Journal of minimally invasive gynecology最新文献

Study objective: To measure the workload effect of an exoscopic camera system during vaginal hysterectomy on workload and learning experience of Obstetrics and Gynecology trainees.

Design: Prospective cohort study SETTING: Two tertiary academic medical centers in the United States PATIENTS/PARTICIPANTS: Obstetrics and Gynecology residents and fellows INTERVENTIONS: Vaginal hysterectomy performed with and without an exoscopic camera system MEASUREMENTS AND MAIN RESULTS: The primary outcome was workload measured using the NASA Task Load Index (NASA-TLX) across six dimensions: mental demand, physical demand, temporal demand, effort, performance, and frustration. The secondary outcomes were trainee perceptions of the surgical experience using Likert scale questions. From June 2021 to January 2024, 39 surveys were completed (21 with camera, 18 without); 10 trainees had paired data. The mean overall NASA-TLX scores did not differ between groups (40.4 [SD 14.9] with camera vs. 47.5 [SD 21.5] without; p=0.14). Physical demand scores were lower with the camera (39.9 [SD 41.3] with vs. 53.1 [SD 19.2] without; p=0.05). Among paired data, median overall NASA-TLX scores were similar (47.4 vs. 49.3; p=0.28), with 7 of 10 trainees reporting lower scores with the camera system. Effect sizes for trainee perceptions showed small positive effects on visualization (Cliff's δ =0.26) and skill building (Cliff's δ =0.29), moderate effect on procedural flow (Cliff's δ =0.46), and large effect on engagement (Cliff's δ =0.50) with the use of the exoscopic camera. No effects were seen for anatomical knowledge application (Cliff's δ =0.04), confidence in anticipation (Cliff's δ =0.06), or intrusion (Cliff's δ =-0.01).

Conclusion: Use of an exoscopic camera system during vaginal hysterectomy was associated with improved trainee engagement and procedural flow, and reduced physical demand, without increasing overall mental workload. These findings support its utility as an educational adjunct in vaginal surgery training.

Summation: In a prospective cohort study, use of an exoscopic camera system during vaginal hysterectomy was associated with improved trainee engagement and reduced physical demand without increasing overall mental workload.

Objective: To demonstrate the laparoscopic, uterus-sparing excision of an accessory cavitated uterine malformation (ACUM) in an adolescent patient and to emphasize the importance of accurate preoperative imaging for intraoperative localization.

Setting: Tertiary referral center for minimally invasive gynecologic surgery.

Participants: An 18-year-old adolescent patient presenting with severe dysmenorrhea and chronic pelvic pain refractory to medical treatment.

Interventions: Laparoscopic excision of a noncommunicating accessory cavitated uterine lesion with preservation of the main uterine cavity.

Conclusion: Preoperative transabdominal ultrasonography and magnetic resonance imaging demonstrated a 35 × 43 mm cystic lesion located in the left anterior uterine wall, clearly separated from the endometrial cavity and consistent with ACUM. During laparoscopy, no obvious uterine bulging was observed, making intraoperative localization challenging. A targeted myometrial incision allowed identification and complete excision of the lesion, which contained chocolate-colored fluid and was lined with endometrium-like tissue. The main uterine cavity was preserved, and layered myometrial reconstruction was performed. Histopathological examination confirmed the diagnosis of ACUM. Laparoscopic uterus-sparing excision is a safe and effective treatment option for adolescent patients with ACUM when guided by accurate preoperative imaging.

Objective: Risk-reducing bilateral salpingooophorectomy (RRSO) lowers the risk of ovarian cancer (OC) by 80-90% in women with a hereditary predisposition to breast and/or ovarian cancer (HBOC/HOC). As genetic testing expands, more women may be candidates for RRSO, which underscores the need to assess the safety of the procedure. We aimed to evaluate the frequency of surgical complications following RRSO to support informed decision-making for women advised to undergo the procedure.

Design: Retrospective cohort study SETTING: Copenhagen University Hospital Herlev, Denmark January 2017-December 2022 PARTICIPANTS: 246 women with HBOC/HOC who underwent risk reducing surgery were included. Patients, who had declined to participate in quality assurance studies were excluded.

Interventions: Risk reducing bilateral/unilateral salpingoophorectomy ± hysterectomy RESULTS: 246 women underwent surgery, and 15 (6.09%) experienced complications. 9 (60%) were Clavien Dindo grade I and 6 (40%) grade II. No grade III, IV, or V complications occurred. Grade I included minor pain or superficial infection not requiring antibiotic treatment, and grade II were all due to infections requiring treatment with antibiotics. No significant differences were found between women with and without complications with respect to age, BMI, previous abdominal surgery or smoking CONCLUSION: The incidence and severity of complications after risk reducing surgery were low. This evidence is valuable in counseling women with HBOC and offers reassurance about the safety of RRSO.

Objective: To study the feasibility and safety of using autologous platelet-rich plasma (PRP) during laparoscopic orthotopic reimplantation of cryopreserved ovarian tissue.

Design: Single-center, interventional, pilot, prospective, cohort study.

Setting: Tertiary university hospital (IRCCS-Azienda Ospedaliero-Universitaria di Bologna-Policlinico Sant'Orsola).

