Laparoscopic subtotal hysterectomy in the era of minimally invasive surgery

An Augmented Reality Endoscope System for Ureter Position Detection

Iatrogenic injury of ureter in the clinical operation may cause the serious complication and kidney damage. To avoid such a medical accident, it is necessary to provide the ureter position information to the doctor. For the detection of ureter position, an ureter position detection and display system with the augmented ris proposed to detect the ureter that is covered by human tissue. There are two key issues which should be considered in this new system. One is how to detect the covered ureter that cannot be captured by the electronic endoscope and the other is how to display the ureter position that provides stable and high-quality images. Simultaneously, any delayed processing of the system should disturb the surgery. The aided hardware detection method and target detection algorithms are proposed in this system. To mark the ureter position, a surface-lighting plastic optical fiber (POF) with the encoded light-emitting diode (LED) light is used to indicate the ureter position. The monochrome channel filtering algorithm (MCFA) is proposed to locate the ureter region more precisely. The ureter position is extracted using the proposed automatic region growing algorithm (ARGA) that utilizes the statistical information of the monochrome channel for the selection of growing seed point. In addition, according to the pulse signal of encoded light, the recognition of bright and dark frames based on the aided hardware (BDAH) is proposed to expedite the processing speed. Experimental results demonstrate that the proposed endoscope system can identify 92.04% ureter region in average.

The Power Law of Learning in Transumbilical Single-Port Laparoscopic Subtotal Hysterectomy

STUDY OBJECTIVE

To analyze the surgical outcomes and learning curve of transumbilical single-port laparoscopic subtotal hysterectomy, which requires sutures of the cervical stump.

DESIGN

A prospective observational study (Canadian Task Force classification II-2).

SETTING

A university-affiliated center.

PATIENTS

From the first (July 2012) and consecutive patients of benign uterine disease scheduled for subtotal hysterectomy until October 2013.

INTERVENTIONS

All single-port laparoscopies were performed using straight instruments by 1 gynecologist. An ancillary port was added whenever technical difficulties could endanger surgical quality.

MEASUREMENT AND MAIN RESULTS

Seventy-five patients were recruited for intention-to-treat analysis with a mean (±SD) age of 44.7 ± 3.8 years and a body mass index of 24.2 ± 3.7 kg/m². No major complication was noted. The mean uterine weight was 432.5 ± 344.0 g with 24 (32%) uteri ≧500 g. The patients' sequential order, or gradually increasing experience, was the determining factor in progressively decreasing operative time. Furthermore, most cases that required an additional ancillary port (67%) were clustered in the first 20 cases, whereas 4 were scattered after the 47th patient because of severe pelvic adhesion. The mean operative time decreased in the power law function of the patients' sequential order with a plateau achieved at the 20th patient.

CONCLUSION

The patients' sequential order was identified as an independent factor of achieving purely single-port access, and the trend of decreasing operative time delineated the existence of a learning curve. Approximately 20 patients were needed for an experienced multiport laparoscopist to reach technical competency in the current series.

Increased expression of integrin-linked kinase during decidualization regulates the morphological transformation of endometrial stromal cells

OBJECTIVE

To study the impact of integrin-linked kinase (ILK) in endometrial stromal cells (ESCs) during decidualization.

DESIGN

Laboratory study with the use of human endometrium.

SETTING

University hospital.

PATIENT(S)

Fertile reproductive-age women who had not received hormonal treatment for 3 months before tissue collection.

INTERVENTION(S)

Endometrium tissue collection, in vitro decidualization of isolated ESCs, and small interfering (si) RNA transfection.

MAIN OUTCOME MEASURE(S)

Immunohistochemistry, ELISA, Western blot analysis, methylthiazolyl tetrazolium assay, and immunofluorescence staining.

RESULT(S)

In vivo expression of ILK is significantly increased in distended-fusiform stromal cells of late secretory endometrium and in cobblestone-shaped decidual cells of early pregnancy. During in vitro decidualization for up to 8 days, confluent cultures of isolated ESCs consistently displayed increased ILK expression and morphologic transformation from fibroblast-like to polygonal cells. Subsequent ILK knockdown by siRNA transfection reversed this transformation, accompanied by decreased phosphorylation of glycogen synthase kinase (GSK) 3β and decreased viable cell numbers. Immunofluorescence staining of the decidualized ESCs demonstrated linkage of increased levels of ILK at the tips of the fan-shaped organization of actin stress fibers located in the submembranous area, which expanded the decidual cells into a typical polygonal appearance. Knock-down of ILK abrogated the polymerization and organization of actin fibers, which reverted the cells to their undecidualized morphology.

CONCLUSION(S)

During human endometrial decidualization, ILK is essential for morphologic transformation of ESCs through organization of the actin cytoskeleton; it may also function through subsequent GSK3β signaling, which requires further studies.