Last Reviewed: 4/25/2025

Reviewers: Aakriti Carrubba, Laura Douglas, Kristin Patzkowsky

Goal:
To develop advanced diagnostic, counseling, and surgical expertise required to evaluate and manage patients with uterine fibroids, with an emphasis on individualized treatment planning, fertility preservation, and mastery of minimally invasive surgical approaches.

Objectives:

By the end of training, fellows should be able to:

• General Principles: 
  • Perform a comprehensive evaluation prior to myomectomy, including focused history and optimal imaging to determine myoma characteristics, feasible surgical route(s), and considerations for tissue extraction.
    • Recognize fibroid-specific factors that can impact surgical counseling and planning, such as fibroid(s) size, number, distribution, location, and appearance in regard to surgical approach(es), fertility counseling, and specimen retrieval method. 
    • Recognize patient factors such as anatomy, reproductive goals, comorbidities, and body habitus that can impact surgical planning. 
  • Describe the pathophysiology of fibroids and the relationship between symptoms, location, and size of fibroids, as well as effects on fertility and pregnancy.
  • Discuss the risks, benefits, and alternatives of non-surgical, procedural (uterine artery embolization, MRI-guided ultrasound-focused ablation, radiofrequency ablation), and surgical (hysteroscopy, myomectomy, hysterectomy) management options.
  • Provide comprehensive counseling for patients considering myomectomy, including alternatives, pre-operative and postoperative fertility and pregnancy implications, surgical risks (including the risk of recurrence and need for future intervention), risks related to various modes of tissue extraction (including the risk of tissue dissemination and occult malignancy), and postoperative expectations.
  • Counsel patients who desire future fertility, including timing of conception, risk of uterine rupture, and need for cesarean sections when appropriate.
  • Recognize the options for perioperative optimization of anemia, methods to reduce intraoperative blood loss, and techniques to minimize the need for transfusion.
• Hysteroscopic Myomectomy
  • Discuss intrauterine resection techniques to ensure complete and safe removal of submucosal fibroids, including optimal visualization, fluid management, and resection plane strategy.
  • Describe the use of both resectoscopes and mechanical hysteroscopic morcellators, and select the appropriate device based on fibroid characteristics and cavity distortion.
  • Utilize methods to prevent adhesion formation following extensive fibroid resections.
• Laparoscopic, Robotic, and Open Myomectomy
  • Demonstrate expert knowledge in surgical management of complex and atypical fibroid cases, including:
    • Cervical and broad ligament fibroids requiring ureterolysis or involving distortion of normal anatomy.
    • Retroperitoneal and parasitic leiomyomas involving prior surgical planes or vascular supply.
  • Tissue extraction:
    • Perform safe and efficient extraction techniques, including contained morcellation via abdominal and vaginal approaches.
    • Critically interpret and incorporate the up-to-date evidence on the incidence of occult malignancy, limitations of morcellated specimen evaluation, risks of morcellation, and strategies to reduce oncologic risk.
  • Prevent operative blood loss by utilizing both pharmacologic (e.g., vasopressin, tranexamic acid) and mechanical (e.g., temporary uterine artery occlusion, tourniquet application, energy devices) interventions.
  • Anticipate, recognize, and manage complications including intraoperative or postoperative hemorrhage, impaired healing, retained tissue, disseminated leiomyomatosis, and uterine synechiae.

References:

Counseling:
1.    Penzias, A., Bendikson, K., Butts, S., Coutifaris, C., Falcone, T., Fossum, G., Gracia, C., Hansen, K., La Barbera, A., Mersereau, J., Odem, R., Paulson, R., Pfeifer, S., Pisarska, M., Rebar, R., Reindollar, R., Rosen, M., Sandlow, J., Vernon, M., 2017. Removal of myomas in asymptomatic patients to improve fertility and/or reduce miscarriage rate: a guideline. Fertility and Sterility 108, 416–425. https://doi.org/10.1016/j.fertnstert.2017.06.034
2.    Pritts, T.L., Ogden, M., Parker, W., Ratcliffe, J., Pritts, E.A., 2024. Intramural Leiomyomas and Fertility: A Systematic Review and Meta-Analysis. Obstetrics & Gynecology 144, 171–179. https://doi.org/10.1097/AOG.0000000000005661
3.    Donnez, J., Taylor, H.S., Marcellin, L., Dolmans, M.-M., 2024. Uterine fibroid–related infertility: mechanisms and management. Fertility and Sterility 122, 31–39. https://doi.org/10.1016/j.fertnstert.2024.02.049
4.    Ezzedine, D., Norwitz, E.R., 2016. Are Women With Uterine Fibroids at Increased Risk for Adverse Pregnancy Outcome? Clinical Obstetrics & Gynecology 59, 119–127. https://doi.org/10.1097/GRF.0000000000000169
5.    Margueritte, F., Adam, C., Fauconnier, A., Gauthier, T., 2021. Time to conceive after myomectomy: should we advise a minimum time interval? A systematic review. Reproductive BioMedicine Online 43, 543–552. https://doi.org/10.1016/j.rbmo.2021.05.016
6.    Lim, W.H., Lamaro, V.P., Sivagnanam, V., 2022. Manifestation and management of intravenous leiomyomatosis: A systematic review of the literature. Surgical Oncology 45, 101879. https://doi.org/10.1016/j.suronc.2022.101879

