Surgical approach to hysterectomy for benign gynaecological disease

Comparison of Surgical Outcomes Between Vaginally Assisted NOTES Hysterectomy and Laparoscopic Hysterectomy in Primary Hospitals: A Prospective Cohort Study

BACKGROUND

This study aimed to compare the operative outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) and total laparoscopic hysterectomy (TLH). We also aimed to determine the feasibility of performing vNOTES hysterectomy in primary hospitals.

METHODS

This prospective cohort study enrolled 54 patients with indications for hysterectomy related to benign uterine disease without prolapse, between September 1, 2020, and November 30, 2024. The patients were categorized into two groups: vNOTES hysterectomy and TLH (n = 27 each). Surgical outcomes, including operative time, blood loss, recovery parameters, and complications, were assessed.

RESULTS

Preoperative baseline characteristics were comparable between the two groups. The vNOTES group had a longer mean operative time (187.6 vs. 154.4 min, p < 0.05) and greater median blood loss (100 vs. 30 mL, p < 0.05) compared to the TLH group. However, there were no significant differences in conversion rates, uterine weights, complications, 24-h pain scores, hospital stay, costs, or readmission rates. The vNOTES group demonstrated shorter times to postoperative ambulation, earlier return of bowel function (anal exhaust), and reduced urinary catheter insertion duration (p < 0.05).

CONCLUSION

vNOTES hysterectomy is feasible in primary hospitals, with surgical outcomes comparable to those of TLH. Patients who underwent vNOTES experienced faster recovery, indicating that it serves as a potential minimally invasive alternative to TLH. However, the small sample size warrants further studies to validate these findings.

Surgical outcomes after gender-affirming hysterectomies: a consecutive case series of 72 patients

BACKGROUND

Hysterectomy is a significant component of gender-affirming treatment for transgender individuals. The choice of surgical technique and associated complications have been studied, but very few studies have used a standardised classification system to grade surgical complications. This study aimed to describe our hospital's experience on gender-affirming hysterectomies with regards to patient demographics, surgical techniques, and postoperative complications using a validated classification system.

METHODS

The study is a prospective follow-up case-series study of 72 consecutive patients undergoing gender-affirming hysterectomy at Karolinska University Hospital between 2016 and 2023. Patient demographics (age and mean body mass index), tobacco and alcohol habits, medical history and comorbidities, route of hysterectomy, complications and 30-days postoperative outcomes were reported. Surgical complications were graded according to the Clavien-Dindo classification system.

RESULTS

The study population, with an average age of 27.6 years, presented diverse medical conditions, with psychiatric diagnoses being the most prevalent. The most common procedure was total laparoscopic hysterectomy, with low intraoperative blood loss. Surgical complications were rare, and primarily required minimal interventions. The 30-day Clavien-Dindo postoperative complication rate of grade II or higher was 19%, although only 4% experienced complications necessitating re-surgery (grade III or higher). Postoperative follow-up emerged as a critical aspect, with 22% of patients seeking non-elective medical attention within the first month, often due to vaginal bleeding or abdominal pain.

CONCLUSIONS

Our findings support the safety and feasibility of gender-affirming hysterectomies, particularly when performed laparoscopically, with very few severe complications observed using a validated scoring system. Extensive follow-up care, as well as addressing common postoperative concerns, is essential. Despite a relatively small sample size and lack of a control group, this study provides valuable insights into transgender healthcare from a previously unstudied region. Future research should preferably include larger cohorts, multicentre and registry-based studies.

Sexual functioning after vaginal natural orifice transluminal endoscopic surgery: combined results of two randomized controlled trials

OBJECTIVE

To explore women's sexual functioning and associated quality of life after vaginal natural orifice transluminal endoscopic surgery (vNOTES) as an alternative to laparoscopy.

DESIGN

Two parallel group, 1:1 randomized single-centre single-blinded trials comparing the effects of vNOTES and laparoscopy.

SETTING

Gynaecology unit of a Belgian teaching hospital.

POPULATION

Women aged between 18 and 70 years with a benign indication for hysterectomy or adnexectomy.

METHODS

After informed consent, women were randomized for vNOTES (experimental group) or laparoscopy (control group). Participants and outcome assessors were blinded. Paper and pencil questionnaires before surgery, as well as at 3 and 6 months after surgery.

MAIN OUTCOME MEASURES

The outcome of interest in this secondary analysis was sexual functioning at 3 and 6 months after surgery. We additionally measured quality of life.

RESULTS

We studied 68 women allocated to the vNOTES (experimental) condition and 67 women allocated to the laparoscopy (control) condition. No significant effects of time, type of surgery, and surgical technique were found on patients' sexual function. At 3 and 6 months post-surgery, an increasing number of negative associations were found between quality of life and aspects of sexual functioning.

CONCLUSIONS

vNOTES applied for hysterectomy and adnexectomy as compared to laparoscopy does not have a differential impact on women's sexual functioning. Sexual function has few links to patients' quality of life before surgery, but grows in relevance as a negative correlate of quality of life after surgery.

vNOTES hysterectomy for patients with large uteri: Initial experience in the largest Tertiary Centre in Singapore

STUDY OBJECTIVE

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is a novel, minimally invasive surgical method that has been increasingly used in gynaecological surgeries, especially hysterectomies. It has been shown to reduce operating time, post-operative recovery time and post-operative pain. However, in patients with large uteri, vNOTES hysterectomy may be more challenging due to the difficulty in mobilising the uterus and poor visualisation of the pelvic structures. Our study aims to evaluate the feasibility and outcomes of patients with large uteri undergoing vNOTES hysterectomy.

STUDY DESIGN

This was a single-centre retrospective study of patients who underwent vNOTES hysterectomy in KK Women's and Children's Hospital (KKH), Singapore's largest gynaecological tertiary care centre, between 15 April 2021 and 21 March 2024.

METHODS

Demographic data and surgical outcomes were analysed for patients with large uteri, defined as uterine weight >280 g, based on the International Society of Gynaecological Endoscopy (ISGE) guidelines. Our subgroup analysis compared surgical outcomes for patients with uterine weight >280 g and uterine weight <280 g. Both groups were compared using the Student t-test and Fisher Exact test for quantitative and qualitative data, respectively. Pearson's correlation coefficient was used to study the association between uterine weight, estimated blood loss and operative time.

RESULTS

Among the 176 patients who underwent vNOTES hysterectomy during this period, 58 patients fit the criteria for a large uterus. There was one patient with intra-operative conversion to laparoscopy due to difficulty in entering the Pouch of Douglas. There were five post-operative complications (2.8 %). In our subgroup analysis, patients with uterine weight >280 g had significantly longer operative time (126.2 ± 48.4 min vs 101.6 ± 39.9 min, p < 0.01) and higher estimated blood loss (271.7 ± 264.9 ml vs 110.8 ± 93.1 ml, p < 0.01) compared to patients with uterine weight <280 g.

CONCLUSION

VNOTES hysterectomy is a safe and feasible approach for patients with large uteruses with low rates of complications and conversion. However, patients should also be counselled on the potential risks of increased operative time and bleeding. Further studies are needed to validate our findings.

[Pelvic floor reconstruction and sexual function]

Urogynecological surgeries aim to restore and preserve quality of life and enable social participation with as few impairments as possible. In addition to bladder and bowel function, sexual function is often affected in the context of pelvic floor dysfunction. This article aims to present the impact of various surgical techniques for pelvic floor reconstruction on female sexual function. Both anatomical knowledge and psychosexual aspects are discussed. Reconstructions using native tissue as well as synthetic mesh and different surgical approaches for the treatment of pelvic organ prolapse and urinary incontinence are examined, also with respect to their effects on sexuality. Surgical outcomes and therapeutic options are presented. The findings highlight the need for individualized patient education and counseling.

Multimodal generative AI for interpreting 3D medical images and videos

This perspective proposes adapting video-text generative AI to 3D medical imaging (CT/MRI) and medical videos (endoscopy/laparoscopy) by treating 3D images as videos. The approach leverages modern video models to analyze multiple sequences simultaneously and provide real-time AI assistance during procedures. The paper examines medical imaging's unique characteristics (synergistic information, metadata, and world model), outlines applications in automated reporting, case retrieval, and education, and addresses challenges of limited datasets, benchmarks, and specialized training.

Laparoscopic Two-Port Myomectomy: A Retrospective Case Series of a Novel Minimally Invasive Approach

OBJECTIVE

This study presents a novel two-port technique for laparoscopic myomectomy, examining perioperative outcomes from 87 cases DESIGN: Retrospective case series.

SETTING

Tertiary academic hospital in Norfolk, Virginia.

PARTICIPANTS

Patients who underwent two-port laparoscopic myomectomy over a six-year period, performed by a single fellowship-trained surgeon. Cases were identified via current procedural terminology (CPT) codes for laparoscopic myomectomy.

INTERVENTIONS

The two-port technique uses a multi-port system at the umbilicus, a 45-degree bariatric laparoscope, and a 5-mm trocar in the right lower quadrant. This method reduces abdominal incisions, improves traction for fibroid removal, enhances triangulation for laparoscopic suturing, and expedites specimen extraction.

RESULTS

Eighty-seven patients were included, with a mean age of 37.5 years (±5.2). The most common fibroid type was FIGO type 2-5. An average of 3.6 fibroids (±3.1) were removed per case. The mean dominant fibroid diameter was 5.2 cm (±2.3), and the mean total fibroid weight removed was 139.8 grams (±114.4). The mean EBL and operative time were 128 mL (±138.9) and 153 minutes (±45.9), respectively. Fibroid number and weight correlated with increasing operative time, while fibroid weight significantly correlated with higher EBL. No conversions to laparotomy occurred. Most patients (74.7%) were discharged on the same day.

CONCLUSION

Two-port laparoscopic myomectomy is a safe and effective option for a variety of fibroid types, with outcome data comparable to previously reported data on conventional laparoscopic methods. This technique combines the benefits of traditional triangulation with improved cosmesis of single-site surgery, while providing a dedicated specimen extraction site. Candidates for two-port myomectomy are those eligible for a conventional laparoscopic approach; however, challenges may arise with intramural fibroids >10 cm, multiple fibroids (≥4), or need for multiple hysterotomy incisions, requiring careful patient selection and surgeon discretion.

SUMMATION

For properly selected patients, a two-port laparoscopic myomectomy technique is safe, effective, and associated with favorable outcomes, including a high same-day discharge rate and minimal complications.

