM may be a better approach b...

JSLS : Journal of the Society of Laparoendoscopic Surgeons, 2014

Background/Objectives: It has been shown that major gynecologic laparoscopy is safe in hospital a... more Background/Objectives: It has been shown that major gynecologic laparoscopy is safe in hospital ambulatory settings, but there is little data to suggest the same in freestanding ambulatory surgery centers. This study evaluates the safety and efficacy of advanced gynecologic laparoscopic surgery using a fast-track model in freestanding ambulatory surgery centers and discusses our institution protocols. Methods: Retrospective, multicenter review was conducted of major gynecologic surgeries from August 1 st 2010 to September 30 th 2011 in 3 surgical centers with one primary surgeon. All patients were treated for symptomatic uterine leiomyomas and/or endometriosis. Primary outcome measures were unplanned admissions and discharge within 23 hours. Results: One hundred and thirty-four patients underwent major laparoscopic gynecologic surgery with a total of 160 procedures: 77 stage IV endometriosis treatment including 7 disk excisions of endometriosis from the large bowel, 3 ureteroneocystostomies and 1 partial bladder resection, 38 myomectomies, and 34 hysterectomies including 12 modified radical hysterectomies. The overall unplanned admission rate was 4.5%. One hundred and thirty-one patients (97.7%) were discharged within 24 hours after surgery. Three patients (2.2%) were transferred to the hospital postoperatively: 1 patient for observation of postoperative anemia and 2 patients for postoperative fever. Three patients (2.2%) were admitted to the hospital after discharge: 1 patient for postoperative ileus, 1 patient for postoperative fever, and 1 patient with septic pelvic thrombophlebitis. These postoperative issues all resolved without complication, and all patients had an uneventful follow-up. Conclusions: With appropriate resources and an experienced surgeon, advanced laparoscopic surgery can be safely performed in a fast-track ambulatory surgery center with a high rate of discharge within 23 hours and low unplanned readmission rate.

The Journal of the American Association of Gynecologic Laparoscopists, 2004

Prevention and early detection of complications are of major importance for growing acceptance of... more Prevention and early detection of complications are of major importance for growing acceptance of advanced laparoscopic surgery. 1 Knowledge of anatomy and excellent surgical skills are necessary to minimize complications. Even in experienced hands, however, not all complications can be prevented, and when they do occur immediate diagnosis is essential. 2 Bowel injury after laparoscopic surgery is rare and may have unusual characteristics and devastating sequelae. 3 Based on the numbers of patients in recent series, it is possible to estimate the risk of gastrointestinal injuries occurring during gynecologic laparoscopy at between 0.6 and 1.6/1000. 4-8 A survey of the surgical and gynecologic literature revealed 266 laparoscopic bowel perforation injuries in 205 969 laparoscopic cases, 58% of the small bowel and 32% of the colon, with a combined incidence of 1.3/ 1000 cases. 9 Only 50% were caused by electrocoagulation. Most (69%) were not recognized at surgery, and 80% of these patients required repair by laparotomy. Laparoscopic surgery involving the sigmoid colon is commonly performed for treatment of severe pelvic endometriosis and adhesions. 10,11 Prompt and accurate diagnosis of proctosigmoid injury is crucial, since it should be treated when it is recognized to avoid severe morbidity and potentially fatal outcome. 3,8 Prevention of bowel injury relies on the surgeon's experience, strict observance of safety rules, perfect familiarity with physical properties of instruments, systematic bowel preparation for patients at risk of bowel complications, supervision of the route taken by trocars, meticulous inspection on completion of surgery of all areas of bowel adhesiolysis, and, in case of doubt, tests for leakage involving the rectosigmoid. 2,8 Performed intraoperatively after bowel resection or proctectomy, rigid proctoscopy is helpful to the surgeon in evaluating anastomosis and checking for anastomotic leaks. After anastomosis is complete, the surgeon introduces saline into the abdominal cavity and clamps above the anastomosis. The lumen can then be insufflated and the anastomosis 47