Hysteroscopic myomectomy:
1.    Loddo, A., Djokovic, D., Drizi, A., De Vree, B.P., Sedrati, A., Van Herendael, B.J., 2022. Hysteroscopic myomectomy: The guidelines of the International Society for Gynecologic Endoscopy (ISGE). European Journal of Obstetrics & Gynecology and Reproductive Biology 268, 121–128. https://doi.org/10.1016/j.ejogrb.2021.11.434
2.    Vitale, S.G., Riemma, G., Carugno, J., Perez-Medina, T., Alonso Pacheco, L., Haimovich, S., Parry, J.P., Di Spiezio Sardo, A., De Franciscis, P., 2022. Postsurgical barrier strategies to avoid the recurrence of intrauterine adhesion formation after hysteroscopic adhesiolysis: a network meta-analysis of randomized controlled trials. American Journal of Obstetrics and Gynecology 226, 487-498.e8. https://doi.org/10.1016/j.ajog.2021.09.015

Laparoscopic, robotic and open myomectomy:
1.    AAGL, 2025. Evidence-Based Practice for Minimization of Blood Loss During Laparoscopic Myomectomy: An AAGL Practice Guideline. Journal of Minimally Invasive Gynecology 32, 113–132. https://doi.org/10.1016/j.jmig.2024.09.021
3.    Lete, I., González, J., Ugarte, L., Barbadillo, N., Lapuente, O., Álvarez-Sala, J., 2016. Parasitic leiomyomas: a systematic review. European Journal of Obstetrics & Gynecology and Reproductive Biology 203, 250–259. https://doi.org/10.1016/j.ejogrb.2016.05.025

Videos:
1.    Navigating Cervical Fibroids during Laparoscopic Hysterectomy: Essential Tips and Tricks - https://surgeryu.aagl.org/view?m=falNdZuvn
2.    Tackling the Broad Ligament FIbroid - https://surgeryu.aagl.org/view?m=nTbMgWYW9

Last Reviewed: 4/25/2025

Reviewers: Elizabeth Banks, Kacey Hamilton, Kristin Patzkowsky, Merima Ruhotina
Goal:
To develop proficiency in the prevention, recognition, and management of surgical complications—including gastrointestinal, genitourinary, vascular, wound, and neurologic injuries—to enhance patient safety, optimize outcomes, and contribute to surgical education and quality improvement initiatives.

Objectives:
By the end of training, fellows should be able to:

• Recognize how comorbidities (e.g., cardiopulmonary, obesity, endocrine disorders) affect perioperative risk and physiological response to surgery.      
• Conduct thorough preoperative assessments, including history, physical exam, appropriate laboratory and imaging studies, and apply validated tools (e.g., ASA classification, frailty indices, STOP-BANG) to evaluate individual surgical risk, identify patients with higher risk of complications, and determine the need for further optimization. 
• Communicate risks, benefits, and perioperative expectations with patients and interdisciplinary teams to support shared decision-making and appropriate perioperative planning for risk reduction. 
• Know the principles and safe use of energy devices (e.g., monopolar, bipolar, ultrasonic) to minimize the risk of thermal injury.
• Demonstrate proficiency in surgical techniques and anatomic knowledge—particularly in cases of distorted anatomy—to prevent injury and facilitate early recognition of complications.
• Utilize intraoperative adjuncts—such as cystoscopy, ureteral stenting, bowel integrity testing, and tissue perfusion assessment—to aid in the early identification and evaluation of surgical complications.
• Learn and apply evidence-based strategies to prevent surgical complications, make informed intraoperative decisions, and perform corrective actions — from conservative management to complex surgical repair or conversion to laparotomy when necessary. 
• Recognize expected postoperative recovery patterns and distinguish those from early signs of complications such as infection, hemorrhage, urinary tract injury, thromboembolic events, bowel dysfunction, and delayed thermal injuries, etc.
• Perform diagnostic evaluations, including physical examination, lab testing, and imaging appropriate to the specific perioperative injuries, complications or illness..
• Initiate evidence-based management plans, including medical therapy, interventional procedures, or reoperation when required for perioperative injuries, complications or illness.
• Organize and coordinate multidisciplinary care in the management of surgical complications.
• Conduct counseling regarding complications, including accountability, causal events, current corrective actions, and long-term implications. Discuss and disclose complications with the patient appropriately and consult risk management where appropriate.
• Engage in quality improvement initiatives, using complication review to identify system-level opportunities for error reduction and education of trainees and colleagues.

