Perceptions of surgical specialists in general surgery, orthopaedic surgery, urology and gynaecology on teaching endoscopic surgery in The Netherlands

BACKGROUND

Specific training in endoscopic skills and procedures has become a necessity for profession with embedded endoscopic techniques in their surgical palette. Previous research indicates endoscopic skills training to be inadequate, both from subjective (resident interviews) and objective (skills measurement) viewpoint. Surprisingly, possible shortcomings in endoscopic resident education have never been measured from the perspective of those individuals responsible for resident training, e.g. the program directors. Therefore, a nation-wide survey was conducted to inventory current endoscopic training initiatives and its possible shortcomings among all program directors of the surgical specialties in the Netherlands.

METHODS

Program directors for general surgery, orthopaedic surgery, gynaecology and urology were surveyed using a validated 25-item questionnaire.

RESULTS

A total of 113 program directors responded (79%). The respective response percentages were 73.6% for general surgeons, 75% for orthopaedic surgeon, 90.9% for urologists and 68.2% for gynaecologists. According to the findings, 35% of general surgeons were concerned about whether residents are properly skilled endoscopically upon completion of training. Among the respondents, 34.6% were unaware of endoscopic training initiatives. The general and orthopaedic surgeons who were aware of these initiatives estimated the number of training hours to be satisfactory, whereas the urologists and gynaecologists estimated training time to be unsatisfactory. Type and duration of endoscopic skill training appears to be heterogeneous, both within and between the specialties. Program directors all perceive virtual reality simulation to be a highly effective training method, and a multimodality training approach to be key. Respondents agree that endoscopic skills education should ideally be coordinated according to national consensus and guidelines.

CONCLUSIONS

A delicate balance exists between training hours and clinical working hours during residency. Primarily, a re-allocation of available training hours, aimed at core-endoscopic basic and advanced procedures, tailored to the needs of the resident and his or her phase of training is in place. The professions need to define which basic and advanced endoscopic procedures are to be trained, by whom, and by what outcome standards. According to the majority of program directors, virtual reality (VR) training needs to be integrated in procedural endoscopic training courses.

Intra-uterine adhesions and fertility outcome: how to optimize success?

PURPOSE OF REVIEW

To review the etiology, diagnosis, and clinical manifestations of intra-uterine adhesions and to address treatment with a specific focus on fertility outcome.

RECENT FINDINGS

Intra-uterine adhesions can cause recurrent pregnancy loss and infertility. The gravid or recently postpartum uterus is particularly susceptible to adhesion formation following instrumentation. While sonohysterography and hysterosalpingography are useful as screening tests of intra-uterine adhesions, hysteroscopy remains the mainstay of diagnosis and treatment. Hysteroscopic lysis of adhesions with scissors, electrosurgery, or laser can restore the size and shape of the endometrial cavity. Significantly obliterated cavities may require multiple procedures to achieve a satisfactory anatomical result. Postoperative mechanical distention of the endometrial cavity and hormonal treatment to facilitate endometrial regrowth appear to decrease the high rate of adhesion reformation. Newer antiadhesive barriers may also prevent the recurrence of intra-uterine adhesions. Endometrial development can remain stunted due to a scant amount of residual functioning endometrium and fibrosis. Potential pregnancy complications, especially placenta accreta, after the treatment of intra-uterine adhesions should be anticipated and discussed with the patient.

SUMMARY

Diagnosis and treatment of intra-uterine adhesions are integral to the optimization of fertility outcomes. Favorable results in terms of pregnancy and live birth rates can be expected after hysteroscopic adhesiolysis.

Laparoscopy compared with laparoscopically guided minilaparotomy for large adnexal masses: a randomized controlled trial

OBJECTIVE

To address the efficacy in terms of intraperitoneal spillage of laparoscopically guided minilaparotomy compared with operative laparoscopy for large adnexal cysts.

METHODS

A randomized controlled trial was carried out at a tertiary referral center from January 2005 to September 2006. Sixty eligible patients affected by nonendometriotic adnexal cysts with diameter between 7 and 18 cm were randomly assigned to either operative laparoscopy or laparoscopically guided minilaparotomy.

RESULTS

The relative risk for intraperitoneal spillage among women treated with laparoscopy was 5.55 (95% confidence interval 1.88-16.33). Operative times were significantly shorter in patients who underwent laparoscopically guided minilaparotomy. Surgical difficulty was significantly higher in patients treated with laparoscopy. However, postoperative stay was shorter.

CONCLUSION

Laparoscopically guided minilaparotomy, when compared with laparoscopy, is able to reduce intraperitoneal spillage in patients with presumably benign large adnexal masses, with minimal increase in patient short- and long-term discomfort. Because data regarding the importance of intraperitoneal spillage during surgery for benign and malignant pathologies, as well as rupture rates during traditional laparotomy, are scarce, traditional laparotomy still represents the standard treatment. In women desiring a minimally invasive strategy for large cysts, laparoscopically guided minilaparotomy should be considered.

CLINICAL TRIAL REGISTRATION

Australian Clinical Trials Registry, www.actr.org.au, ACTR N012607000241437,

LEVEL OF EVIDENCE

I.

A comparison of urinary complications following total laparoscopic radical hysterectomy and laparoscopic pelvic lymphadenectomy to open abdominal surgery

OBJECTIVE

The objective of this study was to compare total laparoscopic radical hysterectomy (TLRH) and laparoscopic pelvic lymphadenectomy (LPS) to total abdominal radical hysterectomy (TARH) and pelvic lymphadenectomy (LPT) in terms of urinary tract lesions and postoperative urinary retention.

METHODS

Starting in 2004, we treated all early stage cervical cancer patients with TLRH and LPS. The control group for this analysis was a historical cohort of patients treated with TARH+LPT. Within the TLRH+LPS group, we assessed whether the width of parametrial tissue removed was a risk factor for urinary tract injuries or postoperative urinary retention.

RESULTS

Fifty women were included in the TLRH+LPS group and forty-eight were included in the TARH+LPT group. There were no conversions from laparoscopy to laparotomy. There was no statistically significant difference in intraoperative urinary complications between the groups. Four (8%) intraoperative urinary tract injuries in the LPS (3 cystotomies and 1 ureteral lesions all repaired laparoscopically) and 2 (4.2%) in the LPT group (2 cystotomies) occurred (p=0.68). Similarly, there was no statistically significant difference in postoperative urinary complications between groups. Urinary postoperative complications were: 1 (2%) ureterovaginal and 1 vesicovaginal fistulas, 1 delayed ureteric fistula in LPS group vs. 0 in LPT group (p=0.24). Urinary retention was complained by 7 (14%) and 7 (14.6%) patients in LPS and LPT groups respectively (p=1.00). The average width of parametrial tissue removed in the LPS group was 32.2+14.0 mm in patients with vs. 39.5+13.6 mm in patients without urinary complications (p=0.11).

CONCLUSIONS

A laparoscopic approach is comparable to the laparotomy in terms of urinary lesions and postoperative retention. The width of parametrium removed does not affect the risk of urinary lesions or postoperative retention.

Isobaric gasless laparoscopy versus minilaparotomy in uterine myomectomy: a randomized trial

BACKGROUND

Isobaric gasless laparoscopy and minilaparotomy have been used as more recent minimally invasive approaches to myomectomy. This randomized trial aimed to compare the surgical and immediate postoperative outcomes for myomectomy performed by isobaric gasless laparoscopy with those for minilaparotomy.

