Gynaecological Endoscopy最新文献

To assess how consultant gynaecologists working in Scotland achieve a pneumoperitoneum for laparoscopic procedures.

An anonymous postal questionnaire.

All consultants working in obstetrics and gynaecology in Scotland.

Questionnaire analysis.

There was a 92% response rate to the questionnaire. Of the respondents, 94.8% performed closed laparoscopy, one (0.8%) performed only open laparoscopy, and six (4.4%) employed both open and closed techniques. The majority worked with the patient in the lithotomy with Trendelenburg position. The commonest entry point, used by 88 respondents, was subumbilical. To create the pneumoperitoneum 94 respondents used 2–2.5 L of gas. Six used pressure measurement and eight used tension to gauge the pneumoperitoneum prior to trocar insertion.

The majority of consultants working in Scotland practise a closed laparoscopy entry technique.

A previously unreported finding of polypropylene mesh erosion into the bladder two years after laparoscopic colposuspension.

As with the vagina, synthetic mesh can erode into the bladder following urogynaecological sling procedures. Previous surgery may be a risk factor. Recurrent urinary tract infection or persistent haematuria following such a procedure should raise suspicion of mesh erosion.

Objective

To describe an interstitial pregnancy which occurred subsequent to and at the site of an hysteroscopic excision of an intrauterine septum.

Setting

University-affiliated reproductive medicine programme.

Subject

A 32-year-old woman undergoing IVF treatment for infertility.

Results

The patient underwent IVF treatment after hysteroscopic resection of an intrauterine septum. Ectopic pregnancy occurred interstitially in the uterine fundus, at the site of the previous septotomy. The pregnancy was excised at laparotomy.

Conclusions

Interstitial ectopic pregnancy may represent a complication of operative hysteroscopy.

To compare the weights of commonly used extracorporeal slip knots.

The weights of seven commonly used types of extracorporeal slip knots and an intracorporeally tied flat square knot were compared. In each arm of the study, 17 knots were tied around a 5-mm jig using a laparoscopic trainer. Knots were weighed using microscales.

A laboratory experiment.

Weight of knot loops in milligrams.

The heaviest ligature was the modified Roeder knot. The Western knot utilized less suture material than all the other knots studied. The flat square knot utilized less suture material than all the slip knots with the exception of the Western ligature.

As other studies have correlated suture mass with the incidence of wound infection, a ligature with a low weight should be chosen in preference to the modified Roeder knot where possible.

To describe a technique for open entry for laparoscopic procedures, utilizing either a standard 5- or 10 mm trocar through an 8- or 12 mm intra-umbilical incision, respectively.

Two teaching hospitals.

A total of 237 patients. The first 186 patients had a 10-mm trocar inserted, and the latter 51 patients a 5-mm trocar entry.

The average time required to achieve pneumoperitoneum was 3.5 min with no complications encountered. Gas leakage overall occurred in 4.2% of patients, though in no case was remedial fascial suturing required. There were two cases of wound infection (0.8%), including an infected umbilical haemotoma. All minor complications occurred in the first 20 patients undergoing surgery.

Open laparoscopy using this technique is safe, quick, and cosmetically excellent with minimal complications and no major disadvantages. It provides an improved safety margin for vascular injury in comparison to closed peritoneal entry, though it is theoretically capable of causing type II visceral injuries.

Tubal pregnancy is responsible for 8.95% of direct maternal deaths and the incidence is rising. Despite a grade A recommendation from the Royal College of Obstetricians and Gynaecologists (RCOG) that the majority of ectopic pregnancies should be managed via the laparoscopic approach, in only 13% of hospitals does this happen routinely. As a reason for this, trainees cite the inability to consolidate and practise the techniques learnt on approved courses well enough to have the confidence to undertake procedures on their own.

A highly realistic training simulation, simple and cheap enough to be available in every gynaecological unit, would allow trainees to practise skills learnt on RCOG-accredited courses on returning to their own hospitals. This would complement supervised training on live patients. Ectopic pregnancy often presents as an emergency, out of hours, when RCOG-accredited preceptors are unavailable to take juniors through the laparoscopic approach. The simulation would be ready for use at all times.

Limbs & Things (Bristol, UK), a company with acknowledged expertise in the development and construction of medical simulations, has developed an ectopic pregnancy simulation, in collaboration with two RCOG-accredited level 3 minimal access surgeons with experience in training in laparoscopic surgery for ectopic pregnancy. Special attention has been given to the achievement of a realistic appearance and fabrication of a material with the potential to allow monopolar and bipolar diathermy. The simulation was evaluated by 52 trainees of different grades and levels of experience in minimal access surgery (MAS), at the National Trainees' Meeting in Obstetrics and Gynaecology, May 1999. Assessment was done, using visual analogue scores, for realism in appearance, cutting, dissection and diathermy, after trainees had performed a standardized exercise directed by a tutor.

Overall, 51 trainees felt this was a valuable exercise in training (98%), and the combined realism score of the simulation was 64.7% (range 40–85%) (SD 13.85%). The MAS level 3 group scored the simulation much more highly at 78.75%, and showed much more consistency (range 75–85%) (SD 2.67%). All members of this group had previously used ectopic simulations, compared with 73% in the level 2 group and 42% in the level 1 group. The level 3 surgeons were not necessarily the most senior grades: 47% were specialist registrar grade 3 (SpR3) or less. Of the senior grades SpR4 and SpR5, 11 of 19 (58%) felt unable to perform laparoscopic salpingectomy with independent competence.

The level 3 trainees demonstrated themselves to be the only discerning group able to consistently score the simulation; they assessed the realism highly and felt this could be a valuable method for training in laparoscopic ectopic surgery. Despite RCOG recommendations that all trainees should be independently able to perform salpingectomy and salpingotomy, only 42% of years 4 and 5 w