Foreword: Minimally Invasive Gynecologic Surgery: Improving Outcomes and Recovery While Reducing Discomfort and Cost xiii

        William F. Rayburn

        Preface: Holistic Approach to Minimally Invasive Gynecologic Surgery xv

        Ted Lee and Nicole Donnellan

        Approach to Diagnosis and Management of Chronic Pelvic Pain in Women: Incorporating Chronic Overlapping Pain Conditions in Assessment and Management 219

        Sara R. Till, Reina Nakamura, Andrew Schrepf, and Sawsan As-Sanie
        Chronic pelvic pain (CPP) is multifactorial in etiology and heterogeneous in presentation. Identification of all pain contributors is essential for successful management. Chronic overlapping pain conditions (COPCs) are a specified group of chronic pain conditions that commonly co-occur in patients. We briefly review individual COPCs and highlight risk factors and mechanisms that appear to be applicable across COPCs. We review evaluation and communication strategies that may help establish a productive therapeutic relationship between clinicians and patients. Management should include treatment of peripheral pain generators as well as co-occurring psychological conditions and central sensitization when present.

        A Practical Approach to Fertility Considerations in Endometriosis Surgery 241

        Jenna Gale and Sukhbir Sony Singh
        Endometriosis surgery requires thoughtful consideration and planning for those with infertility or those who wish to conceive in the future. Clinical history, examination, imaging, and fertility assessment can help plan, prepare and provide goal-directed surgical interventions when required. Further understanding of the benefits and limitations of surgery on future fertility outcomes is essential for those who provide care for patients with endometriosis. Endometriosis is a prevalent gynecologic condition, especially among patients with infertility. Studies demonstrate that, from a fertility perspective, surgery for endometriosis likely has a beneficial impact on the chance of spontaneous conception; however, selecting the appropriate surgical candidate can be challenging. To make a fully informed decision with regard to surgery, it is important to determine the patient’s fertility goals and to conduct a thorough workup. Among patients with endometriosis-related infertility, first-line-assisted reproductive technology (ART) is generally preferred over surgery. Specific consideration in cases of minimal or mild endometriosis, ovarian endometrioma(s), and deep endometriosis (DE) are required for targeted counseling. Patients with symptoms significantly impacting their quality of life (QOL), or indications to proceed with surgery (ie, risk of malignancy, organ obstruction, or dysfunction) are best managed with surgical care by an experienced team. Surgery should be considered cautiously given the risks of damage to ovarian reserve, adhesions, and surgical complications. Risk of damage to ovarian reserve is a particularly important consideration among patients with endometrioma(s), with or without low ovarian reserve, and surgical complications are especially prevalent among patients undergoing surgery for bowel endometriosis. Goal-directed surgical treatment, as opposed to the traditional perspective of complete disease eradication, may be of particular importance among selected patients whereby fertility is a priority.

        Hysterectomy for Chronic Pelvic Pain 257

        Richard Cockrum and Frank Tu
        For well selected patients with chronic pelvic pain (CPP), 74% to 95% of women will report complete or significant improvement in pain after hysterectomy. A thoughtful history, examination, and review of imaging can improve success by linking pain complaints to discrete pathology, menstrual activity, or uterine tenderness. All patients with CPP should be evaluated for chronic overlapping pain conditions (COPCs) (eg, irritable bowel syndrome (IBS), fibromyalgia) and risk factors for persistent pain or chronic postsurgical pain (eg, depression, pain catastrophizing, central sensitization), and offered treatment as indicated. There are special considerations for preoperative planning and enhanced recovery for patients with chronic pain.

        Role of Robotic Surgery in Benign Gynecology 273

        Mireille D. Truong and Lauren N. Tholemeier
        Since Food and Drug Administration approval in 2005, use of the robotic device in gynecologic surgery has continued to increase. There has been a growing number of applications in various surgical specialties including gynecology, and the surgical robot has been established as an additional surgical tool for performing minimally invasive gynecologic surgery. In this article, the authors review the development of robotic gynecologic surgery, clinical considerations, and future directions.

