Laparoscopy Today

CONFERENCE REPORT: Single Port Access (SPA) Bilateral Oopherectomy and Hysterectomy

FROM THE ASIANAMERICAN MULTISPECIALTY SUMMIT III, FEBRUARY 6–9, 2008

STEPHANIE A. KING, MD, ATA ATOGHO, MD, ERICA PODOLSKY MD, PAUL G. CURCILLO II, MD

INTRODUCTION

Laparoscopic techniques have been widely accepted in gynecologic surgery since the 1960's facilitating easier dissection and visualization in the confines of the pelvis. A variety of procedures have become the standard of care making sometimes difficult open procedures safer and quicker. In the 1970's, the single arm operative scope was employed for tubal ligations. This scope required a single abdominal port of entry and allowed one rigid functional instrument to be inserted alongside the scope. Its use was limited in other procedures by the rigidity of the instruments. A single port access (SPA) surgical technique has been developed at our institution. Using one umbilical incision with articulating instrumentation, this technique reduces surgical scarring while broadening the variety of procedures to be performed through a single incision.

METHODS

Five SPA bilateral salpingoophorectomies were performed at our institution. A transverse umbilical incision following the medial fold was used as the portal of entry for all five procedures. A 5 mm trocar was inserted at the midline for a 5 mm scope. Skin flaps were raised laterally allowing for two 5 mm accessory trocars to be inserted inferior and lateral to the initial trocar. Using the accessory trocars the round ligament and infundibulopelvic ligaments were transected. The suspensory ligament, fallopian tube, and mesosalpinx were then dissected. The ovary was removed through the umbilicus. The same procedure was repeated on the opposite side. The fascia was closed using 0 Vicryl and the skin with a running 4 Vicryl subcuticular stitch.

RESULTS

All five women tolerated the procedure well. Operative time and length of stay were comparable to the traditional multiple port procedures. Postoperative recovery was uneventful. No complications were encountered. Cosmetic results were excellent with scars being hidden in the umbilicus.

DISCUSSION

Gynecologic surgery was among the first surgical specialties to adopt minimally invasive surgery. Improved visualization allows for easier dissection of the tight pelvic anatomy. Laparoscopy also allows for reduction of surgical scarring.

In the 1970's the single arm operative scope further reduced operative scarring by utilizing a single incision at the umbilicus. This technique was limited because only one instrument could be inserted alongside the scope. A single eyepiece was used for visualization restricting this procedure to single operator.

Single port access (SPA) surgery uses the umbilicus for a single portal of entry into the abdominal cavity. In more difficult dissection, articulating instruments allowed us to maintain the procedure as a single port technique. The technique of dissection is the same as being done in standard pelvic minimally invasive surgeries. Although the articulating instruments were not necessary for all procedures their availability facilitated difficult dissections.

Hysterectomy, the Trend Towards Laparoscopic and Laparoscopic-Assisted Techniques

LAPAROSCOPIC UPDATE

FARR NEZHAT, MD, JYOTI YADAV, MD

Hysterectomy is the most frequently performed major gynecologic procedure with approximately 600,000 cases in the United States each year. In this era of advanced operative laparoscopy and minimally invasive surgery, where almost all types of procedures have been performed endoscopically, a considerable number of hysterectomies are still being performed through large abdominal incisions. However, a slow but gradually increasing trend has occurred towards laparoscopic or laparoscopic-assisted vaginal hysterectomies, 0.3% in 1990 to 9.9% in 1997 [1]. The extent of laparoscopic involvement has ranged from simply before vaginal hysterectomy to evaluate the peritoneal and pelvic cavity and to assess the feasibility of vaginal hysterectomy [2], to performing the most advanced and complicated procedures, such as total laparoscopic radical hysterectomy with pelvic and paraaortic lymphadenectomy [3].

As per data from the nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, the indications for laparoscopic hysterectomies have been leiomyomas (28%), endometriosis (19%), menstrual irregularities (15%), prolapse (13%), malignancy (5%), and pelvic inflammatory disease (3%). The advantage of a laparoscopic approach over the open abdominal route in terms of intraoperative blood loss, short- and long-term postoperative morbidity, and recovery has been demonstrated repeatedly [4-7]. However, little benefit over the vaginal approach has been seen [8].

