Environmental sustainability and gynaecological surgery: Which factors influence behaviour? An interview study

OBJECTIVE

To assess the various factors that influence environmentally sustainable behaviour in gynaecological surgery and examine the differences between gynaecologists and residents.

DESIGN

An interview study.

SETTING

Academic and non-academic hospitals in the Netherlands.

POPULATION

Gynaecologists (n = 10) and residents (n = 6).

METHODS

Thematic analysis of semi-structured interviews to determine the various factors that influence environmentally sustainable behaviour in gynaecological surgery and to examine the differences between gynaecologists and residents. By using the Desmond framework and the COM-B BCW, both organisational and individual factors related to behaviour were considered.

MAIN OUTCOME MEASURES

Factors that influence environmentally sustainable behaviour.

RESULTS

Awareness is increasing but practical knowledge is insufficient. It is crucial to integrate education on the environmental impact of everyday decisions for residents and gynaecologists. Gynaecologists make their own choices but residents' autonomy is limited. There is the necessity to provide environmentally sustainable surgical equipment without compromising other standards. There is a need for a societal change that encourages safe and open communication about environmental sustainability. To transition to environmentally sustainable practices, leadership, time, collaboration with the industry and supportive regulatory changes are essential.

CONCLUSION

This study lays the groundwork for promoting more environmentally sustainable behaviour in gynaecological surgery. The key recommendations, addressing hospital regulations, leadership, policy revisions, collaboration with the industry, guideline development and education, offer practical steps towards a more sustainable healthcare system. Encouraging environmentally sustainable practices should be embraced to enhance the well-being of both our planet and our population, driving us closer to a more environmentally sustainable future in healthcare.

User experience of wearing comfort of reusable versus disposable surgical gowns and environmental perspectives: A cross-sectional survey

OBJECTIVE

To determine the user experience of wearing comfort of reusable sterile surgical gowns and compare these gowns with conventional disposable surgical gowns.

DESIGN

Cross-sectional survey.

SETTING

An academic hospital in the Netherlands.

POPULATION

Gynaecologists, surgeons, residents and operating room assistants (n=80).

METHODS

Quantitative and qualitative data were obtained via a written questionnaire. Participants provided subjective comments and scored the reusable gown on each individual topic with a score from 1 to 5 (1 = unsatisfactory, 2 = moderate, 3 = good, 4 = very good, 5 = excellent) and compared the reusable gown with the conventional disposable alternative (better, equal or worse).

MAIN OUTCOME MEASURES

Wearing comfort: ventilation and temperature regulation, fit and length, functionality, barrier function and ease of use.

RESULTS

The results of the overall scores of the reusable gown are scored as 'very good' (mean 4.3, SD ± 0.5) by its users. Regarding comparison of the gowns, more than 79% (lowest score 79%, highest score 95%) of the participants scored the reusable gown equal or higher on six of seven topics. The topic 'ease of use' was scored equal or higher by 59% of the participants. Subjective comments provided information on possible improvements.

CONCLUSIONS

The findings of this study demonstrate that there is professional acceptance regarding the utilisation of reusable surgical gowns. To facilitate broader adoption, it is imperative to foster collaboration among suppliers and healthcare institutions. The reusable surgical gown is an environmentally sustainable, safe and comfortable alternative in the operating room.

Histological analysis of (antral) follicle density in ovarian cortex tissue attached to stripped endometriomas

PURPOSE

When resecting endometriomas with the stripping technique, in the majority of cases, a thin line of adjacent ovarian cortex is attached to the endometrioma. In this study, we performed histological analysis to determine (antral) follicle density in the ovarian cortex tissue attached to stripped endometriomas and assessed patient- and surgical characteristics that could affect this.

METHODS

Histological slides of previously removed endometriomas were assessed. Follicles in the attached ovarian tissue were classified according to maturation, and follicular density was determined. Immunofluorescent staining of antral follicles in a subset of endometriomas was also performed.

RESULTS

In 90 out of 96 included endometriomas (93.7%), ovarian tissue attached to the cyst wall was observed. One thousand nine hundred forty-four follicles at different maturation stages were identified (3 follicles/mm3). Follicle density was negatively associated with age (p < 0.001). Antral follicles (< 7-mm diameter) were present in the ovarian tissue attached to 35 endometriomas (36.5%) derived from younger patients compared to endometriomas where none were detected (30 versus 35 years, p = 0.003). Antral follicle density was 1 follicle/mm3. Based on immunofluorescence, healthy antral follicles were identified in two out of four examined endometriomas.