        Laparoscopic Abdominal Cerclage 287

        Shabnam Gupta and Jon Ivar Einarsson
        Cervical insufficiency is a well-established cause of infant morbidity and mortality. Recommended treatment of cervical insufficiency includes a procedure in which a stitch, termed a cerclage, is placed around the cervix to keep it closed. Abdominal cerclage is the preferred approach for patients with refractory cervical insufficiency or anatomic limitations to vaginal cerclage placement. Laparoscopic abdominal cerclage has many benefits over an open approach and has been increasingly performed over the last 20 years due to surgeon skillset and improved neonatal survival compared with repeat vaginal cerclage. Laparoscopic abdominal cerclage is a highly effective, well-tolerated surgical treatment of selected patients.

        Emerging Treatment Options for Fibroids 299

        Briana L. Baxter, Hye-Chun Hur, and Richard S. Guido
        Leiomyomas (fibroids) are common, usually benign, monoclonal tumors that arise from the uterine myometrium. Clinical presentation is variable; some patients are asymptomatic, whereas others experience heavy menstrual bleeding, pain, bulk symptoms, and/or alterations in fertility. Previously, treatment options for fibroids were largely surgical. However, over the last decade, options have grown to include many medical and procedural options that allow for uterine and fertility preservation. Clinicians must become familiar with these options to adequately counsel patients desiring treatment of fibroids.

        Office Hysteroscopy: Setting up Your Practice for Success 315

        Anna Zelivianskaia and James K. Robinson III
        Video content accompanies this article at
        Office hysteroscopy is a highly effective procedure for the evaluation and treatment of intrauterine pathology. The “see and treat” approach allows for patient treatment with the fewest amount of patient visits. The development of smaller cameras and instruments, as well as the employment of a vaginoscopy technique, has led to greater tolerability of office hysteroscopy and significant success of the “see and treat” approach. Most office hysteroscopic procedures can be accomplished with minimal premedication. There are many choices for equipment types and sterilization methods for the office hysteroscopy practice. Reimbursement for office hysteroscopy has improved, but economic challenges remain.

        Hysteroscopic Myomectomy 329

        Nash S. Moawad and Hannah Palin
        Video content accompanies this article at
        Hysteroscopic myomectomy is the treatment of choice for symptomatic submucosal myomas, with excellent success rate and low complication rate.

        Evaluation and Management of Common Intraoperative and Postoperative Complications in Gynecologic Endoscopy 355

        Brittany Lees and Jubilee Brown
        Gynecologic laparoscopy is a safe and effective route of surgery for many types of procedures. The potential for injury does exist, and prevention and timely recognition of complications are essential for maintaining the quality and safety of minimally invasive surgical procedures. Each facet of care, including preoperative preparation, appropriate patient positioning, trocar placement, and surgical technique, is reviewed, and recommendations are made to facilitate the performance of safe surgery and immediate recognition of complications if they do arise.

        Abdominal Wall Endometriosis 369

        Christine E. Foley, Patricia Giglio Ayers, and Ted T. Lee
        Abdominal wall endometriosis (AWE) is a rare type of endometriosis defined as endometrial glands and stroma located within the abdominal wall. Patients with a history of prior abdominal surgery classically present with cyclic abdominal pain and a palpable mass. Definitive diagnosis is made by pathologic tissue examination, but preoperative imaging with ultrasonography or MRI helps narrow the differential and informs surgical management. Surgical management is traditionally via an open approach; however, laparoscopic removal of AWE is recommended for subfascial or rectus lesions. Following surgical excision, more than 90% of patients experience complete symptom relief.

        Enhanced Recovery After Surgery in Minimally Invasive Gynecologic Surgery 381

        Lisa Chao, Emily Lin, and Kimberly Kho
        Enhanced recovery after surgery (ERAS) is a multimodal, multidisciplinary approach to optimize patient outcomes by minimizing surgical stress with the goal of returning to normal physiologic function. Using minimally invasive surgery as the preferred route for gynecologic surgery is an integral component of ERAS and is strongly correlated with improved postoperative outcomes. Implementation of ERAS programs in minimally invasive gynecologic surgery results in substantial improvements in clinical outcomes with higher rates of same-day discharge, reduction in postoperative nausea and vomiting, improved patient satisfaction, and decreased opioid consumption without increase in complications, readmissions, or health care costs.