References:
General: 
Mourad J., Henderson S., Magrina J. (2018) Complications of Laparoscopy. In: Gomes-da-Silveira G., da Silveira G., Pessini S. (eds) Minimally Invasive Gynecology. Springer, Cham.
Baggish, Michael S. 2020. Major Complications Associated with Laparoscopic Surgery. In: Michael Baggis and Mickey Karram. Atlas of Pelvic Anatomy and Gynecologic Surgery. Ch 119 1333-1369. Infectious Morbidity
Seaman, Sierra J.; Han, Esther; Arora, Chetna; Kim, Jin Hee. Surgical site infections in gynecology: the latest evidence for prevention and management. Current Opinion in Obstetrics and Gynecology 33(4):p 296-304, August 2021.

Urologic Injury: 
Patel UJ, Heisler CA. Urinary Tract Injury During Gynecologic Surgery: Prevention, Recognition, and Management. Obstet Gynecol Clin North Am. 2021 Sep;48(3):535-556.
Wong JMK et al. Urinary Tract Injury in Gynecologic Laparoscopy for Benign Indications: A Systematic Review. Obstet Gynecol. 2018 Jan;131(1):100-108.
Dallas KB, Rogo-Gupta L, Elliott CS. Urologic Injury and Fistula After Hysterectomy for Benign Indications, Obstetrics & Gynecology: August 2019 - Volume 134 - Issue 2 - p 241-249.

Neuropathic Complications:
Deepanjana Das, Katie Propst, Mary Ellen Wechter, Rosanne M. Kho. Evaluation of Positioning Devices for Optimization of Outcomes in Laparoscopic and Robotic-Assisted Gynecologic Surgery, Journal of Minimally Invasive Gynecology.
Abdalmageed OS, Bedaiwy MA, Falcone T. Nerve Injuries in Gynecologic Laparoscopy. J Minim Invasive Gynecol. 2017;24(1):16-27.
Video article: Moawad, G et al. Pelvic Neuroanatomy: An Overview of Commonly Encountered Pelvic Nerves in Gynecologic Surgery. JMIG: June 2020, pre-press.

Bowel Injury: 
Eisner IS et al. Prevention and management of bowel injury during gynecologic laparoscopy: an update, Current Opinion in Obstetrics and Gynecology: August 2019 - Volume 31 - Issue 4; p 245-250.
Glaser, Laura M. MD; Milad, Magdy P. MD, MS Bowel and Bladder Injury Repair and Follow-up After Gynecologic Surgery, Obstetrics & Gynecology: February 2019 - Volume 133 - Issue 2 - p 313-322.
Yuk JS et al. Incidence of bowel injury during gynecologic surgery for benign indications: A nationwide cross-sectional study of cases from 2009 to 2018. Int J Gynaecol Obstet. 2022 Aug;158(2):338-345.

Vascular Injury: 
Victoria Asfour, Edward Smythe & Rizwan Attia (2018) Vascular injury at laparoscopy: a guide to management, Journal of Obstetrics and Gynaecology, 38:5, 598-606, DOI: 10.1080/01443615.2017.1410120.
King NR, Lin E, Yeh C, Wong JMK, Friedman J, Traylor J, Tsai S, Chaudhari A, Milad MP. Laparoscopic Major Vascular Injuries in Gynecologic Surgery for Benign Indications: A Systematic Review. Obstet Gynecol. 2021 Mar 1;137(3):434-442.

Bleeding Morbidity: 

Gingold JA et al. Perioperative Interventions to Minimize Blood Loss at the Time of Hysterectomy for Uterine Leiomyomas: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol. 2019 Nov-Dec;26(7):1234-1252.e1. 

Vaginal Cuff Complications: 
Nezhat, C et al. Vaginal Cuff Dehiscence and Evisceration, Obstetrics & Gynecology: October 2018 - Volume 132 - Issue 4 - p 972-985.
Ucella S, et al. Laparoscopic vs transvaginal cuff closure after total laparoscopic hysterectomy: a randomized trial by the Italian Society of Gynecologic Endoscopy. Am J Obstet Gynecol. 2018 May;218(5):500.e1-500.e13.
 

Last Reviewed: 4/25/2025

Reviewers: Elizabeth Banks, Dmitry Fridman, Laura Hamilton
Goal:
To develop diagnostic, surgical, and decision-making expertise required to evaluate and manage adenomyosis, with an emphasis on individualized treatment planning, symptom relief, fertility preservation, and minimally invasive techniques.

