Gynecological Surgery最新文献

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.

Background: Uterine-preserving prolapse surgery offers the chance to retain fertility; however, limited data is available for the safety of pregnancy following surgery and the effect of pregnancy on surgical outcome. Our operative technique involves mesh encircling the cervix and uterine arteries, which raises concerns that compromise of uterine blood flow during pregnancy may lead to foetal growth restriction. We also think this necessitates delivery by caesarean section. We report on six pregnancy outcomes following laparoscopic hysteropexy. Primary outcomes were live birth and birth weight. Secondary outcomes were integrity of mesh and immediate effect on prolapse.

Results: All patients had successful pregnancy outcomes with birth weights on or above the 10th centile. There was no effect on mesh integrity seen in any of the cases. There was no deterioration in apical prolapse when assessed post delivery, but two patients had new onset anterior vaginal wall prolapse.

Conclusions: We think our technique of hysteropexy is safe for those wishing to conceive. Larger numbers are needed to allow robust evidence-based guidance for patients and clinicians.

Background: Studies have shown that vaginal vault prolapse can affect up to 43% of women following hysterectomy for pelvic organ prolapse. Many techniques have been described to prevent and treat vaginal vault prolapse. The primary objective of our study was to compare McCall's culdoplasty (when performed along side vaginal hysterectomy) with laparoscopic uterosacral plication (when performed along side total laparoscopic hysterectomy) for prevention of vaginal vault prolapse. Secondary outcomes included inpatient stay and perioperative complications. A retrospective comparison study comparing 73 patients who underwent 'laparoscopic hysterectomy and uterosacral plication' against 70 patients who underwent 'vaginal hysterectomy and McCall culdoplasty'. All operations were carried out by two trained surgeons.

Results: There was no significant difference between BMI or parity. There were statistically significantly more patients presenting with post hysterectomy vault prolapse (PHVP) in the group of patients who had undergone uterosacral plication (12 out of 73) compared with McCalls culdoplasty (0 out of 70) P = 0.000394. Inpatient stay in the uterosacral plication group was significantly shorter mean 1.8 compared to 3.6 for McCall group (P-Value is <0.00001). There was no significance in the perioperative complications between both groups (P = 0.41).

Conclusions: McCalls is a superior operation to prevent PHVP compared to uterosacral plication with no difference in terms of perioperative complications.

Background: Uterovaginal prolapse in very elderly women is a growing problem due to increased life expectancy. Surgeons and anaesthetists may be wary of performing quality of life surgery on this higher risk group. Where surgery is undertaken, it is commonly performed vaginally; there is a perception that this is better tolerated than abdominal surgery. Little data is published about laparoscopic prolapse surgery tolerability in this population, and laparoscopic surgery is perceived within the urogynaecological community as complex and lengthy and hence inherently unsuitable for the very elderly. In Oxford, UK, laparoscopic abdominal surgical techniques are routinely employed for urogynaecological reconstructive surgery. The authors offer abdominal laparoscopic prolapse surgery to patients suitable for general anaesthesia with apical vaginal prolapse, irrespective of age. We here report outcomes in this elderly patient cohort and hypothesise these to be acceptable. This is a retrospective case note review of all patients aged 79 years old and above undergoing laparoscopic prolapse surgery (hysteropexy or sacrocolpopexy) in two centres in Oxford, UK, over a 5-year period (n = 55). Data were collected on length of surgery, length of stay, intraoperative complications, early and late post-operative complications and surgical outcome.

Results: Mean age was 82.6 years (range 79-96). There were no deaths. Minor post-operative complications such as UTI and constipation were frequent, but there were no serious (Clavien-Dindo grade III or above) complications; 80% achieved objective good anatomical outcome.

Conclusions: Laparoscopic prolapse surgery appears well tolerated in the elderly with low operative morbidity and mortality.

Background: To evaluate surgical outcome in a consecutive series of patients with conventional and robot assisted total laparoscopic hysterectomy.

Methods: A retrospective cohort study was performed among patients with benign and malignant indications for a laparoscopic hysterectomy. Main surgical outcomes were operation room time and skin to skin operating time, complications, conversions, rehospitalisation and reoperation, estimated blood loss and length of hospital stay.

Results: A total of 294 patients were evaluated: 123 in the conventional total laparoscopic hysterectomy (TLH) group and 171 in the robot TLH group. After correction for differences in basic demographics with a multivariate linear regression analysis, the skin to skin operating time was a significant 18 minutes shorter in robot assisted TLH compared to conventional TLH (robot assisted TLH 92m, conventional TLH 110m, p0.001). The presence or absence of previous abdominal surgery had a significant influence on the skin to skin operating time as did the body mass index and the weight of the uterus. Complications were not significantly different. The robot TLH group had significantly less blood loss and lower rehospitalisation and reoperation rates.

Conclusions: This study compares conventional TLH with robot assisted TLH and shows shorter operating times, less blood loss and lower rehospitalisation and reoperation rates in the robot TLH group.

Background: A Spigelian hernia is a rare hernia through the Spigelian fascia between the rectus muscle and the semilunar line. This hernia is well known in surgery. Symptoms vary from insidious to localised pain, an intermittent mass and/or a bowel obstruction.

Results: The Spigelian hernia is poorly known in gynaecology. Spigelian hernias may be causally related to secondary trocar insertion. This review is written to increase awareness in gynaecology and is illustrated by a case report in which the diagnosis was missed for 4 years even by laparoscopy. Smaller hernias risk not to be diagnosed and will thus not be treated. Even larger Spigelian hernias might not be recognised and treated appropriately.

Conclusions: The gynaecologist should consider a Spigelian hernia in women with localised pain in the abdominal wall lateral of the rectus muscle some 5 cm below the umbilicus. Smaller hernias can be closed by laparoscopy without a mesh. Larger hernias require a mesh repair.