METHODS

A total of 100 patients with symptomatic uterine myomas requiring myomectomy were randomly allocated to the gasless laparoscopy group or the minilaparotomy group. The randomization procedure was based on a computer-generated list. The primary outcome was a comparison of the discharge times between the two procedures. A power calculation verified that more than 26 patients for each group was necessary to detect a difference of more than 24 h in discharge time with an alpha error level of 5% and a beta error of 80%. Continuous outcome variables were analyzed using the Student's t-test. Discrete variables were analyzed with the chi-square test or Fisher's exact test. A p value less than 0.05 was considered statistically significant.

RESULTS

The mean discharge time was longer for minilaparotomy than for gasless laparoscopy (98.4 +/- 1.4 vs 52.8 +/- 1.6 h; p < 0.001). Gasless laparoscopy resulted in shorter times for canalization (21.6 +/- 1.1 vs 32 +/- 1.3 h; p < 0.05) and surgery (79.5 +/- 25.1 vs 103.5 +/- 24.9 min; p < 0.001). The intraoperative blood loss was less with gasless laparoscopy (154.2 +/- 1.2 vs 188.6 +/- 1.3 ml; p < 0.001). No intraoperative complications occurred, and no case was returned to the theater in either group. No conversion to standard laparotomy was necessary.

CONCLUSIONS

Isobaric gasless laparoscopy and minilaparotomy can be suitable options for uterine myomectomy. Several surgical and immediate postoperative outcomes were significantly better in the gasless laparoscopy group than in the minilaparotomy group. However, further controlled prospective studies are required to confirm the results.

Combined vaginal-laparoscopic-abdominal approach for the surgical treatment of rectovaginal endometriosis with bowel resection: a comparison of this new technique with various established approaches by laparoscopy and laparotomy

BACKGROUND

A new combined vaginal-laparoscopic-abdominal approach for rectovaginal endometriosis allows intraoperative digital bowel palpation to assess bowel infiltration and prevents unnecessary bowel resections. This technique was compared to various established approaches where bowel resection was indicated by clinical symptoms and imaging results only.

METHODS

Patients operated for rectovaginal endometriosis with endometriotic bowel involvement between March 2002 and April 2006 at the gynecological department Charité, Berlin, Germany were included. Bowel involvement was suspected by clinical symptoms, clinical examination, and/or results of imaging techniques. The study group (SG) was operated by the combined vaginal-laparoscopic-abdominal approach (n = 30) and the control group (CG) (n = 18) by laparoscopy (n = 4), laparotomy (n = 3), laparoscopy followed by laparotomy for bowel resection (n = 8) or laparoscopy followed by vaginal bowel resection (n = 3). In all cases histopathology was performed.

RESULTS

The study group and the control group were comparable regarding age, body mass index, symptoms, American Society for Reproductive Medicine (ASRM) classification, colorectal operative procedures, operating times, length of the resected bowel specimen, and concomitant surgical procedures. However, only in the CG were protective stomas required (p = 0.047). There were significantly less complications in the SG (p = 0.027). No patient experienced leakage of anastomosis. Bowel involvement by endometriosis was confirmed by histopathology in the SG in all cases whereas in the CG only in 16/18 (88.9%) cases. Hospitalization time was significantly shorter in the SG. Rehospitalizations were necessary only in the CG to repair one rectovaginal fistula and to reverse three stomas.

CONCLUSIONS

With the presented technique of a combined vaginal-laparoscopic-abdominal surgical procedure for rectovaginal endometriosis, we showed that the complication rate, rehospitalization rate, and hospitalization time were significantly lower than in the patients of the CG. Furthermore, the combined vaginal-laparoscopic-abdominal technique allowed better evaluation of the invasiveness of the endometriotic lesion and avoided unnecessary bowel surgery.

Bowel endometriosis: presentation, diagnosis, and treatment

Bowel endometriosis opens a new frontier for the gynecologist, as it forces the understanding of a new anatomy, a new physiology, and a new pathology. Although some women with bowel endometriosis may be asymptomatic, the majority of them develop a variety of gastrointestinal complains. No clear guideline exists for the evaluation of patients with suspected bowel endometriosis. Given the fact that, besides rectal nodules, bowel endometriosis can not be diagnosed by physical examination, imaging techniques should be used. Several techniques have been proposed for the diagnosis of bowel endometriosis including double-contrast barium enema, transvaginal ultrasonography, rectal endoscopic ultrasonography, magnetic resonance imaging, and multislice computed tomography enteroclysis. Medical management of bowel endometriosis is currently speculative; expectant management should be carefully balanced with the severity of symptoms and the feasibility of prolonged follow-up. Several studies demonstrated an improvement in quality of life after extensive surgical excision of the disease. Bowel endometriotic nodules can be removed by various techniques: mucosal skinning, nodulectomy, full thickness disc resection, and segmental resection. Although the indications for colorectal resection are controversial, recent data suggest that aggressive surgery improves symptoms and quality of life.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to describe the varied appearance of bowel endometriosis, recall that it is difficult to diagnose preoperatively, and explain that surgical treatment offers the best treatment in symptomatic patients through a variety of surgical techniques which is best accomplished with a team approach.

Uterine rupture during pregnancy soon after a laparoscopic adenomyomectomy

Although laparoscopic adenomyomectomy may be a possible risk factor for uterine rupture in subsequent pregnancy, few reports have described it. A 35-year-old woman became pregnant 1 month after laparoscopic adenomyomectomy. At the 28th week, uterine contraction occurred, leading to intravenous ritodrine infusion. Severe abdominal pain and a non-reassuring fetal heart rate occurred abruptly and an emergency cesarean section was carried out. The uterus ruptured at the site of previous surgery of the uterine body, which was reconstructed. The mother and the infant did well postoperatively. We report the second case of uterine rupture during pregnancy subsequent to laparoscopic adenomyomectomy. A history of adenomyomectomy and a short interval to subsequent pregnancy may be risk factors for uterine rupture. (Reprod Med Biol 2007; 6: 175-177).

Primer on risk management for the gynaecological laparoscopist

The gynaecologist practising operative laparoscopy should be seen as part of a team that actively promotes patient safety, minimizing risks and optimizing outcomes. Building a culture of safety which focuses on proactive initiatives to manage risk and remove individual 'blame' should be an integral part of any operative laparoscopy unit. Thus, when adverse clinical incidents or outcomes occur, reporting of such events is encouraged and seen to be acceptable behaviour within the framework of complete patient care. By recognizing and analysing adverse outcomes, the team can develop strategies to prevent or manage a recurrence of such events. Implementing systems or solutions to prevent harm to patients is the cornerstone of any risk management programme. In this review, we discuss the development and implementation of risk management strategies in the clinical setting, and in particular how this applies to operative laparoscopy.

The role of robotic surgery in gynecology

PURPOSE OF REVIEW

To discuss the recent experience and feasibility of integrating robot-assisted technology into minimally invasive gynecologic surgery. Current applications in gynecology and their associated outcomes will be analyzed.

RECENT FINDINGS

Since the late 1990s, the use of computer-assisted or robotic technology in minimally invasive gynecologic surgery has increased. Much of this experience revolves around the da Vinci surgical system, which was approved by the Food and Drug Administration for gynecologic applications in April 2005. The largest body of experience exists with robot-assisted laparoscopic hysterectomy, particularly those classified as American Association of Gynecologic Laparoscopists type IVE or Laparoscopic Supracervical Hysterectomy III. Other notable applications are in the areas of myomectomy, tubal reanastomosis, sacrocolpopexy, and cancer staging. Advantages of the robotic approach are the improved dexterity and precision of the instruments coupled with three-dimensional imaging. Limitations include the absence of haptic (tactile) feedback, bulkiness of the system, lack of vaginal access, and cost.