Objectives:
By the end of training, fellows should be able to:

• Describe the pathophysiology, clinical impact, and natural history of adenomyosis, including its heterogeneous presentation, relationship to endometriosis, and potential impact on fertility and quality of life.
• Recognize the varied clinical presentations of adenomyosis, including dysmenorrhea, abnormal uterine bleeding (AUB), dyspareunia, and infertility, and assess the overlap with other gynecologic conditions.
• Interpret imaging studies—particularly transvaginal ultrasound and MRI—to identify adenomyosis, differentiate focal from diffuse disease, and guide treatment planning. Apply Morphological Uterus Sonographic Assessment (MUSA) terminology when describing sonographic features of adenomyosis.
• Evaluate and develop an individualized treatment plan across medical and surgical options, including hormonal therapy, uterine-sparing procedures (e.g., adenomyomectomy, focused ultrasound, uterine artery embolization), and hysterectomy.
• Perform minimally invasive surgical management of adenomyosis, including laparoscopic hysterectomy and fertility-preserving adenomyomectomy, with an understanding of anatomical challenges and appropriate case selection.
• Counsel patients on prognosis, treatment options, and reproductive implications, including the uncertain relationship between adenomyosis and IVF success, and the risks of recurrence or incomplete symptom relief.
• Integrate current literature and evolving surgical techniques into clinical decision-making, while identifying limitations in available evidence and tailoring care to patient goals and preferences.

References:
Chapron C, et al. Diagnosing adenomyosis: an integrated clinical and imaging approach. Hum Reprod Update. 2020 Apr 15;26(3):392-411.
Nirgianakis K, et al. Fertility, pregnancy and neonatal outcomes of patients with adenomyosis: a systematic review and meta-analysis. Reprod Biomed Online. 2021 Jan;42(1):185-206.
Osada H. Uterine adenomyosis and adenomyoma: the surgical approach. Fertil Steril. 2018 Mar;109(3):406-417.
Bulun SE, et al. Endometriosis and adenomyosis: shared pathophysiology. Fertil Steril. 2023 May;119(5):746-750.

Last Reviewed: 4/25/2025

Reviewers: Dmitry Fridman, Kacey Hamilton, Merima Ruhotina
Goal:
To cultivate the highest standards of professional conduct in MIGS through self-awareness, ethical integrity, effective communication, and commitment to continuous improvement within diverse, multidisciplinary surgical environments.

Objectives:
By the end of training, fellows should be able to:

• Demonstrate ethical and respectful behavior toward patients, families, colleagues, trainees, and the interdisciplinary care team—modeling integrity, empathy, and accountability.
• Maintain cultural humility and responsiveness to diversity in patient background and identity, including but not limited to race, ethnicity, culture, gender identity, sexual orientation, religion, disability, and socioeconomic status.
• Protect patient privacy and autonomy, and engage in shared decision-making principles during informed consent discussions, including full disclosure of risks, benefits, alternatives, and cost considerations.
• Recognize and address personal limitations related to fatigue, stress, punctuality, appearance, interpersonal dynamics, and time management, especially as they relate to surgical performance and patient safety.
• Seek and incorporate feedback constructively, integrating feedback into ongoing professional development, team communication, and teaching practices.
• Navigate ethical dilemmas in surgical care, including those involving reproductive autonomy, industry relationships, surgical innovation, and conflicts of interest—consistent with institutional policies and national guidelines.
• Maintain transparency and compliance in all professional interactions, including appropriate disclosure of relationships with the pharmaceutical and device industries.
• Participate in quality improvement efforts, demonstrating the ability to critically reflect on outcomes, complications, and near misses to inform both personal learning and system-level changes.
• Stay current with evolving treatment options and best practices, and apply critical appraisal skills to emerging evidence, especially in areas of rapid surgical innovation and limited data.
• Serve as a professional role model, demonstrating the core values of MIGS—precision, compassion, collaboration, and innovation—in both clinical care and education.

References:
Professionalism, Ethics, Accountability and Communication
ACOG Committee Opinion (CO) No. 541: Professional relationships with industry.
Committee on Patient Safety and Quality Improvement; Committee on Professional Liability. ACOG CO No. 681.
ACOG CO No. 709: Commercial Enterprises in Medical Practice.
ACOG CO No. 801: Assessing and Adopting New Medical Devices for Obstetric and Gynecologic Care.
ACOG CO No. 729: Importance of Social Determinants of Health and Cultural Awareness in the Delivery of Reproductive Health Care.
ACOG CO No. 683: Behavior that undermines a culture of safety.
ACOG CO No. 791: Professional use of digital and social media.
ACOG CO 796: Sexual Misconduct. 