CONCLUSIONS

Ovarian tissue attached to stripped endometriomas holds potential as a non-invasive source for antral follicles. In theory, application of IVM could be an interesting alternative FP option in young patients with endometriomas who undergo cystectomy in order to transform the surgical collateral damage to a potential oocyte source. Our results encourage future research with fresh tissue to further assess the quality and potential of these follicles.

TRIAL REGISTRATION

Clinical Trials.gov Identifier: B21.055 (METC LDD), date of registration 12-08-2021, retrospectively registered.

The (cost-) effectiveness Of Surgical excision of Colorectal endometriosis compared to ART treatment trAjectory (TOSCA study) - a study protocol

Currently, the optimal treatment to increase the chance of pregnancy and live birth in patients with colorectal endometriosis and subfertility is unknown. Evidence suggests that that both surgery and in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) are effective in improving live birth rate (LBR) among these women. However, the available evidence is of low quality, reports highly heterogeneous results, lacks direct comparison between both treatment options and does not assess whether a combination strategy results in a higher LBR compared to IVF/ICSI-only treatment. Additionally, the optimal timing of surgery within the treatment trajectory remains unclear. The primary objective of the TOSCA study is to assess the effectiveness of surgical treatment (potentially combined with IVF/ICSI) compared to IVF/ICSI-only treatment to increase the chance of an ongoing pregnancy resulting in a live birth in patients with colorectal endometriosis and subfertility, measured by cumulative LBR. Secondary objectives are to assess and compare quality of life and cost-effectiveness in both groups. Patients will be followed for 40 months after inclusion or until live birth. The TOSCA study is expected to be completed in 6 years.

Effect of unidirectional airflow ventilation on surgical site infection in cardiac surgery: environmental impact as a factor in the choice for turbulent mixed air flow

BACKGROUND

Surgical site infection (SSI) in the form of postoperative deep sternal wound infection (DSWI) after cardiac surgery is a rare, but potentially fatal, complication. In addressing this, the focus is on preventive measures, as most risk factors for SSI are not controllable. Therefore, operating rooms are equipped with heating, ventilation and air conditioning (HVAC) systems to prevent airborne contamination of the wound, either through turbulent mixed air flow (TMA) or unidirectional air flow (UDAF).

AIM

To investigate if the risk for SSI after cardiac surgery was decreased after changing from TMA to UDAF.

METHODS

This observational retrospective single-centre cohort study collected data from 1288 patients who underwent open heart surgery over 2 years. During the two study periods, institutional SSI preventive measures remained the same, with the exception of the type of HVAC system that was used.

FINDINGS

Using multi-variable logistic regression analysis that considered confounding factors (diabetes, obesity, duration of surgery, and re-operation), the hypothesis that TMA is an independent risk factor for SSI was rejected (odds ratio 0.9, 95% confidence interval 0.4-1.8; P>0.05). It was not possible to demonstrate the preventive effect of UDAF on the incidence of SSI in patients undergoing open heart surgery when compared with TMA.

CONCLUSION

Based on these results, the use of UDAF in open heart surgery should be weighed against its low cost-effectiveness and negative environmental impact due to high electricity consumption. Reducing energy overuse by utilizing TMA for cardiac surgery can diminish the carbon footprint of operating rooms, and their contribution to climate-related health hazards.

Evaluation of the effect of previous endometriosis surgery on clinical and surgical outcomes of subsequent endometriosis surgery

PURPOSE

Patients often undergo repeat surgery for endometriosis, due to recurrent or residual disease. Previous surgery is often considered a risk factor for worse surgical outcome. However, data are scarce concerning the influence of subsequent endometriosis surgery.

METHODS

A retrospective study in a centre of expertise for endometriosis was conducted. All endometriosis subtypes and intra-operative steps were included. Detailed information regarding surgical history of patients was collected. Surgical time, intra-operative steps and major post-operative complications were obtained as outcome measures.