Participants: Five eligible consecutive patients, who previously cryopreserved ovarian tissue before chemo(radio) therapy for oncologic diseases and were scheduled for orthotopic reimplantation with the use of autologous PRP to treat iatrogenic premature ovarian failure, were compared with a historical cohort of 19 similar patients who underwent orthotopic reimplantation without the use of autologous PRP.

Interventions: Before surgery, autologous PRP (10 mL) was transformed into gel using calcium gluconate. Autotransplantation was performed by standard four-port laparoscopy, creating pockets in the ovarian cortex and/or peritoneal cavity to insert frozen-thawed ovarian tissue fragments covered by gelled PRP. Pre-, intra- and postoperative data were collected (characteristics of the study population, adverse reactions, operative time, surgical complications, menstrual resumption).

Results: Study outcomes included: rate of adverse reactions, rate of intra- and postoperative surgical complication, total intraoperative time, rate of restored endocrine function and median (absolute range) time to first menses (expressed in months) during follow-up. The mean (range) age at ovarian tissue retrieval and at transplantation were 30 (27-31) and 38 (36-41) years for the PRP group, and 33 (24-34) and 41 (34-42) years for the non-PRP group. During the study period, no intra- and postoperative complication nor adverse reaction to PRP use was observed. All patients treated with PRP experienced resumption of regular ovarian function after a median (range) period of 3 (1-6) months, with a significant shorter time in the PRP group. One patient in the experimental group conceived three months after surgery and had one live birth at the time of this report.

Conclusion: Autologous PRP appears to be a feasible and safe adjunct in orthotopic ovarian tissue transplantation, potentially enhancing the restoration of ovarian function.

Study objective: To describe reproductive outcomes and clinical safety considerations associated with assisted reproductive technology (ART) in women with a history of surgically treated catamenial pneumothorax (thoracic endometriosis syndrome).

Design: Retrospective case series conducted from January 2014 to December 2023.

Setting: Single tertiary academic center integrating reproductive medicine and thoracic surgery.

Participants: Women aged 18-43 years with surgically treated catamenial pneumothorax were included.

Interventions: Exposure was ART in women with catamenial pneumothorax ultimately managed surgically, performed either before and/or after the thoracic operation; the timing of ART relative to surgery was recorded.

Measurements and main results: Primary outcomes were reproductive outcomes (including live birth rate per patient and per transfer) and safety outcomes (pneumothorax occurrence/recurrence and ART-related complications). Ten of the eleven patients (91 %) had right-sided catamenial pneumothorax. Five women (45 %) had undergone pelvic endometriosis surgery before thoracic management. Nineteen ovarian stimulation cycles were performed. Among infertile patients, seven of ten (70 %) achieved at least one live birth: five after in vitro fertilization with autologous oocytes, one after oocyte donation, and one after intrauterine insemination with donor sperm. Four women (36 %) experienced their first pneumothorax episode within four months of assisted reproductive technology. No thoracic recurrences were observed after surgery, despite subsequent ovarian stimulations.

Conclusion: ART was associated with positive reproductive outcomes and a low rate of reported adverse events in women with a history of surgically treated catamenial pneumothorax, with no observed thoracic recurrences following treatment. Prospective studies are needed to further characterize outcomes and risks.

Objective: Cervical insufficiency, the inability of uterine cervix to retain pregnancy in absence of labor, is a major cause of preterm births and stillbirths. Therapeutic options include expectant management, progesterone, pessaries, or surgical cerclage [1]. Minimally invasive approaches provide several advantages over laparotomy, including decreased blood loss, lower post-operative pain, shorter hospital stay and faster recovery while achieving comparable or improved obstetric outcomes [2,3]. Robot-assisted transabdominal cerclage (RA-TAC) is gaining popularity due to the enhanced three-dimensional visualization, improved dexterity and precision in performing fine dissection and knot-tying [4]. This video article demonstrates our RA-TAC technique and setup in a complex patient using the Hugo™ RAS system (Medtronic, Minneapolis, MN, USA) [5].

Setting: Academic Hospital, IRCCS Policlinico di S. Orsola Bologna, Italy PARTICIPANTS: A 40-year-old woman, BMI 36 kg/m^2, with an unfavorable obstetric history and a strong desire for further pregnancy.

Intervention: All possible therapeutic strategies and related complications have been discussed with the patient. Considering her strong desire for pregnancy, her surgical and obstetric history- including prior preterm deliveries despite vaginal cerclage (2020-2021)- and her BMI, a preconceptional RA-TAC was planned. A "straight" port placement in a "compact" docking configuration was installed. Surgery was performed under general anesthesia in 49 minutes. There were no intraoperative or postoperative complications. After 15 months, the patient successfully delivered a healthy 2896 g male infant via elective cesarean section at 36+6 weeks, with no need for perinatal care; the cerclage was removed and bilateral salpingectomy was performed.

Conclusions: Robotic-assisted surgery represents a feasible option for transabdominal cerclage, particularly in patients with obesity or intra-abdominal adhesions. Surgeon ergonomics, three-dimensional visualization, unrestricted range of motion, improved tremor control are key-advantages in procedures demanding maximal precision. While current literature lacks strong evidence demonstrating superiority of robotic-assisted over laparoscopic cerclage, this video illustrates technique, feasibility and potential benefits of RA-TAC.