Gynecological Surgery最新文献

Background: Uterine manipulator is a very useful tool in performing total laparoscopic hysterectomy (TLH) for large uteri; however, in some cases, it cannot be used due to unfavorable anatomical conditions. The feasibility and safety of TLH for very large uteri without the use of uterine manipulator has not yet been established.

Results: We describe two emblematic cases of TLH for huge fibromatous uteri: the first one for a uterus weighing 5700 g, which is the largest uterus laparoscopically removed to date reported in literature, and the second one for a uterus of 3670 g associated with a severe lymph node neoplastic disease.In both cases, TLH was successfully and safely performed even without the use of uterine manipulator, thus allowing a rapid recovery, especially in the second case, which was essential for a fast start of the most appropriate oncological treatment, the best quality of life and undoubtedly cosmetic advantages.

Conclusions: Although we believe in the great usefulness of the uterine manipulator in performing TLH for huge uteri, in the present paper, we demonstrate the feasibility and safety of such complex surgery also when the use of this tool is not possible due to unfavorable anatomical condition.

Background: Fresh frozen cadaver training has been proposed as a better model than virtual reality simulators in laparoscopy training. We aimed to explore the relationship between cadaveric surgical training and increased surgical confidence.To determine feasibility, we devised two 1-day cadaveric surgical training days targeted at trainees in obstetrics and gynaecology. Seven defined surgical skills were covered during the course of the day. The relationship between surgical training and surgical confidence was explored using both quantitative (confidence scores) and qualitative tools (questionnaires).

Results: Participants rated a consistent improvement in their level of confidence after the training. They universally found the experience positive and three overarching themes emerged from the qualitative analysis including self-concept, social persuasion and stability of task.

Conclusions: It is pragmatically feasible to provide procedure-specific cadaveric surgical training alongside supervised clinical training. This small, non-generalisable study suggests that cadaveric training may contribute to an increase in surgical self-confidence and efficacy. This will form the basis of a larger study and needs to be explored in more depth with a larger population.

Background: Congenital diaphragmatic hernia (CDH) is a congenital anomaly with high mortality and morbidity mainly due to pulmonary hypoplasia and hypertension. Temporary fetal tracheal occlusion to promote prenatal lung growth may improve survival. Entrapment of lung fluid stretches the airways, leading to lung growth.

Methods: Fetal endoluminal tracheal occlusion (FETO) is performed by percutaneous sono-endoscopic insertion of a balloon developed for interventional radiology. Reversal of the occlusion to induce lung maturation can be performed by fetoscopy, transabdominal puncture, tracheoscopy, or by postnatal removal if all else fails.

Results: FETO and balloon removal have been shown safe in experienced hands. This paper deals with the technical aspects of balloon insertion and removal. While FETO is invasive, it has minimal maternal risks yet can cause preterm birth potentially offsetting its beneficial effects.

Conclusion: For left-sided severe and moderate CDH, the procedure is considered investigational and is currently being evaluated in a global randomized clinical trial (https://www.totaltrial.eu/). The procedure can be clinically offered to fetuses with severe right-sided CDH.

Background: Laparoscopic hysterectomy (LH) for the treatment of early-stage endometrial carcinoma/cancer (EC) has demonstrated to be safe in several randomized controlled trials. Yet, data on implementation of LH in clinical practice are limited. In the present study, implementation of LH for EC was evaluated in a large oncology network in the Netherlands.

Results: Retrospectively, a total of 556 EC patients with FIGO stage I-II were registered in the selected years. The proportion of LH gradually increased from 11% in 2006 to 85% in 2015. LH was more often performed in patients with low-grade EC and was not related to the studied patient characteristics. The introduction of TLH was frequently preceded by LAVH. Patients treated in teaching hospitals were more likely to undergo a LH compared to patients in non-teaching hospitals. The conversion rate was 7.7%, and the overall complication rates between LH and AH were comparable, but less postoperative complications in LH.

Conclusions: Implementation of laparoscopic hysterectomy for early-stage EC increased from 11 to 85% in 10 years. Implementation of TLH was often preceded by LAVH and was faster in teaching hospitals.

Background: Intrauterine devices (IUDs) are the most popular form of contraception used worldwide; however, IUD is not risk-free. IUD migrations, especially uterine perforations, were frequently occurred in patients. The aim of this study was to investigate the clinical characteristics and intraoperative findings in patients with migrated IUDs.

Results: 29 cases of uterine perforation associated with migrated IUDs and 69 control patients were followed between January 2008 to March 2015. Patients who used IUDs within first 6 months from the last delivery experienced a characteristically high rate of the perforation of the uterine wall. A significantly larger number of IUD insertion associated with uterine perforation were performed in rural hospitals or operated at a lower level health care system. There was no clear difference in the age and presented symptoms in patients between two groups. Majority of contraceptive intrauterine devices was the copper-releasing IUDs. Furthermore, patients who used V-shaped IUD showed significantly higher incidence of pelvic adhesions when compared with the users of O-shaped IUDs.

Conclusions: Unique clinical characteristics of IUD migration were identified in patients with uterine perforation. Hysteroscopy and/or laparoscopy were the effective approaches to remove the migrated IUDs. Improving operating skills is required at the lower level of health care system.

Background: The purpose of this study is to evaluate current practice amongst gynaecologists across the UK, regarding safety aspects of inpatient hysteroscopy under anaesthesia, specifically in relation to entry and specimen retrieval.A survey was created using survey monkey. The first round was circulated to all registrar trainees and consultant gynaecologists across Wales. Following a good response, the survey was then circulated to all members of the British Society of Gynaecological Endoscopy (BSGE).