Prevention and Treatment of Intraoperative Complications During Gynecological Laparoscopic Surgery: Practical Tips and Tricks-A Narrative Review

Several complications can occur during laparoscopic gynecological surgery. The insertion of trocars and the induction of pneumoperitoneum are essential steps, but they can still pose potential risks during laparoscopic surgery. Bowel injuries are the most common during gynecological procedures as a result of thermal damage and trocar placement, while vessel injuries may carry a high mortality rate. Gynecologic surgeons should be aware of the risks associated with laparoscopic procedures and be able to prevent and treat potential complications. We conducted a literature search using three electronic databases (Pubmed/MEDLINE, Google Scholar, Embase) from inception to May 2024 to identify the most common intraoperative gynecological laparoscopic complications, including those related to trocar insertion, bowel, urinary, and vessel injury. The aim of this narrative review is to describe the most common complications during gynecological laparoscopic surgery and to outline the safety rules and techniques necessary for their prevention and treatment.

Comparative outcomes of hysterectomy using single-port umbilical laparoscopy versus vaginal natural orifice transluminal endoscopic surgery

BACKGROUND

This study compared two minimally invasive hysterectomy techniques-single-port umbilical laparoscopy (SPLS) and vaginal natural orifice transluminal endoscopic surgery (vNOTES)-in terms of operating time, blood loss, postoperative pain, and hospitalization duration.

METHODS

We retrospectively analyzed patients who underwent hysterectomy via SPLS or vNOTES. Inclusion criteria were patients who had a hysterectomy with bilateral salpingectomy, with additional procedures such as salpingo-oophorectomy or sentinel lymph node dissection as indicated.

RESULTS

Among the 121 patients studied, 63 underwent SPLS and 58 underwent vNOTES. The mean operative time was 67.3 ± 15.9 min for vNOTES and 75.7 ± 12.1 min for SPLS. Six patients (9.5%) in the SPLS group and four (6.9%) in the vNOTES group underwent sentinel lymph node biopsies for endometrial cancer. Pain assessment at six, 12, and 24 h after surgery indicated lower visual analog scale (VAS) scores in the vNOTES group. Notably, patients in that group reported reduced shoulder and umbilical pain at 24 h postoperatively. Those patients also showed improved sexual function index scores and reduced dyspareunia, although the differences were not statistically significant.

CONCLUSIONS

The vNOTES approach to hysterectomy is a viable alternative, characterized by shorter operative times and decreased postoperative pain without increasing complication rates.

Comparison of Pelvic Organ Prolapse and Sexual Function After Vaginal Natural Orifice Transluminal Endoscopic Surgery and Conventional Laparoscopic Hysterectomy

Aim: In our study, we aimed to comprehensively evaluate the surgical parameters of patients who underwent total laparoscopic hysterectomy (TLH) and vaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy and their effects on the development of pelvic organ prolapse (POP) and sexual function one year later. Materials and Methods: This retrospective and comparative study involved a review of medical records for 42 patients who underwent total laparoscopic hysterectomy (TLH) for benign conditions and 42 patients who underwent hysterectomy using vaginal natural orifice transluminal endoscopic surgery (vNOTES) at our clinic between January 2023 and January 2024. Evaluations of preoperative and postoperative pelvic organ prolapse and sexual function were conducted, and the anatomical and functional outcomes of both surgical methods were compared. Results: In this study, there was no statistically significant difference between the groups in terms of age (p < 0.299), BMI (p < 0.819), parity (p < 0.615), surgical indications and menopausal status (p < 0.535) (p > 0.05). The vNOTES method was found to be significantly shorter than TLH in terms of surgical time (vNOTES: 58 min, TLH: 80 min, p < 0.001). However, there was no significant difference between the two methods in terms of preoperative and postoperative hematocrit values, hospital stay and FSFI scores (p > 0.05). Among the POP-Q parameters, a significant difference was observed only in the Aa parameter in favor of the vNOTES method (p < 0.003). Conclusions: In our study, the vNOTES method provided a shorter surgical time and better anterior vaginal support compared to TLH, but both methods offered similar results in terms of sexual function. More comprehensive studies are needed to clarify the long-term effects.

Pelvic Organ Prolapse Mesh Graft Revision Surgery: Rates of Complication by Surgical Approach

Objective

To determine complication rates after surgery for revision of pelvic organ prolapse mesh grafts, and to compare complication rates by surgical approaches.

Methods

A retrospective, population-based cohort study was conducted using the American College of Surgeons National Quality Improvement Program database. Patients undergoing mesh revision by gynecology or urology were classified into vaginal, abdominal, or laparoscopic approaches. Patients having a revision of a midurethral sling were excluded. A multivariable logistic regression analysis was completed. The primary outcome was a composite of surgical complications excluding urinary tract infections. Severe Clavien-Dindo IV complications, rates of readmission, rates of reoperation and urinary tract infections were secondary outcomes.

Results

Of 1,849 patients, 1,706 underwent vaginal, 78 underwent abdominal, and 65 underwent laparoscopic approach. The composite complication rate, excluding urinary tract infections, was 12.8% in the vaginal group, 21.8% in the abdominal group and 16.9% in the laparoscopic group (P = .052). Compared to a vaginal approach, the abdominal and laparoscopic groups had higher odds of complications (abdominal: adjusted odds ratio [OR] 2.70, 95% confidence interval [CI] 1.29-5.70; laparoscopic: adjusted OR 1.48, 95% CI 0.60-3.68). The abdominal and laparoscopic groups had higher odds of readmission compared to the vaginal group (abdominal: adjusted OR 2.36, 95% CI 0.81-6.90; laparoscopic: adjusted OR 4.12, 95% CI 1.49-11.40). Clavien-Dindo IV complications were rare and only seen after vaginal approach (0.4%, n = 6).

Conclusion

Complications were least common after vaginal mesh graft revision surgery, as compared to an abdominal or laparoscopic approach. Serious complications were rare.

A Survey of Surgeon Interest in Individually Sized Laparoscopic Instruments

Objectives

Allowing surgeons the option of individually sized laparoscopic instruments can potentially improve the ergonomics of laparoscopic surgery. We investigate interest in individually sized laparoscopic instruments among minimally invasive trained surgeons.

Materials and Methods

Cross-sectional survey of 166 surgeons performing laparoscopic surgery in the disciplines of obstetrics/gynecology, general surgery, and urology. Items investigated surgeon knowledge, attitudes, potential usefulness, and interest regarding dissemination and implementation of individually sized laparoscopic instruments.

Results

Overall mean knowledge of individually sized laparoscopic instruments ranged from strongly disagree to disagree and did not differ by glove size. Overall mean attitudes, dissemination, and implementation for individually sized laparoscopic instruments were between neutral and agree. Overall mean usefulness for individually sized laparoscopic instruments was neutral. There was a general pattern of small glove size having greater mean values than medium glove size for individually sized laparoscopic instruments for the topics of attitudes, usefulness, dissemination, and implementation.

Conclusion

We found that those with small glove sizes are interested in individually sized laparoscopic instruments. We recommend that as surgeon demographics continue to diversify, especially with a larger number of women typically with smaller glove sizes becoming surgeons, there is a potential benefit for individually sized laparoscopic instruments. Hospitals, surgical centers, and clinical practices should consider making such individually sized laparoscopic instruments available to surgeons. This can potentially address the ergonomic concerns of surgeons and also improve surgical practice.

Uptake, views, opinions and practice of same-day discharge following total laparoscopic hysterectomy: a national survey of UK gynaecologists

Background

Total laparoscopic hysterectomy (TLH) is associated with reduced post-operative pain and enhanced recovery, allowing same-day discharge (SDD). However, adoption of SDD TLH is not established, and practice varies.

Objectives

To conduct a national survey of UK gynaecologists with an interest in laparoscopic surgery to obtain their views, opinions and experience of SDD TLH.

Methods

Members of the British Society for Gynaecological Endoscopy were invited to complete an online questionnaire between January 2023 and January 2024.

Main Outcome Measures

The questionnaire consisted of 16 questions about SDD TLH covering three domains: (i) service provision, (ii) prognostic variables and (iii) information giving and education.

Results

One hundred and forty-eight clinicians from 148/215 NHS hospitals (69%) responded. One hundred and thirty one (89%) respondents thought that SDD following TLH was beneficial, and 48 (32%) hospitals had an established service. Adequate pain control was considered the most important factor to achieve SDD TLH, followed by control of nausea and vomiting. Seventy-eight (53%) respondents removed the urinary catheter at the end of the procedure. All respondents believed that managing patients' expectations was important to achieve compliance with SDD and 123 (83%) thought that developing an online preadmission patient information resource was needed.

Conclusions

One third of UK NHS hospitals have a SDD TLH service but there is variation in availability and protocols (pre-, peri- and post-operative management). These data can help develop health service strategy to promote SDD after TLH and standardise protocols.

What is New?

The survey quantifies and demonstrates hospital-level variation in uptake and practice of SDD provision after TLH.

Use of a Vessel Sealer for Hysterectomy at Time of Prolapse Repair: A Randomized Clinical Trial

IMPORTANCE

Electrosurgical vessel sealing devices for vaginal hysterectomy have demonstrated reduced postoperative pain. This modality, however, has not been evaluated in patients undergoing vaginal hysterectomy with pelvic reconstruction.

OBJECTIVE

The aim of the study was to describe postoperative pain levels utilizing the LigaSure vessel sealing device for vaginal hysterectomy in patients undergoing major reconstructive surgery.

STUDY DESIGN

In this single-blinded, randomized controlled trial, participants were randomized to vaginal hysterectomy utilizing the LigaSure vessel sealing device versus standard clamping and suturing techniques. Following hysterectomy, all participants underwent major vaginal reconstruction, including apical suspension via high uterosacral ligament fixation. The primary outcome was postoperative pain on a 100-mm visual analog scale 3-6 hours after surgery. Secondary outcomes included hysterectomy operative time, blood loss, pain scores and narcotic use on days 1, 3, 5, and 2 weeks after surgery.

RESULTS

A total of 95 participants were randomized: 48 (50.5%) in the intervention arm and 47 (49.5%) in the control arm. Between 3 and 6 hours postoperatively, there was no difference in overall pain scores (49 vs 50.5). Groups also had similar hysterectomy operative times (40.5 minutes vs 38 minutes) and blood loss (100 mL vs 100 mL). Pain scores and narcotic use on postoperative days 1, 3, 5, and 2 weeks were not different.

