Facts Views and Vision in ObGyn最新文献

Background: The advantages and disadvantages of Robotic Laparoscopic Surgery (RLS) compared to other minimally invasive surgical approaches are debated in the literature.

Objective: To evaluate the learning curves (LC) and their assessment methods for Robotic Laparoscopic Surgery (RLS) and Laparoscopic Surgery (LPS) in gynaecologic procedures.

Materials and methods: A systematic review of the literature was performed including the English language observational or interventional studies reporting the absolute number of procedures needed to achieve competency in RLS and LPS gynaecologic procedures, along with an objective and reproducible LC assessment method.

Main outcome measures: Number of procedures needed to achieve competency in RLS and LPS and LC assessment methods were extracted from included studies.

Results: Six studies with a total of 545 women were included. Several surgical procedures and methods for LC assessment were assessed in the included studies. For radical hysterectomy, bilateral salpingo-oophorectomy and lymph node dissection, the minimum number of procedures required to reach the LC was smaller in RLS than LPS in two studies out of four. For sacrocolpopexy, the number of procedures required to reach the LC was lower in RLS and LPS in one study out of two.

Conclusion: RLS learning curve was reported to be quicker than that of LPS for radical hysterectomy, bilateral salpingo-oophorectomy and lymph node dissection. However, a standardised and widely accepted method for LC assessment in endoscopic surgery is needed, as well as further randomised clinical trials, especially involving inexperienced surgeons.

What is new?: This study may be the first systematic review to evaluate the LCs and their assessment methods for RLS and LPS in gynaecologic procedures.

Background: Current evidence on the role of macro- and micronutrients in the aetiopathogenesis of endometriosis is controversial.

Objectives: In this systematic review, we aimed to investigate the effect of macronutrients, dairy products, fruits, and vegetables on the occurrence and progression of endometriosis.

Materials and methods: A systematic literature review of eligible articles retrieved from medical databases, including PubMed, Cochrane, and Academic Search, was performed from inception to May 2023.

Main outcome measures: The role of nutritional diet effects in endometriosis.

Results: Our search yielded 12 studies, including five prospective cohort trials and seven case-control studies. The analysis of this literature supports the idea that processed and unprocessed red meat increases the risk of endometriosis, while no conclusive evidence exists about the effects of other protein sources on the disease. Studies on total fat consumption, including monounsaturated, polyunsaturated, saturated, and trans-unsaturated fats, do not suggest a definitive association with endometriosis. Green leafy vegetables and fresh fruit consumption may reduce the risk of endometriosis. Furthermore, the evidence regarding fibre consumption is not conclusive. Dairy products were found to have a risk-reducing effect on the disease. However, there was no consensus about the role of vitamin D in endometriosis.

Conclusions: The certainty of the relationship between endometriosis and outcomes of nutritional factors was "very low" to "low," which limits current literature from being applied for conclusive interpretations. Further large-scale randomised trials and consequent meta-analyses are recommended for high-level evidence.

What is new?: This article presents an overview of evidence-based studies on the relationship between endometriosis and macronutrients. In addition, the possible influence of other nutritional variables on the development of endometriosis and the limitations of nutritional studies.

Background: The Adiana® Permanent Contraception System was a hysteroscopic tubal occlusion device but was withdrawn from the market in 2012.

Objective: To evaluate the safety, feasibility and efficacy of the Adiana hysteroscopic tubal occlusion.

Materials and methods: A prospective observational multicentre cohort study of 300 women undergoing hysteroscopic sterilisation using the Adiana® was conducted in the Netherlands between 2009 and 2012. All procedures were performed using the same study protocol. Three months after bilateral placement a hysterosalpingography (HSG) was performed to confirm tubal occlusion. In 2018-2020 follow-up questionnaires were sent to all women.

Main outcome measures: The primary outcome was the success rate of the Adiana tubal occlusion technique. Successful tubal occlusion was defined as an uneventful procedure with occluded fallopian tubes according to the HSG after 3 months. Secondary outcomes were the success rate of the device placement, the number of complications during placement and the pregnancy rate.

Results: Bilateral placement of Adiana devices was achieved in 93.5% of cases. Bilateral confirmed occlusion by HSG was accomplished in 87.9% of cases with successful Adiana placement. This was 77.1% in the intention-to-treat group. Complications and side effects were reported in 4.4% of women. The pregnancy rate was 3.6% in women with proven bilateral tubal occlusion.

Conclusion: Hysteroscopic tubal occlusion using the Adiana technology is associated with a pregnancy rate of 3.6%. Although this technology was removed from the commercial market, this evaluation of the Adiana technology could provide useful information for the development of potential new, more effective hysteroscopic tubal occlusion devices.

What’s new?: Hysteroscopic tubal occlusion techniques are no longer available on the market. This evaluation of Adiana could provide useful information for the development of potential new hysteroscopic tubal occlusion devices.

Background: To decrease the risk of unsuspected malignancies disseminating, several studies have shown the safety of using a containment bag to limit tissue dissemination during manual or power morcellation. Furthermore, in 2020, the FDA recommended performing laparoscopic power morcellation for myomectomy or hysterectomy only within a tissue containment system.

Objective: To show step-by-step a new surgical technique using vaginal power morcellation within an endoscopic pouch without adding or extending other incisions.

Materials and methods: Video article describing vaginal power morcellation.

Results: To perform power morcellation through vaginal introit, additional operative time was only 13 minutes.

Conclusions: Vaginal power morcellation using a contained bag system is technically feasible and efficient. Furthermore, it may prevent intraperitoneal dissemination of tissue fragments whilst minimising the need for additional surgical incisions.

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.