The indications for laparoscopic and laparoscopic-assisted vaginal hysterectomy are generally those that would preclude a vaginal approach, ie, similar to those for abdominal hysterectomy. Notably, the 9% increase in laparoscopic hysterectomies from 1990 to 1997 corresponds to the decline in the rate of abdominal hysterectomies during the same period. Broadly, the considerations are prior surgery or pelvic inflammatory disease necessitating lysis of adhesions, endometriosis and a coexistent pelvic mass requiring evaluation. Considerations like large uteri, adnexectomy, surgery in an obese patient and the role of laparoscopy in gynecologic malignancies are a matter of debate and are dependent on the surgeon's experience. Moreover, as experience in vaginal surgery continues to decline with each consecutive batch of graduating residents, with rapid technological developments in the field of laparoscopy, and as data regarding various outcomes mature, increasing numbers of indications for the laparoscopic approach to hysterectomy will continually be defined.

Some of the factors that have limited the widespread adoption of the laparoscopic approach have been concerns regarding cost, complications, learning curve, operative time and the lack of well-defined indications. In terms of cost, several studies over the last decade have demonstrated that with the use of reusable instruments, shorter length of stay with laparoscopic procedures, and decreasing operative times with experience, the cost of a laparoscopic hysterectomy is comparable to the cost of a vaginal or an abdominal hysterectomy [9-11]. The incremental savings from quicker recovery and return to work and fewer postoperative visits certainly reduce the overall cost following laparoscopic hysterectomy [12].

As for the complication rate and length of the procedure, these are dependent on surgeon experience and expertise in laparoscopic procedures. Nezhat et al [13] in their series of 361 laparoscopic hysterectomies had no mortality, major vessel, or urinary tract injury, and one case of small bowel perforation. Wattiez et al [14] in their series of over 1600 laparoscopic hysterectomies over 10 years demonstrated a significant decline in major complication rates, conversion rates to laparotomy, and operative time from 5.6% to 1.3%, 4.7% to 1.4%, and 115 minutes to 90 minutes, respectively, with increasing surgical experience. A large Finnish study [15] attempted to define the learning curve for laparoscopic hysterectomies by demonstrating a significant drop in all major complications beyond 30 procedures. The rate of conversion to laparotomy has been described as ranging from 4% to 11%, for reasons like large uteri, diminished uterine mobility, excessive dense abdominal adhesions, and uncontrolled hemorrhage [16].

Recently, there has been a resurgence of interest in the supracervical hysterectomy for benign conditions. Proponents of this approach tout the preservation of neurovascular integrity, and as a result less bowel, bladder, and sexual dysfunction, as well as complications, as reasons for offering supracervical hysterectomy, although none of the retrospective and prospective randomized studies so far has substantiated this contention.17,18 Limited data are available on the outcome of this procedure via laparoscopy and how it compares with total laparoscopic or assisted vaginal hysterectomy.

In conclusion, the vaginal approach should be preferred for hysterectomy, whenever feasible. Laparoscopic, or laparoscopic-assisted vaginal hysterectomy can diminish the need for laparotomy in more than 90% of cases. Defining guidelines for training, credentialing, and improvement in instrumentation will help in minimizing complications, decreasing operative time, and improving patient satisfaction.

Address reprint requests to: Farr Nezhat, MD,
25 Columbus Cir, Apt 60B, New York, NY 10023, USA. Tel: 212 241 9434, Fax: 212 987 6386,
E-mail: Farr.Nezhat@mssm.edu

Farr Nezhat, MD, is a Past President of the Society of Laparoendoscopic Surgeons. He is the Director and Fellowship Director of the Gynecologic Minimally Invasive Surgery Division, and a Professor of Obstetrics and Gynecology at the Mount Sinai School of Medicine in New York. A pioneering leader in the application of minimal access surgery to pelvic malignant and benign gynecologic pathologies, he is nationally and internationally known for his research, teaching and clinical contributions to the field of gynecologic and pelvic surgery.

Jyoti Yadav, MD, is an Instructor at New York Medical College and an Attending Physician in Obstetrics, Gynecology and Gynecologic Minimally Invasive Surgery at Our Lady of Mercy Medical Center in Bronx, New York. In 2004, Dr. Yadav completed a fellowship in Gynecologic Minimally Invasive Surgery at Mount Sinai Hospital in New York, New York. She has expertise in advanced hysteroscopic and laparoscopic procedures for challenging conditions like fibroids and severe endometriosis.