SUMMARY

Current evidence demonstrates the safety and feasibility of the robotic approach for gynecologic surgery. Experience is still in its infancy, however, and prospective trials are needed to compare the efficacy against conventional laparoscopy and to help determine not only who should be doing robotic-assisted surgery but also for which applications.

What is new in surgical treatment of vesicoureteric reflux?

In addition to conventional open surgery and endoscopic techniques, laparoscopic correction of vesicoureteric reflux, sometimes even robot-assisted, is becoming an alternative surgical treatment modality for this condition in a number of centres around the world. At least for a subgroup of patients laparoscopists are trying to develop new techniques in an effort to combine the best of both worlds: the minimal invasiveness of the STING and the same lasting effectiveness as in open surgery. The efficacy and potential advantages or disadvantages of these techniques are still under investigation. The different laparoscopic techniques and available data are presented.

The benefits of virtual reality simulator training for laparoscopic surgery

PURPOSE OF REVIEW

Virtual reality is a computer-generated system that provides a representation of an environment. This review will analyse the literature with regard to any benefit to be derived from training with virtual reality equipment and to describe the current equipment available.

RECENT FINDINGS

Virtual reality systems are not currently realistic of the live operating environment because they lack tactile sensation, and do not represent a complete operation. The literature suggests that virtual reality training is a valuable learning tool for gynaecologists in training, particularly those in the early stages of their careers. Furthermore, it may be of benefit for the ongoing audit of surgical skills and for the early identification of a surgeon's deficiencies before operative incidents occur. It is only a matter of time before realistic virtual reality models of most complete gynaecological operations are available, with improved haptics as a result of improved computer technology.

SUMMARY

It is inevitable that in the modern climate of litigation virtual reality training will become an essential part of clinical training, as evidence for its effectiveness as a training tool exists, and in many countries training by operating on live animals is not possible.

Transcervical sterilization

PURPOSE OF REVIEW

To discuss the methods for achieving success with currently available transcervical sterilization procedures for permanent female contraception.

RECENT FINDINGS

The transcervical approach has long been thought to be the optimal method for permanent female sterilization, with tubal access achieved by blind, direct (hysteroscopic) or indirect (radiological) techniques, and occlusion being achieved by chemical, mechanical, or thermal techniques. Some combination of these access and occlusion methods encompasses all the current procedures and two types predominate. Quinacrine sterilization is a procedure that is widely used in the developing world, while hysteroscopic procedures such as the Essure and Adiana procedures are either currently available or emerging as visually controlled, device-dependent methods for reliable transcervical sterilization that may be performed in an outpatient or office setting with minimal anesthesia and high patient acceptability. Other devices are used but have less supportive data for their continued use.

SUMMARY

Transcervical methods of female sterilization have good tubal access and occlusion rates, high patient acceptability, and can be performed in an outpatient setting. This combination of factors may offer significant advantages to traditional laparoscopic approaches and render them more cost-effective.

Uterine myomas: management

OBJECTIVE

To review the currently available literature regarding the current management alternatives available to women with uterine myomas.

DESIGN

Literature review of 198 articles pertaining to uterine myomas.

RESULT(S)

Many advances have been made in the management of uterine myomas. Watchful waiting; medical therapy; hysteroscopic myomectomy; endometrial ablation; laparoscopic myomectomy; abdominal myomectomy; abdominal, vaginal, and laparoscopic hysterectomy; uterine artery embolization; uterine artery occlusion; and focused ultrasound are now available.

CONCLUSION(S)

Many options are now available to women with uterine myomas. The presently available literature regarding the treatment of myomas is summarized.

Total laparoscopic hysterectomy: indications, techniques and outcomes

PURPOSE OF REVIEW

The indications, techniques and outcomes of laparoscopic associated hysterectomy and especially total laparoscopic hysterectomy are thoroughly reviewed.

RECENT FINDINGS

The original technique for total laparoscopic hysterectomy is detailed as it is still applicable. The total laparoscopic hysterectomy operation has not changed to any major degree over the past 15 years. The technique detailed works well and lessens the chance for a ureteral injury. Expansion of the technique has occurred in oncology. Evidence-based studies support the use of vaginal hysterectomy if possible over laparoscopic and abdominal hysterectomy. They also support a laparoscopic approach to hysterectomy over total abdominal hysterectomy.

SUMMARY

Despite evidence-based studies, gynecologic surgical specialists have been slow to adopt both laparoscopic and vaginal hysterectomy into their practice. This trend may increase in the near future. Adoption of laparoscopic associated hysterectomy has been extremely slow.

Safety, feasibility, and costs of outpatient laparoscopic extraperitoneal aortic nodal dissection for locally advanced cervical carcinoma

OBJECTIVE

To report on the safety, feasibility, and costs of outpatient laparoscopic extraperitoneal aortic lymph node dissection (LEPSS) for locally advanced cervical carcinoma.

METHODS

A retrospective analysis of all outpatient LEPSS procedures performed at our institution between August 2005 and February 2007 was performed. All patients with clinical stage IIB-IVA cervical carcinoma with no evidence of bulky aortic lymphadenopathy (>1.0 cm) on pre-operative computed tomography were offered the procedure. If present, pelvic nodal disease could not exceed greater than 1.5 cm. Records were reviewed for demographics, operative findings, complications, length of stay, and CT scan aortic nodal status. As a comparison, the average costs for outpatient LEPSS and outpatient CT, MRI, and PET scan at our institution were calculated.

RESULTS

A total of eighteen outpatient LEPSS procedures were identified. The median age was 49 (22-72). The median BMI was 29 (18-51). The median operative time was 108 min (60-135 min). The median aortic nodal count was 10 (5-20 nodes). The median blood loss was 25 ml (10-50 ml). There were no intraoperative complications. There was no conversion from a retroperitoneal to a transperitoneal approach. No patient required overnight hospitalization. One patient experienced a lymphocyst postoperatively. There was no delay in the initiation of chemoradiation for any of the patients with a median onset of 10 days from the date of surgery. At least 20% of the patients had one or more medical co-morbidities such as obesity, diabetes, hypertension, or a prior abdominal surgery. Occult aortic nodal metastasis was detected in 11% of the patients with a negative pre-operative CT scan. The average calculated costs at our institution for outpatient LEPSS was $5233 dollars versus $1520 dollars for CT scan, $4830 dollars for MRI and $5494 dollars for a PET scan.

CONCLUSIONS

To our knowledge this is the first reported experience of outpatient laparoscopic extraperitoneal aortic lymph node dissection for locally advanced cervical cancer. Outpatient LEPSS appears to be a safe and feasible procedure in the hands of an experienced surgeon, however further study is warranted. From a cost analysis perspective, outpatient LEPSS appears equivalent to PET scan and MRI, but is more expensive than CT scan.

Pregnancy Outcome After Transcervical Hysteroscopic Sterilization

BACKGROUND

Hysteroscopic, transcervical sterilization involves placement of microinserts in tubal ostia. As with any contraceptive method, pregnancy can occur. This case reports the outcome when pregnancy occurred after microinsert placement.

CASE

A multiparous woman presented at 16 weeks of gestation. Hysteroscopic sterilization was performed 2 years earlier, although a postprocedure hysterosalpingogram was not done to verify tubal occlusion. The patient had a normal-term pregnancy. Postpregnancy hysterosalpingogram revealed both microinserts were embedded in the uterine fundus and myometrium.