Fertility and Sterility, 2010

Objective: To investigate the coexistence of endometriosis in women presenting with symptomatic l... more Objective: To investigate the coexistence of endometriosis in women presenting with symptomatic leiomyomas. Design: Retrospective study. Setting: Tertiary university medical center. Patient(s): We reviewed the medical records of 131 patients who underwent laparoscopic myomectomy or hysterectomy. All patients were consented for possible concomitant diagnosis and treatment of endometriosis. Intervention(s): All patients underwent laparoscopic myomectomy or hysterectomy. Main Outcome Measure(s): The main outcome measure of the study was the presence or absence of endometriosis. Result(s): Of the 131 patients, 113 were diagnosed with endometriosis and fibroids, while 18 were diagnosed with fibroids alone. Patients with fibroids were on average 4.0 years older than those with endometriosis and fibroids (41 vs. 45). Patients with both diagnoses were also more likely to present with pelvic pain and nulliparity than those with fibroids alone. Conclusion(s): An overwhelming majority of patients with symptomatic fibroids were also diagnosed with endometriosis. Overlooking the concomitant diagnosis of endometriosis in these women may lead to suboptimal treatment of the patients. Further studies are needed to evaluate the impact of surgical treatments on symptom resolution. (Fertil Steril Ò 2010;94:720-3. Ó2010 by American Society for Reproductive Medicine.

Fertility and Sterility, 2005

was termination of the pregnancy by fetal intracardiac KCI and intraplacental methotrexate. A pre... more was termination of the pregnancy by fetal intracardiac KCI and intraplacental methotrexate. A preoperative MRI was performed to further evaluate the uterine anomaly as there are anatomical variations in the attachment of the rudimentary horn to the unicornuate uterus. Treatment was completed with laparoscopic resection of the rudimentary horn and pregnancy. 4:28 p.m.

Obstetrics & Gynecology, 1995

American journal of obstetrics and gynecology, Jan 13, 2017

The most common location of extragenital endometriosis is the bowel. Medical treatment may not pr... more The most common location of extragenital endometriosis is the bowel. Medical treatment may not provide long-term improvement in patients who are symptomatic, and consequently most of these patients may require surgical intervention. Over the past century, surgeons have continued to debate the optimal surgical approach to treating bowel endometriosis, weighing the risks against the benefits. In this expert review we will describe how the recommended surgical approach depends largely on the location of disease, in addition to size and depth of the lesion. For lesions approximately 5-8 cm from the anal verge, we encourage conservative surgical management over resection to decrease the risk of short- and long-term complications.

JSLS : Journal of the Society of Laparoendoscopic Surgeons, 2015

This document reflects emerging clinical and scientific advances as of the date issued and is sub... more This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.

JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons

The value of robotic surgery for gynecologic procedures has been critically evaluated over the pa... more The value of robotic surgery for gynecologic procedures has been critically evaluated over the past few years. Its drawbacks have been noted as larger port size, location of port placement, limited instrumentation, and cost. In this study, we describe a novel technique for robotic-assisted laparoscopic hysterectomy (RALH) with 3 important improvements: (1) more aesthetic triangular laparoscopic port configuration, (2) use of 5-mm robotic cannulas and instruments, and (3) improved access around the robotic arms for the bedside assistant with the use of pediatric-length laparoscopic instruments. We reviewed a series of 44 women who underwent a novel RALH technique and concomitant procedures for benign hysterectomy between January 2008 and September 2011. The novel RALH technique and concomitant procedures were completed in all of the cases without conversion to larger ports, laparotomy, or video-assisted laparoscopy. Mean age was 49.9 years (SD 8.8, range 33-70), mean body mass index ...

Surgical technology international, 1995

Operative laparoscopy is an alternative to laparotomy for most gynecologic surgical procedures, b... more Operative laparoscopy is an alternative to laparotomy for most gynecologic surgical procedures, but its role in gynecologic oncology has been considered only recently. Laparoscopy has been applied to gynecologic cancer with good results. Advantages include better visualization of the abdominal cavity and more rapid recovery, allowing earlier initiation of either chemotherapy or radiotherapy. Concerns include the risk for dissemination of neoplastic disease if less radical surgery is performed. With improvements in technology and advanced clinical experience, laparoscopic radical surgery can be performed with adequate tissue margins, conforming to accepted guidelines. Further, studies have shown that the yield of pelvic nodes significantly increases with experience. The danger of abdominal wall tumor implantation after laparoscopy for malignant conditions should be considered, but is infrequent. Careful techniques and the use of a laparoscopic pouch can prevent peritoneal disseminati...

JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons

The purpose of this study was to examine our experience with laparoscopic and laparoscopically as... more The purpose of this study was to examine our experience with laparoscopic and laparoscopically assisted management of bowel endometriosis and to recommend treatment approaches, considering patient goals for both pain mitigation or fertility, or both. The medical records of 187 women treated laparoscopically for intestinal endometriosis were reviewed retrospectively for presenting symptoms, methods of surgical treatment, complications, and efficacy of treating pain and infertility. The extent of resection was determined by the severity of the endometriotic lesion, tempered by the patient's fertility goals. The most common patient complaint preceding surgery was pelvic pain. In addition, 58 (31%) patients experienced impaired fertility. Of the patients available for long-term follow-up, 152 (85%) reported complete or significant long-term pain relief. Complete pain relief in the immediate postoperative period was significantly more likely with partial bowel resection compared with...

JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons

To evaluate the short- and long-term results of laparoscopic enterolysis in patients with chronic... more To evaluate the short- and long-term results of laparoscopic enterolysis in patients with chronic pelvic pain following hysterectomy. Forty-eight patients were evaluated at time intervals from 2 weeks to 5 years after laparoscopic enterolysis. Patients were asked to rate postoperative relief of their pelvic pain as complete/near complete relief (80-100% pain relief), significant relief (50-80% pain relief), or less than 50% or no pain relief. We found that after 2 to 8 weeks, 39% of patients reported complete/near complete pain relief, 33% reported significant pain relief, and 28% reported less than 50% or no pain relief. Six months to one year postlaparoscopy, 49% of patients reported complete/near complete pain relief, 15% reported significant pain relief, and 36% reported less than 50% or no pain relief. Two to five years after laparoscopic enterolysis, 37% of patients reported complete/near complete pain relief, 30% reported significant pain relief, and 33% reported less than 50...

JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons

The continually changing definition of operative laparoscopy as well as the ever-widening boundar... more The continually changing definition of operative laparoscopy as well as the ever-widening boundaries of its use are discussed in this report. It is important to prepare residents to adequately undertake advanced laparoscopic surgery as laparotomy is gradually replaced by laparoscopy for many routine procedures. Since degree of training and experience strongly correlate with complication rates, more focus on laparoscopy during graduate education would be beneficial to residents in order to keep them up to date with the rapid development of this field.

JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons

To review the literature regarding the role of laparoscopy during pregnancy, particularly adnexal... more To review the literature regarding the role of laparoscopy during pregnancy, particularly adnexal mass and non-obstetric surgery, incorporating the results of a series of 9 cases of laparoscopy during pregnancy at our centers. A Medline search was performed to review the literature, and the reference lists provided by those articles were further explored for citations regarding laparoscopic adnexal surgery, appendectomy, and cholecystectomy. Our series of 9 patients consisted of pregnant patients with adnexal mass or acute abdomen who would otherwise have undergone exploratory laparotomy. Follow-up data for these 9 cases were collected by office visits, inquiry to the primary referring physicians, and telephone calls to the patient. The literature search yielded 42 additional cases of operative pelvic laparoscopy and 51 cases of abdominal operative laparoscopy (cholecystectomy and appendectomy). The publications, particularly regarding cholecystectomy, were supportive of the laparos...

JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons

The direct trocar technique is an alternative to Veress needle insertion and open laparoscopy for... more The direct trocar technique is an alternative to Veress needle insertion and open laparoscopy for accessing the abdominal cavity for operative laparoscopy. We review our approach to abdominal entry in 1385 laparoscopies performed between September 1993 and June 2000 by our group at Stanford University Hospital, a tertiary Medical Center. We performed a retrospective chart review of 1385 patients who underwent operative laparoscopy during the study years. The mode of abdominal entry, patient demographics, and complications were reviewed. The transumbilical direct trocar entry method was used in 1223 patients. In 133 patients, the Veress needle insertion technique was used. Open laparoscopy was used in 22 patients. Three (0.21%) major complicadons occurred: 1 enterotomy, 1 omental herniation, and 1 bowel hemiation. One complication was related to primary access (0.072%) in a patient who had an open laparoscopy. She sustained an enterotomy during placement of the primary trocar. The bo...

