Facts Views and Vision in ObGyn最新文献

Background: Fortunately, interstitial pregnancies are a rare early pregnancy presentation, yet they can be challenging to managed and are associated with a high risk of intra-abdominal haemorrhage. Once detected, surgical laparoscopic resection can be the preferred management method for both patient safety and for definitive treatment.

Objective: The video presents a new technique for laparoscopic resection of an interstitial pregnancy which enables the procedure to be effectively bloodless.

Materials and methods: We report on a new technique for laparoscopic cornual resection. As shown in the video, staying in the marginal zone may result in the enblock resection of the gestational sac. Using meticulous applications of bipolar energy and cutting with scissors in the marginal zone, the operation may be completed with almost no blood loss and minimal damage to the adjacent healthy myometrium.

Results: The operation lasted 30 min with almost no blood loss. The patient had an uneventful recovery and was discharged on the first postoperative day.

Conclusions: Staying in the marginal zone during dissection permits even less experienced laparoscopists to complete laparoscopic cornual resection with minimal blood loss concomitantly with minimal trauma to the adjacent myometrium.

Background: Technological advances in visual systems have contributed to overcoming the limitations in spatial perception of minimally invasive techniques. To date, there is a lack of literature on the advantages of 3D vision systems over 4K in laparoscopic surgery, although benefits have been observed in the training setting.

Objectives: To compare operating times, perioperative outcomes, and task achievement using 3D and 4K vision systems for vaginal cuff closure performed by residents during total laparoscopic hysterectomy (TLH). All surgeons in training have obtained the Gynaecological Endoscopic Surgical Education and Assessment (GESEA) certificate.

Materials and methods: This is a prospective randomised trial (NCT04637022). Women undergoing total hysterectomies for benign conditions between January 2021 and November 2023 were enrolled in the study. Vaginal cuff closures were performed by surgeons in training who had obtained the second level of the GESEA programme certificate.

Results: Fifty-four patients were enrolled. There were no statistically significant differences in time between 3D and 4K vision for vaginal cuff closure (p=0.918). No statistically significant differences were observed for mean estimated blood loss (EBL) (overall: 62.85 ± 22.73mL; 3D: 65 ± 24.83mL; 4K: 61.11 ± 21.18; p=0.556) and median hospital stay (p=0.234). Three non-severe intraoperative complications in the 3D group (p=0.048) and three postoperative complications in the entire cohort (p=0.685) were reported.

Conclusions: The operating time for vaginal cuff closure performed by trainee surgeons is similar when comparing 3D vision during conventional laparoscopy and 4K vision systems. The choice of surgical vision systems may be guided by a cost analysis and surgeon preferences.

What is new?: Substantial evidence is lacking regarding the advantages of incorporating 3D vision into standard laparoscopy for gynaecological surgery. This research seeks to assess whether the 3D visual system can provide benefits as compared to 4K visualisation during laparoscopic vaginal cuff closure performed by surgeons in training within the GESEA 2 certification programme.

Adhesions are recognised as one of the most common complications of abdominal surgery; their diagnosis and prevention remains a significant unmet need in surgical therapy, affecting negatively a patient's quality of life and healthcare budgets. In addition, postoperative pelvic adhesions pose a high risk of reduced fertility in women of childbearing age. These 2023 Global Recommendations on Adhesion Prevention in Gynaecological Laparoscopic Surgery provide agreed-upon statements to guide clinical practice, with the ultimate goal of improving patient outcomes.

Background: The treatment of endometriosis and adenomyosis requires a complex, multidisciplinary approach. Some centres have established multidisciplinary teams (MDT) and regular meetings. There are currently no international data or recommendations.

Objectives: To examine existing MDT meetings and define consensus recommendations to support implementation and conduct.