CONCLUSION

This case demonstrates how pregnancy can occur after hysteroscopic microinsert placement and details how it might be avoided.

Laparoscopic myomectomy for large myomas

The aim of this study was to assess the feasibility and efficacy of laparoscopic myomectomy (LM) for large myomas. A subpopulation of 51 patients with myomas 8 cm or larger in diameter was selected from 155 patients who underwent LM at Kangbuk Samsung Hospital from July 2003 to November 2006. The mean age of the patients was 34.9 +/- 5.6 yr, mean parity was 0.6 +/- 0.9, and 8 patients had a previous operative history. The most common operative indication was a palpable abdominal mass (24 patients, 47%). The mean operating time was 85.6 +/- 38.9 min, and the mean diameter of the largest myoma was 9.3 +/- 1.8 cm. The mean change in hemoglobin concentration was 2.1 +/- 1.2 g/dL. Histopathological diagnosis included 49 patients of leiomyoma (96.1%) and 2 patients of leiomyoma with adenomyosis (3.9%). Postoperatively, a transfusion was done in 7 patients, and a case of subcutaneous emphysema was noted. None of the operations was switched to laparotomy. With the newly-developed screw and the port placement system that was modified from the Choi's 4-trocar method to obtain better surgical vision, LM of large myomas proved to be one of the efficient and feasible methods.

Comparison of total laparoscopic and abdominal radical hysterectomy for patients with early-stage cervical cancer

OBJECTIVE

To compare intraoperative, pathologic, and postoperative outcomes of total laparoscopic radical hysterectomy with abdominal radical hysterectomy and pelvic lymphadenectomy for women with early-stage cervical cancer.

METHODS

We reviewed all patients who underwent total laparoscopic radical hysterectomy or abdominal radical hysterectomy and pelvic lymphadenectomy between 2004 and 2006.

RESULTS

Fifty-four patients underwent abdominal radical hysterectomy, and 35 underwent total laparoscopic radical hysterectomy. Mean age was 41.8 years, and mean body mass index 28.1. There was no difference in demographic or tumor factors between the two groups. Mean estimated blood loss was 548 mL with abdominal radical hysterectomy compared with 319 mL with total laparoscopic radical hysterectomy (P=.009), and 15% of patients who underwent abdominal radical hysterectomy required a blood transfusion compared with 11% who underwent total laparoscopic radical hysterectomy (P=.62). Mean operative time was 307 minutes for abdominal radical hysterectomy compared with 344 minutes for total laparoscopic radical hysterectomy (P=.03). On pathologic examination, there was no significant difference in the amount of parametrial tissue, vaginal cuff, or negative margins obtained. A mean 19 pelvic nodes were obtained during abdominal radical hysterectomy compared with 14 during total laparoscopic radical hysterectomy (P=.001). The median duration of hospital stay was significantly shorter for total laparoscopic radical hysterectomy (2.0 compared with 5.0 days, P<.001). For abdominal radical hysterectomy, 53% of patients experienced postoperative infectious morbidity compared with 18% for total laparoscopic radical hysterectomy (P=.001). There was no difference in postoperative noninfectious morbidity. There was no difference in return of urinary function.

CONCLUSION

Total laparoscopic radical hysterectomy reduces operative blood loss, postoperative infectious morbidity, and postoperative length of stay without sacrificing the size of radical hysterectomy specimen margins; however, total laparoscopic radical hysterectomy is associated with increased operative time.

Genital tuberculosis: an important cause of Asherman's syndrome in India

OBJECTIVE

To demonstrate the association between genital endometrial tuberculosis and Asherman's syndrome.

MATERIALS AND METHODS

A total of 28 women who underwent hysteroscopy with or without laparoscopy for suspected Asherman's syndrome from symptoms (amenorrhoea or oligomenorrhoea, and or primary or secondary infertility) and who were found to have genital tuberculosis on endometrial biopsy (histopathology or culture) or positive polymerase chain reaction (PCR) on endometrial aspirate or positive findings of tuberculosis on laparoscopy or hysteroscopy were enrolled in this retrospective study.

RESULTS

The mean age and parity were 26.5 years and 0.3, respectively. There was past history of TB in 67.8% women. All women had menstrual dysfunction, with oligomenorrhoea and hypomenorrhoea in 16 (57%) women and amenorrhoea in 12 (42.8%). All women had primary (n = 19, 67.8%) or secondary (n = 9, 32%) infertility. On hysteroscopy, there were various grades of adhesions in all women, with grade I in 17.8%, grade II in 28.5%, grade III in 28.5% and grade IV in 17.5% women. Only four women (14.3%) had open ostia, while others had bilateral (28.5%) or unilateral (21.3%) blocked ostia or inability to see ostia (28.5%). On laparoscopy performed on 18 women, there were varying grades of adhesions in 16 (88.8%) women, with beading (33.3%), tubercles (33.3%), caseation (11.1%) and tubo-ovarian masses (11.1%). The diagnosis of genital TB was made by histopathology (tuberculous granuloma) on endometrial biopsy in 28.6%, positive culture in 3.6%, positive polymerase chain reaction (PCR) in 46.4% and observation of tubercles, beading or caseation on laparoscopy in 17.8% or shaggy cavity with caseation on hysteroscopy in 3.6% women.

CONCLUSION

Genital tuberculosis appears to be an important and common cause of Asherman's syndrome in India, causing oligomenorrhoea or amenorrhoea with infertility.

To compare the efficacy of two doses of intraperitoneal bupivacaine for pain relief after operative laparoscopy in gynecology

AIM

To evaluate the effect of two doses of intraperitoneal bupivacaine administration for pain relief after operative gynecological laparoscopy.

DESIGN

Prospective randomized study.

MATERIALS AND METHODS

The study group comprised 52 women undergoing gynecological laparoscopic surgery. A dose of either 0.125% bupivacaine 10 ml (50 mg) or 0.25% bupivacaine (100 mg) was instilled intraperitoneally at the end of the procedure. Pain scores were recorded in the postoperative period on a scale of 0-10 at 2, 4, 6 and 8 h intervals after the surgery. Any other side effect and the time and dose of analgesia required were noted. The results were compared in the two groups.

RESULTS

One hundred milligrams of bupivacine provided pain relief for a longer duration (8 h), as compared to 50 mg of the drug (4-6 h). This difference was statistically significant. Analgesic requirement was also less in the 100 mg group.

CONCLUSION

One hundred milligrams of intraperitoneal bupivacaine is much better than 50 mg in relieving pain after laparoscopic surgery.

Laparoscopic 'drilling' by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome

BACKGROUND

Surgical ovarian wedge resection was the first established treatment for women with anovulatory polycystic ovary syndrome (PCOS) but was largely abandoned due to the risk of postsurgical adhesions and the introduction of medical ovulation induction with clomiphene and gonadotrophins. However, women with PCOS who are treated with gonadotrophins often have an over-production of follicles which may result in ovarian hyperstimulation syndrome (OHSS) and multiple pregnancies. Moreover, gonadotrophins, though effective, are costly and time-consuming requiring intensive monitoring. Surgical therapy with laparoscopic ovarian 'drilling' (LOD) may avoid or reduce the need for gonadotrophins or may facilitate their usefulness. The procedure can be done on an outpatient basis with less trauma and fewer postoperative adhesions than with traditional surgical approaches. Many uncontrolled observational studies have claimed that ovarian drilling is followed, at least temporarily, by a high rate of spontaneous ovulation and conception or that subsequent medical ovulation induction becomes easier.

