Journal of minimally invasive gynecology最新文献

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.

Study objective: To compare patient pain perception with extension of the umbilical versus suprapubic laparoscopic port site at the time of tissue morcellation.

Design: Prospective nonrandomized pilot study SETTING: Academic hospital PARTICIPANTS: Women undergoing surgery with anticipated manual morcellation for tissue extraction. Sixty-four patients were enrolled, 14 were excluded, 27 were included in the suprapubic morcellation group and 23 in the umbilical morcellation group.

Interventions: Patients were assigned to suprapubic or umbilical port site extension for morcellation based on surgeon preference, specimen size and location, and patient characteristics. Pain perception was obtained through a survey with a ten point pain scale.

Measurements and main results: The worst pain scores at 24 hours post-operatively did not significantly differ between groups (suprapubic vs. umbilical: 7.4 ± 2.4 vs. 7.3 ±1.7, p=0.528). The difference increased at 2 weeks post-operatively (5.8 ± 2.8 vs. 4.9 ± 2.5, p=0.244). Opioid use at 2 weeks, measured as morphine milligram equivalents (MME), was higher in the suprapubic group than the umbilical, (36.3 ± 33.5 vs. 17.3 ± 19.8, p = 0.037) but the difference was not statistically significant after covariate adjustment. Satisfaction scores were high in both groups (suprapubic vs. umbilical: 4.4 ± 0.8 vs. 4.7 ± 0.7, p = 0.321). There were no statistical differences in length of hospital stay, post-operative complications, and post-operative hernia.

Conclusion: In this pilot study, we observed no clear differences in patient-reported postoperative pain at 24 hours or 2 weeks between umbilical and suprapubic port extension for specimen morcellation. Although pain scores tended to be higher in the suprapubic group and MME lower with umbilical morcellation at 2 weeks, these differences were not statistically significant after multivariable adjustment.

Study objective: Analyze the association of Body Mass Index (BMI) and perioperative outcomes following major laparoscopic surgery for benign gynecologic conditions.

Design: Retrospective exploratory Institutional Review Board exempt study SETTING: Single site academic institution PARTICIPANTS: Patients ≥18 years old who underwent major laparoscopic surgery from January 2018 to December 2023 by minimally invasive gynecologic surgeons (MIGS).

Interventions: Surgery type and perioperative outcomes by obesity class (not overweight, overweight, Class I, Class II, Class III, Class IV and V) were compared. Manual chart review was conducted using REDCap software. Trend tests compared variables across BMI categories using a p-value of 0.05 as the significance level. Complications were categorized by CLASSIC and Clavien-Dindo Classifications. An adjusted regression analysis assessed the impact of BMI on complications and procedure times.

Measurements and main results: Of the 883 patients, 489 (55%) were classified as obese, with 126 (14%) patients meeting criteria for Class III obesity and 31 (4%) with a BMI ≥50 kg/m² (Class IV and V). Patients with higher BMI categories were more likely to identify as a non-white race, have comorbidities, and have Medicaid insurance. Patients with higher BMI categories had a higher likelihood of comorbidities (p <0.001). Increasing BMI was also associated with higher EBL, blood transfusion, longer procedure times, and longer LOS (p <0.001). Complications were increased with higher BMI on univariate, but not multivariate, analysis. There were no significant differences in postoperative complications categorized by Clavien-Dindo Classification, readmission rates or conversion to laparotomy among BMI categories.

Conclusion: Higher BMI groups had an overall increased risk of complications compared to non-obese individuals, a difference that was not present after adjustment for confounding factors. Additionally, postoperative complication rates were not different following major laparoscopic surgery for benign gynecologic conditions.

Objective: To demonstrate the use of ultrasound-guided hysteroscopic technique for the successful surgical management of a missed abortion in a patient with uterus didelphys and complex cervical anatomy.

Design: Video case report demonstrating a stepwise, ultrasound-guided hysteroscopic approach.

Setting: The case was managed in a tertiary referral center with a multidisciplinary team.

Participants: A 36-year-old woman, gravida 4 para 3, with a known Müllerian anomaly and right renal agenesis, presented with a missed abortion at 9 weeks of gestation. Although the anomaly was previously suspected, the exact diagnosis - whether bicornuate uterus or didelphys uterus - remained unclear due to the presence of a single identifiable cervix. In this case, ultrasound identified the pregnancy within the right uterine horn.

Interventions: Under general anesthesia, a thorough speculum examination revealed a potential opening to the right uterine horn. Ultrasound-guided cervical dilation was attempted but proved unsuccessful due to the tortuous nature of the canal. Therefore, ultrasound-guided hysteroscopic approach was employed with a multidisciplinary team including gynecology, anesthesia, and sonography specialists. Surgical hysteroscopy facilitated precise navigation and evacuation of the gestational sac from the right uterine horn under ultrasound guidance. The procedure was completed without complications. Hysteroscopic and sonographic follow-up after two months, demonstrated a normal endometrial lining and no retained products of conception.