CONCLUSIONS

While vessel sealing devices may reduce pain after vaginal hysterectomy alone, these benefits were not detected following concomitant major pelvic reconstruction. Similar operative times and blood loss between groups may be due to the expertise of the surgical subspecialist and not the device itself.

Intra- and Postoperative Complications in 4565 vNOTES Hysterectomies: International Registry Cohort Study

OBJECTIVE

To present the rates of intra- and postoperative complications and conversions in a large cohort of unselected vNOTES hysterectomies, performed by surgeons with different levels of expertise.

DESIGN

International register-based cohort study.

SETTING

Hysterectomies in the iNOTESs registry, 2015 to January 2024, performed by 201 surgeons from multiple countries.

POPULATION

4565 patients undergoing vNOTES hysterectomy.

METHODS

Descriptive data are presented in frequencies (n) and percent (%).

MAIN OUTCOME MEASURE

Intra- and postoperative complications. Conversions.

RESULTS

Intraoperative and postoperative complication rates were 3.2% (n = 144) and 2.5% (n = 115), respectively. Conversions occurred in 1.6% (n = 72), of which 10 (0.2%) to laparotomy, and 82% of the conversions occurred within the first 50 cases of the surgeon's learning curve. The most common intraoperative complication was cystotomy, occurring in 1.3%, and almost half were performed by inexperienced surgeons. Other intraoperative organ injuries occurred in 20 cases (0.44%). Postoperatively, the most common complications were haemorrhage (n = 28), vault complications (n = 26) including 11 infected vault hematomas, cystitis (n = 18) and non-specific infections (n = 14). The vNOTES hysterectomies were performed by 201 surgeons, of which 9.5% had performed more than 50 vNOTES cases, representing 70% of the registered cases in the registry. The remaining 30% of the hysterectomies mainly represent learning curve data from 90% of the included surgeons. The complication rate decreased with increasing surgical experience.

CONCLUSIONS

The largest study population of vNOTES hysterectomies is presented, including both learning curve data and data from experienced surgeons, with acceptable rates of intra- and postoperative complications. No implication was found of vNOTES being inferior to other minimally invasive methods.

Comparative analysis of spinal anesthesia versus general anesthesia in single-port access laparoscopic adnexal surgery: a propensity score matching study

This study evaluated the safety and efficacy of spinal anesthesia as an alternative to general anesthesia in single-port access (SPA) laparoscopic adnexal surgeries. 110 patients were recruited and, after propensity score matching, 63 (general anesthesia: 42, spinal anesthesia: 21) were analyzed. During surgery, the Trendelenburg position was limited to 15°, and CO2 pressure maintained at 8-12 mmHg. Postoperative pain and nausea/vomiting scores were assessed up to 48 h post-surgery. No significant differences in patient characteristics were noted between groups. Immediately postoperative, the spinal anesthesia group showed significantly lower pain scores (4.74 ± 1.48 in spinal anesthesia vs. 0.67 ± 0.66 in general anesthesia; p <.001) and nausea/vomiting scores (p =.027). Intraoperative hypotension occurred in both groups (28.6% in spinal anesthesia vs. 33.3% in general anesthesia; p =.774) and was managed with ephedrine. No other intraoperative or postoperative complications were noted. Conclusively, spinal anesthesia is a viable and safe option for SPA laparoscopic salpingo-oophorectomy, effectively reducing immediate postoperative pain and nausea/vomiting.

An Analysis of Opioid Consumption and Patient Recovery after Hysterectomy by Surgical Approach

Background: Minimally invasive hysterectomy is preferred to open hysterectomy due to lower morbidity, but recent data regarding the association of surgical approach with patient recovery and opioid consumption are lacking. Objective: To analyze how postoperative opioid use and return to baseline activity vary by surgical approach for hysterectomy. Study design: This was a retrospective cohort study including hysterectomy patients from the Michigan Surgical Quality Collaborative registry that was linked to the State of Michigan's prescription drug monitoring program. We analyzed two primary outcomes with respect to surgical approach: opioid consumption in the 30 days following surgery, measured in morphine milligram equivalents (MMEs), and return to baseline activity >4 weeks after surgery. Adjusting for demographics, comorbidities, preoperative opioid use, surgical indication, clinical events at 30 days postoperatively, and surgical approach, we used multivariable linear regression and logistic regression models to identify factors associated with our primary outcomes. Results: Lower opioid consumption was reported with minimally invasive hysterectomy, with mean postoperative opioid consumption (95% CI) of 32.70 (27.15-38.26) MMEs for vaginal, 39.91 (37.17-42.65) MMEs for laparoscopic, and 54.97 (48.81-61.13) MMEs for open hysterectomy. Other covariates associated with lower opioid consumption included older age and year of surgery in 2019 versus 2018. Predicted probability of return to baseline activities >4 weeks after surgery was 51% (44-57%), 43% (40-45%), and 64% (60-69%) for vaginal, laparoscopic, and open hysterectomy, respectively. Conclusion: Minimally invasive approaches to hysterectomy are associated with lower postoperative opioid consumption and a more rapid recovery relative to open hysterectomy.

Umbilical Morcellation and Postoperative Pain in Patients Undergoing Benign Hysterectomy

Background

Morcellation has allowed patients with enlarged uteri to obtain a minimally invasive hysterectomy with improved outcomes; however, there is little information regarding postoperative pain. Our study aims to compare pain scores and opioid requirements in patients undergoing umbilical morcellation during benign minimally invasive hysterectomy versus those who do not require morcellation.

Methods

A retrospective cohort study was performed at a tertiary care center including patients who underwent total laparoscopic or supracervical hysterectomy by one high volume surgeon from 2019 to 2022. Baseline characteristics, postoperative pain scores, and morphine milligram equivalents in the acute and late setting were recorded. Two-sample t test for continuous variables and χ2 or Fisher's exact test for categorical variables were used to compare differences. A multiple regression model evaluated the effect of groups with the adjustment of confounders.

Results

A total of 232 patients underwent hysterectomy in which 57 underwent umbilical manual morcellation and 175 did not. There was no difference in postoperative complications, readmissions, or blood products required (P > 0.05). Individuals that underwent umbilical morcellation had longer operative times (226.6 vs 120.1 minutes, P < 0.01), more blood loss (311.1 vs 82.0 mL, P < 0.01), longer length of stay (0.60 vs 0.44 days, P < 0.01), increased uterine weight (1,293.2 vs 151.6 g, P < 0.01), and fibroid pathology (93.0% vs 46.3%, P < 0.01). There were no differences in postoperative pain scores, immediate and later opioid use between groups on multivariate analysis.

Conclusions

Patients who undergo umbilical morcellation, typically for large fibroid uteri, have similar postoperative pain scores, opioid use, and postoperative complications to those who undergo hysterectomy for other indications.

Should an Interval Appendicectomy Be Performed by a Minimally Invasive Gynaecologist?

Objective

We aimed to explore the abnormal pathology findings in appendix specimens removed based on intraoperative abnormal appearance during elective surgery for benign gynaecological conditions by a minimally invasive gynaecologist, as well as the associated complication rate.

Materials and Methods

This retrospective cohort study was conducted in a tertiary referral surgical centre for benign gynaecological conditions between the years 2004-2023. It included patients who underwent appendicectomy by a trained minimally invasive gynaecologist based on observations during surgery for benign gynaecological conditions. Data included demographic, clinical, surgical and pathological information followed by postoperative complication data obtained from electronic medical records and direct communication with surgical colleagues. The primary outcome was the evaluation of the abnormal pathological findings in the appendix. The secondary outcome was the complication rate associated with appendicectomy in these cases.

Results

The study cohort included 34 women who met inclusion criteria and underwent a laparoscopic surgery for endometriosis, chronic pelvic pain or a benign ovarian mass. Indications for appendicectomy included twelve cases (38.2%) with apparent appendiceal immobility (stiffness), fourteen cases (41.2%) with an appendix adherent to ovaries or the pelvic side walls, and seven cases (20.6%) with an abnormal appearance (large, wide, long, coiled, or curved). Pathological findings revealed six cases (17.6%) of acute or chronic appendicitis, four cases (11.8%) of endometriosis, five cases (14.7%) of abnormal pathological conditions, and three cases (8.8%) of cancer (two cases of well-differentiated adenocarcinoma and one case of low-grade appendiceal mucinous cystadenoma). Postoperative complication rate was 5.8% (two cases).

Conclusion

This study supports incorporating appendicectomy by trained gynaecological specialists during gynaecological elective surgery when abnormal findings are encountered. Further research and guidelines in this area can provide even greater clarity and direction for the future of gynaecological surgical practice.

Does Frequent Use of Advanced Energy Devices Improve Hysterectomy Outcomes?

Background and Objectives: The objective of this study was to assess the efficient use of advanced energy devices by examining the impact of their usage frequency on surgical outcomes of total laparoscopic hysterectomies. Materials and Methods: A retrospective study was conducted between 2020 and 2023 by a single surgeon. The patients' medical records and surgical videos were reviewed. Cases were categorized into three groups based on the frequency of usage of advanced energy devices: Group 1 (≤10 uses), Group 2 (11-20 uses), and Group 3 (≥21 uses). The differences in blood loss, surgery time, and surgical outcomes among these groups were analyzed. This study was conducted as a single-center retrospective analysis. It included 126 patients who underwent total laparoscopic hysterectomy and provided informed consent for video recording. To evaluate the usage of advanced energy devices, anonymized surgical videos were reviewed, and outcomes were analyzed based on the frequency of usage of advanced energy devices. Results: The time required for surgery differed significantly among the three groups (p = 0.006). However, no significant differences were observed in the changes in hemoglobin levels or estimated blood loss (p = 0.255 and 0.053, respectively). Additionally, the application of hemostatic agents, the need for intraoperative or postoperative transfusions, and the use of intravenous hemostatic agents postoperatively showed no notable variation. Complication rates, including rates of hematoma, urinary tract injury, gastrointestinal injury, and infections necessitating reoperation, were also comparable. Conclusions: The findings suggest that the prudent and strategic use of advanced energy devices, rather than their frequent application, may improve surgical efficiency without increasing the risk of complications.

Comparison between learning curves of robot-assisted and laparoscopic surgery in gynaecology: a systematic review

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.

