Journal of minimally invasive gynecology最新文献

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.

Objective: This video illustrates key technical steps and refined strategies to improve safety, precision, and reproducibility when performing Laparoscopic Lateral Suspension (LLS) for the treatment of pelvic organ prolapse (POP) [1].

Setting: This video includes intraoperative laparoscopic video footage performed at the Division of Gynecology and Obstetrics at the University Hospital of Cagliari, Italy.

Participants: The case presented involves different women with stage II-III cystocele and apical prolapse, with preserved uterine anatomy and no significant posterior compartment defect.

Interventions: All patients underwent LLS to surgically treat POP using a T-shaped prosthetic mesh fixed to the uterine cervix or isthmus and the anterior vaginal wall, with arms suspended retroperitoneally and tension-free to the lateral abdominal wall. The procedure included six tips and techniques: bladder suspension technique to the anterior abdominal wall with the use of a Foley segment [2]; accurate measurement of the anterior vaginal wall with a segment of a Foley catheter; optimal mesh tailoring; use of a 10-mm suprapubic trocar; application of the first stitch on the anterior vaginal wall; and peritoneum traction to improve procedural outcomes. These steps were presented as a standardized, step-by-step process to improve intraoperative exposure, control mesh deployment and arm traction, and enhance overall reproducibility of LLS.

Conclusion: LLS may be an alternative to laparoscopic sacral colpopexy, particularly for cystocele and apical prolapse repair when promontory access is difficult [3-5]. The refinements presented here aim to increase reproducibility and intraoperative control during vesicovaginal dissection, mesh sizing, and retroperitoneal tunneling. The dual use of a Foley segment for atraumatic bladder retraction and standardized measurement offers a low-cost strategy, while stepwise mesh deployment and gentle peritoneal traction support safe, consistent suspension.

Objective: Transvaginal natural orifice transluminal endoscopic surgery(vNOTES) combines the benefits of traditional vaginal surgery-such as the absence of abdominal incisions, reduced postoperative pain, and improved cosmetic outcomes-with enhanced endoscopic visualization and working space compared to conventional vaginal instrumentation.^1-3This is particularly relevant in urogynecological surgery, where lower urinary tract injuries, especially bladder and ureteral damage, are among the most frequent complications.^4,5We present the feasibility and safety of performing high uterosacral ligament suspension(HUS) and bilateral adnexectomy via a vNOTES approach, with intraoperative ureteral visualization achieved using indocyanine green.

Design: Stepwise demonstration of the technique with narrated video footage.

Setting: A 63-year-old woman presenting with symptomatic pelvic organ prolapse(POP-Q: II Stage). Given that the patient presented with persistent and bothersome symptoms and an associated apical support defect, conservative management and isolated anterior repair were considered insufficient; therefore, an apical support procedure was selected to ensure durable anatomical and functional outcomes, and the proposed surgical management consisted of HUS with bilateral adnexectomy(upon patient's request), performed via vNOTES. The aims of the surgical approach and potential postoperative complications were clearly explained to the patient prior to obtaining informed consent.

Interventions: Firstly, a cystoscopy was performed, with bilateral ureteral injection of IGC at a concentration of 0.25 mg/mL, with a total volume of 3 mL per side. Then the GelPoint vPATH1 device(Applied Medicine, Rancho Santa Margarita, CA) was placed in the vagina and a low-pressure pneumoperitoneum was established. The uterosacral ligaments were identified by direct pulling. The suspension stitches are then placed crossing the uterosacral ligaments in their cranial part. Finally, a bilateral salpingo-oophorectomy was performed. The total operative time was 24 minutes, with minimal blood loss.

Conclusion: Determining the pelvic course of the ureters by transperitoneal ICG visualization was pivotal to avoid ureteral kinking during placement of the suspension sutures and to dynamically confirm ureteral patency following apical suspension. The vNOTES HUS with Real-Time ICG injection is technically feasible and allows clear and reliable identification of the uterosacral ligament. Our technique allows a good identification of mooring points for suspension, an improved vision of adjacent anatomical structures and avoiding any blindfold surgical maneuvers limiting the risk of ureteral injuries, making it a safer and more reproducible procedure.

Study objective: The development of uterine niche-also known as cesarean scar defect or isthmocele-is a potential long-term sequela after cesarean delivery, and may be associated with abnormal uterine bleeding, pelvic pain, and infertility. Previous literature examining prevalence consists of small cohort and case control studies. We aimed to calculate the incidence of uterine niche after primary cesarean delivery using a nationally representative database.

Design, settings, participants, intervention: Retrospective cohort study of individuals who underwent primary singleton cesarean delivery within the Vizient Clinical Database 2021-2024. Vizient is a healthcare performance improvement company that receives de-identified administrative and patient claims data.

Measurements: Niche cases were identified using International Classification of Diseases (ICD)-10 codes and imaging findings. The primary outcome was incidence of uterine niche, defined as number of cases of niche divided by the person-time-at-risk after primary cesarean delivery. Secondary outcomes included time to niche development and risk factors associated with niche.

Main results: Overall, 517,763 individuals underwent primary cesarean delivery during the study period. The mean age of the cohort was 32.7 years (SD 6.2) at primary cesarean delivery. There were 62,433 (12.1%) niche events over 915,842 person-years, resulting in an incidence rate of 68.2 events per 1,000 person-years after primary cesarean delivery (95% CI 67.6-68.7). Overall, 98.3% of niche cases developed after the first cesarean delivery. Mean time to diagnosis following primary cesarean delivery was 0.79 years (SD 0.58). Using multivariable logistic regression modeling, increased age, Back, Asian, or Hispanic race or ethnicity, history two or more deliveries, having non-commercial insurance, and history of tobacco use were associated with increased likelihood of developing a uterine niche.

Conclusion: The population incidence of uterine niche following cesarean delivery was 68.2 per 1,000 person-years, with mean time to diagnosis 0.79 years after primary cesarean. These data should inform complete counseling regarding the risks of cesarean delivery.