RESULTS

595 patients were included, of which 45.9% had previous endometriosis surgery. 7.9% had major post-operative complications and 4.4% intra-operative complications. The patient journey showed a median of 3 years between previous endometriosis surgeries. Each previous therapeutic laparotomic surgery resulted on average in 13 additional minutes (p = 0.013) of surgical time. Additionally, it resulted in more frequent performance of adhesiolysis (OR 2.96, p < 0.001) and in a higher risk for intra-operative complications (OR 1.81, p = 0.045), however no higher risk for major post-operative complications (OR 1.29, p = 0.418). Previous therapeutic laparoscopic endometriosis surgery, laparotomic and laparoscopic non-endometriosis surgery showed no association with surgical outcomes. Regardless of previous surgery, disc and segmental bowel resection showed a higher risk for major post-operative complications (OR 3.64, p = 0.017 respectively OR 3.50, p < 0.001).

CONCLUSION

Previous therapeutic laparotomic endometriosis surgery shows an association with longer surgical time, the need to perform adhesiolysis, and more intra-operative complications in the subsequent surgery for endometriosis. However, in a centre of expertise with experienced surgeons, no increased risk of major post-operative complications was observed.

Biomarker identification for endometriosis as a target for real-time intraoperative fluorescent imaging: A new approach using transcriptomic analysis to broaden the search for potential biomarkers

Intra-operative fluorescent imaging of endometriosis could help to optimize surgical treatment. Potential biomarkers to use as target for endometriosis-binding fluorescent probes were identified using a new five-phase transcriptomics-based approach to broaden the search for biomarkers. Using publicly available datasets, a differentially expressed gene (DEG) analysis was performed for endometriosis versus surgically relevant surrounding tissue (peritoneum, bladder, sigmoid, rectum, transverse colon, small intestine, vagina, and fallopian tubes) for which data was available. The remaining relevant surrounding tissues were analyzed for low expression levels. DEGs with a predicted membranous or extracellular location and with low expression levels in surrounding tissue were identified as candidate targets. Modified Target Selection Criteria were used to rank candidate targets based on the highest potential for use in fluorescent imaging. 29 potential biomarkers were ranked, resulting in Folate receptor 1 as the most potential biomarker. This is a first step towards finding a fluorescent tracer for intra-operative visualization of endometriosis. Additionally, this approach, using transcriptomics analysis to identifying candidate targets for a specific type of tissue for use in fluorescence-guided surgery could be translated to other surgical fields. TWEETABLE ABSTRACT: A new approach using transcriptomics analysis is shown to identify candidate targets for intra-operative fluorescent imaging for endometriosis, resulting in 29 potential candidates.

Clavien-Dindo, comprehensive complication index and classification of intraoperative adverse events: a uniform and holistic approach in adverse event registration for (deep) endometriosis surgery

STUDY QUESTION

What is the additional value of the comprehensive complication index (CCI) and ClassIntra system (classification for intraoperative adverse events (ioAEs)) in adverse event (AE) reporting in (deep) endometriosis (DE) surgery compared to only using the Clavien-Dindo (CD) system?

SUMMARY ANSWER

The CCI and ClassIntra are useful additional tools alongside the CD system for a complete and uniform overview of the total AE burden in patients with extensive surgery (such as DE), and with this uniform data registration, it is possible to provide greater insight into the quality of care.

WHAT IS KNOWN ALREADY

Uniform comparison of AEs reported in the literature is hampered by scattered registration. In endometriosis surgery, the usage of the CD complication system and the CCI is internationally recommended; however, the CCI is not routinely adapted in endometriosis care and research. Furthermore, a recommendation for ioAEs registration in endometriosis surgery is lacking, although this is vital information in surgical quality assessments.

STUDY DESIGN SIZE DURATION

A prospective mono-center study was conducted with 870 surgical DE cases from a non-university DE expertise center between February 2019 and December 2021.

PARTICIPANTS/MATERIALS SETTING METHODS

Endometriosis cases were collected with the EQUSUM system, a publicly available web-based application for registration of surgical procedures for endometriosis. Postoperative adverse events (poAEs) were classified with the CD complication system and CCI. Differences in reporting and classifying AEs between the CCI and the CD were assessed. ioAEs were assessed with the ClassIntra. The primary outcome measure was to assess the additional value toward the CD classification with the introduction of the CCI and ClassIntra. In addition, we report a benchmark for the CCI in DE surgery.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 870 DE procedures were registered, of which 145 procedures with one or more poAEs, resulting in a poAE rate of 16.7% (145/870), of which in 36 cases (4.1%), the poAE was classified as severe (≥Grade 3b). The median CCI (interquartile range) of patients with poAEs was 20.9 (20.9-31.7) and 33.7 (33.7-39.7) in the group of patients with severe poAEs. In 20 patients (13.8%), the CCI was higher than the CD because of multiple poAEs. There were 11 ioAEs reported (11/870, 1.3%) in all procedures, mostly minor and directly repaired serosa injuries.