OBJECTIVES

To determine the effectiveness and safety of laparoscopic ovarian drilling compared with ovulation induction for subfertile women with clomiphene-resistant PCOS.

SEARCH STRATEGY

We used the search strategy of the Menstrual Disorders and Subfertility Group.

SELECTION CRITERIA

We included randomised controlled trials of subfertile women with clomiphene-resistant PCOS who undertook laparoscopic ovarian drilling in order to induce ovulation.

DATA COLLECTION AND ANALYSIS

Sixteen trials were identified and nine were included in the review. All trials were assessed for quality criteria. The primary outcomes were live birth, ovulation and pregnancy rates and the secondary outcomes were rates of miscarriage, multiple pregnancy, ovarian hyperstimulation syndrome and cost.

MAIN RESULTS

There was no evidence of a difference in live birth or clinical pregnancy rate between LOD and gonadotrophins and the pooled odds ratios (OR) (all studies) were 1.04 (95% CI 0.59 to 1.85) and 1.08 (95% CI 0.69 to 1.71) respectively. Multiple pregnancy rates were lower with ovarian drilling than with gonadotrophins (1% versus 16%; OR 0.13, 95% CI 0.03 to 0.52). There was no evidence of a difference in miscarriage rates between the two groups (OR 0.81, 95% 0.36 to 1.86).

AUTHORS' CONCLUSIONS

There was no evidence of a difference in the live birth rate and miscarriage rate in women with clomiphene-resistant PCOS undergoing LOD compared to gonadotrophin treatment. The reduction in multiple pregnancy rates in women undergoing LOD makes this option attractive. However, there are ongoing concerns about long-term effects of LOD on ovarian function.

Laparoscopic entry: a review of techniques, technologies, and complications

OBJECTIVE

To provide clinical direction, based on the best evidence available, on laparoscopic entry techniques and technologies and their associated complications.

OPTIONS

The laparoscopic entry techniques and technologies reviewed in formulating this guideline include the classic pneumoperitoneum (Veress/trocar), the open (Hasson), the direct trocar insertion, the use of disposable shielded trocars, radially expanding trocars, and visual entry systems.

OUTCOMES

Implementation of this guideline should optimize the decision-making process in choosing a particular technique to enter the abdomen during laparoscopy.

EVIDENCE

English-language articles from Medline, PubMed, and the Cochrane Database published before the end of September 2005 were searched, using the key words laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. RECOMMENDATIONS AND SUMMARY STATEMENT: 1. Left upper quadrant (LUQ, Palmer's) laparoscopic entry should be considered in patients with suspected or known periumbilical adhesions or history or presence of umbilical hernia, or after three failed insufflation attempts at the umbilicus. (II-2 A) Other sites of insertion, such as transuterine Veress CO(2) insufflation, may be considered if the umbilical and LUQ insertions have failed or have been considered and are not an option. (I-A) 2. The various Veress needle safety tests or checks provide very little useful information on the placement of the Veress needle. It is therefore not necessary to perform various safety checks on inserting the Veress needle; however, waggling of the Veress needle from side to side must be avoided, as this can enlarge a 1.6 mm puncture injury to an injury of up to 1 cm in viscera or blood vessels. (II-1 A) 3. The Veress intraperitoneal (VIP-pressure </= 10 mm Hg) is a reliable indicator of correct intraperitoneal placement of the Veress needle; therefore, it is appropriate to attach the CO(2) source to the Veress needle on entry. (II-1 A) 4. Elevation of the anterior abdominal wall at the time of Veress or primary trocar insertion is not routinely recommended, as it does not avoid visceral or vessel injury. (II-2 B) 5. The angle of the Veress needle insertion should vary according to the BMI of the patient, from 45 degrees in non-obese women to 90 degrees in obese women. (II-2 B) 6. The volume of CO(2) inserted with the Veress needle should depend on the intra-abdominal pressure. Adequate pneumoperitoneum should be determined by a pressure of 20 to 30 mm Hg and not by predetermined CO(2) volume. (II-1 A) 7. In the Veress needle method of entry, the abdominal pressure may be increased immediately prior to insertion of the first trocar. The high intraperitoneal (HIP-pressure) laparoscopic entry technique does not adversely affect cardiopulmonary function in healthy women. (II-1 A) 8. The open entry technique may be utilized as an alternative to the Veress needle technique, although the majority of gynaecologists prefer the Veress entry. There is no evidence that the open entry technique is superior to or inferior to the other entry techniques currently available. (II-2 C) 9. Direct insertion of the trocar without prior pneumoperitoneum may be considered as a safe alternative to Veress needle technique. (II-2) 10. Direct insertion of the trocar is associated with less insufflation-related complications such as gas embolism, and it is a faster technique than the Veress needle technique. (I) 11. Shielded trocars may be used in an effort to decrease entry injuries. There is no evidence that they result in fewer visceral and vascular injuries during laparoscopic access. (II-B) 12. Radially expanding trocars are not recommended as being superior to the traditional trocars. They do have blunt tips that may provide some protection from injuries, but the force required for entry is significantly greater than with disposable trocars. (I-A) 13. The visual entry cannula system may represent an advantage over traditional trocars, as it allows a clear optical entry, but this advantage has not been fully explored. The visual entry cannula trocars have the advantage of minimizing the size of the entry wound and reducing the force necessary for insertion. Visual entry trocars are non-superior to other trocars since they do not avoid visceral and vascular injury. (2 B).

Progesterone receptor modulators and the endometrium: changes and consequences

Progesterone receptor modulators (PRMs) have been used for contraceptive research, as well as for treatment of fibroids, endometriosis and heavy or irregular menstrual bleeding. Long-term treatment with these compounds results in changes to the endometrium resulting in potential confusion in trying to characterize endometrial biopsies. A meeting was held to discuss the properties of PRMs, the effects of perturbed hormonal control of the endometrium and the need for further understanding of the biology of progesterone receptor action to facilitate the development of new PRMs. A panel of pathologists was convened to evaluate endometrial changes associated with a minimum of three months of chronic treatment with PRMs. Four different agents were used in the treatment regimens but the pathologists were blinded to treatment regimen or agent. The panel agreed that the endometrial biopsies did not fit into a classification of either proliferative or secretory endometrium but exhibited an unusual architecture that could be characterized as glandular dilatation. There was little evidence of mitosis, consistent with a proposed anti-proliferative effect of PRMs. The panel concluded that the biopsies did not reveal evidence of safety concern and that pathologists and investigators familiar with endometrial effects of chronic PRM exposure should consider working with pharmaceutical companies and regulatory agencies to develop standard descriptions of PRM-associated endometrial changes as well as the types of histologic changes that would signal a need for intervention.

Uterine artery occlusion: what is the evidence?

Symptomatic uterine fibroids are a relatively common gynecologic condition. In the past, fibroids were exclusively treated by myomectomy and/or hysterectomy. With the advent of uterine artery embolization or uterine artery occlusion, there now exist minimally invasive approaches to fibroid therapy especially for women in whom surgery is contraindicated or for those who wish to retain their uterus and possibly fertility. Fertility and pregnancy outcomes after these minimally invasive therapies are currently being evaluated.

Virtual hysteroscopy by multidetector computed tomography

Currently accepted techniques that evaluate the uterus and female reproductive system in the infertility workup algorithm include hysterosonography, hysteroscopy and hysterosalpingography. Based on high speed multidetector computed tomography (MDCT) which can acquire high-quality volumetric data of the pelvic region in a single brief scan, MDCT virtual hysteroscopy is proposed as a developing, non-invasive alternative diagnostic procedure for the evaluation of uterine pathology and other gynecologic disorders. Findings of the technique are illustrated.

