Gynecology and Minimally Invasive Therapy-GMIT最新文献

Postoperative ovarian vein thrombosis (OVT) is a rare complication following hysterectomy. Due to its ambiguous presentation, most frequently presenting as a fever with no known source and lower quadrant abdominal pain, OVTs are commonly diagnosed incidentally on computed tomography as a low-attenuation thrombus in place of the ovarian vein. The cornerstones of OVT treatment include anticoagulation and antibiotic therapy; however, there are no current guidelines to inform provider decision-making regarding specific anticoagulant agents, dosing, or length of therapy. We present a patient with a history of deep-vein thrombosis, who presented to the emergency department with OVT following a laparoscopic hysterectomy. She was treated with apixaban, a direct oral anticoagulant (DOAC), and experienced repeated episodes of vaginal bleeding and hematoma expansion. We present this case to instill a high index of suspicion for OVT after laparoscopic hysterectomy, and to discuss the role of DOACs in patients with thromboembolic disease and concurrent bleeding.

Objectives: This study aimed to evaluate hysteroscopic-guided suction evacuation for the treatment of cesarean scar pregnancy (CSP).

Materials and methods: This was a retrospective analysis of CSP over 2 years. This study was conducted at KK Women's and Children's Hospital (KKH), Singapore, thirty-seven patients with a CSP. Hysteroscopic-guided suction evacuation to treat CSP used alone or in combination with laparoscopy depending on residual myometrial thickness (RMT) and future fertility requirements.

Results: The majority of women (29) were diagnosed under 9-week gestation. Just over a third (13) had an RMT of more than 3 mm. Women with an RMT <3 mm had added laparoscopy. In total, 22 women had hysteroscopic-guided suction evacuation with 9 having it performed under laparoscopic guidance because the RMT was under 3 mm. The remaining patients underwent either laparoscopic repair (5 cases) or vaginal repair (1 case) done under laparoscopic guidance.

Conclusion: Hysteroscopic-guided suction evacuation of CSP has the potential to become part of the routine management for uncomplicated cases of CSP in women with an RMT of greater than 3 mm who do not wish for future pregnancy. Its use, in combination with other minimally invasive techniques, can be extended to more complex cases where the RMT is <3 mm and future fertility is desired.

Adenomyosis is a complex issue in reproductive-age women not only on worsening of quality of life due to severe dysmenorrhea or heavy menstrual bleeding but also on the impact of infertility. A 39-year-old female, gravida 0 para 0, with a history of bilateral ovarian endometrioma post laparoscopic surgery presented to our hospital due to suspected deep infiltrative endometriosis (DIE), adenomyosis, and repeated implantation failure. Initially, gonadotropin-releasing hormone analog treatment for DIE with progestin-primed ovarian stimulation protocol was arranged. Four D5 blastocysts were obtained and freezed. Two frozen embryo transfer were performed after ultrasound-guided high-intensity focused ultrasound (USgHIFU) treatment of adenomyosis. She later had a dichorionic diamniotic twin pregnancy, and two healthy newborns were delivered by Cesarean section at gestational age of 35 weeks due to antepartum hemorrhage with placenta previa and preeclampsia. In conclusion, USgHIFU can be a potential treatment option in segmented in vitro fertilization in future.

Objectives: The objective of this study was to assess the effect of local infiltration of anesthetic to the vaginal vault on postoperative pain after total laparoscopic hysterectomy.

Materials and methods: This was a single-center, randomized trial. Women assigned to laparoscopic hysterectomy were randomly divided into two groups. In the intervention group (n = 30), the vaginal cuff was infiltrated with 10 ml of bupivacaine, whereas the control group (n = 30) did not receive local anesthetic infiltration to vaginal vault. The primary outcome measure was to analyze the efficacy of bupivacaine infiltration in the study group by comparing the postoperative pain in both the groups at 1, 3, 6, 12, and 24 h using pain visual analog scale (VAS). The secondary outcome was to measure the need for rescue opioid analgesia.