LIMITATIONS REASONS FOR CAUTION

This study was conducted at a single center; thus, trends in AE rates and type of AEs could differ from other centers. Furthermore, no conclusion could be drawn on ioAEs in relation to the postoperative course because the power of this database is not robust enough for that purpose.

WIDER IMPLICATIONS OF THE FINDINGS

From our data, we would advise to use the Clavien-Dindo classification system together with the CCI and ClassIntra for a complete overview of AE registration. The CCI appeared to provide a more complete overview of the total burden of poAEs compared to only reporting the most severe poAEs (as with CD). If the use of the CD, CCI, and ClassIntra is widely adapted, uniform data comparison will be possible at (inter)national level, providing better insight into the quality of care. Our data could be used as a first benchmark for other DE centers to optimize information provision in the shared decision-making process.

STUDY FUNDING/COMPETING INTERESTS

No funding was received for this study. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Esketamine in the treatment of chronic endometriosis-induced pain: a case report

Introduction:

The pathophysiology of endometriosis-induced pain is complex and current pain management is often inadequate. As a consequence, the quality of life of endometriosis patients is reduced due to persistent and often recurrent severe pain, affecting emotional well-being.

Case description:

In this case report, we present a 28-year-old patient with deep endometriosis and severe pain resistant to conventional therapy, who experienced, after an 8-h infusion with esketamine, no pain symptoms for 8 weeks.

Discussion:

Current treatment options to suppress chronic pain symptoms in patients with (deep) endometriosis are often inadequate. Esketamine targets key components of the condition (inflammation, pain, depression), but the use of this drug in the treatment of chronic pain due to endometriosis has not been reported yet. Future trials are necessary to assess the effect of esketamine in the treatment of chronic pain due to endometriosis.

Conclusion:

This case report highlights the potential of esketamine infusion therapy in the treatment of endometriosis patients with persistent pain despite conventional therapy.

Operating Room Performance Optimization Metrics: a Systematic Review

Literature proposes numerous initiatives for optimization of the Operating Room (OR). Despite multiple suggested strategies for the optimization of workflow on the OR, its patients and (medical) staff, no uniform description of 'optimization' has been adopted. This makes it difficult to evaluate the proposed optimization strategies. In particular, the metrics used to quantify OR performance are diverse so that assessing the impact of suggested approaches is complex or even impossible. To secure a higher implementation success rate of optimisation strategies in practice we believe OR optimisation and its quantification should be further investigated. We aim to provide an inventory of the metrics and methods used to optimise the OR by the means of a structured literature study. We observe that several aspects of OR performance are unaddressed in literature, and no studies account for possible interactions between metrics of quality and efficiency. We conclude that a systems approach is needed to align metrics across different elements of OR performance, and that the wellbeing of healthcare professionals is underrepresented in current optimisation approaches.

Treatment preferences for medication or surgery in patients with deep endometriosis and bowel involvement - a discrete choice experiment

Objective

To study the preferences of women with deep endometriosis (DE) with bowel involvement when they have to choose between conservative (medication) or surgical treatment.

Design

Labelled discrete choice experiment (DCE).

Setting

Dutch academic and non‐academic hospitals and online recruitment.

Population or Sample

A total of 169 women diagnosed with DE of the bowel.

Methods

Baseline characteristics and the fear of surgery were collected. Women were asked to rank attributes and choose between hypothetical conservative or surgical treatment in different choice sets (scenarios). Each choice set offered different levels of all treatment attributes. Data were analysed by using multinomial logistic regression.

Main Outcome Measures

The following attributes – effect on/risk of pain, fatigue, pregnancy, endometriosis lesions, mood swings, osteoporosis, temporary stoma and permanent intestinal symptoms – were used in this DCE.