References

1.    Farquhar CM, Steiner CA. Hysterectomy rates in the United States 1990-1997. Obstet Gynecol. 2002;99(2):229-234.

2.    Kovac RS, Cruishank SH, Retto HF. Laparoscopy-assisted vaginal hysterectomy Gynecol Surg. 1990;6:185.

3.    Nezhat C, Burrell MO, Nezhat F, et al. Laparo-scopic radical hysterectomy with para-aortic and pelvic node dissection. Am J Obstet Gynecol. 1992;166:864-865.

4.    Nezhat C, Nezhat F, Gordon S, et al. Laparo-scopic versus abdominal hysterectomy. J Repro Med. 1992;37:247-250.

5.    Garry R, Fountain J, Mason S, et al. The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ. 2004;328(7432):129-136.

6.    Marana R, Busacca M, Zupi E, Garcea N, Paparella P, Catalano G. Laparoscopically assisted vaginal hysterectomy versus total hysterectomy: a prospective, randomized, multicenter study. Am J Obstet Gynecol. 1999;180:270-275.

7.    Olsson J, Ellstrom M, Hahlin M. A randomized prospective trial comparing laparoscopic and abdominal hysterectomy. Br J Obstet Gynecol. 1996;103:345-350.

8.    Summitt R, Stovall T, Lipscomb G, Ling F. Randomized comparison of laparoscopy-assisted vaginal hysterectomy with standard vaginal hysterectomy in an outpatient setting. Obstet Gynecol. 1992;80:895-901.

9.    Nezhat C, Bess O, Admon D, Nezhat CH, Nezhat F. Hospital cost comparison between abdominal, vaginal, and laparoscopy-assisted vaginal hysterectomies. Obstet Gynecol. 1994;83(5 pt 1):713-716.

10.    Sculpher M, Manca A, Abbott J, Fountain J, Mason S, Garry R. Cost effectiveness analysis of laparoscopic hysterectomy compared with standard hysterectomy: results from a randomized trial. BMJ. 2004;328:134-140.

11.    Johns A, Carrera B, Jones J, DeLeon F, Vincent R, Safely C. The medical and economic impact of laparoscopically assisted vaginal hysterectomy in a large, metropolitan, not-for-profit hospital. Am J Obstet Gynecol. 1995;172:1709-1719.

12.    Ellstrom M, Ferraz-Nunes J, Hahlin M, Olsson JH. A randomized trial with a cost-consequence analysis after laparoscopic and abdominal hysterectomy. Obstet Gynecol. 1998;91(1):30-34.

13.    Nezhat CH, Nezhat C, Admon D, Seidman D, Nezhat F. Complications of 361 laparoscopic hysterectomies. J Am Assoc Gynecol Laparosc. 1994;1(4 pt 2):S25.

14.    Wattiez A, Soriano D, Cohen SB, et al. The learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases. J Am Assoc Gynecol Laparosc. 2002;9(3):339-345.

15.    Makinen J, Johansson J, Tomas C, et al. Morbidity of 10,110 hysterectomies by type of approach. Hum Reprod. 2001;16:1473-1478.

16.    Cristoforoni PM, Palmieri A, Gerbaldo D, Montz FJ. Frequency and cause of aborted laparoscopic-assisted vaginal hysterectomy. J Am Assoc Gynecol Laparosc. 1995;3(1):33-37.

17.    Thakar R, Ayers S, Clarkson P, Stanton S, Manyonda I. Outcomes after total and subtotal abdominal hysterectomy. N Engl J Med. 2002;347:1318-1325.