The Management of Iatrogenic Ureterovaginal Fistula in a Resource-Limited Setting: A 12-Year Experience at Four Fistula Surgery Centers in Uganda

Background Ureterovaginal fistulae usually follow iatrogenic injury to the ureter during pelvic surgery. This manifests as urine incontinence and results in serious psychosocial effects on women. Ureterovaginal fistulae unlike vesicovaginal fistulae present challenges in diagnosis and management especially in resource-constrained settings. Objective The objective of this study is to describe the magnitude, etiology, diagnosis, management, and outcomes of iatrogenic ureterovaginal fistula in Uganda over a 12-year period. Methods A retrospective review of charts for women who had fistula repair at four fistula repair centers in Uganda from 2010 to 2021 was conducted. The diagnosis of ureterovaginal fistula was made clinically using a history of leakage of urine through the vagina following a pelvic surgery, a negative methylene blue dye test, and a three-swab test. All women were managed using open transvesical ureteral reimplantation with or without a Boari flap. The outcome of surgery was successful fistula repair with urine continence and was determined at two months post-surgery. Results Overall, 477 women were managed for genitourinary fistulae during the study period. Approximately one in every 10 women with genitourinary fistula had an iatrogenic ureterovaginal fistula (n=47, 9.8%). The mean age of women with ureterovaginal fistula was 31.9 (SD: ±11.8) years. The majority of ureterovaginal fistulae (n=33, 70.7%) followed cesarean sections done at general hospitals (n=22, 46.8%) by medical officers (n=32, 68.1%). Clinical assessment was accurate in diagnosing ureterovaginal fistula. Successful fistula repair was achieved in 45 (95.7%) cases. Conclusion Iatrogenic ureterovaginal fistulae are common in Uganda, and most follow cesarean section performed at lower-level health facilities by medical officers. In resource-limited settings where advanced diagnostic techniques are not available or not affordable, simple stepwise clinical evaluation is effective in making a diagnosis. Open ureteral reimplantation with or without a Boari flap has a high successful repair rate.

Small bowel obstruction secondary to uterine fibroids: a case presentation

Small bowel obstruction (SBO) is a serious condition with distinct symptoms such as constipation, vomiting, and abdominal distension. It is commonly caused by well-recognised factors. Recent advancements in imaging techniques and minimally invasive procedures have significantly improved our ability to accurately select patients for surgical intervention and promptly identify common SBO causes. Nonetheless, it is crucial to recognise that diagnosing rare SBO causes remains a challenge. We present a rare case of mechanical bowel obstruction caused by massive uterine fibroids in a 44-year-old woman. Large uterine fibroids can cause mechanical small intestine obstruction, although this is not a common cause. Diagnostic imaging, particularly computed tomography, plays a crucial role in diagnosing and determining appropriate management plans. Accurate monitoring and imaging can lead to improved patient outcomes by avoiding unnecessary surgical intervention and reducing morbidity and mortality rates. Treatment options include both medical and surgical methods. Both approaches have proven effective, with surgical procedures being the last resort if medical treatments are unsuccessful. The accuracy and efficacy of these surgical methods have shown promising results and significant prognostic benefits. It is critical to identify and report rare causes of bowel obstruction to improve future recognition and enhance patient outcomes.

Conventional vaginal approach vs. transvaginal natural orifice transluminal endoscopic surgery for treating apical prolapse, a randomized controlled study

OBJECTIVE

Vaginal hysterectomy combined with uterosacral suspension (USLS) is a technique for treating pelvic organ prolapse. Vaginal natural orifice transluminal endoscopic surgery (vNOTES) has been described as an alternative minimal invasive approachfor treating various gynecological and non-gynecological pathologies. The aim was to compare the surgical time between conventional vaginal hysterectomy combined with USLS and vNOTES hysterectomy combined with USLS.

STUDY DESIGN

Multi-center randomized controlled trial performed 2019-2021 at Rambam Health Care Campus (Israel) and Imelda Hospital (Belgium). Thirty women underwent vNOTES procedures and 30 women underwent conventional vaginal procedures. The primary outcome was total surgical time. Secondary outcomes included hysterectomy time, USLS time, intraoperative bleeding, length of hospitalization, pain during the first 24 h postoperative, the need of analgesia, intraoperative and postoperative adverse events, and patient-reported outcomes questionnaires. Parametric statistical methods were used to analyze the data.

RESULTS

Compared to conventional vaginal procedures, vNOTES procedures were shorter in total surgical time (77 vs. 93 min, p = 0.004), hysterectomy time (26 vs 33 min, p < 0.001), and USLS time (20 vs 26 min. p = 0.02). Blood loss was higher in conventional vaginal compared to vNOTES surgery, as reflected by the mean blood loss estimate (143 vs 60 ml. p < 0.001) and the delta-hemoglobin (pre-operation minus the post-operation hemoglobin level (1.8 vs 1.2 ml/dL, p = 0.01). There was no difference between the groups regarding analgesics used, postoperative pain, surgical objective outcomes, and scores on patient-reported outcomes questionnaires. Adverse events were significantly more frequent in the conventional vaginal group than in the vNOTES group (p < 0.001 for intraoperative events and p = 0.05 for events that occurred in the follow-up time interval).

CONCLUSION

vNOTES hysterectomy with USLS has lower surgical times than conventional vaginal hysterectomy with USLS, lower blood loss and less adverse events. Other surgical objective and subjective outcomes were similar between the approaches.

Constant high-level visual acuity during total laparoscopic hysterectomy using the OpClear® system

BACKGROUND

Operative vision can frequently be critically reduced during laparoscopic surgery by condensation and other matter accumulating on the distal laparoscope lens. By delivering saline and carbon dioxide across the lens, the OpClear system is designed to maintain operative vision without needing scope removal for lens cleaning. This study evaluates the system's efficacy in providing high-level visual acuity during laparoscopic hysterectomy while examining its utility through its impact on operative duration.

METHODS

A retrospective audit compared efficacy and utility for the three years before and after the implementation of OpClear in a single unit. Thirty-three cases were reviewed pre-OpClear, while 82 cases were analysed in the post-OpClear group. All cases involved routine total laparoscopic hysterectomies (TLH) performed by the same surgeon (AT) with similar complexity levels.

RESULTS

The OpClear system provided a consistently high level of visual acuity throughout the laparoscopic procedures. Scope removals, which typically result in non-productive operating time, were virtually eliminated. Consequently, in highly comparable cases, OpClear usage resulted in a 17-minute reduction in operating time over cases performed without the device. Additionally, in the OpClear group, there were trends towards reduced blood loss and shorter hospital stays, with patients in the OpClear group being discharged on first rather than second postoperatively.

CONCLUSIONS

The findings of this audit suggest that the OpClear system provides continuous high-level vision during laparoscopic hysterectomy. Further, reducing periods of non-productive time associated with scope removal for cleaning resulted in shorter operating times. Thus, the system has the potential to enhance safety, improve theatre utilisation and alleviate some of the surgical stresses associated with laparoscopic surgery.

Impact of trainees involvement on surgical outcomes of abdominal and laparoscopic myomectomy

BACKGROUND

To determine the association of trainees involvement with surgical outcomes of abdominal and laparoscopic myomectomy including operative time, rate of transfusion, and complications.

METHODS

A retrospective cohort study of 1145 patients who underwent an abdominal or laparoscopic myomectomy from 2008-2012 using the American College of Surgeons National Surgical Quality Improvement Program database (Canadian Task Force Classification II-2).

RESULTS

Overall, 64% of myomectomies involved trainees. Trainees involvement was associated with a longer operative time for abdominal myomectomies (mean difference 20.17 minutes, 95% Confidence Interval (CI) [11.37,28.97], p < 0.01) overall and when stratified by fibroid burden. For laparoscopic myomectomy, there was no difference in operative time between trainees vs no trainees involvement (mean difference 4.64 minutes, 95% CI [-18.07,27.35], p = 0.67). There was a higher rate of transfusion with trainees involvement for abdominal myomectomies (10% vs 2%, p < 0.01; Odds Ratio (OR) 5.62, 95% CI [2.53,12.51], p < 0.01). Trainees involvement was not found to be associated with rate of transfusion for laparoscopic myomectomy (4% vs 5%, p = 0.86; OR 0.82, 95% CI [0.16,4.14], p = 0.81). For abdominal myomectomy, there was a higher rate of overall complications (15% vs 5%, p < 0.01; OR 2.96, 95% CI [1.77,4.93], p < 0.01) and minor complications (14% vs 4%, p < 0.01; OR 3.71, 95% CI [2.09,6.57], p < 0.01) with no difference in major complications (3% vs 2%, p = 0.23). For laparoscopic myomectomy, there was no difference in overall (6% vs 10% p = 0.41; OR 0.59, 95% CI [0.18,2.01], p = 0.40), major (2% vs 0%, p = 0.38), or minor (5% vs 10%, p = 0.32; OR 0.52, 95% CI [0.15,1.79], p = 0.30) complications.

CONCLUSION

Trainees involvement was associated with increased operative time, rate of transfusion, and complications for abdominal myomectomy, however, did not impact surgical outcomes for laparoscopic myomectomy.

Association Among Surgeon Volume, Surgical Approach, and Uterine Size for Hysterectomy for Benign Indications

OBJECTIVE

To assess the relationship between surgeon volume and surgical approach for patients undergoing hysterectomy for benign indications among uteri of varying sizes.

METHODS

This was a retrospective cohort study of patients who underwent hysterectomy for benign indications from 2012 to 2021 within the Michigan Surgical Quality Collaborative registry. For each hysterectomy, the relative annual volume of the performing surgeon was assessed by calculating the proportion of hysterectomy cases contributed by the surgeon each calendar year relative to the total number of hysterectomies in the registry for that year. Hysterectomies were stratified into tertiles: those performed by low-volume surgeons, intermediate-volume surgeons, and high-volume surgeons. Uterine size was represented by the uterine specimen weight and categorized to facilitate clinical interpretation. Multivariable logistic regression models were developed incorporating interaction terms for surgeon volume and uterine size to explore potential effect modification.

RESULTS

A total of 54,150 hysterectomies were included. Hysterectomies performed by intermediate- and high-volume surgeons were more likely to be performed through a minimally invasive approach compared with those performed by low-volume surgeons (intermediate-volume: adjusted odds ratio [aOR] 1.68, 95% CI, 1.47-1.92; high-volume: aOR 2.14, 95% CI, 1.87-2.46). Moreover, this likelihood increased with increasing uterine weight. For uteri weighing between 1,000 g and 1,999 g, the odds of minimally invasive approach was significantly higher among intermediate-volume surgeons (aOR 3.38, 95% CI, 2.04-5.12) and high-volume (aOR 9.26, 95% CI, 5.64-15.2) surgeons, compared with low-volume surgeons. After including an interaction term for uterine weight and surgeon volume, we identified effect modification of surgeon volume on the relationship between uterine size and choice of minimally invasive surgery.