Results

In the ranking, osteoporosis was ranked with low importance, whereas in the DCE, a lower chance of osteoporosis was one of the most important drivers when choosing a conservative treatment. Women with previous surgery showed less fear of surgery compared with women without surgery. Low anterior resection syndrome was almost equally important for patients as the chance of pain reduction. Pain reduction had higher importance than improving fertility chances, even in women with desire for a future child.

Conclusions

The risk of developing low anterior resection syndrome as a result of treatment is almost equally important as the reduction of pain symptoms. Women with previous surgery experience less fear of surgery compared with women without a surgical history.

Tweetable Abstract

First discrete choice experiment in patients with deep endometriosis.

First discrete choice experiment in patients with deep endometriosis.

Decline in surgeon volume after successful implementation of advanced laparoscopic surgery in gynecology: An undesired side effect?

INTRODUCTION

The implementation of advanced minimally invasive surgical (MIS) techniques has broadened. An extensive body of literature shows that high hospital and surgeon volumes lead to better patient outcomes. However, no information is available regarding volume trends in the post-implementation phase of MIS. This study investigated these trends and poses suggestions to adjust these developments. This knowledge can provide guidance to optimize patient safe performance of new surgical techniques.

MATERIAL AND METHODS

A national retrospective cohort study in the Netherlands. The number of advanced laparoscopic (level 3 and 4) and robotic procedures and the number of gynecologists performing them were collected through a web-based questionnaire to determine hospital and gynecological surgeon volume. These volumes were compared with our previously collected data from 2012.

RESULTS

The response rate was 85%. Hospitals produced larger volumes for advanced laparoscopic and robotic procedures. However, still 63% of the hospitals perform low-volume level 4 laparoscopic procedures. Additionally, gynecological surgeon volumes appeared to decrease for level 3 procedures, as the group of gynecologists performing fewer than 20 procedures expanded (64% vs. 44% in 2012), with 15% of the gynecologists performing fewer than ten procedures. Despite an increase in surgeon volumes for level 4 laparoscopy and robotic surgery, volumes continued to be low, as still 49% of gynecologists performed fewer than 10 level 4 procedures per year and 41% performed fewer than 20 robotic procedures per year.

CONCLUSIONS

The broad implementation of advanced MIS procedures resulted in an increasing number of these procedures with increasing hospital volumes. However, as a side-effect, a disproportionate rise in number of gynecologists performing these procedures was observed. Therefore, surgeon volumes remain low and even decreased for some procedures. Centralization of complex procedures and training of specialized MIS gynecologists could improve surgeon volumes and therefore consequently enhance patient safety.

Assessment of fitness to perform using a validated self-test in obstetric and gynecological night shifts in the Netherlands

BACKGROUND

The field of obstetrics and gynecology requires complex decision-making and skills because of unexpected high-risk situations. These skills are influenced by alertness, reaction time, and concentration. Night shifts result in sleep deprivation, which might impair these functions, although it is still unclear to what extent.

OBJECTIVE

This study aimed to investigate whether a night shift routinely impairs the obstetrics and gynecology consultants' and residents' fitness to perform and whether this reaches a critical limit compared with relevant frames of reference.

STUDY DESIGN

Residents (n=33) and consultants (n=46) in obstetrics and gynecology conducted multiple measurements (n=415) at precall, postcall, and noncall moments with the fitness to perform self-test. The self-test consists of an adaptive pursuit tracking task that is able to objectively measure alertness, reaction time, concentration, and hand-eye coordination and Visual Analog Scale tests to subjectively score alertness. The test is validated with a sociolegal reference of a 0.06% ethanol blood concentration (the peak level after 2 units of alcohol, the legal driving limit). This equals -1.37% on the objective score and -8.17 points on subjective alertness. Linear mixed models were used to analyze the difference within subjects over a night shift, integrating repeated measures over time.

RESULTS

The overnight objective difference between postcall and precall measurements was -0.62 (P<.05) for residents and 0.28 (P=NS) for consultants, both not exceeding the sociolegal reference as a group. Objective impairment exceeded the reference for 31% of the residents and 28% of the consultants. Subjective alertness decreased in residents (-18.26; P<.001) and consultants (-10.85; P<.001), both exceeding the reference. No residents had to continue work postcall versus 7.8% of the consultants. None of the consultants that had to continue work were in an objective critically impaired state.