Patients' preferences in the evaluation of postmenopausal bleeding

OBJECTIVE

To assess patients' preferences for diagnostic management of postmenopausal bleeding (PMB).

DESIGN

A structured interview.

SETTING

A teaching hospital with office hysteroscopy facilities.

POPULATION

Thirty-nine women with PMB and with a completed work-up including an office hysteroscopy.

METHODS

A structured interview was taken from 39 women who had had an office hysteroscopy in the diagnostic work-up for PMB. Women were informed about the probability of endometrial carcinoma versus benign disease and about advantages and disadvantages of different diagnostic strategies, i.e. expectant management after ultrasound or complete diagnostic work-up, including invasive procedures.

MAIN OUTCOME MEASURES

Women were informed about the probability of endometrial carcinoma versus benign disease and about advantages and disadvantages of different diagnostic strategies, i.e., expectant management after ultrasound or complete diagnostic work-up including invasive procedures. Women were asked to make a trade-off between different options.

RESULTS

Most women wanted to be 100% certain that carcinoma could be ruled out. Only 5% of the women were willing to accept more than 5% risk of false reassurance. If the risk of recurrent bleeding due to benign disease exceeded 25%, the majority of women would prefer immediate diagnosis and treatment of benign lesions.

CONCLUSION

Women with PMB are prepared to undergo hysteroscopy to rule out any risk on cancer. This finding implicates that the measurement of endometrial thickness with transvaginal ultrasound as a first-line test in the assessment of PMB should be reconsidered.

Innovations in contraception: a review

New forms of contraception have been developed to improve the safety and tolerability of contraceptive methods without compromising efficacy. The newest developments in contraception including low and ultra-low doses of estrogen, less-androgenic 19 nor-testosterone progestins, and the nonsteroidal progestin drospirenone, the Quick Start method to improve compliance of oral contraceptives, and the contraceptive transdermal patch, the vaginal estrogen-progestin ring, the levonorgestrel intrauterine system, and the hysteroscopic transcervical sterilization techniques are discussed.

Radiofrequency global endometrial ablation followed by hysteroscopic sterilization

STUDY OBJECTIVE

To describe the feasibility of performing Essure hysteroscopic sterilization immediately after NovaSure global endometrial ablation (GEA).

DESIGN

Descriptive feasibility study (Canadian Task Force classification III).

SETTING

Midwestern United States academic medical center.

PATIENTS

Twenty-five women (aged 35-49 years) with menorrhagia who elected GEA treatment and requested concurrent permanent sterilization.

INTERVENTIONS

NovaSure GEA followed immediately by Essure hysteroscopic sterilization. Patients returned 3 months after the procedure for hysterosalpingography (HSG) to document tubal occlusion.

MEASUREMENTS AND MAIN RESULTS

The inserts were placed successfully in all 25 patients; 21 returned for 3-month follow-up HSG, as recommended. Bilateral tubal occlusion was documented at 3 months in 19 patients (90%) and unilateral occlusion in 2 patients. Six-month postprocedural HSG in these 2 patients documented bilateral tubal occlusion. Hysterosalpingography was not performed in 4 patients. In all 21 patients with appropriate follow-up, complete occlusion was documented, and the ability to perform or interpret HSG was not affected by endometrial ablation.

CONCLUSION

Essure hysteroscopic sterilization can be safely performed after NovaSure GEA. Intrauterine synechiae do not appear to adversely affect the ability to perform HSG at 3 months or to document tubal occlusion.

Italian multicenter study on complications of laparoscopic myomectomy

STUDY OBJECTIVE

To study intraoperative and postoperative complications of laparoscopic myomectomy and patients' characteristics influencing this risk.

DESIGN

Prospective study, with a review of the patient records by the first author (Canadian Task Force classification II-2).

SETTING

Four Italian referral centers.

PATIENTS

The incidence and type of complications occurring in 2050 laparoscopic myomectomies undertaken from January 1998 through December 2004 were recorded.

INTERVENTIONS

The surgical technique, as well as the expertise of the operators, was the same for the 4 centers. Injection of vasoconstrictive agents was used in 37%. The serosa was always incised in a vertical fashion; mechanical enucleation of the myoma was completed whenever possible; suture was performed in 1 or 2 layers with deep and large stitches swaged to 1 or 0 polyglactin sutures that were tied intracorporeally or extracorporeally.

MEASUREMENTS AND MAIN RESULTS

Single or multiple myomectomies (n = 2050) for symptomatic myomas measuring at least 4 cm in diameter were performed. Most patients (48%) had more than 1 myoma, with a maximum of 15 per patient (myomas removed for patients: 2.26 +/- 1.8, mean +/- SD). Myoma size ranged from 1 to 20 cm (mean 6.40 +/- 2.6 SD). Myomas smaller than 4 cm were removed during myomectomy for larger ones. Total complication rate was 11.1% (225/2050 cases). Minor complications accounted for 9.1% (187/2050 cases) and major complications for 2.02% (38/2050 cases). The most serious events were hemorrhages (14 cases, 0.68%) requiring blood transfusions in 3 cases (0.14%); 10 postoperative hematomas (0.48%, one in the broad ligament and 9 in the myomectomy scar); 1 bowel injury (0.04%); 1 postoperative acute kidney failure (0.04%); and 2 unexpected sarcomas (0.09%). Failure to complete planned surgery occurred in 7 cases (0.34%). Two patients were readmitted for surgery (0.09%): 1 had a laparoscopic hysterectomy because of a severe blood loss, and the other had drainage of a hematoma in the broad ligament. After a follow-up period of 41.70 +/- 23.03 months (mean +/- SD), 386 (22.9%) patients conceived, with a pregnancy rate in patients wishing pregnancy of 69.8%; among them, 1 (0.26%) recorded spontaneous uterine rupture at 33 weeks gestation. Odds ratio computed to estimate the risk of complications in relation to the patient characteristics showed that the probability of complications significantly rises with an increase in the number (more than 3 myomas OR: 4.46, p <.001) and with the intramural (OR: 1.48, p <.05) or the intraligamentous location of myomas (OR: 2.36, p <.01) whereas the myoma size seems to influence particularly the risk of major complications (OR: 6.88, p <.001).

CONCLUSIONS

This is one of the largest series reported of laparoscopic myomectomy and the first focused on complications. The complication rate appears to be better than acceptable in comparison with complication rates reported after laparotomic myomectomies. Laparoscopic myomectomy, when performed by an experienced surgeon, can be considered a safe technique with an extremely low failure rate and good results in terms of pregnancy outcome.

Long-term complications of endometrial ablation: Cause, diagnosis, treatment, and prevention

At first, total endometrial ablation seemed extremely safe in the short term. However, as time passed, certain unique long-term complications became evident. The problem is that after this procedure, intrauterine scarring and contracture can occur. Any bleeding from persistent or regenerating endometrium behind the scar may be obstructed and cause problems such as central hematometra, cornual hematometra, postablation tubal sterilization syndrome, retrograde menstruation, and potential delay in the diagnosis of endometrial cancer. The incidence of these complications is probably understated because most radiologists and pathologists have not been educated about the findings to make the appropriate diagnosis of cornual hematometra and postablation tubal sterilization syndrome. This review will thoroughly discuss how to diagnose and treat these problems. Possible ways of preventing these long-term complications will also be discussed.