Materials and methods: Online questionnaires were sent through the European Endometriosis League (EEL) based on a Delphi protocol. After a literature review and assessment of existing MDT meetings, essential aspects for consensus statements were identified. The consensus statements were evaluated using a 5-point Likert scale with the possibility to modify them. Results were analysed between rounds and reported to the respondents. Consensus, defined as ≥70% agreement, concluded the Delphi process when achieved in the majority of statements.

Main outcome measures: Prevalence and type of existing MDT meetings and recommendations.

Results: In round 1, 69 respondents participated, with 49.3% (34) having an MDT meeting at their institutions, of which 97% are multidisciplinary. 50 % meet once a month and 64.7% indicated that less than 25% of their patients are discussed. Throughout the three rounds, 47 respondents from 21 countries participated. During the process, 82 statements were defined, with an agreement of 92.7% on the statements.

Conclusions: This study assessed existing MDT meetings for endometriosis and adenomyosis and developed recommendations for their implementation and conduct. The consensus group supports the strengths of MDT meetings, highlighting their role in offering guideline-based, multidisciplinary, and personalised care.

What is new?: This study presents the first international data and recommendations on MDT meetings for endometriosis and adenomyosis.

Background: Despite discouragement from many scientific societies, routine preoperative testing remains a common practice. Minor gynaecological surgery, being widely performed in everyday practice, represents an opportunity for implementing cost-reduction policies by avoiding unnecessary diagnostic assessments.

Objectives: To assess whether performing routine preoperative blood tests affects postoperative complications and cost-effectiveness in patients undergoing minor gynaecological surgery.

Materials and methods: An interim subgroup analysis of a retrospective study conducted by Fondazione Policlinico Gemelli (Rome) and Azienda Sanitaria Universitaria Friuli Centrale (Udine) was performed. Patients who underwent surgery under general anaesthesia were included. The studied population was divided based on the preoperative work up. Clinical data, surgical features and complications were collected.

Main outcome measures: Intraoperative and postoperative complications, healthcare expenditure in two groups.

Results: Subgroup analysis included 1191 patients in Centre A (Rome) who underwent routine complete preoperative tests and 500 patients in Centre B (Udine), who underwent exams only if indicated. Population characteristics were similar in two groups. Postoperative complications were observed in 1.2% and 1.4% of cases in Group A and Group B, respectively (p=0.70). Severe complications occurred in 0.3% of cases in Group A and 0.4% in Group B. Group B showed a cost saving of approximately 70 Euros per procedure (p < 0.001).

Conclusions: Preliminary data indicate that routine perioperative assessment did not reduce complication rates, hospital readmissions or surgical reinterventions. Given the high number of procedures, performing specific preoperative tests only when indicated may result in significant cost reduction.

What is new?: This study selectively highlights the potential benefits to overall public health expenditure that could be achieved through stricter adherence to guidelines on preoperative assessment in minor gynaecological surgery.

Background: Uterine scar defect (also called uterine niche or isthmocele) associated to retained products of conception (RPOC) is an uncommon occurrence following caesarean section. Typically, the primary indicator is abnormal vaginal bleeding, and an accurate diagnosis can be established through ultrasound evaluation. Several surgical and endoscopic treatments have been described.

Objectives: To show a step-by-step video of combined hysteroscopic and laparoscopic approach to perform isthmocele repair in a patient with caesarean scar defect and RPOC.

Materials and methods: We report a case of a 34-year-old patient who was referred to our Digital Hysteroscopic Clinic (DHC) for abnormal vaginal bleeding and persistent pelvic pain, three months after a caesarean section. A single-step diagnostic approach through transvaginal ultrasound and diagnostic hysteroscopy revealed the presence of an isthmic uterine niche within the caesarean scar area, containing a poorly vascularised heterogeneous hyperechoic focal mass measuring 33x11x33 millimetres.

Main outcome measures: Removal of RPOC and surgical complications.