CONCLUSION

This study provides insight and awareness of individual performance after night shifts with clear frames of reference. The performance of residents is negatively and significantly affected by night shifts; therefore, a scheduled day off after a night shift is justified. Consultants showed no overall impairment; however, a quarter did exceed the alcohol limit reference after their night shift. If not logistically feasible to schedule a protected day off after a night shift, our group recommends safe shift scheduling, including options to transfer care after a demanding night shift to prevent working in a compromised state.

Septum resection versus expectant management in women with a septate uterus: an international multicentre open-label randomized controlled trial

STUDY QUESTION

Does septum resection improve reproductive outcomes in women with a septate uterus?

SUMMARY ANSWER

Hysteroscopic septum resection does not improve reproductive outcomes in women with a septate uterus.

WHAT IS KNOWN ALREADY

A septate uterus is a congenital uterine anomaly. Women with a septate uterus are at increased risk of subfertility, pregnancy loss and preterm birth. Hysteroscopic resection of a septum may improve the chance of a live birth in affected women, but this has never been evaluated in randomized clinical trials. We assessed whether septum resection improves reproductive outcomes in women with a septate uterus, wanting to become pregnant.

STUDY DESIGN, SIZE, DURATION

We performed an international, multicentre, open-label, randomized controlled trial in 10 centres in The Netherlands, UK, USA and Iran between October 2010 and September 2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women with a septate uterus and a history of subfertility, pregnancy loss or preterm birth were randomly allocated to septum resection or expectant management. The primary outcome was conception leading to live birth within 12 months after randomization, defined as the birth of a living foetus beyond 24 weeks of gestational age. We analysed the data on an intention-to-treat basis and calculated relative risks with 95% CI.

MAIN RESULTS AND THE ROLE OF CHANCE

We randomly assigned 80 women with a septate uterus to septum resection (n = 40) or expectant management (n = 40). We excluded one woman who underwent septum resection from the intention-to-treat analysis, because she withdrew informed consent for the study shortly after randomization. Live birth occurred in 12 of 39 women allocated to septum resection (31%) and in 14 of 40 women allocated to expectant management (35%) (relative risk (RR) 0.88 (95% CI 0.47 to 1.65)). There was one uterine perforation which occurred during surgery (1/39 = 2.6%).

LIMITATIONS, REASONS FOR CAUTION

Although this was a major international trial, the sample size was still limited and recruitment took a long period. Since surgical techniques did not fundamentally change over time, we consider the latter of limited clinical significance.

WIDER IMPLICATIONS OF THE FINDINGS

The trial generated high-level evidence in addition to evidence from a recently published large cohort study. Both studies unequivocally do not reveal any improvements in reproductive outcomes, thereby questioning any rationale behind surgery.

STUDY FUNDING/COMPETING INTEREST(S)

There was no study funding. M.H.E. reports a patent on a surgical endoscopic cutting device and process for the removal of tissue from a body cavity licensed to Medtronic, outside the scope of the submitted work. H.A.v.V. reports personal fees from Medtronic, outside the submitted work. B.W.J.M. reports grants from NHMRC, personal fees from ObsEva, personal fees from Merck Merck KGaA, personal fees from Guerbet, personal fees from iGenomix, outside the submitted work. M.G. reports several research and educational grants from Guerbet, Merck and Ferring (location VUMC) outside the scope of the submitted work. The remaining authors have nothing to declare.

TRIAL REGISTRATION NUMBER

Dutch trial registry: NTR 1676.

TRIAL REGISTRATION DATE

18 February 2009.

DATE OF FIRST PATIENT’S ENROLMENT

20 October 2010.

Potential Risk and Safety Measures in Laparoscopy in COVID-19 Positive Patients

Background. During the COVID-19 pandemic the question arises if laparoscopy, as an aerosol forming procedure, poses a potential risk for viral transmission of SARS-CoV-2 to healthcare workers. Methods. A literature search was conducted using PubMed, Embase and MEDLINE. Articles reporting information regarding COVID-19 or other relevant viruses and laparoscopy, surgical smoke, aerosols and viral transmission were included. Results. Although aerosols produced during laparoscopy do not originate from the respiratory tract, the main transmission route of SARS-CoV-2, research did show SARS-CoV-2 to be present in other body fluids. The transmission risk via this route is however considered very low. As previous research showed potential viral transmission during laparoscopy for viruses that spread through contaminated body fluids, there might be a potential risk of SARS-CoV-2 transmission during laparoscopy, albeit considered very small. Conclusion. Due to the small risk compared to widely known benefits of laparoscopy, there is no reason to replace laparoscopy by laparotomy due to COVID-19 infection. To avoid the potential small risk of viral transmission, additional safety measures are advised.