The use of a xenogenic barrier to prevent mesh erosion with laparoscopic sacrocolpopexy

STUDY OBJECTIVE

To assess the efficacy of a xenogenic barrier in preventing vaginal mucosal erosion and the use of a collagen-coated polypropylene mesh in preventing small bowel obstruction with laparoscopic sacrocolpopexy for the treatment of severe vaginal prolapse.

DESIGN

Prospective longitudinal study (Canadian Task Force classification II-1).

SETTING

Private urogynecology clinic.

PATIENTS

A total of 31 consecutive post-hysterectomy patients with severe apical vaginal prolapse (pelvic organ prolapse quantification [POP-Q] stages 2-4).

INTERVENTIONS

Laparoscopic sacrocolpopexy, in conjunction with other laparoscopic and/or vaginal procedures, was used to correct pelvic floor disease. A Y-shaped polyester multifilament mesh, with a resorbable collagen coating, was used for the implant. The inner surfaces of the Y-shaped synthetic mesh had porcine dermal strips attached to act as a buffer/barrier for the vaginal wall.

MEASUREMENTS AND MAIN RESULTS

A total of 29 (94%) of 31 patients were cured at 12 months (defined as POP-Q < stage II). There were no more failures in the 28 patients followed-up at 24 months. Two patients had recurrent apical prolapse (Point C = -1 and 0). There were no small bowel obstructions and no vaginal mesh erosions during the 2-year follow-up. There was significant improvement in the sexual and quality of life questionnaires after repair.

CONCLUSION

Laparoscopic sacrocolpopexy is an effective treatment for apical vault prolapse. There were no cases of vaginal erosion in the first 2 years of follow-up with the "combination" biosynthetic mesh. It is suggested that the interposition of a collagen barrier between the synthetic mesh and the vaginal mucosa prevents erosion. Biosynthetic engineering appears promising in aiding the prevention of the most common complication in pelvic floor reconstructive surgery with permanent implants. The use of permanent synthetic mesh plays an important role in the success of sacrocolpopexy, removing the dependence on the use of poor in situ tissue seen in classic and site-specific repairs. The use of biologic barriers developed specifically for certain actions may be useful in minimally invasive vaginal repair surgery.

Surgical conservation of both ovaries in an adolescent with uterine müllerian adenosarcoma: a case report

Fertility-sparing and minimally invasive surgeries are advancing everyday in gynecologic oncology. However, data on conservation of ovaries in uterine müllerian adenosarcoma are limited due to its very rare incidence in reproductive-aged females. Conservation of both ovaries along with adjuvant chemotherapy was performed in a 14-year-old girl with uterine adenosarcoma. After 30 months, she had no evidence of disease. Therefore, surgical conservation of ovaries might be a solution for fertility sparing in uterine müllerian adenosarcoma.

Future research into abnormal uterine bleeding

Abnormal uterine bleeding in terms of menstrual disorders and postmenopausal bleeding are common clinical problems in both primary and secondary care. Advances in diagnostic and therapeutic technologies have offered opportunities to improve the outcomes of women suffering with these complaints. Future research should concentrate on a robust approach to the assessment of these health technologies, including the use of outcome assessments of importance to patients such as effects on health-related quality of life and taking account of patient preferences. In addition, economic evaluations need to be conducted alongside clinical research to facilitate a rational basis on which to allocate resources and upon which to base clinical decisions. Specific areas highlighted for research in this review include the role of diagnostic technologies incorporating the clinical context within which diagnostic work-up takes place. The clinical application of progesterone antagonists and selective progesterone receptor modulators is a developing area with potential for the treatment of menorrhagia. The place of minimally invasive therapies for the treatment of menstrual dysfunction and fibroid-associated menorrhagia needs more examination, as does the place of outpatient 'ambulatory' settings to provide convenient, effective 'see and treat' targeted services in both primary and secondary care.

The emerging presence of interstitial cystitis in gynecologic patients with chronic pelvic pain

Emerging data are changing the pelvic pain paradigm for gynecologic patients. Historically, interstitial cystitis (IC) was rarely considered as a cause of chronic pelvic pain (CPP), but recent data suggest that IC is a common cause of CPP in gynecologic patients and perhaps is even the most common cause. It is important to consider the bladder as a generator of symptoms early in the evaluation of the gynecologic patient with CPP. New tools have been developed to aid the gynecologist in ruling out IC in patients with CPP, including a new IC symptom questionnaire and the Potassium Sensitivity Test (PST). By determining whether the pain is of bladder origin, the physician can more successfully treat the patient with CPP.

Autofluorescence Ductoscopy: A New Imaging Technique for Intraductal Breast Endoscopy

BACKGROUND

Conventional diagnostic imaging techniques of the female breast, eg, ultrasound, mammography, breast magnetic resonance imaging, or ductography, can only give indirect information about the inside of breast ducts. Diagnostic ductoscopy is the first approach for direct visualization of intraductal lesions. Autofluorescence ductoscopy is a new, noninvasive imaging technique that better identifies intraductal lesions under direct vision.

MATERIALS AND METHODS

We describe the technical development of autofluorescence ductoscopy and initial experience with early clinical evaluation at Frauenklinik (OB/GYN) of Technical University Munich, Germany, and its potential future application. In contrast to standard white light breast endoscopy, autofluorescence ductoscopy uses a different light spectrum and, after sophisticated data processing, can mark suspicious intraductal lesions in blue-violet colors. Autofluorescence ductoscopy adds new visual information previously not seen in white-light endoscopy. Technical development is completed and clinical evaluation is under way.

RESULTS

In a small series, the autofluorescence ductoscope was used and confirmed the initial expectations. No complication was expected or occurred. At present time, it is being used on an experimental basis for evaluation of its clinical benefits.

CONCLUSION

The clinical evaluation of autofluorescence ductoscopy is a work in progress at an early stage. This technique is intended to improve visualization and identification of breast duct walls and lesions and possibly allows an instant visual semiquantitative histologic evaluation of nonbenign ductal lesions.

Laparoscopic-assisted vaginal hysterectomy for patients with extensive pelvic adhesions: A strategy to minimise conversion to laparotomy

AIM

To evaluate a strategy for successful laparoscopic-assisted vaginal hysterectomy (LAVH) in patients with extensive pelvic adhesion.

METHODS

Two hundred and thirty-six patients who underwent LAVH at National Taiwan University Hospital were retrospectively enrolled. Twenty-three patients (9.7%) had unexpected extensive pelvic adhesions. A special procedure of uterine artery preligation through retroperitoneal downstream ureter tracking was applied to overcome this problem. The clinical characteristics of the study group were analysed. The operative parameters and the outcome were compared between those with and without extensive pelvic adhesions.

RESULTS

Having extensive adhesions, 17 patients were associated with endometriosis and the other six were secondary to previous Caesarean delivery or pelvic inflammation. The cul-de-sac was partially and totally obliterated in 10 and 13 patients, respectively. These 23 patients had longer operation time (184 vs 146 min, P < 0.05), more blood loss (146 vs 89 mL, P < 0.05), but smaller extirpated uteri (278 vs 372 g, P = 0.063), compared with the other 213 patients. The average hospital stay was comparable (3.2 vs 3.4 days) and there were no ureteral injuries or excessive bleeding. Most importantly, not a single case was converted to laparotomy.

CONCLUSION

Pelvic adhesions of various underlying diseases are associated with increased complication and conversion rates during LAVH. Although this technique is not new, we believe that the special procedure of uterine artery preligation through retroperitoneal downstream ureter tracking may provide a safe approach for general gynecologists to complete successful LAVH in patients with unexpected extensive pelvic adhesions.