Results: All retained placental tissue was removed and the uterine wall defect was corrected. No complications occurred and the patient was discharged two days after the procedure. Patient was asymptomatic at 3 months follow up and ultrasound and hysteroscopy showed a reconstituted uterine wall.

Conclusion: An integrated hysteroscopic and laparoscopic approach seems to be an effective conservative method to remove RPOC and perform isthmocele repair with optimal surgical results.

Background: A uterine niche after caesarean section may play a role in secondary infertility. The transvaginal approach is a newly developed minimally invasive surgical technique for repairing a uterine isthmocele.

Objectives: To report on the feasibility, effectiveness, and safety of the transvaginal uterine niche repair. The technique is demonstrated in a live-surgery video.

Materials and methods: A retrospective chart review involving all patients with secondary infertility who underwent a transvaginal uterine niche repair in Ziekenhuis Oost-Limburg between August 2019 and July 2022 was conducted.

Main outcome measures: We compared the pre- and postoperative residual myometrial thickness as a primary surgical outcome measurement. The pregnancy ratio and the peri- and postoperative complications were also reported.

Results: A total of 26 patients underwent a transvaginal uterine niche repair with an average operation time of 44 minutes. No major surgical complications were reported. 23 patients (88%) had good postoperative myometrial integrity, while 3 patients had a partial or complete postoperative recurrence of the uterine niche. The average pre- and postoperative myometrial thicknesses were 1.6 mm and 6.4 mm respectively. 64% of patients desiring pregnancy became pregnant after the transvaginal niche repair. There were no obstetric complications reported.

Conclusions: A transvaginal approach is a safe and effective technique for uterine niche repair. It offers good results in re-establishing myometrial integrity and may favour fertility outcomes. It represents a valid minimal invasive procedure for patients with a very thin residual myometrial thickness and secondary infertility without leaving a visual scar.

Uterine fibroids are the most common benign tumours of the female reproductive tract and can cause a range of symptoms including abnormal uterine bleeding, pain, pressure symptoms and subfertility. Surgery may be required for some symptomatic fibroids via abdominal or transvaginal routes. The European Society for Gynaecological Endoscopy Uterine Fibroids Working Group developed recommendations based on the best available evidence and expert opinion for the surgical treatment of uterine fibroids. In this first part of the recommendations, abdominal approaches to surgical treatment of fibroids including laparoscopic, robot- assisted and open myomectomy are described.

Background: Inguinofemoral lymphoceles are a common postoperative complication after inguinofemoral lymphadenectomy (LNE) and a challenge for patients as well as physicians. We report here our preliminary experience in the surgical management of a recurrent lymphocele using indocyanine green (ICG) detection, followed by robotic-assisted closure of the lymphatic leaks.

Objectives: The aim of this article is to illustrate the surgical steps of ICG-assisted detection of inguinal lymphatic leaks and their surgical treatment by means of robot-assisted suturing. Furthermore, the feasibility of the approach will be evaluated.

Materials and methods: A 59-year-old woman with locally advanced squamous cell carcinoma of the vulva and previous conventional bilateral inguinofemoral LNE presented with symptomatic therapy-resistant lymphoceles in the groin. After a lengthy and frustrating course of standard therapy, she was offered the off-label option surgical treatment with ICG detection and subsequent robot-assisted ligation of the leaks, using the Da Vinci robotic system™.

Main outcome measures: Perioperative data, specific aspects of the surgical approach specifics, objective and subjective outcomes of the new approach.

Results: The procedure was performed as planned, with no intraoperative complications or device-related issues. The postoperative course was uneventful, and the patient developed no further lymphoceles.

Conclusion: Visualisation of the leakage by ICG combined with minimally invasive robotic-assisted laparoscopy is a promising therapy option. The pictures and videos demonstrate our experience in regard of the safety, feasibility, and usefulness of this procedure. Further studies will be needed, to prove the absolute efficacy of the technique and express a general recommendation in regard of this approach for the treatment of inguinofemoral lymphoceles.