18.    Learman LA, Summitt RL Jr, Varner RE, et al. A randomized comparison of total or supracervical hysterectomy: surgical complications and clinical outcomes. Obstet Gynecol. 2003;102(3):453-462.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: JSLS Intrafascial Supracervical Hysterectomy

A Safer, Simpler Classic Intrafascial Supracervical Hysterectomy Technique • Kim DH et al 2005;9(2):159-162. The authors describe a “new” Classic Intrafascial Supracervical Hysterectomy (CISH) technique that is safer, more convenient, and faster than the conventional technique.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: JSLS Improved Cost-effectiveness in Laparoscopic Hysterectomy

Replacement of Expensive, Disposable Instruments With Cheap, Old-fashioned, Surgical Techniques for Improved Cost-effectiveness in Laparoscopic Hysterectomy • Morrison JE, Jacobs VR. 2004;8:201-206. The classical intrafascial supracervical laparoscopic hysterectomy procedure can be made more cost-effective by substituting expensive disposable devices with classic conservative surgical techniques.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Uterine Fibroids and Bleeding

UPDATE

HERBERT A. GOLDFARB, MD

The approach to the gynecological patient with abnormal bleeding requires specific diagnosis prior to any consideration of specific therapy. The first intervention after a thorough pelvic and rectovaginal examination should be an endovaginal pelvic ultrasound. Should the uterus be quite large, an abdominal ultrasound may be performed. The endometrial cavity can be best visualized by saline infusion ultrasound. In the absence of fibroids or endometrial polyps, an endometrial biopsy will differentiate anovulatory or dysfunctional bleeding that can be treated with cyclic progesterone. Ovulatory metrorrhagia (secretory) that is recurrent is best treated with an endometrial ablation procedure.

GLOBAL ENDOMETRIAL ABLATION PROCEDURES

The first technique described in 1985 by Goldrath [1] used a bare Nd:Yag laser fiber dragged along the endometrium to destroy the entire lining. Vancaille [2] subsequently described a rollerball electrode via the hysteroscopic resectoscope. Later variants of the procedure utilized a loop electrode to resect the endometrium with the distinct advantage of obtaining tissue for evaluation, and finally some operators finished off the procedure with the grooved electrode at a high power to finely sculpture the cavity.

ThermaChoice. Neuwirth [3] developed a balloon (latex–silicon) device that expanded inside a basically normal (<10 cm) cavity filled with up to 30 cc of D5w pressurized to 160 to 180 mm Hg and heated to 87°C. Distortion of the cavity due to fibroids is a contraindication. This procedure is approved for premenopausal women with menorrhagia due to benign causes for whom childbearing is complete [4].

Novasure. This procedure consists of an impedance–controlled bipolar grid and moisture transfer with controlled and contoured tissue ablation. Treatment time averages 90 seconds. This self-
terminating procedure is based on tissue impedance. Amenorrhea rates of 47% to 58% result. It is approved for patients with polyps and submucous fibroids <2 cm [5,6].

Her Option. A 5.5-mm cryoprobe is placed in the endometrial cavity, and by using abdominal ultrasound guidance, the probe is cooled to -90°C. A 3.5- to 5-cm elliptical ice ball forms. A temp is reached of -20°C 1.5 cm from the edge of the ice ball. The procedure requires 10 to 20 minutes to complete. The bladder is filled to help monitor the procedure via abdominal ultrasound. Inclusion criteria are a cavity <10 cm and uterine volume <300 cc. This procedure is not approved for use with cavitary myomas [7].

Microsulis Microwave. This procedure, recently approved by the FDA, is a non-contact system that uses a microwave generator to develop radiant heat and destroy tissue. Anderson, the lead investigator, has shown that the radiant energy is not limited by cavitary distortion. The uterus is sounded, the radiant wand is placed in the cavity and the intrauterine temperature monitored. The wand is oscillated manually and slowly withdrawn until the endometrium is completely ablated. Results are comparable to those achieved with electrosurgical ablations [8].

Hydrothermablation. Hot water is delivered into the uterine cavity and the process is monitored using a hysteroscope. The cavity should be <10 cm. Fibroids and polyps can be treated with this method. The procedure is microprocessor controlled with visual control of low-pressure gravity fed saline heated to 90°C for 10 minutes. An insulated hysteroscopic sheath 7.8 mm accepts a 3-mm hysteroscope. Results are 54% amenorrhea: 23% oligo, and 14% eumenorrhea [9].

The downside to all these methods is cost, which is approximately $700 to $900 per case, requiring an approved facility for reimbursement, which is at the mercy of the third party carrier. All of the described procedures are effective, with the operative hysteroscopic technique requiring the greatest learning curve.