Obstetrics and Gynecology Clinics of North America, 2012

INFERTILITY IS A GROWING CONCERN Approximately 85% to 90% of healthy young couples conceive withi... more INFERTILITY IS A GROWING CONCERN Approximately 85% to 90% of healthy young couples conceive within 1 year of trying, and most conceive within 6 months. 1 However, 10% to 15% of couples have difficulty conceiving and experience infertility or subfertility, which is defined as 1 year of unprotected intercourse without conception. 2 Although overall rates of infertility have remained stable during the last 30 years in the United States the overall birth and fertility rates are declining because of several social and cultural trends: women achieving advanced education and careers, delaying marriage for men and women, delaying childbearing, more frequent divorce, and reliable contraception and family planning. Comparatively, the first US census in 1790 indicated that the crude birth rate was 55 per 1000 of the total population. During the postwar "baby boom" of Conflicts of interest: Dr Erica Dun declares no conflicts of interest. Dr Ceana Nezhat is a consultant for Conceptus, Hologic, Lumenis, Intuitive Surgical, and Karl Storz; medical advisor for Plasma Surgical; and on the scientific advisory board for SurgiQuest. Financial support: No financial support was received to write this article.

Obstetrics & Gynecology, 2014

To determine whether the office visceral slide test is an effective screening test for predicting... more To determine whether the office visceral slide test is an effective screening test for predicting obliterating periumbilical adhesions compared with two ultrasound tests performed in the operating room. METHODS: Women undergoing benign laparoscopic gynecologic surgery between July 2012 and August 2013 were invited to participate. All participants had an office-based ultrasound test at their preoperative visit (the office visceral slide test), two operating room ultrasound tests (the preoperative examination with visceral slide and the periumbilical ultrasound-guided saline infusion test), and then their scheduled laparoscopic procedure. We measured the ability of the three screening tests to detect obliterating periumbilical adhesions. RESULTS: Eighty-two women completed the study; 12 women were excluded because they had no history of surgery and 70 women with a history of abdominal and pelvic surgery were analyzed in the study group. The study group (n570) had a median of two (range, 1-6) previous abdominal surgeries. The median number of previous laparotomies was 0 (range, 0-5). The median number of previous laparoscopies was 1 (range, 0-6). At laparoscopy, 6 of 70 women (8.6%) had periumbilical adhesions diagnosed; 18 of 70 women (25.7%) had any adhesions located in the abdomen or pelvis. The office visceral slide test had a sensitivity of 83.3%, specificity of 100%, positive predictive value of 100%, negative predictive value of 98.5% and diagnostic accuracy of 98.6%. CONCLUSION: The office visceral slide test is a simple and reliable test for detecting obliterating periumbilical adhesions in the outpatient setting.

Obstetrics & Gynecology, 2019

JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons

To compare robotic-assisted laparoscopic hysterectomy (RALH) with a matched control group of stan... more To compare robotic-assisted laparoscopic hysterectomy (RALH) with a matched control group of standard laparoscopic hysterectomy (LH). A retrospective chart review of all RALH was performed. All cases were compared with a matched control group of standard LH. Comparisons were based on Fisher's exact, Mann-Whitney, and exact chi-square tests. Between January 2006 and August 2007, 26 consecutive RALH were performed (10 with bilateral salpingo-oophorectomy). These were compared with 50 matched control standard LH (22 with bilateral salpingo-oophorectomy). The 2 groups were matched by age (P=0.49), body mass index (P=0.25), gravidity (P=0.11), previous abdomino-pelvic surgery (P=0.37), and size of the excised uterus (P=0.72). Mean surgical time for RALH was 276 minutes (range, 150 to 440) compared with 206 minutes (range, 110 to 420) for standard LH (P=0.01). Blood loss, hospitalization length, and postoperative complications were not significantly different. No conversion to laparot...

JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons

Natural orifice transluminal endoscopic surgery involves the introduction of instruments through ... more Natural orifice transluminal endoscopic surgery involves the introduction of instruments through a natural orifice into the peritoneal cavity to perform diagnostic and therapeutic surgical interventions. We report the utilization of the vaginal opening at the time of laparoscopic-assisted vaginal hysterectomy or total laparoscopic hysterectomy as a natural orifice for appendectomy. We reviewed cases of 42 patients who underwent total laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy followed by appendectomy, performed by applying a stapler and removing the appendix transvaginally. By using a small-diameter laparoscope, the appendix was mobilized, especially in patients with adhesions, endometriosis, or retrocecal appendix, to facilitate transvaginal access with the stapler. All procedures were performed successfully without intraoperative or major postoperative complications. The appendectomy portion of the procedure took approximately 5 minutes to 10 minutes. ...

JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons

Laparoscopic myomectomy has recently gained wide acceptance. However, this procedure remains tech... more Laparoscopic myomectomy has recently gained wide acceptance. However, this procedure remains technically highly demanding and concerns have been raised regarding the prolonged time of anesthesia, increased blood loss, and possibly a higher risk of postoperative adhesion formation. Laparoscopic-assisted myomectomy (LAM) is advocated as a technique that may lessen these concerns regarding laparoscopic myomectomy while retaining the benefits of laparoscopic surgery, namely, short hospital stay, lower costs, and rapid recovery. By decreasing the technical demands, and thereby the operative time, LAM may be more widely offered to patients. In carefully selected cases, LAM is a safe and efficient alternative to both laparoscopic myomectomy and myomectomy by laparotomy. These cases include patients with numerous large or deep intramural myomas. LAM allows easier repair of the uterus and rapid morcellation of the myomas. In women who desire a future pregnancy, LAM may be a better approach b...

JSLS : Journal of the Society of Laparoendoscopic Surgeons, 2014

Background/Objectives: It has been shown that major gynecologic laparoscopy is safe in hospital a... more Background/Objectives: It has been shown that major gynecologic laparoscopy is safe in hospital ambulatory settings, but there is little data to suggest the same in freestanding ambulatory surgery centers. This study evaluates the safety and efficacy of advanced gynecologic laparoscopic surgery using a fast-track model in freestanding ambulatory surgery centers and discusses our institution protocols. Methods: Retrospective, multicenter review was conducted of major gynecologic surgeries from August 1 st 2010 to September 30 th 2011 in 3 surgical centers with one primary surgeon. All patients were treated for symptomatic uterine leiomyomas and/or endometriosis. Primary outcome measures were unplanned admissions and discharge within 23 hours. Results: One hundred and thirty-four patients underwent major laparoscopic gynecologic surgery with a total of 160 procedures: 77 stage IV endometriosis treatment including 7 disk excisions of endometriosis from the large bowel, 3 ureteroneocystostomies and 1 partial bladder resection, 38 myomectomies, and 34 hysterectomies including 12 modified radical hysterectomies. The overall unplanned admission rate was 4.5%. One hundred and thirty-one patients (97.7%) were discharged within 24 hours after surgery. Three patients (2.2%) were transferred to the hospital postoperatively: 1 patient for observation of postoperative anemia and 2 patients for postoperative fever. Three patients (2.2%) were admitted to the hospital after discharge: 1 patient for postoperative ileus, 1 patient for postoperative fever, and 1 patient with septic pelvic thrombophlebitis. These postoperative issues all resolved without complication, and all patients had an uneventful follow-up. Conclusions: With appropriate resources and an experienced surgeon, advanced laparoscopic surgery can be safely performed in a fast-track ambulatory surgery center with a high rate of discharge within 23 hours and low unplanned readmission rate.