Results: There were 212 responses including, 140 consultants, 36 senior registrars, 17 junior registrars and 18 clinical nurse specialists. In total, 136 out of 212 (64.7%) always perform a vaginal examination prior to hysteroscopy. 10.4% always sound the uterus, and 5.2% always dilate the uterus prior to insertion of the hysteroscope. Twenty-three consultants, six senior registrars, three junior registrars and one clinical nurse specialist knew how to position the internal cervical os as visualised through the scope when using a 30° hysteroscope. 35.8% of candidates always perform a post-procedure cavity check, and 9% use suction to flush the cavity to aid vision during the post-procedure cavity check. The majority (76%) predicted dilatation as the stage most likely to cause uterine perforation and predicted the most likely site for perforation as the posterior uterine wall in the anteverted uterus and the anterior uterine wall in the retroverted uterus.

Conclusion: This study highlights varied practice across the UK regarding safety aspects of hysteroscopy, in relation to entry and specimen retrieval. There is a need for increased awareness of the risks of hysteroscopy and paramount precautions that should be performed routinely as part of their practice. Standardised guidelines may be a beneficial tool to help bring about this change in practice, leading to a reduction in uterine perforation rates.

Background: There are safety concerns regarding the use of mesh in vaginal surgery with a call for long-term follow-up data. This study was designed to evaluate the long-term safety and efficacy of vaginal repairs performed for recurrent cystocele using Perigee (non-absorbable trans-obturator) mesh.

Methods: A retrospective consecutive cohort of 48 women who underwent surgery for recurrent prolapse between March 2007 and December 2011 in a single centre was reviewed. Satisfaction was assessed using the patient global impression of improvement (PGI-I). Symptoms were assessed with the pelvic floor distress inventory (PFDI). Women were questioned regarding pain, sexual activity and pelvic floor surgery performed since the original procedure and examined for erosion. Women were compared to 25 controls from a consecutive cohort of repeat anterior colporrhapies.

Results: The mean length of follow-up was 6.5 years (78 months; range 48-106). Significantly more women in the mesh group reported that they were "much better" or "very much better" (69 vs 40% p = 0.02). The rate of mesh erosion at follow-up was 11.6%. Two women in the mesh group required surgical excision of eroded mesh in the operating room (4%). The reoperation rate for a combination of de novo stress incontinence, recurrent prolapse and mesh exposure was similar in each group (33% mesh vs 32% native tissue).

Conclusions: A vaginal mesh repair using a non-absorbable trans-obturator mesh has improved satisfaction compared to an anterior colporrhaphy.

Background: Pelvic endometriosis is often mentioned as one of the variables influencing surgical outcomes of laparoscopic hysterectomy (LH). However, its additional surgical risks have not been well established. The aim of this study was to analyze to what extent concomitant endometriosis influences surgical outcomes of LH and to determine if it should be considered as case-mix variable.

Results: A total of 2655 LH's were analyzed, of which 397 (15.0%) with concomitant endometriosis. For blood loss and operative time, no measurable association was found for stages I (n = 106) and II (n = 103) endometriosis compared to LH without endometriosis. LH with stages III (n = 93) and IV (n = 95) endometriosis were associated with more intra-operative blood loss (p = < .001) and a prolonged operative time (p = < .001) compared to LH without endometriosis. No significant association was found between endometriosis (all stages) and complications (p = .62).

Conclusions: The findings of our study have provided numeric support for the influence of concomitant endometriosis on surgical outcomes of LH, without bowel or bladder dissection. Only stages III and IV were associated with a longer operative time and more blood loss and should thus be considered as case-mix variables in future quality measurement tools.

Background: Training of basic laparoscopic psychomotor skills improves the acquisition of more advanced laparoscopic tasks, such as laparoscopic intra-corporeal knot tying (LICK). This randomized controlled trial was designed to evaluate whether pre-training of basic skills, as laparoscopic camera navigation (LCN), hand-eye coordination (HEC), and bimanual coordination (BMC), and the combination of the three of them, has any beneficial effect upon the learning curve of LICK. The study was carried out in a private center in Asunción, Paraguay, by 80 medical students without any experience in surgery. Four laparoscopic tasks were performed in the ENCILAP model (LCN, HEC, BMC, and LICK). Participants were allocated to 5 groups (G1-G5). The study was structured in 5 phases. In phase 1, they underwent a base-line test (T₁) for all tasks (1 repetition of each task in consecutive order). In phase 2, participants underwent different training programs (30 consecutive repetitions) for basic tasks according to the group they belong to (G1: none; G2: LCN; G3: HEC; G4: BMC; and G5: LCN, HEC, and BMC). In phase 3, they were tested again (T₂) in the same manner than at T₁. In phase 4, they underwent a standardized training program for LICK (30 consecutive repetitions). In phase 5, they were tested again (T₃) in the same manner than at T₁ and T₂. At each repetition, scoring was based on the time taken for task completion system.

Results: The scores were plotted and non-linear regression models were used to fit the learning curves to one- and two-phase exponential decay models for each participant (individual curves) and for each group (group curves). The LICK group learning curves fitted better to the two-phase exponential decay model. From these curves, the starting points (Y0), the point after HEC training/before LICK training (Y1), the Plateau, and the rate constants (K) were calculated. All groups, except for G4, started from a similar point (Y0). At Y1, G5 scored already better than the others (G1 p = .004; G2 p = .04; G3 p < .0001; G4 NS). Although all groups reached a similar Plateau, G5 has a quicker learning than the others, demonstrated by a higher K (G1 p < 0.0001; G2 p < 0.0001; G3 p < 0.0001; and G4 p < 0.0001).

Conclusions: Our data confirms that training improves laparoscopic skills and demonstrates that pre-training of all basic skills (i.e., LCN, HEC, and BMC) shortens the LICK learning curve.