Management of Heavy Menstrual Bleeding: Is Hysterectomy the Radical Mastectomy of Gynecology?

Both hysterectomy for heavy menstrual bleeding and radical mastectomy for breast cancer are steeped in the history of surgery and have recently been challenged as being too radical for the disorder at hand. Radical mastectomy has largely been replaced with local removal of the tumor with subsequent radiation and/or chemotherapy. Alternatives to hysterectomy include a number of medical interventions, most notably intrauterine progestin-releasing systems, and endometrial ablation, a procedure that has a relatively high success rate and one that is now feasible for many women in an office or procedure room setting. However, although radical mastectomy rates have dropped precipitously, hysterectomy rates, at least in the United States remain relatively stable. Determining the proportion of hysterectomies that are done for heavy menstrual bleeding is difficult, largely because of coding issues, so it is difficult to measure the impact of new medical and minimally invasive surgical procedures. Nevertheless, it seems clear that many women are not exposed to the plethora of options to hysterectomy, a fact that may reflect a number of issues that may include training, skill, and financial incentives or disincentives. Clearly, options to hysterectomy are not a panacea, but if women are empowered to select from all of the options available, the rate of hysterectomy for bleeding should decrease while maintaining, or even enhancing the patient's satisfaction with care.

Anesthesia for outpatient gynecologic surgery

PURPOSE OF REVIEW

Anesthesia care for patients undergoing ambulatory gynecologic surgery has improved incrementally over the past few years. Emphasis has evolved beyond the safe provision of care, because this has largely been achieved. Comfort, speed, and efficiency have taken on new importance.

RECENT FINDINGS

Many changes relate to improvements in non-narcotic analgesic techniques and use of various supralaryngeal airways, such as the ProSeal LMA. Also, use of depth of anesthesia monitors and administration of potent short-acting beta-blockers and narcotics to control hemodynamic variables are examples of new anesthesia developments well applied to ambulatory gynecologic cases. Finally, anesthesia care is changing in some instances because surgical techniques are advancing, such as hysteroscopy, and can now be done in an office with little or no anesthesia.

SUMMARY

Local anesthetic use in gynecologic laparoscopy appears to improve postoperative pain control modestly, especially when given into the peritoneal cavity. Supralaryngeal airways, such as ProSeal LMA, appear to provide effective ventilation in laparoscopy, although their ability to protect against aspiration is unclear. The speed and comfort of emergence, recovery, and discharge may be improved by consciousness monitoring during general anesthesia and by drugs intended to modulate hemodynamics.

How Do Feedback and Instructions Affect the Performance of a Simulated Surgical Task?

PURPOSE

This study was conducted to objectively evaluate the effect of feedback and instructional material on the acquisition of surgical psychomotor skills for a model system based on mandibular fracture repair.

MATERIALS AND METHODS

This study was a prospective cohort study comprised of students in the preclinical years of dental or medical education. The students were divided into 4 groups and exposed to different levels of feedback/written instructions (including none) in the testing environment. Each subject was given a pair of aluminum bars, representing a fractured human mandible, and a standardized set of tools, including a fixed length of stainless steel wire to fix the bars together. The strength of fixation was measured, using a calibrated testing apparatus, as the amount of load that the fixed sample could tolerate to the point of failure. All subjects completed 5 successive trials under the same conditions. Descriptive statistics were recorded to provide comparisons between groups. Bivariate statistics were computed to compare the different study groups; multiple-comparison testing was used to evaluate differences among the groups. A P value <or= .05 was considered statistically significant.

RESULTS

The sample was comprised of 61 students, divided into 4 groups. The students who received neither instructions nor feedback had the lowest average performance scores. Those who received both feedback and instructions had the highest average performance scores. The students who received instructions only fared better than those who received feedback only, but only immediately after receiving instructions. Differences between the groups tended to dissipate after a few trials.

CONCLUSIONS

Written instructions and performance feedback can enhance the acquisition of psychomotor skills related to the performance of a complex task.

A videolaparoscopia no diagnóstico e tratamento da obstrução intestinal

A obstrução intestinal constitui complicação freqüente, de etiologia multifatorial, apresentação clínica variável e alta morbidade. Uma vez esgotados os recursos conservadores em casos específicos, a laparotomia exploradora é empregada para o diagnóstico final e tratamento em grande número de pacientes. Apesar do sucesso da via laparoscópica no manuseio de diversas afecções, a utilização desta via na abordagem inicial da obstrução do intestino delgado tem sido bastante limitada e alvo de numerosas críticas. Entretanto, o acúmulo de experiência com o método nos últimos anos, aliado ao avanço tecnológico e instrumental, têm permitido tratar número cada vez maior de pacientes obstruídos por meio do acesso laparoscópico. Assim, o surgimento de novos instrumentos como grampeadores laparoscópicos, pinças e trocáteres menos traumáticos ajudaram a tornar a videolaparoscopia factível e segura nestes pacientes. Neste artigo, os autores apresentam uma revisão sobre o papel da vídeo-cirurgia em casos selecionados de obstrução intestinal, ressaltando a contribuição dos métodos minimamente invasivos para o arsenal diagnóstico e terapêutico desta importante complicação.

Using the Care Dependency Scale for fall risk screening

AIM

This paper is a report of a study conducted to estimate the sensitivity and specificity of the Care Dependency Scale as a measure of risk of falling for individuals in hospital and nursing home settings.

BACKGROUND

Falls and their consequences are common problems in hospitals and nursing homes and nurses should assess the potential risks of their patients. Items in fall risk scales resemble a general nursing assessment, which leads to redundant assessment procedures. It would be beneficial to have a single generic instrument for general assessment and fall risk screening.

METHODS

Standardized questionnaires were used in a cross-sectional study in 2004 and data were gathered from 9943 German nursing home residents and hospital patients (response rate 77.1%). Sensitivity and specificity of all Care Dependency Scale scores were calculated for fall risk. Relationships between the 15 scale items and falls were described using odds ratios and logistic regression analysis.

FINDINGS

Patients with falls in hospitals were more care dependent than those without falls. Sensitivity and specificity values showed that with the Care Dependency Scale a differentiation is possible between the falls group and the no-falls group. High odds ratios and logistic regression analysis suggest that the Care Dependency Scale item 'Avoidance of danger' indicated fall risk. Nursing home residents with and without falls had similar care dependency scores.

CONCLUSION

Nursing assessment in hospitals could be simplified by using the Care Dependency Scale for fall risk screening. Its value in fall risk screening in nursing homes requires further testing.

Minimally invasive surgery in the diagnosis and treatment of abdominal pain in children

PURPOSE OF REVIEW

Children with abdominal pain sometimes require surgical intervention, and laparoscopy is increasingly the preferred approach for the diagnosis and treatment of both acute and chronic abdominal pain in children. This review describes the current state of the art and recent developments in the application of minimally invasive surgical techniques for the treatment of children with various abdominal pain syndromes.

RECENT FINDINGS

Laparoscopy provides distinct advantages over traditional open surgery, including less pain, shorter recovery and improved cosmesis. Cumulative experience and ongoing outcomes research continue to substantiate the safety and efficacy of the approach when applied thoughtfully and by experienced practitioners. In fact, as minimally invasive surgery is being applied to treat more wide-ranging disorders, it is becoming apparent that for many conditions laparoscopy should be adopted as the standard of care.

SUMMARY

Recent advances in minimally invasive surgery have clearly benefited children with abdominal pain who need surgery, and as techniques improve and instruments get smaller we can expect this trend to continue into the future.