Uterine Artery Embolization. First reported in 1995 by Ravina [10], uterine artery embolization is a temporizing method in a hemorrhaging patient awaiting a hysterectomy. More than 20 000 procedures have been performed since 1997. Speis [11] reported on 200 patients with fibroids and menorrhagia with improvement in 87% to 91%. Bulk symptoms were improved in 90%. Hospitalization was required in 10.5% of patients. Complications include misplaced polyvinyl particles. Immediate menopause secondary to uterine ovarian anastomosis was experienced by 10% to 15% of patients. Submucosal myomas often prolapse and require hysteroscopic surgery. Other complications include infection, necrosis, pulmonary embolus, and readmission for severe pain. Volume reduction is reported to be 40% to 60%. Volumetric reduction of 10x10x10 cm with a 40% reduction will result in a size of 8x8x8 cm. Therefore, 7 to 8 cm should be a rational size limit for uterine artery embolization.

FIBROID SOLUTIONS

Large multinodular myomatous uteri require surgical intervention. The diagnostic insight provided by magnetic resonance imaging (MRI) can help the clinician make the decision as to what course to recommend. Myomectomy should not only be offered to women wishing to be pregnant. Preserving the uterus for many women has very significant psychological implications. Myomectomy can be performed laparoscopically, and Miller [12,13] has reported on a large series of cases. Most very large myomatous uteri can be made whole with mini-laparoscopic techniques.

Myolysis and Variants. Goldfarb [14] performed Nd:Yag laser myolysis in 1990 and subsequently converted to bipolar electromyolysis, developing sturdy 5-cm needles for the procedure. The present technique was described in the journal of the AAGL in 1995 and subsequently in the Society of Laparoendoscopic Surgeons’ journal in 1999 [15]. The procedure involves undermining identifiable myomas with electrified bipolar needles using the endpoint of cyanosis. Pretreatment with GnRh analog allows a therapeutic trial. Symptoms should abate prior to definitive therapy. Pelvic ultrasound, (MRI), and endometrial biopsy are performed preoperatively. Average volume reduction was 72%. Hysterectomy was avoided in 93.5% of cases. Complications of myolysis (<1%) were minimal. Fibroid degeneration was rare as was infection. Hysterectomy in the myolsis and ablation group was 2.5% in cavities <9 cm.

Cryomyolysis. A cryoprobe is placed laparoscopically into a fibroid via a 5-mm trocar, and an ice ball is created that can extend to 5 cm causing myoma cells necrose. The downside is the expense of the equipment, ranging up to $35000 plus $750 per case. Cryomyolysis has also been described as an MRI-guided procedure. If you add the expense of an MRI to that of the cryoprobe, then you have a procedure whose expense cannot be justified. Electrobipolar myolysis needles sell for about $750 and can be used for years [16,17].

Radiofrequency Myolysis Technique (RITA). After initial puncture, a StarBurst-type probe is advanced into a myoma and with RF coagulation 45D to 50D results in protein denaturation. Cost is similar to that of cryo [18].

Myolysis is effective in select cases of moderate-sized myomas 5-cm to 7-cm after a therapeutic trial with a GnRh agonist. All systems described are effective but cannot compete with Bipolar electromyolysis in price and ease of performance.

OTHER NEW TECHNIQUES

Intravaginal occlusion of the uterine artery described by Istre [19] and Lichtinger utilizes a specialized clamp placed in the uterine fornix. The uterine blood vessels lie within 1 cm to 3 cm from the fornix. A Doppler is attached to the clamp and identifies the occlusion of uterine blood flow. Vessels are pinched for 6 hours. Studies have shown that even after uterine embolization, uterine reperfusion takes place after 6 hours. Postprocedure MRIs have revealed fibroid microcirculation clotting confirming myoma death.

CONCLUSION

Multiple techniques have been described in the ongoing attempt to offer women alternatives to hysterectomy. All have been presented at major meetings and most have been published in refereed journals. It is important to differentiate what we can do from what is cost effective and appropriate for our patients. When all other factors are equal, cost is an important factor. Patients need to be educated and share in their health care decisions.