CONCLUSION

For uteri up to 3,000 g in weight, hysterectomies performed by high-volume surgeons have a higher likelihood of being performed through a minimally invasive approach compared with those performed by low-volume surgeons.

Effect of whole-day work on surgical performance during simulated laparoscopic surgery: study protocol for a controlled cross over laboratory trial

Introduction

Laparoscopy has become a fundamental aspect of surgery, presenting new challenges such as fatigue, encompassing both muscular and cognitive components. Given its potential to affect surgical precision and create difficulties for the surgeon, it is crucial to study the mechanisms of fatigue for patient safety and the well-being of surgeons. This study aims to demonstrate the influence of general fatigue on surgeons' performance, incorporating assessments of movement quality through balance, kinematics, and muscle activation, as well as perceived workload. Additionally, the study seeks to evaluate how surgeons' experience may affect fatigue outcomes.

Methods and analysis

A controlled cross-over laboratory trial involving 29 residents and surgeons from the obstetrics and gynecology department of Nantes University Hospital is underway. Recruitment started in March 2023 and ended in September 2023. Participants with varying levels of experience perform two one-hour sessions of training box exercises, one in the morning (control condition) and the other at the end of a workday. The primary outcome is a composite score derived from the time to complete the Suturing and Knot Tying Training and Testing (SUTT) exercise, along with the number and quality of stitches. Secondary outcomes include perceived fatigue, discomfort, physical strain, muscle tension, mental workload, muscle activation (measured by surface electromyography), balance (measured using a force platform), and kinematics (measured using motion capture).

Ethics and dissemination

The study received ethical approval from the local ethics committee CERNI in December 2022 (n°13,122,022). Results will be presented in international conferences, submitted to peer-reviewed journals, and serve as a feasibility study for subsequent publications.

Racial and Ethnic Disparities in Sacrocolpopexy Approach

IMPORTANCE

Racial inequity elevates risk for certain diagnoses and health disparities. Current data show disparities for Black women when comparing open versus minimally invasive hysterectomy. It is unknown if a similar disparity exists in surgical management of pelvic organ prolapse.

OBJECTIVE

The objective of this study was to determine whether racial or ethnic disparities exist for open abdominal versus minimally invasive sacrocolpopexy.

STUDY DESIGN

Cross-sectional data of the Healthcare Cost and Utilization Project National Inpatient Sample and the Nationwide Ambulatory Surgery Sample for the year 2019 was used. Bivariate analysis identified demographic and perioperative differences between abdominal versus minimally invasive sacrocolpopexy, which were compared in a multivariable logistic regression.

RESULTS

Forty-one thousand eight hundred thirty-seven patients underwent sacrocolpopexy: 35,820 (85.6%), minimally invasive sacrocolpopexy, and 6,016, (14.4%) abdominal sacrocolpopexy. In an unadjusted analysis, Black patients were more likely to undergo an abdominal sacrocolpopexy compared to non-Hispanic White patients (OR 2.14, 95% CI 1.16-3.92, P <0.01). Hispanic patients were more likely to undergo abdominal sacrocolpopexy compared to non-Hispanic White patients (OR 1.69, 95% CI 1.26-2.26, P <0.001). Other factors associated with abdominal sacrocolpopexy are zip code quartile, payer status, composite comorbidity score, hospital control, and hospital bed size. In the regression model, Black patients remained more likely to undergo abdominal sacrocolpopexy compared to those who identified as White (aOR 2, 95% CI 1.26-3.16, P < 0.003). Hispanic patients were more likely to undergo abdominal sacrocolpopexy compared to those who identified as White (aOR 1.73, 95% CI 1.31-2.28, P < 0.001).

CONCLUSION

Abdominal sacrocolpopexy was more likely to occur in patients who identified as Black or Hispanic.

Different minimally invasive surgical methods to hysterectomy for benign gynecological disease: A systematic review and network meta-analysis

Background and Aims

This network meta-analysis aimed to compare the perioperative efficacy of various minimally invasive hysterectomy procedures for treating benign gynecological diseases and to assess whether vaginal natural orifice transluminal endoscopic hysterectomy (VNOTEH), a recently emerging procedure, is inferior to traditional laparoscopy.

Methods

We searched PubMed, Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI), China Biology Medicine disc (CBM), Wanfang Data, and China VIP Database from inception to August 2022 and updated in June 2023. We included randomized controlled trials (RCTs) comparing different minimally invasive hysterectomy techniques in patients with benign gynecological conditions. The intervention measures included nine minimally invasive hysterectomies. The two researchers used the Cochrane risk-of-bias assessment tool for study appraisal. All statistical analyses and drawings were performed using STATA 17.0 and R 4.4.1. A network meta-analysis (NMA) was conducted to compare the effectiveness of minimally invasive hysterectomy and rank its relative impact probabilistically.

Results

A total of 78 RCTs involving 7640 patients and nine minimally invasive hysterectomy methods with 16 intervention combinations were included in this study. Among these, 2, 63, and 13 studies were deemed to have a low, medium, and high risk of bias, respectively. Based on the Surface Under the Cumulative Ranking (SUCRA) probability ranking results of NMA, laparoendoscopic single-site surgery-laparoscopic-assisted vaginal hysterectomy (LESS-LAVH) demonstrated superior outcomes in terms of complications, infections, and 24-h postoperative pain scores. LAVH exhibited better performance in injuries and hospital stays, total laparoscopic hysterectomy showed the least blood loss, and vaginal hysterectomy had the shortest operation time.

Conclusion

LESS-LAVH and LAVH are recommended options, if feasible. Meanwhile, VNOTEH can achieve comparable results to traditional laparoscopy but requires careful attention to the risk of injury and infection. Future research should aim to broaden the search scope by including high-quality, large-scale, multicenter RCTs.

Recurrent pelvic organ prolapse after hysterectomy; a 10-year national follow-up study

PURPOSE

Hysterectomy may be a risk factor for pelvic organ prolapse (POP). We assessed the risk of recurrent POP (operations and visits) after hysterectomy among women with previous POP. We also studied patient and operation related risk factors for POP recurrence.

METHODS

This retrospective cohort study included 1697 women having previous POP diagnosis or POP at the time of hysterectomy (FINHYST 2006 cohort). Follow-up was until the end of 2016. The data was derived from the Finnish National Care register linked to the cohort. Hysterectomy approaches and other demographics were compared to the risk of a prolapse diagnosis and/or surgery. Cox regression model was used to identify hazard ratios.

RESULTS

Following hysterectomy, a total of 280 women (16.5%) had a POP reoperation and 359 (21.2%) had an outpatient visit due to POP. Vaginal vault prolapse repair was the most common POP reoperation (n = 181, 10.7%), followed by anterior wall repair (n = 120, 7.1%). Median time to POP reoperation was 3.7 years. Hysterectomy approach did not affect reoperations or visits. Previous cesarean section and anterior repair during hysterectomy were associated with decreased risk, whereas concomitant sacrospinous fixation and uterus prolapse as the main indication led to increased risk of anterior/vault prolapse reoperations. Concomitant posterior repair decreased posterior reoperations and visits, but uterus weight over 500 g caused a fivefold increased risk of posterior prolapse visit. Residential status was associated with elevated risk of any POP reoperations and visits.

CONCLUSIONS

Approximately one out of five women suffering from POP ensue POP reoperation or visit after hysterectomy. These high rates are independent on hysterectomy approach, but probably indicate that hysterectomy may worsen previous pelvic floor dysfunction.

Reviving forgotten techniques: Vaginal salpingectomy in public health system, a retrospective cohort study

OBJECTIVE

To evaluate the viability of the vaginal route as an alternative to laparoscopy for patients seeking permanent surgical contraception.

METHODS

We conducted a retrospective cohort study in 2021, dividing patients into two groups based on their preference: vaginal and laparoscopic salpingectomy. The statistical analysis was conducted using STATA, employing standard statistical methods based on the distribution of variables.

RESULTS

The study included 64 patients, with 34 undergoing the vaginal approach and 30 the laparoscopic route. No statistically significant differences were observed in baseline characteristics or complications between the two groups. Both surgical methods were found to be feasible. The vaginal route demonstrated a significantly shorter mean surgical time (P < 0.001). The laparoscopic route exhibited significantly less intraoperative blood loss (P < 0.001) and fewer hospitalization hours (P = 0.008). Postoperative satisfaction and pain levels did not show statistically significant differences.

CONCLUSION

Vaginal salpingectomy is a feasible technique with low complication rates, making it a potential option for gynecologists to offer their patients. We propose vaginal route inclusion in the training curriculum for gynecologic surgeons during the residency program, without any subspecialty requirements.

Decreasing Utilization of Vaginal Hysterectomy in the United States: An Analysis by Candidacy for Vaginal Approach

INTRODUCTION AND HYPOTHESIS

The objective was to assess trends in hysterectomy routes by patients who are likely and unlikely candidates for a vaginal approach.

METHODS

We performed a retrospective cohort study of patients who underwent vaginal, abdominal, or laparoscopic/robotics-assisted laparoscopic hysterectomy between 2017 and 2020 using the National Surgical Quality Improvement Program database. Patients undergoing hysterectomy for a primary diagnosis of benign uterine pathology, dysplasia, abnormal uterine bleeding, or pelvic floor disorders were eligible for inclusion. Patients who were parous, had no history of pelvic or abdominal surgery, and had a uterine weight ≤ 280 g on pathology were considered likely candidates for vaginal hysterectomy based on an algorithm developed to guide the surgical approach. Average annual changes in the proportion of likely vaginal hysterectomy candidates and route of hysterectomy were assessed using logistic regression.

RESULTS

Of the 77,829 patients meeting the inclusion criteria, 13,738 (17.6%) were likely vaginal hysterectomy candidates. Among likely vaginal hysterectomy candidates, the rate of vaginal hysterectomy was 34.5%, whereas among unlikely vaginal hysterectomy candidates, it was 14.1%. The overall vaginal hysterectomy rate decreased -1.2%/year (p < 0.01). This decreasing trend was nearly twice as rapid among likely vaginal hysterectomy candidates (-1.9%/year, p < .01) compared with unlikely vaginal hysterectomy candidates (-1.1%/year, P < 0.01); the difference in trends was statistically significant (p < 0.01).