Results: Group I (intervention group) had lesser mean VAS score at 1^st, 3^rd, 6^th, 12^th, and 24 h compared to Group II (control group). There was an additional requirement of opioid analgesia for postoperative pain in Group II than in Group I, which was statistically significant (P < 0.05).

Conclusion: Injection of local anesthetic into the vaginal cuff increased the number of women experiencing only minor pain after laparoscopic hysterectomy and decreased postoperative opioid usage and its side effects. Local anesthesia of the vaginal cuff is safe and feasible.

In surgical fields, sharp dissection is a basic surgical technique, and the prognosis and oncological outcomes are known to be affected by the technique of dissection. Even in gynecologic surgery, we believe that the basic surgical technique is sharp dissection. We herein present our technique and discuss its significance. Sharp dissection should entail the removal of a single thin line between the residual tissue and the excised tissue. If this line becomes multiple or thicker, it is not sharp dissection but blunt dissection. The accumulation of this thin line of sharp dissection can form surgical layers. What is important is moderate tissue tension and how to use monopolar. One can sharply cut the loose connective tissue assisted by moderate tissue tension. With regard to the use of monopolar, it is essential that it not be applied directly to the tissue, but rather be used with or without touching the tissue. Inadvertent blunt dissection should be minimized, as most surgical procedures can be performed with sharp dissection. We usually perform sharp dissection for open surgery as well as minimally invasive surgery. We obstetricians and gynecologists should reconsider the significance of sharp dissection and practice it in gynecological surgery.

The incidence of cesarean scar pregnancy (CSP) is increasing reflecting the global increase in cesarean section (CS) rate which has almost doubled since 2000. CSP differs from other types of ectopic pregnancy in its ability to progress while still carrying a significant risk of maternal morbidity. Little is known about precise etiology or natural history although current interest in the pathology of placenta accretes spectrum disorders might be enlightening. Early detection and treatment of CSP are challenging. Once diagnosed, the recommendation is to offer early termination of pregnancy because of the potential risks of continuing the pregnancy. However, as the likelihood of future pregnancy complications for any CSP varies depending on its individual characteristics, this might not always be necessary nor might it be the patient's preferred choice if she is asymptomatic, hemodynamically stable, and wants a baby. The literature supports an interventional rather than a medical approach but the safest and most efficient clinical approach to CSP in terms of treatment modality and service delivery has yet to be determined. This review aims to provide an overview of CSP etiology, natural history, and clinical implications. Treatment options and methods of CSP repair are discussed. We describe our experience in a large tertiary center in Singapore with around 16 cases/year where most treatment modalities are available as well as an "accreta service" for continuing pregnancies. We present a simple algorithm for approach to management including a method of triaging for those CSPs suitable for minimally invasive surgery.

We present the first case of a pregnant woman with teratoma, who underwent vaginal natural orifice transluminal endoscopic surgery (vNOTES). Mature ovarian cystic teratomas compromise 20%-30% of all ovarian tumors. The best surgical management is still unclear, especially during pregnancy. A 21-year-old pregnant woman (gravida 1, para 0) at 14 weeks and 3 days of gestational age was admitted with an intermittent mild sharp and dull pain in her right lower abdomen when walking or moving lower limbs. Pelvic ultrasonography revealed a 5.9 cm × 5.4 cm heterogeneous mass that was suspected as a teratoma in the right adnexa. Initially, laparoendoscopic single-site ovarian cystectomy (OC) was arranged. However, the ovarian tumor was impeded by the enlarged uterus. The OC procedure was changed to vNOTES OC. The vNOTES OC was performed smoothly and the pathology confirmed the mass to be a teratoma. After the operation, she recovered well and was discharged 2 days after the operation without any complication. In conclusion, the application of vNOTES in the second-trimester pregnancy might be considered safe and effective. The vNOTES can be performed safely in selected patients and by an experienced surgeon.