Last Reviewed: 4/25/2025

Reviewers: Aakriti Carrubba, Laura Douglass, Kacey Hamilton, Mireille Truong
Goal:

• To develop and demonstrate expertise in the design, implementation, and evaluation of educational initiatives—including surgical simulation with a focus on simulation-based training for minimally invasive surgical techniques. To conduct, analyze, and interpret research that advances minimally invasive gynecologic surgery.
• To prepare MIGS fellows to become effective surgical educators by equipping them with the knowledge, skills, and experience to design, implement, and evaluate evidence-based educational activities, with a particular focus on the use of simulation as a tool for teaching, assessment, and innovation.

Objectives:
By the end of training, fellows should be able to:

• Foundations of Education & Simulation
  • Describe and apply principles of simulation and surgical education, including curriculum development frameworks, mastery learning, deliberate practice, cognitive load theory, debriefing techniques, objective assessment tools, and instructional strategies.
  • Explore and critically assess innovations and emerging technologies in surgical education.
• Design & Implementation 
  • Develop, implement, and conduct surgical educational activities utilizing evidence-based simulation practices and strategies (e.g., scenario-based, psychomotor skills-based, in-situ simulation, standardized patients).
  • Design and conduct simulation sessions in various formats (skills-based, team-based, in situ, interprofessional) to enhance psychomotor and surgical skills, team communication, medical knowledge, patient care, and decision-making, while incorporating tools to measure learner performance.
  • Demonstrate appropriate use of low- and high-fidelity simulation resources, including cadaver labs, dry labs, in vivo and ex vivo tissue models, virtual reality systems, standardized patients, and tabletop/team-based exercises.
• Facilitation & Assessment 
  • Demonstrate knowledge and utilize objective assessment and performance feedback techniques for simulation and education.
  • Develop and lead simulation scenarios with structured debriefing to promote reflective learning, clinical reasoning, and team communication.
• Scholarship 
  • Explain and apply principles of research in simulation and surgical education to design and conduct scholarly projects. 
• Educational Principles & Teaching Skills
  • Develop and facilitate effective educational sessions tailored to residents, medical students, and interdisciplinary teams by integrating evidence-based teaching strategies. Implement training programs to prepare learners for specialty-specific assessments, such as the EMIG examination.
  • Lead structured debriefings that promote reflective learning, deliver actionable feedback, and employ validated assessment tools to evaluate learner performance.
  • Apply principles of curriculum development to assess existing structured educational programs, such as courses, longitudinal simulation tracks, and competency-based training initiatives and provide constructive feedback to learners
• Simulation-Based Education
  • Create and maintain simulation curricula for minimally invasive gynecologic surgery that address progressive skill acquisition, reinforcement, and assessment over time.
  • Design and conduct simulation sessions in various formats (skills-based, team-based, in situ, interprofessional) to enhance psychomotor and surgical skills, team communication, medical knowledge, patient care, and decision-making as well as tools to measure learner performance
  • Appropriately select and utilize low- and high-fidelity simulation resources, including cadaver labs, dry labs, in vivo and ex vivo tissue models, virtual reality systems, standardized patients, and tabletop exercises.
  • Contribute to MIGS surgical education by evaluating educational interventions, disseminating outcomes, and integrating best practices into simulation-based training.
• Research Design & Analysis
  • Formulate clinically relevant research questions in complex gynecology and gynecologic surgery , grounded in current literature and clinical gaps.
  • Understand research ethics, IRB processes, and patient privacy regulations relevant to clinical and educational research in surgery.
  • Select appropriate research methodologies (quantitative, qualitative, or mixed methods) and study designs for surgical education, patient outcomes, or innovation assessment.
  • Apply principles of statistical analysis to interpret data, collaborating with biostatistics and epidemiology experts when needed.
  • Critically appraise surgical literature, integrating findings into evidence-based practice.
• Research Dissemination & Scholarship
  • Prepare abstracts, manuscripts, and presentations that meet the standards of peer-reviewed journals and national meetings.
  • Mentor junior trainees in the fundamentals of research design, data collection, and scholarly writing

References:

Orejuela FJ, Aschkenazi SO, Howard DL, et al.Gynecologic surgical skill acquisition through simulation with outcomes at the time of surgery :a systematic review and meta-analysis. Am J Obstet Gynecol 2022.
Gala R, Orejuela F, Gerten K, et al. Effect of validated skills simulation on operating room performance in obstetrics and gynecology residents: a randomized controlled trial. Obstet Gynecol 2013;121:578–84.
Shore EM, Grantcharov TP, Husslein H,etal. Validating a standardized laparoscopy curriculum for gynecology residents: a randomized controlled trial. Am J Obstet Gynecol 2016;215: 204.e1–11.
Tripathi S, Ray A, Dhawan T, Khan MA, Ahmad R. Revolutionizing Surgical Education: Integrating Virtual Reality-Based Simulation to Enhance Competency in Junior Surgeons. Cureus. 2025 Jun 18;17(6):e86289. doi: 10.7759/cureus.86289. PMID: 40688976; PMCID: PMC12275502.