CONCLUSIONS

The rate of vaginal hysterectomy performed for eligible indications decreased between 2017 and 2020 in a national surgical registry. This negative trend was more pronounced among patients who were likely candidates for vaginal hysterectomy based on favorable parity, surgical history, and uterine weight.

Structural Requirements for the Outpatient Treatment of Benign Diseases of the Uterus

In many cases, outpatient surgical treatment of benign diseases of the uterus has advantages over inpatient care. This has been demonstrated by the healthcare situation in other countries. However, the prerequisite for the provision of outpatient services is that this does not lead to any impairment in the quality of care or of patient safety. The ultimate goal should not be to reduce costs but rather to maintain and, ideally, improve the quality of care. This requires that services are not just defined by the surgical procedure but also by the entire treatment chain, including, for example, psychosocial support, and are remunerated accordingly. It is particularly worrying that the final decision as to whether an outpatient operation is possible is not the responsibility of the operating unit, but of the "Medizinischer Dienst," with the corresponding options and threats of sanctions. This situation is unique internationally and requires a paradigm shift. Furthermore, structural prerequisites must be maintained which currently only exist inadequately in Germany. Since a substantial proportion of planned outpatient operations require immediate or secondary inpatient treatment, there must be a barrier-free transition between the outpatient and inpatient sectors. This will require the creation of networks between outpatient service providers and one or more hospitals that are equipped and competent to manage even complex complications. It is important to create structures that, with intensive involvement of the operating unit, include adequate preoperative evaluation and patient education as well as needs-oriented postoperative care at home. The current separation of sectors is a significant hinderance. Moreover, when expanding and promoting outpatient surgery, the aspect of training and further education of specialist staff must be taken into account, as well as cross-sectoral quality assurance. Based on a review of the international literature, this article presents 13 recommendations for adequate structures when providing outpatient services which should serve as a prerequisite for the greatest possible guarantee of patient safety.

Implementation and outcomes in benign gynecological surgery with HUGO™ RAS system 12 months initial experience

We share our experience with the Hugo™ Robotic-Assisted Surgery system in benign gynecological surgeries. We retrospectively analyzed patients who underwent elective robotic surgeries for benign gynecological conditions at our surgical center from February 2023 to February 2024. Data collected included patient demographics, surgery indications, and outcomes. Perioperative data on port-placement time, arm configurations, docking, and console time were documented. Procedural outcome data including troubleshooting and overall satisfaction were also recorded. The primary outcome was perioperative data on port placement, docking time, arm configuration, and console time. The secondary outcome was defined as team satisfaction, system troubleshooting, arm repositioning, and complications graded 3-4 on the Clavien-Dindo Scale. A total of 60 patients underwent procedures for benign gynecological conditions using the Hugo™ RAS over the 12-month study period, primarily for pelvic endometriosis (53%), hysterectomies (27%), and adnexal surgery (10%). The mean port-placement time was 13 min and 41 s. In 31% of cases, low-port placement was used, with arm positioning being asymmetrical in 63% and symmetrical in 37%, demonstrating the system's flexibility in customizing port configurations while optimizing cosmetic outcomes. Docking time averaged 5 min and 51 s, and console time was 1 h and 5 min. Operational challenges included arm tremors and limited workspace for the assistant. This study details our knowledge using the Hugo™ RAS. Learning curves of port placement, arm positioning, docking, and procedure time can be rapidly adapted in a well-trained team. Our experience suggests the technology is still in its learning curve period.

Cervical stump leiomyomata after supracervical hysterectomy; a case report with review of literature

BACKGROUND

Despite being a highly debated issue, subtotal or supracervical hysterectomy (SCH) is still considered a safe and effective treatment for women with benign gynecological lesions. Benign and malignant cervical diseases have been reported after SCH, with fibroids being the most frequently diagnosed lesions in the excised cervical stump. Recurrence of cervical disease after SCH usually presents with vaginal bleeding, pelvic mass, or abdominal pain; moreover, it may necessitate reoperation and resection of the cervical stump or trachelectomy. Trachelectomy is known to be a difficult surgical procedure that may be associated with significant intra- and post-operative morbidity.

CASE PRESENTATION

We presented here a case of a 41-year-old nulliparous woman with a pelvic mass related to the cervical stump presented 2 years after subtotal hysterectomy, performed due to interactable abnormal uterine bleeding, which was attributed to a multiple fibroid uterus. Six years ago, she complained of pelvic pain, excessive vaginal discharge, and spotting. A transvaginal sonography and magnetic resonance imaging with contrast were performed, which revealed a 10.2 × 7.6 × 6.5 cm heterogeneous pelvic mass with irregular borders and marked vascularity on color Doppler. Surgical exploration and resection of the mass with cervical stump excision were performed. Histopathology confirmed the diagnosis of cervical stump multiple benign leiomyomata with no atypical features.

CONCLUSION

Recurrence or De novo development of leiomyomata and other cervical lesions might occur after supracervical or subtotal hysterectomy; thus, thorough pre-operative counseling for women requesting a SCH regarding the pros and cons of the procedure compared with total hysterectomy should be optimized. Meticulous follow-up, including the continuation of routine cervical cytological smears, is mandatory for patients with a retained cervix.

European Society for Gynaecological Endoscopy (ESGE) Good Practice Recommendations on surgical techniques for removal of fibroids: part 1 abdominal (laparoscopic and open) myomectomy

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.

Enhanced recovery after surgery (ERAS) in prolapse repair: A prospective study on pre-emptive uterosacral/cervical block

OBJECTIVE

Enhanced recovery after surgery (ERAS) protocols have been introduced in gynecology. Postoperative pain management after vaginal procedures remains a relevant issue. In the present study we aimed to evaluate the effectiveness of pre-emptive uterosacral/cervical block (PUCB) for postoperative pain control in patients with uterovaginal prolapse undergoing vaginal hysterectomy and pelvic floor repair. We also evaluated the impact on the length of recovery.

METHODS

This was a pilot study analyzing 40 women who underwent pelvic organ prolapse repair through uterosacral ligament suspension. Patients who chose to undergo PUCB were considered as cases, otherwise as controls. After general or spinal anesthesia induction, the treatment group received the PUCB with ropivacaine plus clonidine injections at 2, 4, 8, and 10 o'clock of the cervix. The control group did not receive additional treatment. Pain intensity was measured at rest and after forceful cough at 1, 4, 8, 12, 24, and 48 h postoperatively.

RESULTS

We found a significant reduction in pain values at 1 h (rest and forceful cough) and 24 h (forceful cough) in the PUCB group. The incidence of moderate/severe pain was inferior in the PUCB group at 1 h (rest) and 24 h (rest and forceful cough). There were no differences in terms of the use of rescue opioids (0% vs. 5%; P = 0.311) and length of hospital stay (2.5 ± 0.6 vs. 2.3 ± 0.6; P = 0.180).

CONCLUSIONS

For the first time, we demonstrated the impact of pre-emptive uterosacral/cervical block on pain control up to 24 h after surgery. Clonidine as a sensory blockade extender appears promising in enhancing the efficacy of local anesthetics.

Vaginal assisted NOTES hysterectomy in The Netherlands; A prospective cohort study

Objectives

Vaginal assisted Natural Orifice Transluminal Endoscopic Surgery (NOTES) combines the benefits of vaginal and endoscopic surgery. This study presents the results of the first vaginal assisted NOTES hysterectomies (VANH) in The Netherlands.

Study design

A prospective cohort study was performed in two non-academic teaching hospitals in The Netherlands. Data was collected from patients who underwent a VANH for benign indications between August 2019 and April 2023. Baseline characteristics and data of intra- and postoperative surgical outcomes were recorded and analysed. The VANHs were performed by four experienced vaginal and endoscopic gynaecological surgeons.

Results

A total of 200 patients underwent a VANH. Indications were dysfunctional menstrual bleeding (61 %; n = 122), abnormal cervical cytology (15.5 %; n = 31), abdominal pain (11.5 %; n = 23), post ablation/sterilization pain syndrome (3.5 %; n = 7), uterine fibroids (5.0 %; n = 10), atypical endometrial hyperplasia (2.5 %; n = 5) and Lynch or BRCA gene mutation carriers (1.0 %, n = 2). The mean surgical time was 61.4 min ( ± 22.8 min) with a mean blood loss of 88 mL ( ± 89 mL) and a mean uterine weight of 150 g ( ± 112 g). In 2.0 % (n = 4) of the cases a conversion was necessary. Same day discharge (SDD) was feasible in 80.2 % (n = 105) of the patients planned in day-care. In 2.0 % (n = 4) an intra-operative complication and in 9.0 % (n = 18) a post-operative complication occurred.

Conclusion

This study shows vNOTES to be a safe and feasible surgical technique and can be safely implemented with appropriate patient selection and skilled surgeons. It highlights the importance of surgeon awareness of the challenges inherent in the initial stages of the implementation of a new surgical technique when performing their first vNOTES procedures. Additional randomized clinical trials are needed to show superiority of vNOTES compared to traditional surgery.

Early versus delayed oral feeding after major gynaecologic surgery

BACKGROUND

This is an updated and expanded version of the original Cochrane review, first published in 2014. Postoperative oral intake is traditionally withheld after major abdominal gynaecologic surgery until the return of bowel function. The concern is that early oral intake will result in vomiting and severe paralytic ileus, with subsequent aspiration pneumonia, wound dehiscence, and anastomotic leakage. However, clinical studies suggest that there may be benefits from early postoperative oral intake. Currently, gynaecologic surgery can be performed through various routes: open abdominal, vaginal, laparoscopic, robotic, or a combination. In this version, we included women undergoing major gynaecologic surgery through all of these routes, either alone or in combination.

OBJECTIVES

To assess the effects of early versus delayed (traditional) initiation of oral intake of food and fluids after major gynaecologic surgery.