Address reprint requests to: Herbert A. Goldfarb, MD, 35 Delwick Ln, Short Hills, NJ, 07078, USA.
Tel: 973 744 7470, Fax: 973 744 1274, E-mail: HGoldfarb@NoHysterectomy.com

Herbert A. Goldfarb, MD, is an Assistant Clinical Professor of Ob-Gyn at the New York University School of Medicine and the Director of Gynecological Endoscopy at NYU Downtown Medical Center. In 1986, Dr Goldfarb performed the first video laser laparoscopic surgery in the New York metropolitan area and the first Nd:YAG laser hysteroscopic ablation of the endometrium. In 1990, he pioneered the myoma coagulation (myolysis) procedure, and developed bipolar needles designed to make the procedure easier to perform. Dr Goldfarb, an advocate of alternative solutions to hysterectomy, has authored two books and several scientific articles and book chapters. The No-Hysterectomy Option was written in 1990, with a second edition published in 1997 and Overcoming Fertility was published in 1995.

References

1.    Goldrath MH, Fuller FA, Segal S. Laser photovaporization of the endometrium for the treatment of menorrhagia. Am J Obstet Gynecol. 1981;140:14-19.

2.    Vancaille T. Electrocoagulation with a ball and resectoscope. Obstet Gynecol. 1989;74:425.

3.    Neuwirth RS. Cost effective management of heavy uterine bleeding: ablative methods versus hysterectomy. Curr Opin Obstet Gynecol. 2001;13(4):407-410.

4.    Vilos GA, Vilos EC, Pendley L. Endometrial Ablation with a thermal balloon for the treatment of menorrhagia. J Am Assoc Gynecol Laparosc. 1996;3:383-387.

5.    Busund B, Erno LE, Gronmark A, Istre O. Endometrial ablation with NovaSure GEA, a pilot study. Acta Obstet Gynecol Scand. 2003;82(1):65-68.

6.    Gallinat A, Nugent W, Novasure impedance-controlled system for endometrial ablation. J Am Assoc Gynecol Laparosc. 2002;9(93):283-289.

7.    Rutherford TJ, Zreik TG, Troiano RN, et al. Endometrial cryoablation, A minimally invasive procedure for abnormal bleeding. J Am Assoc Gynecol Laparosc. 1998;5(1):23-28.

8.    Kanaoka Y, Hirai K, Ishiko O, Ogita S. Microwave endometrial ablation at a frequency of 2.455 GHz. A pilot study. J Reprod Med. 2001;46(6):559-563.

9.    Corson SL. A multicenter evaluation of endometrial ablation by Hydro Thermablator and rollerball for treatment of menorrhagia. J Am Assoc Gynecol Laparosc. 2001;8(3):359-367.

10.    Ravina J, Herbreteau D, Ciraru-Vigneron N, et al. Arterial embolization to treat uterine myomata. Lancet. 1995;346:671-672.

11.    Speis J, Ascher SA, Roth AR, Kim J, Levy EB. Uterine artery embolization for leiomyomata. Obstet Gynecol. 2001;98:29-34.

12.    Miller CE. Contemporary approach to laparoscopic myomectomy. Oper Tech Gynecol Surg. 2000:5(2):1-11.

13.    Miller CE. Myomectomy: comparison of open and laparoscopic techniques. Obstet Gynecol Clin North Am. 2000;27(2):407-420.

14.    Goldfarb HA, Myoma coagulation (Myolysis). Obstet Gynecol Clin North Am. 2000;27(2):421-430.

15.    Goldfarb HA. Combining Myoma Coagulation with endometrial ablation/resection reduces subsequent surgery rates. JSLS. 1999;3(4):253-260.

16.    Olive DL, Rutherford T, Zreik T, Palter S. Cryomyolysis in the Conservative Treatment of Uterine Fibroids. J Am Assoc Gynecol Laparosc. 1996;3(4 suppl):S36.

17.    Zreik TG, Rutherford TJ, Palter SF, et al. Cryomyolysis, a new procedure for the conservative treatment of uterine fibroids. J Am Assoc Gynecol Laparosc. 1998;5(1):33-38.

18.    Lee BB. Radiofrequency ablation of uterine fibroids; A new minimally invasive hysterectomy alternative. Obstet Gynecol. 2002;99(suppl):9S.

19.    Istre O. New approaches to uterine artery occlusion, vaginal technique. Presented at: The Contemporary Management of Uterine Fibroids. April 2003; Santa Fe Springs, CA.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source