Vulvar Condyloma Wide Local Excision with use of SONOPET

A 30-year-old female underwent in-vitro fertilization and preimplantation genetic testing. The patient conceived after her first frozen embryo transfer (FET). Beta-hCG was measured at 85 and was doubling appropriately. Ultrasound showed an angular pregnancy with heart beat confirmed by MRI. The patient has a deep arcuate uterus which may have predisposed to angular pregnancy. She was given 3 doses of methotrexate unsuccessfully. Due to concern of rupture, she underwent a hysteroscopic injection of methotrexate inside the gestational sac at 7 weeks. Hysteroscopy showed the gestational sac within the angular portion of the uterus as well as the needle penetrating the gestational sac to inject the 50mg methotrexate (see video). Fetal heart rate ceased and the patient passed products of conception 1 week later. The patient had no further complications and had a normal pregnancy on her next FET that resulted in a livebirth.

Introduction:

The prevalence of adnexal masses in pregnancy ranges from 0.05 to 2.4 percent and approximately 1 to 6 percent of these masses are malignant. Patients typically present on prenatal ultrasound asymptomatically but some can have abdominal and back pain as well. Concerns for the fetus and complications in pregnancy cause surgeries to be postponed until after delivery; however, some adnexal masses require evaluation for malignancy.

We present a case of a 28-year-old female with a cystic adnexal mass that required laparoscopic salpingo-oophorectomy at 17 weeks gestation.

Methods:

After the patient was prepped and draped,the initial laparoscopic port was placed in the left upper quadrant, 3 cm below the costal margin and in the midclavicular line. This area, known as Palmer’s point, was chosen as the site for the initial port placement in order to avoid the gravid uterus. After intraperitoneal placement, the abdomen was insufflated with CO2 gas. Laparoscopic ports were placed at the umbilicus and in the right lower quadrant under direct visualization. The port placed at the umbilicus was an Applied Medical GelPOINT Advanced Access Platform. The entire abdominal and pelvic cavities were examined for any lesions. An initial washing was done to examine for malignant cells. The left ovary was examined and determined to be normal. The right ovary was noted to be enlarged, to approximately 10 cm, and was displaced into the posterior cul de sac. Next the infundibulopelvic ligament, broad ligament, ovarian vessels, and ureter are identified. The ureter, which is typically able to be identified at the pelvic brim where it crosses over the bifurcation of the iliac vessels and passes medially, was noted to be well below the plane of dissection. If the ureter is unable to be located trans-peritoneally, a peritoneal incision can be made parallel to the ovarian vessels and the ureter located retroperitoneally in the medial leaflet of the broad ligament. The right fallopian tube and right utero-ovarian ligament were transected using the Ligasure bipolar device. We evaluated for hemostasis of the pedicles. The right suspensory ligament of the ovary containing the ovarian vessels was then isolated and cauterized and transected using the Ligasure bipolar device.  A laparoscopic retrieval bag was introduced through the GelPOINT advanced access platform, the specimen was placed in the bag, and then the bag was brought to the surface of the patient’s abdomen. We were able to drain straw colored fluid from the cyst with the cyst contained safely within the bag. The remainder of the specimen was then able to be removed, contained within the bag. The patient’s abdomen was deflated and the ports were removed. The fascia at the umbilicus was closed with an 0 Vicryl (polyglactin) suture so as to avoid herniation at the site of the larger incision accommodating the GelPOINT. The rest of the ports were closed using subcuticular sutures.

Discussion:

Pathology revealed a mature cystic teratoma. The patient was discharged home on the same day of surgery with no complications. Fetal heart tones were within normal limits pre- and post-procedure. Laparoscopic surgery is a safe treatment for pregnant women with non-obstetrical surgical issues, including adnexal masses.

Contributors: Dr. Jimmy Lin, Dr. Juana Hutchinson-Colas, Dr. Nell Maloney-Patel

Rectovaginal fistulas can occur for a number of reasons, including obstetric trauma, iatrogenic, radiation damage and Crohn’s disease. Symptoms range from asymptomatic to uncontrollable passage of gas or feces from the vagina leading to poor quality of life for some patients. For those patients whom surgery is indicated, there are several different approaches depending on the fistula etiology and previous attempts at repair. These range from simple fistulectomy to transabdominal repair with tissue interposition to Martius flap interposition. Our patient in the video had previously underwent multiple various repairs which failed to provide adequate resolution of her fistula and therefore presented for a Modified Martius flap repair. The benefit of such a repair is to provide neovascularity at the site of repair with minimal cosmetic effect.