SEARCH METHODS

On 13 June 2023, we searched the Cochrane Gynaecology and Fertility Group's Specialised Register, CENTRAL, MEDLINE, Embase, the citation lists of relevant publications, and two trial registries. We also contacted experts in the field for any additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared the effect of early versus delayed initiation of oral intake of food and fluids after major gynaecologic surgery, performed by abdominal, vaginal, laparoscopic, and robotic approaches. Early feeding was defined as oral intake of fluids or food within 24 hours post-surgery, regardless of the return of bowel function. Delayed feeding was defined as oral intake after 24 hours post-surgery, and only after signs of postoperative ileus resolution. Primary outcomes were: postoperative ileus, nausea, vomiting, cramping, abdominal pain, bloating, abdominal distension, need for postoperative nasogastric tube, time to the presence of bowel sounds, time to the first passage of flatus, time to the first passage of stool, time to the start of a regular diet, and length of postoperative hospital stay. Secondary outcomes were: infectious complications, wound complications, deep venous thrombosis, urinary tract infection, pneumonia, satisfaction, and quality of life.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed the risk of bias, and extracted the data. We calculated the risk ratio (RR) with a 95% confidence interval (CI) for dichotomous data. We examined continuous data using the mean difference (MD) and a 95% CI. We tested for heterogeneity between the results of different studies using a forest plot of the meta-analysis, the statistical tests of homogeneity of 2 x 2 tables, and the I² value. We assessed the certainty of the evidence using GRADE methods.

MAIN RESULTS

We included seven randomised controlled trials (RCTs), randomising 902 women. We are uncertain whether early feeding compared to delayed feeding has an effect on postoperative ileus (RR 0.49, 95% CI 0.21 to 1.16; I² = 0%; 4 studies, 418 women; low-certainty evidence). We are uncertain whether early feeding affects nausea or vomiting, or both (RR 0.94, 95% CI 0.66 to 1.33; I² = 67%; random-effects model; 6 studies, 742 women; very low-certainty evidence); nausea (RR 1.24, 95% CI 0.51 to 3.03; I² = 74%; 3 studies, 453 women; low-certainty evidence); vomiting (RR 0.83, 95% CI 0.52 to 1.32; I² = 0%; 4 studies, 559 women; low-certainty evidence), abdominal distension (RR 0.99, 95% CI 0.75 to 1.31; I² = 0%; 4 studies, 559 women; low-certainty evidence); need for postoperative nasogastric tube placement (RR 0.46, 95% CI 0.14 to 1.55; 3 studies, 453 women; low-certainty evidence); or time to the presence of bowel sounds (MD -0.20 days, 95% CI -0.46 to 0.06; I² = 71%; random-effects model; 3 studies, 477 women; low-certainty evidence). There is probably no difference between the two feeding protocols for the onset of flatus (MD -0.11 days, 95% CI -0.23 to 0.02; I² = 9%; 5 studies, 702 women; moderate-certainty evidence). Early feeding probably results in a slight reduction in the time to the first passage of stool (MD -0.18 days, 95% CI -0.33 to -0.04; I² = 0%; 4 studies, 507 women; moderate-certainty evidence), and may lead to a slightly sooner resumption of a solid diet (MD -1.10 days, 95% CI -1.79 to -0.41; I² = 97%; random-effects model; 3 studies, 420 women; low-certainty evidence). Hospital stay may be slightly shorter in the early feeding group (MD -0.66 days, 95% CI -1.17 to -0.15; I² = 77%; random-effects model; 5 studies, 603 women; low-certainty evidence). The effect of the two feeding protocols on febrile morbidity is uncertain (RR 0.96, 95% CI 0.75 to 1.22; I² = 47%; 3 studies, 453 women; low-certainty evidence). However, infectious complications are probably less common in women with early feeding (RR 0.20, 95% CI 0.05 to 0.73; I² = 0%; 2 studies, 183 women; moderate-certainty evidence). There may be no difference between the two feeding protocols for wound complications (RR 0.82, 95% CI 0.50 to 1.35; I² = 0%; 4 studies, 474 women; low-certainty evidence), or pneumonia (RR 0.35, 95% CI 0.07 to 1.73; I² = 0%; 3 studies, 434 women; low-certainty evidence). Two studies measured participant satisfaction and quality of life. One study found satisfaction was probably higher in the early feeding group, while the other study found no difference. Neither study found a significant difference between the groups for quality of life (P > 0.05).

AUTHORS' CONCLUSIONS

Despite some uncertainty, there is no evidence to indicate harmful effects of early feeding following major gynaecologic surgery, measured as postoperative ileus, nausea, vomiting, or abdominal distension. The potential benefits of early feeding include a slightly faster initiation of bowel movements, a slightly sooner resumption of a solid diet, a slightly shorter hospital stay, a lower rate of infectious complications, and a higher level of satisfaction.

Ergonomics in the operating room and surgical training: a survey on the Italian scenario

Introduction

Surgical-related injuries are frequent, in fact the reported percentage of musculoskeletal disorders in surgeons is between 47% and 87%. These conditions are caused by long periods of standing, incorrect postures, repeated movements, little rest between operations, the lack of integrated operator rooms, the correct number and arrangement of monitors and the use of non-ergonomic instruments. This survey aims to assess the Italian overview both highlighting how prevalent surgical-related injury is in our surgeons and whether there is an operating room ergonomics education program in Italian surgical specialty schools.

Methods

An anonymous questionnaire was designed through SurveyMonkey© web application. This survey was composed of 3 different sections concerning the general characteristics of the participants, their surgical background and any training performed, and any injuries or ailments related to the surgical activity. The survey was carried out in the period 1th of December 2022 and the 6th of February 2023.

Results

At the close of our survey, 300 responses were collected. Among the participants, the two most represented specialties were Gynecology and Obstetrics (42.3%) and General Surgery (39.7%) and surgeons were mainly employed in the Northern regions of Italy (54.8%). Analyzing the participants' background, 61.7% of the respondents had laparoscopic training during their training and only 53.1% had a pelvic trainer during their residency. In accordance with 98.7% of the respondents, during surgery we have the feeling of being in an uncomfortable position that causes discomfort or muscle pain, and regarding the frequency of these discomforts, the majority of our study population experiences these problems monthly (46.2%), while in 29.6% it is experienced weekly, 12.1% annually and finally 12.1% daily. The surgical approach that is most correlated with these disorders is laparoscopy (62.7%) while the one that causes the least discomfort is robotic surgery (1.4%). These discomforts cause 43.9% of our population to take a break or do short exercises to reduce pain during surgery, and the body areas most affected are the back (61.6%), neck (40.6%) and shoulders (37.8%).

Conclusion

Despite this, our survey allows us to highlight some now-known gaps present in the surgical training program of our schools and the lack of protection toward our surgeons during their long career.

Designing a core data set for benign hysterectomy registration system and its implementation in a referral teaching hospital in Northwest Iran

BACKGROUND AND AIMS

Although minimally invasive hysterectomy offers advantages, abdominal hysterectomy remains the predominant surgical method. Creating a standardized dataset and establishing a hysterectomy registry system present opportunities for early interventions in reducing volume and selecting benign hysterectomy methods. This research aims to develop a dataset for designing benign hysterectomy registration system.

METHODS

Between April and September 2020, a qualitative study was carried out to create a data set for enrolling patients who were candidate for hysterectomy. At this stage, the research team conducted an information needs assessment, relevant data element identification, registry software development, and field testing; Subsequently, a web-based application was designed. In June 2023the registry software was evaluated using data extracted from medical records of patients admitted at Al-Zahra Hospital in Tabriz, Iran.

RESULTS

During two months, 40 patients with benign hysterectomy were successfully registered. The final dataset for the hysterectomy patient registry comprise 11 main groups, 27 subclasses, and a total of 91 Data elements. Mandatory data and essential reports were defined. Furthermore, a web-based registry system designed and evaluated based on data set and various scenarios.

CONCLUSION

Creating a hysterectomy registration system is the initial stride toward identifying and registering hysterectomy candidate patients. this system capture information about the procedure techniques, and associated complications. In Iran, this registry can serve as a valuable resource for assessing the quality of care delivered and the distribution of clinical measures.

Hysterectomy Techniques and Outcomes for Benign Large Uteri: A Systematic Review

OBJECTIVE

To identify the optimal hysterectomy approach for large uteri in gynecologic surgery for benign indications from a perioperative morbidity standpoint.

DATA SOURCES

PubMed and Embase databases were searched from inception through September 19, 2022. Meta-analyses were conducted as feasible.

METHODS OF STUDY SELECTION

This review included studies that compared routes of hysterectomy with or without bilateral salpingo-oophorectomy for large uteri (12 weeks or more or 250 g or more) and excluded studies with any concurrent surgery for pelvic organ prolapse, incontinence, gynecologic malignancy, or any obstetric indication for hysterectomy.

TABULATION, INTEGRATION, AND RESULTS

The review included 25 studies comprising nine randomized trials, two prospective, and 14 retrospective nonrandomized comparative studies. Studies were at high risk of bias. There was lower operative time for total vaginal hysterectomy compared with laparoscopically assisted vaginal hysterectomy (LAVH) (mean difference 39 minutes, 95% CI, 18-60) and total vaginal hysterectomy compared with total laparoscopic hysterectomy (mean difference 50 minutes, 95% CI, 29-70). Total laparoscopic hysterectomy was associated with much greater risk of ureteral injury compared with total vaginal hysterectomy (odds ratio 7.54, 95% CI, 2.52-22.58). There were no significant differences in bowel injury rates between groups. There were no differences in length of stay among the laparoscopic approaches. For LAVH compared with total vaginal hysterectomy, randomized controlled trials favored total vaginal hysterectomy for length of stay. When rates of blood transfusion were compared between these abdominal hysterectomy and robotic-assisted total hysterectomy routes, abdominal hysterectomy was associated with a sixfold greater risk of transfusion than robotic-assisted total hysterectomy (6.31, 95% CI, 1.07-37.32). Similarly, single studies comparing robotic-assisted total hysterectomy with LAVH, total laparoscopic hysterectomy, or total vaginal hysterectomy all favored robotic-assisted total hysterectomy for reduced blood loss.

CONCLUSION

Minimally invasive routes are safe and effective and have few complications. Minimally invasive approach (vaginal, laparoscopic, or robotic) results in lower blood loss and shorter length of stay, whereas the abdominal route has a shorter operative time.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021233300.

Four-handed Technique for Total Laparoscopic Hysterectomy: An Italian Experience

Objectives

In our previous article, we proposed the novel four-handed technique (FHT) for total laparoscopic hysterectomy (TLH), which, according to us, is more helpful compared to the traditional TLH route. The objectives of the study were to analyze the FHT-TLH feasibility and efficiency by comparing some surgical outcomes recorded from 750 FHT-TLH performed in our hospital to literature data about the traditional TLH route and to underline the great opportunity this novel technique offers to the young specialists and residents to be more confident with gynecological laparoscopy.