Last Reviewed: 4/25/2025

Reviewers: Elizabeth Banks, Aakriti Carrubba, Laura Douglas, Merima Ruhotina, 
Goal:
To develop diagnostic, surgical, and decision-making expertise required to evaluate and manage acute pelvic pain, with an emphasis on life-threatening and fertility-threatening conditions requiring high-level surgical judgment and technical proficiency.

Objectives:
By the end of training, fellows should be able to:

• Describe the pathophysiology of conditions causing acute pelvic pain that demand advanced surgical decision-making and technical skill, including cesarean scar ectopic pregnancy, interstitial pregnancy, tubo-ovarian abscess, and adnexal torsion.
• Develop and refine a comprehensive differential diagnosis for acute pelvic pain, integrating history, examination, and clinical presentation.
• Select and interpret diagnostic imaging—including transvaginal ultrasound, MRI, and CT—to confirm diagnoses and guide management planning.
• Manage cesarean scar and interstitial ectopic pregnancies surgically and/or with interventional approaches, including laparoscopic, hysteroscopic, and combined techniques when appropriate.
• Treat surgically tubo-ovarian abscess (TOA), including intraoperative decision-making regarding drainage versus salpingo-oophorectomy, with consideration of fertility preservation and patient stability.
• Perform laparoscopic evaluation and surgical management of adnexal torsion, emphasizing ovary-sparing techniques, assessment of viability, and strategies to reduce recurrence.

References:
Miller, R., Gyamfi-Bannerman, C., 2022. Society for Maternal-Fetal Medicine Consult Series #63: Cesarean scar ectopic pregnancy. American Journal of Obstetrics and Gynecology 227, B9–B20. https://doi.org/10.1016/j.ajog.2022.06.024
Schwartz, B.I., Huppert, J.S., Chen, C., Huang, B., Reed, J.L., 2018. Creation of a Composite Score to Predict Adnexal Torsion in Children and Adolescents. Journal of Pediatric and Adolescent Gynecology 31, 132–137. https://doi.org/10.1016/j.jpag.2017.08.007
Akdam, A., Bor, N., Fouks, Y., Ram, M., Laskov, I., Levin, I., Cohen, A., 2022. Recurrent Ovarian Torsion: Risk Factors and Predictors for Outcome of Oophoropexy. Journal of Minimally Invasive Gynecology 29, 1011–1018. https://doi.org/10.1016/j.jmig.2022.05.007
Lau, S., Tulandi, T., 1999. Conservative medical and surgical management of interstitial ectopic pregnancy. Fertility and Sterility 72, 207–215. https://doi.org/10.1016/S0015-0282(99)00242-3
Goje, O., Markwei, M., Kollikonda, S., Chavan, M., Soper, D.E., 2021. Outcomes of Minimally Invasive Management of Tubo-ovarian Abscess: A Systematic Review. Journal of Minimally Invasive Gynecology 28, 556–564. https://doi.org/10.1016/j.jmig.2020.09.014

Videos:
Laparoscopic Oophoropexy with Combined Combined Fixation to the Uterosacal Ligament in a Prepubertal Girl with Recurrent Ovarian Torsionand Pelvic Side Wall - https://surgeryu.aagl.org/view?m=l5Sbjv1dE
Laparoscopic Oophoropexy: Treatment for Recurrent Ovarian Torsion -   https://surgeryu.aagl.org/view?m=91laVkkjs 
Minimally Invasive Surgical Management of Tubo-Ovarian Abscess - https://surgeryu.aagl.org/view?m=UKYNa0aRX 
Laparoscopic Management of an Advanced Interstitial Pregnancy - https://surgeryu.aagl.org/view?m=iR9Prevgb

Last Reviewed: 4/25/2025

Reviewers: Elizabeth Banks, Aakriti Carrubba, Meena Misal, Kristin Patzkowsky
Goal:
To develop diagnostic, surgical, and decision-making expertise required to evaluate and manage chronic pelvic pain, with an emphasis on multimodal assessment, trauma-informed care, interdisciplinary collaboration, and individualized treatment planning.