Conclusion: This case underscores the importance of adapting surgical strategies to complex anatomical variations in patients with Müllerian anomalies. Ultrasound-guided hysteroscopy offers a safe and effective solution when standard methods such as D&C fail due to obstructive cervical anatomy. Its direct visualization capabilities allow for precise intervention, minimize procedural risks, and improve patient outcomes. Incorporating advanced hysteroscopic techniques into clinical practice is essential for managing challenging uterine malformations.

Objective: The aim of this study was to identify clinical and imaging factors associated with prolonged operative time and to explore whether CNN-derived ultrasound features provide incremental predictive value beyond conventional clinical variables.

Design: Retrospective cohort study SETTING: Single academic medical center PARTICIPANTS: A total of 247 patients who underwent laparoscopic ovarian cystectomy for presumed benign ovarian tumors were included in the study. Eligible participants were 18 years or older, had preoperative ultrasound images and complete operative records, and were initially planned for ovarian cystectomy. Patients were excluded if they were scheduled for oophorectomy, or if other major procedures such as myomectomy or hysterectomy were planned concurrently.

Interventions: We used two predictive models: a logistic regression model based on preoperative clinical variables (e.g., CA-125 levels, bilaterality of ovarian cysts, and robotic surgery) to predict prolonged operative time, defined as the upper quartile (25%) of operative duration in our cohort, and a second logistic regression model combining these variables with CNN-derived features from preoperative ultrasound images to enhance predictive accuracy.

Results: Multivariable analysis revealed that robotic surgery, bilaterality of ovarian cysts, CA-125 levels, and two CNN-derived imaging features were independently associated with prolonged operative time. Incorporation of CNN-derived ultrasound features increased the AUC from 0.889 to 0.920, although the difference did not reach statistical significance.

Conclusion: The combined model, incorporating clinical and CNN-extracted imaging features, demonstrates the feasibility of predicting prolonged operative time in laparoscopic ovarian cystectomy. This approach may support preoperative risk stratification and serve as a foundation for future studies exploring its role in surgical scheduling and resource planning, pending external validation.

Glossary: CNN (Convolutional Neural Network): A type of deep learning model that processes image data by extracting hierarchical spatial features.

Objective: To evaluate the effectiveness of intraperitoneal crystalloid fluid instillation in reducing postoperative shoulder-tip pain and related outcomes after elective gynecologic laparoscopy for benign conditions Data Sources: A systematic search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials was conducted up to December 2025. Search terms included combinations of "gynecologic laparoscopy", "shoulder pain", "intraperitoneal", "saline", and "ringer's lactate" Methods of Study Selection: Randomized controlled trials comparing intraperitoneal crystalloid fluid instillation (normal saline or Ringer's lactate) with standard desufflation techniques without intraperitoneal fluid instillation in women undergoing elective benign gynecologic laparoscopy were included Tabulation, Integration, and Results: Data were independently extracted by two reviewers. Continuous endpoints were compared using pooled mean differences (MDs) and binary outcomes with risk ratios (RR), with 95% confidence intervals (CIs). Statistical analysis was performed using R statistical software version 4.5.1 (R Foundation for Statistical Computing). Primary outcomes included shoulder-tip pain intensity measured by visual analog scale (VAS 1-10) or numeric rating scales at 12, 24, and 48 hours postoperatively with a 1-point reduction being clinically significant. Secondary outcomes included abdominal pain at 12, 24, and 48h, postoperative abdominal distension, estimated blood loss, operative time, postoperative hospital stay, postoperative nausea and vomiting. Eleven RCTs were included, comprising a total of 1,143 patients. Intraperitoneal crystalloid instillation was associated with a significant reduction in postoperative shoulder-tip pain at 12h (MD -1.46; 95% CI -2.56 to -0.36; PI -4.07 to 1.15; p= 0.02), 24h (MD -1.17; 95% CI -2.10 to -0.24; PI -3.64 to 1.29; p= 0.02), and 48h (MD -0.96; 95% CI -1.84 to -0.08; PI -2.92 to 1.00; p= 0.04) compared with standard dessuflation techniques. No differences were observed in secondary outcomes, including abdominal pain at 12, 24, and 48 hours, postoperative abdominal distension, estimated blood loss, operative time, postoperative hospital stay, or incidence of postoperative nausea and vomiting. Furthermore, in studies where postoperative NSAIDs were routinely administered, intraperitoneal crystalloid instillation did not demonstrate reduction in shoulder-tip pain Conclusion: Intraperitoneal crystalloid fluid instillation was associated with a reduction in postoperative shoulder-tip pain following laparoscopic gynecologic surgery for benign conditions, without evidence of adverse effects on other perioperative outcomes. These findings suggest that this simple and low-cost intervention may be considered as an adjunct to reduce postoperative pain in patients undergoing laparoscopic gynecologic surgery for benign conditions.