Materials and Methods

This was a retrospective analysis carried out by collecting data regarding patient characteristics and surgical outcomes (operative time, blood loss, surgical complications, use of analgesics, and length of hospitalization) from 750 hospital records of women who underwent FHT-TLH (with or without adnexectomy) due to benign or malignant pathology from January 2015 to December 2021 at our hospital.

Results

We performed a total of 750 FHT-TLH, with or without adnexectomy. The mean skin-to-skin operative time for a FHT-TLH was 50 min, and the mean blood loss was 150 mL. No visceral damage was caused during surgeries. Only two patients underwent exploratory laparotomy with total abdominal hysterectomy due to the inability to proceed laparoscopically. Nonsteroidal anti-inflammatory drugs were administered only twice a day as analgesics, with advantage. The mean length of stay in the hospital after the procedure was 1.5 days, with discharge on the evening of the 1st day after surgery. No major postoperative complications occurred. The only minor postoperative complication described, in just three patients, was cellulitis of the vaginal vault.

Conclusion

Our FHT-TLH experience represents an alternative to the traditional TLH route, which allows to apply a minimally invasive approach with some advantages for patients compared to the traditional TLH route, such as early recovery and reduced operating time, blood loss, use of analgesics, and hospital stay. Moreover, it allows young specialists and residents to be more confident with gynecological laparoscopy, particularly when operating as the first assistant, to improve their laparoscopic surgical skills faster than the traditional TLH route allows them.

Opportunities for change and levelling up: a trust wide retrospective analysis of 8 years of laparoscopic and abdominal myomectomy

Background

Laparoscopic myomectomy is increasingly considered the gold standard uterine preserving procedure and has well documented benefits over the open approach. Barriers that women have in accessing the most appropriate treatment need to be addressed to ensure optimal patient care and outcomes.

Objectives

To analyse rates of open and laparoscopic myomectomy at a large NHS trust and identify how many cases could potentially have been performed laparoscopically, and any variation between sites.

Materials and Methods

A retrospective review of preoperative imaging reports and a surgical database containing information for all myomectomies performed between 1st January 2015 and 31st December 2022.

Main outcome measures

Number of procedures suitable for alternative surgical approach; length of hospital stay; estimated blood loss; cost differences.

Results

846 myomectomies were performed; 656 by laparotomy and 190 by laparoscopy. 194/591 (32.8%) open myomectomies could have been performed laparoscopically and 26/172 (15.1%) laparoscopic myomectomies may have been better performed via an open approach. Length of hospital stay, and estimated blood loss were significantly higher in the open group. Had cases been performed as indicated by pre-operative imaging, the cost differences ranged from -£115,752 to £251,832.

Conclusions

There is disparity in access to the gold standard care of laparoscopic myomectomy. Due to multifactorial reasons, even at sites where the rate of laparoscopic myomectomy is high, there is still underutilisation of this approach. It is clear that there is scope for change and "levelling up" of this imbalance.

What is new?

Robust pathways and guidelines must be developed, and more laparoscopic surgeons should be trained to optimise care for women with fibroids.

Comparative Analysis of Total Laparoscopic Hysterectomy Versus Non-descent Vaginal Hysterectomy for Benign Uterine Pathologies in Women: A Systematic Review

Hysterectomy, which can be conducted through abdominal or vaginal routes, is one of the most common gynecological procedures performed worldwide. When the patient is not able to undergo a vaginal hysterectomy due to contraindications involving a narrow pelvis or endometriosis and technical difficulties, laparoscopic removal of the uterus is the recommended method over abdominal hysterectomy. Additionally, the type of surgery depends on the expertise of the surgeon. Therefore, this systematic review aimed to evaluate different measures related to total laparoscopic (TLH) versus non-descent vaginal hysterectomy (NDVH) in women with benign uterine pathologies. ScienceDirect, PubMed, and Google Scholar databases were searched from 2019 to 2023 for a literature review using keywords including "Non-descent Vaginal Hysterectomy," AND "Total Laparoscopic Hysterectomy," AND "Benign Uterine Pathologies." This systematic review includes five studies based on the selection criteria. The data were extracted and a quality assessment of the studies was performed. The review concluded that NDVH has an advantage over TLH as a scarless surgery performed in a very short period and with minimum blood loss with fewer complications and in terms of cost-effectiveness. However, the postoperative parameters and satisfaction with the TLH technique were better than the NDVH technique, but the procedure was much more time-consuming and needed laparoscopic surgical expertise. The duration of hospitalization in NDVH and TLH was nearly the same. Furthermore, both techniques could be employed for salpingo-oophorectomy or when there are adnexal masses and adhesions present; however, TLH may be the best course of action.

Total vNOTES hysterectomy versus conventional total laparoscopic hysterectomy in virgin transgender men

BACKGROUND AND AIM

Comparison of the applicability, safety, and surgical outcomes of total vaginal NOTES hysterectomy (TVNH) using natural orifice transluminal endoscopic surgery, which is considered a natural orifice surgery for hysterectomy with bilateral salpingo-oophorectomy (HBSO) in virgin transgender men, with conventional total laparoscopic hysterectomy (TLH).

MATERIAL AND METHODS

A retrospective cohort study was conducted between 2019 and 2021. The results of transgender male individuals who underwent HBSO operations using TVNH (n = 21) were compared with those who underwent operations using TLH (n = 62).

RESULTS

TVNH was performed in 21 individuals, while TLH was performed in 62 individuals. Patients in the TVNH approach group had a longer operation duration than those in the TLH group (p = .001). Patients in the TVNH group experienced less pain at two hours (5 ± 1.56), six hours (4 ± 1.57), 12 h (2 ± 0.91), and 24 h (1 ± 0.62) postoperatively (p = .001). The postoperative hospitalization duration was shorter in the TVNH group (1.6 ± 1.01) than in the TLH group (2.9 ± 0.5) (p = .001).

CONCLUSIONS

For the HBSO operation of female-to-male transgender individuals, TVNH, which is completely endoscopically performed, can be preferred and safely conducted as an alternative surgical method to conventional laparoscopy.

Nomogram for predicting difficult total laparoscopic hysterectomy: a multi-institutional, retrospective model development and validation study

BACKGROUND

Total laparoscopic hysterectomy (TLH) is the most commonly performed gynaecological surgery. However, the difficulty of the operation varies depending on the patient and surgeon. Subsequently, patient's outcomes and surgical efficiency are affected. The authors aimed to develop and validate a preoperative nomogram to predict the operative difficulty in patients undergoing TLH.

METHODS

This retrospective study included 663 patients with TLH from Southwest Hospital and 102 patients from 958th Hospital in Chongqing, China. A multivariate logistic regression analysis was used to identify the independent predictors of operative difficulty, and a nomogram was constructed. The performance of the nomogram was validated internally and externally.

RESULTS

The uterine weight, history of pelvic surgery, presence of adenomyosis, surgeon's years of practice, and annual hysterectomy volume were identified as significant independent predictors of operative difficulty. The nomogram demonstrated good discrimination in the training dataset [area under the receiver operating characteristic curve (AUC), 0.827 (95% CI, 0.783-0.872], internal validation dataset [AUC, 0.793 (95% CI, 0.714-0.872)], and external validation dataset [AUC, 0.756 [95% CI, 0.658-0.854)]. The calibration curves showed good agreement between the predictions and observations for both internal and external validations.

CONCLUSION

The developed nomogram accurately predicted the operative difficulty of TLH, facilitated preoperative planning and patient counselling, and optimized surgical training. Further prospective multicenter clinical studies are required to optimize and validate this model.

Distinguishing the Uterine Artery, the Ureter, and Nerves in Laparoscopic Surgical Images Using Ensembles of Binary Semantic Segmentation Networks

Performing a minimally invasive surgery comes with a significant advantage regarding rehabilitating the patient after the operation. But it also causes difficulties, mainly for the surgeon or expert who performs the surgical intervention, since only visual information is available and they cannot use their tactile senses during keyhole surgeries. This is the case with laparoscopic hysterectomy since some organs are also difficult to distinguish based on visual information, making laparoscope-based hysterectomy challenging. In this paper, we propose a solution based on semantic segmentation, which can create pixel-accurate predictions of surgical images and differentiate the uterine arteries, ureters, and nerves. We trained three binary semantic segmentation models based on the U-Net architecture with the EfficientNet-b3 encoder; then, we developed two ensemble techniques that enhanced the segmentation performance. Our pixel-wise ensemble examines the segmentation map of the binary networks on the lowest level of pixels. The other algorithm developed is a region-based ensemble technique that takes this examination to a higher level and makes the ensemble based on every connected component detected by the binary segmentation networks. We also introduced and trained a classic multi-class semantic segmentation model as a reference and compared it to the ensemble-based approaches. We used 586 manually annotated images from 38 surgical videos for this research and published this dataset.

Robotic-assisted hysterectomy for benign gynecologic disease in the United States: in-hospital use of opioid and non-opioid analgesics

To compare the in-hospital opioid and non-opioid analgesic use among women who underwent robotic-assisted hysterectomy (RH) vs. open (OH), vaginal (VH), or laparoscopic hysterectomy (LH). Records of women in the United States who underwent hysterectomy for benign gynecologic disease were extracted from the Premier Healthcare Database (2013-2019). Propensity score methods were used to create three 1:1 matched cohorts stratified in inpatients [RH vs. OH (N = 16,821 pairs), RH vs. VH (N = 6149), RH vs. LH (N = 11,250)] and outpatients [RH vs. OH (N = 3139), RH vs. VH (N = 29,954), RH vs. LH (N = 85,040)]. Opioid doses were converted to morphine milligram equivalents (MME). Within matched cohorts, opioid and non-opioid analgesic use was compared. On the day of surgery, the percentage of patients who received opioids differed only for outpatients who underwent RH vs. LH or VH (maximum difference = 1%; p < 0.001). RH was associated with lower total doses of opioids in all matched cohorts (each p < 0.001), with the largest difference observed between RH and OH: median (IQR) of 47.5 (25.0-90.0) vs. 82.5 (36.0-137.0) MME among inpatients and 39.3 (19.5-66.0) vs. 60.0 (35.0-113.3) among outpatients. After the day of surgery, fewer inpatients who underwent RH received opioids vs. OH (78.7 vs. 87.5%; p < 0.001) or LH (78.6 vs. 80.6%; p < 0.001). The median MME was lower for RH (15.0; 7.5-33.5) versus OH (22.5; 15.0-55.0; p < 0.001). Minor differences were observed for non-opioid analgesics. RH was associated with lower in-hospital opioid use than OH, whereas the same magnitude of difference was not observed for RH vs. LH or VH.