Objectives:
By the end of training, fellows should be able to:

• Physiology
  • Define the diagnostic criteria of chronic pelvic pain and describe its clinical relevance.
  • Describe the contribution of multiple organ systems—gynecologic, urologic, gastrointestinal, musculoskeletal, neurologic, and vascular—to chronic pelvic pain and explain the pathophysiology of each.
• Evaluation
  • Elicit a comprehensive pain history, incorporating validated pain assessment tools, and develop a thorough differential diagnosis of chronic pelvic pain.
  • Perform a focused, trauma-informed physical examination, including localization of pain and evaluation of neurologic, visceral, dermatologic, and musculoskeletal components. Include assessment of pelvic floor musculature, trigger points, sensitization, vulvodynia, and pudendal neuralgia.
  • Order appropriate laboratory tests and imaging based on the history and exam, including mental health screening tools, genitourinary cultures, and targeted imaging studies.
• Management
  • Counsel patients regarding non-opioid medical therapies for organ- and system-specific causes of chronic pelvic pain, and discuss the risks of long-term opioid use.
  • Recognize indications for referral to allied health professionals (e.g., pelvic floor physical therapy, psychology) and to other specialties (e.g., urology, gastroenterology, PM&R, pain management).
  • Describe interventional treatments for chronic pelvic pain—including injections, laparoscopy, presacral neurectomy, adhesiolysis, and hysterectomy—addressing their efficacy, risks, benefits, and cost-effectiveness.

References:

Lamvu, G., Carrillo, J., Ouyang, C., Rapkin, A., 2021. Chronic Pelvic Pain in Women: A Review. JAMA 325, 2381. https://doi.org/10.1001/jama.2021.2631
Colemeadow, J., Sahai, A., Malde, S., 2020. Clinical Management of Bladder Pain Syndrome/Interstitial Cystitis: A Review on Current Recommendations and Emerging Treatment Options. RRU Volume 12, 331–343. https://doi.org/10.2147/RRU.S238746
Barnabei, V.M., 2020. Vulvodynia. Clin Obstet Gynecol 63, 752–769. https://doi.org/10.1097/GRF.0000000000000576
Cain, A., Carter, K., Salazar, C., Young, A., 2022. When and How to Utilize Pudendal Nerve Blocks for Treatment of Pudendal Neuralgia. Clinical Obstetrics & Gynecology 65, 686–698. https://doi.org/10.1097/GRF.0000000000000715
Bendek, B., Afuape, N., Banks, E., Desai, N.A., 2020. Comprehensive review of pelvic congestion syndrome: causes, symptoms, treatment options. Current Opinion in Obstetrics & Gynecology 32, 237–242. https://doi.org/10.1097/GCO.0000000000000637
Tu, F.F., Hellman, K.M., Backonja, M.M., 2011. Gynecologic management of neuropathic pain. American Journal of Obstetrics and Gynecology 205, 435–443. https://doi.org/10.1016/j.ajog.2011.05.011

Videos: 
A guide for practicing trauma-informed care for patients with chronic pelvic pain. https://youtu.be/YJuWeCWepqU?si=XxS1JaixcO2qsKrB

Supplemental:

Chronic Pelvic Pain: Untangling Nociceptive, Neuropathic and Nociplastic Pelvic Pain with the Initial History Intake - https://surgeryu.aagl.org/view?m=PBMBkibpV

Last Reviewed: 4/25/2025

Reviewers: Kacey Hamilton, Kristin Patzkowsky, Merima Ruhotina
Goal:
To develop advanced surgical judgment, technical expertise, and patient-centered counseling skills required to perform hysterectomy in complex clinical scenarios, with an emphasis on fertility, ovarian function, long-term pelvic health, and minimally invasive approaches.

Objectives:
By the end of training, fellows should be able to:

• Patient Counseling
  • Provide thorough counseling on the long-term effects of hysterectomy, including impact on sexual function, ovarian function, pelvic floor prolapse (and preventive strategies), and incontinence.
  • Counsel patients on risks and benefits of concurrent procedures, including oophorectomy, salpingectomy, and supracervical versus total hysterectomy.
  • Appropriately counsel younger patients on long-term health effects and quality-of-life implications of hysterectomy.
• Surgical Technique
  • Execute laparoscopic and robotic-assisted hysterectomy in patients with severe endometriosis, large uteri, multiple prior cesarean deliveries, and prior pelvic surgery, with strategies to minimize blood loss and optimize outcomes.
  • Be comfortable with the following procedures:
• Ureterolysis.
  • Isolation and ligation of the uterine artery at its origin.
  • Normalization of obliterated anterior and posterior cul-de-sacs.
  • Adhesiolysis, including enterolysis, ovariolysis, and salpingolysis.
  • Utilize advanced visualization techniques to enhance surgical accuracy in cases with distorted anatomy.
• Leadership & Consultation 
  • Serve as an intraoperative consultant to general gynecologists and surgical teams for complex hysterectomy cases, providing guidance on advanced dissection strategies and complication management.