The Journal of the American Association of Gynecologic Laparoscopists, 2004

Prevention and early detection of complications are of major importance for growing acceptance of... more Prevention and early detection of complications are of major importance for growing acceptance of advanced laparoscopic surgery. 1 Knowledge of anatomy and excellent surgical skills are necessary to minimize complications. Even in experienced hands, however, not all complications can be prevented, and when they do occur immediate diagnosis is essential. 2 Bowel injury after laparoscopic surgery is rare and may have unusual characteristics and devastating sequelae. 3 Based on the numbers of patients in recent series, it is possible to estimate the risk of gastrointestinal injuries occurring during gynecologic laparoscopy at between 0.6 and 1.6/1000. 4-8 A survey of the surgical and gynecologic literature revealed 266 laparoscopic bowel perforation injuries in 205 969 laparoscopic cases, 58% of the small bowel and 32% of the colon, with a combined incidence of 1.3/ 1000 cases. 9 Only 50% were caused by electrocoagulation. Most (69%) were not recognized at surgery, and 80% of these patients required repair by laparotomy. Laparoscopic surgery involving the sigmoid colon is commonly performed for treatment of severe pelvic endometriosis and adhesions. 10,11 Prompt and accurate diagnosis of proctosigmoid injury is crucial, since it should be treated when it is recognized to avoid severe morbidity and potentially fatal outcome. 3,8 Prevention of bowel injury relies on the surgeon's experience, strict observance of safety rules, perfect familiarity with physical properties of instruments, systematic bowel preparation for patients at risk of bowel complications, supervision of the route taken by trocars, meticulous inspection on completion of surgery of all areas of bowel adhesiolysis, and, in case of doubt, tests for leakage involving the rectosigmoid. 2,8 Performed intraoperatively after bowel resection or proctectomy, rigid proctoscopy is helpful to the surgeon in evaluating anastomosis and checking for anastomotic leaks. After anastomosis is complete, the surgeon introduces saline into the abdominal cavity and clamps above the anastomosis. The lumen can then be insufflated and the anastomosis 47

Fertility and Sterility, 2010

Objective: To investigate the coexistence of endometriosis in women presenting with symptomatic l... more Objective: To investigate the coexistence of endometriosis in women presenting with symptomatic leiomyomas. Design: Retrospective study. Setting: Tertiary university medical center. Patient(s): We reviewed the medical records of 131 patients who underwent laparoscopic myomectomy or hysterectomy. All patients were consented for possible concomitant diagnosis and treatment of endometriosis. Intervention(s): All patients underwent laparoscopic myomectomy or hysterectomy. Main Outcome Measure(s): The main outcome measure of the study was the presence or absence of endometriosis. Result(s): Of the 131 patients, 113 were diagnosed with endometriosis and fibroids, while 18 were diagnosed with fibroids alone. Patients with fibroids were on average 4.0 years older than those with endometriosis and fibroids (41 vs. 45). Patients with both diagnoses were also more likely to present with pelvic pain and nulliparity than those with fibroids alone. Conclusion(s): An overwhelming majority of patients with symptomatic fibroids were also diagnosed with endometriosis. Overlooking the concomitant diagnosis of endometriosis in these women may lead to suboptimal treatment of the patients. Further studies are needed to evaluate the impact of surgical treatments on symptom resolution. (Fertil Steril Ò 2010;94:720-3. Ó2010 by American Society for Reproductive Medicine.

Fertility and Sterility, 2005

was termination of the pregnancy by fetal intracardiac KCI and intraplacental methotrexate. A pre... more was termination of the pregnancy by fetal intracardiac KCI and intraplacental methotrexate. A preoperative MRI was performed to further evaluate the uterine anomaly as there are anatomical variations in the attachment of the rudimentary horn to the unicornuate uterus. Treatment was completed with laparoscopic resection of the rudimentary horn and pregnancy. 4:28 p.m.

Obstetrics & Gynecology, 1995

American journal of obstetrics and gynecology, Jan 13, 2017

The most common location of extragenital endometriosis is the bowel. Medical treatment may not pr... more The most common location of extragenital endometriosis is the bowel. Medical treatment may not provide long-term improvement in patients who are symptomatic, and consequently most of these patients may require surgical intervention. Over the past century, surgeons have continued to debate the optimal surgical approach to treating bowel endometriosis, weighing the risks against the benefits. In this expert review we will describe how the recommended surgical approach depends largely on the location of disease, in addition to size and depth of the lesion. For lesions approximately 5-8 cm from the anal verge, we encourage conservative surgical management over resection to decrease the risk of short- and long-term complications.

JSLS : Journal of the Society of Laparoendoscopic Surgeons, 2015

This document reflects emerging clinical and scientific advances as of the date issued and is sub... more This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.

JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons

The value of robotic surgery for gynecologic procedures has been critically evaluated over the pa... more The value of robotic surgery for gynecologic procedures has been critically evaluated over the past few years. Its drawbacks have been noted as larger port size, location of port placement, limited instrumentation, and cost. In this study, we describe a novel technique for robotic-assisted laparoscopic hysterectomy (RALH) with 3 important improvements: (1) more aesthetic triangular laparoscopic port configuration, (2) use of 5-mm robotic cannulas and instruments, and (3) improved access around the robotic arms for the bedside assistant with the use of pediatric-length laparoscopic instruments. We reviewed a series of 44 women who underwent a novel RALH technique and concomitant procedures for benign hysterectomy between January 2008 and September 2011. The novel RALH technique and concomitant procedures were completed in all of the cases without conversion to larger ports, laparotomy, or video-assisted laparoscopy. Mean age was 49.9 years (SD 8.8, range 33-70), mean body mass index ...

Surgical technology international, 1995

Operative laparoscopy is an alternative to laparotomy for most gynecologic surgical procedures, b... more Operative laparoscopy is an alternative to laparotomy for most gynecologic surgical procedures, but its role in gynecologic oncology has been considered only recently. Laparoscopy has been applied to gynecologic cancer with good results. Advantages include better visualization of the abdominal cavity and more rapid recovery, allowing earlier initiation of either chemotherapy or radiotherapy. Concerns include the risk for dissemination of neoplastic disease if less radical surgery is performed. With improvements in technology and advanced clinical experience, laparoscopic radical surgery can be performed with adequate tissue margins, conforming to accepted guidelines. Further, studies have shown that the yield of pelvic nodes significantly increases with experience. The danger of abdominal wall tumor implantation after laparoscopy for malignant conditions should be considered, but is infrequent. Careful techniques and the use of a laparoscopic pouch can prevent peritoneal disseminati...

JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons

The purpose of this study was to examine our experience with laparoscopic and laparoscopically as... more The purpose of this study was to examine our experience with laparoscopic and laparoscopically assisted management of bowel endometriosis and to recommend treatment approaches, considering patient goals for both pain mitigation or fertility, or both. The medical records of 187 women treated laparoscopically for intestinal endometriosis were reviewed retrospectively for presenting symptoms, methods of surgical treatment, complications, and efficacy of treating pain and infertility. The extent of resection was determined by the severity of the endometriotic lesion, tempered by the patient's fertility goals. The most common patient complaint preceding surgery was pelvic pain. In addition, 58 (31%) patients experienced impaired fertility. Of the patients available for long-term follow-up, 152 (85%) reported complete or significant long-term pain relief. Complete pain relief in the immediate postoperative period was significantly more likely with partial bowel resection compared with...

JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons

To evaluate the short- and long-term results of laparoscopic enterolysis in patients with chronic... more To evaluate the short- and long-term results of laparoscopic enterolysis in patients with chronic pelvic pain following hysterectomy. Forty-eight patients were evaluated at time intervals from 2 weeks to 5 years after laparoscopic enterolysis. Patients were asked to rate postoperative relief of their pelvic pain as complete/near complete relief (80-100% pain relief), significant relief (50-80% pain relief), or less than 50% or no pain relief. We found that after 2 to 8 weeks, 39% of patients reported complete/near complete pain relief, 33% reported significant pain relief, and 28% reported less than 50% or no pain relief. Six months to one year postlaparoscopy, 49% of patients reported complete/near complete pain relief, 15% reported significant pain relief, and 36% reported less than 50% or no pain relief. Two to five years after laparoscopic enterolysis, 37% of patients reported complete/near complete pain relief, 30% reported significant pain relief, and 33% reported less than 50...

JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons

The continually changing definition of operative laparoscopy as well as the ever-widening boundar... more The continually changing definition of operative laparoscopy as well as the ever-widening boundaries of its use are discussed in this report. It is important to prepare residents to adequately undertake advanced laparoscopic surgery as laparotomy is gradually replaced by laparoscopy for many routine procedures. Since degree of training and experience strongly correlate with complication rates, more focus on laparoscopy during graduate education would be beneficial to residents in order to keep them up to date with the rapid development of this field.

JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons

To review the literature regarding the role of laparoscopy during pregnancy, particularly adnexal... more To review the literature regarding the role of laparoscopy during pregnancy, particularly adnexal mass and non-obstetric surgery, incorporating the results of a series of 9 cases of laparoscopy during pregnancy at our centers. A Medline search was performed to review the literature, and the reference lists provided by those articles were further explored for citations regarding laparoscopic adnexal surgery, appendectomy, and cholecystectomy. Our series of 9 patients consisted of pregnant patients with adnexal mass or acute abdomen who would otherwise have undergone exploratory laparotomy. Follow-up data for these 9 cases were collected by office visits, inquiry to the primary referring physicians, and telephone calls to the patient. The literature search yielded 42 additional cases of operative pelvic laparoscopy and 51 cases of abdominal operative laparoscopy (cholecystectomy and appendectomy). The publications, particularly regarding cholecystectomy, were supportive of the laparos...

JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons

The direct trocar technique is an alternative to Veress needle insertion and open laparoscopy for... more The direct trocar technique is an alternative to Veress needle insertion and open laparoscopy for accessing the abdominal cavity for operative laparoscopy. We review our approach to abdominal entry in 1385 laparoscopies performed between September 1993 and June 2000 by our group at Stanford University Hospital, a tertiary Medical Center. We performed a retrospective chart review of 1385 patients who underwent operative laparoscopy during the study years. The mode of abdominal entry, patient demographics, and complications were reviewed. The transumbilical direct trocar entry method was used in 1223 patients. In 133 patients, the Veress needle insertion technique was used. Open laparoscopy was used in 22 patients. Three (0.21%) major complicadons occurred: 1 enterotomy, 1 omental herniation, and 1 bowel hemiation. One complication was related to primary access (0.072%) in a patient who had an open laparoscopy. She sustained an enterotomy during placement of the primary trocar. The bo...

Obstetrics and Gynecology Clinics of North America, 2012

INFERTILITY IS A GROWING CONCERN Approximately 85% to 90% of healthy young couples conceive withi... more INFERTILITY IS A GROWING CONCERN Approximately 85% to 90% of healthy young couples conceive within 1 year of trying, and most conceive within 6 months. 1 However, 10% to 15% of couples have difficulty conceiving and experience infertility or subfertility, which is defined as 1 year of unprotected intercourse without conception. 2 Although overall rates of infertility have remained stable during the last 30 years in the United States the overall birth and fertility rates are declining because of several social and cultural trends: women achieving advanced education and careers, delaying marriage for men and women, delaying childbearing, more frequent divorce, and reliable contraception and family planning. Comparatively, the first US census in 1790 indicated that the crude birth rate was 55 per 1000 of the total population. During the postwar "baby boom" of Conflicts of interest: Dr Erica Dun declares no conflicts of interest. Dr Ceana Nezhat is a consultant for Conceptus, Hologic, Lumenis, Intuitive Surgical, and Karl Storz; medical advisor for Plasma Surgical; and on the scientific advisory board for SurgiQuest. Financial support: No financial support was received to write this article.

Obstetrics & Gynecology, 2014

To determine whether the office visceral slide test is an effective screening test for predicting... more To determine whether the office visceral slide test is an effective screening test for predicting obliterating periumbilical adhesions compared with two ultrasound tests performed in the operating room. METHODS: Women undergoing benign laparoscopic gynecologic surgery between July 2012 and August 2013 were invited to participate. All participants had an office-based ultrasound test at their preoperative visit (the office visceral slide test), two operating room ultrasound tests (the preoperative examination with visceral slide and the periumbilical ultrasound-guided saline infusion test), and then their scheduled laparoscopic procedure. We measured the ability of the three screening tests to detect obliterating periumbilical adhesions. RESULTS: Eighty-two women completed the study; 12 women were excluded because they had no history of surgery and 70 women with a history of abdominal and pelvic surgery were analyzed in the study group. The study group (n570) had a median of two (range, 1-6) previous abdominal surgeries. The median number of previous laparotomies was 0 (range, 0-5). The median number of previous laparoscopies was 1 (range, 0-6). At laparoscopy, 6 of 70 women (8.6%) had periumbilical adhesions diagnosed; 18 of 70 women (25.7%) had any adhesions located in the abdomen or pelvis. The office visceral slide test had a sensitivity of 83.3%, specificity of 100%, positive predictive value of 100%, negative predictive value of 98.5% and diagnostic accuracy of 98.6%. CONCLUSION: The office visceral slide test is a simple and reliable test for detecting obliterating periumbilical adhesions in the outpatient setting.