References:

Counseling / surgical planning:  

AAGL, 2014. AAGL Practice Report: Practice Guidelines for Laparoscopic Subtotal/Supracervical Hysterectomy (LSH). Journal of Minimally Invasive Gynecology 21, 9–16. https://doi.org/10.1016/j.jmig.2013.08.001
Ko, J.S., Suh, C.H., Huang, H., Zhuo, H., Harmanli, O., Zhang, Y., 2021. Association of Race/Ethnicity with Surgical Route and Perioperative Outcomes of Hysterectomy for Leiomyomas. Journal of Minimally Invasive Gynecology 28, 1403-1410.e2. https://doi.org/10.1016/j.jmig.2020.11.008
Alzamora, M.C., Valentine, L.N., Billow, M.R., 2025. Womb for debate: the complexities of early-age hysterectomies. Current Opinion in Obstetrics & Gynecology. https://doi.org/10.1097/GCO.0000000000001031
Dedden, S.J., Werner, M.A., Steinweg, J., Lissenberg-Witte, B.I., Huirne, J.A.F., Geomini, P.M.A.J., Maas, J.W.M., 2023. Hysterectomy and sexual function: a systematic review and meta-analysis. The Journal of Sexual Medicine 20, 447–466. https://doi.org/10.1093/jsxmed/qdac051
Huang, Y., Wu, Meng, Wu, C., Zhu, Q., Wu, T., Zhu, X., Wu, Mingfu, Wang, S., 2023. Effect of hysterectomy on ovarian function: a systematic review and meta-analysis. J Ovarian Res 16, 35. 
https://doi.org/10.1186/s13048-023-01117-1
Aagesen, A.H., Klarskov, N., Gradel, K.O., Husby, K.R., 2023. Hysterectomy on benign indication and risk of pelvic organ prolapse surgery: A national matched cohort study. Acta Obstet Gynecol Scand 102, 774–781. 
https://doi.org/10.1111/aogs.14561
Christoffersen, N.M., Klarskov, N., Gradel, K.O., Husby, K.R., 2023. Increased risk of stress urinary incontinence surgery after hysterectomy for benign indication—a population-based cohort study. American Journal of Obstetrics and Gynecology 229, 149.e1-149.e9. 
https://doi.org/10.1016/j.ajog.2023.04.029
Rush, S.K., Ma, X., Newton, M.A., Rose, S.L., 2022. A Revised Markov Model Evaluating Oophorectomy at the Time of Hysterectomy for Benign Indication: Age 65 Years Revisited. Obstetrics & Gynecology 139, 735–744. https://doi.org/10.1097/AOG.0000000000004732

Surgical Technique

Ito, T.E., Vargas, M.V., Moawad, G.N., Opoku-Anane, J., Shu, M.K.M., Marfori, C.Q., Robinson, J.K., 2017. Minimally Invasive Hysterectomy for Uteri Greater Than One Kilogram. JSLS 21, e2016.00098. https://doi.org/10.4293/JSLS.2016.00098
Tanaka, Y., Higami, S., Shiraishi, M., Shiki, Y., 2023. Total laparoscopic hysterectomy when there is posterior cul-de-sac obliteration: a step-by-step nerve-sparing technique. American Journal of Obstetrics and Gynecology 229, 178–180. https://doi.org/10.1016/j.ajog.2023.03.033
Jan, H., Ghai, V., 2019. Ureterolysis for Laparoscopic Hysterectomy. Journal of Minimally Invasive Gynecology 26, 401. 
https://doi.org/10.1016/j.jmig.2018.05.023
Gueli Alletti, S., Restaino, S., Finelli, A., Ronsini, C., Lucidi, A., Scambia, G., Fanfani, F., 2020. Step by Step Total Laparoscopic Hysterectomy with Uterine Arteries Ligation at the Origin. Journal of Minimally Invasive Gynecology 27, 22–23. https://doi.org/10.1016/j.jmig.2019.06.001
Carlin, G.L., Bodner-Adler, B., Husslein, H., Ritter, M., Umek, W., 2021. The effectiveness of surgical procedures to prevent post-hysterectomy pelvic organ prolapse: a systematic review of the literature. Int Urogynecol J 32, 775–783. https://doi.org/10.1007/s00192-020-04572-2
Nezhat, C., Grace, L.A., Razavi, G.M., Mihailide, C., Bamford, H., 2016. Reverse Vesicouterine Fold Dissection for Laparoscopic Hysterectomy After Prior Cesarean Deliveries. Obstet Gynecol 128, 629–633. https://doi.org/10.1097/AOG.0000000000001593

Supplemental:
Louie, M., Strassle, P.D., Moulder, J.K., Dizon, A.M., Schiff, L.D., Carey, E.T., 2018. Uterine weight and complications after abdominal, laparoscopic, and vaginal hysterectomy. American Journal of Obstetrics and Gynecology 219, 480.e1-480.e8. https://doi.org/10.1016/j.ajog.2018.06.015