Prognosis in fertilisation rate and outcome in IVF cycles in patients with and without endometriosis: a population-based comparative cohort study with controls

Background:

Subfertility occurs in 30-40% of endometriosis patients. Regarding the fertilisation rate with in vitro fertilisation (IVF) and endometriosis, conflicting data has been published. This study aimed to compare endometriosis patients to non-endometriosis cycles assessing fertilisation rates in IVF.

Methods:

A population-based cohort study was conducted at the Leiden University Medical Center. IVF cycles of endometriosis patients and controls (unexplained infertility and tubal pathology) were analysed. The main outcome measurement was fertilisation rate.

Results:

503 IVF cycles in total, 191 in the endometriosis group and 312 in the control. The mean fertilisation rate after IVF did not differ between both groups, 64.1%±25.5 versus 63.9%±24.8 (p=0.95) respectively, independent of age and r-ASRM classification. The median number of retrieved oocytes was lower in the endometriosis group (7.0 versus 8.0 respectively, p=0.19) and showed a significant difference when corrected for age (p=0.02). When divided into age groups, the statistical effect was only seen in the group of ≤ 35 years (p=0.04). In the age group ≤35, the endometriosis group also showed significantly more surgery on the internal reproductive organs compared to the control group (p<0.001). All other outcomes did not show significant differences.

Conclusion:

Similar fertilisation rates were found in endometriosis IVF cycles compared to controls. The oocyte retrieval was lower in the endometriosis group, however this effect was only significant in the age group ≤ 35 years. All other secondary outcomes did not show significant differences. In general, endometriosis patients with an IVF indication can be counselled positively regarding the chances of becoming pregnant, and do not need a different IVF approach.

EQUSUM: Endometriosis QUality and grading instrument for SUrgical performance: proof of concept study for automatic digital registration and classification scoring for r-ASRM, EFI and Enzian

STUDY QUESTION

Is electronic digital classification/staging of endometriosis by the EQUSUM application more accurate in calculating the scores/stages and is it easier to use compared to non-digital classification?

SUMMARY ANSWER

We developed the first digital visual classification system in endometriosis (EQUSUM). This merges the three currently most frequently used separate endometriosis classification/scoring systems (i.e. revised American Society for Reproductive Medicine (rASRM), Enzian and Endometriosis Fertility Index (EFI)) to allow uniform and adequate classification and registration, which is easy to use. The EQUSUM showed significant improvement in correctly classifying/scoring endometriosis and is more user-friendly compared to non-digital classification.

WHAT IS KNOWN ALREADY

Endometriosis classification is complex and until better classification systems are developed and validated, ideally all women with endometriosis undergoing surgery should have a correct rASRM score and stage, while women with deep endometriosis (DE) should have an Enzian classification and if there is a fertility wish, the EFI score should be calculated.

STUDY DESIGN SIZE DURATION

A prospective endometriosis classification proof of concept study under experts in deep endometriosis was conducted. A comparison was made between currently used non-digital classification formats for endometriosis versus a newly developed digital classification application (EQUSUM).

PARTICIPANTS/MATERIALS SETTING METHODS

A hypothetical operative endometriosis case was created and summarized in both non-digital and digital form. During European endometriosis expert meetings, 45 DE experts were randomly assigned to the classic group versus the digital group to provide a proper classification of this DE case. Each expert was asked to provide the rASRM score and stage, Enzian and EFI score. Twenty classic forms and 20 digital forms were analysed. Questions about the user-friendliness (system usability scale (SUS) and subjective mental effort questionnaire (SMEQ)) of both systems were collected.

MAIN RESULTS AND THE ROLE OF CHANCE

The rASRM stage was scored completely correctly by 10% of the experts in the classic group compared to 75% in the EQUSUM group (P < 0. 01). The rASRM numerical score was calculated correctly by none of the experts in the classic group compared with 70% in the EQUSUM group (P < 0.01). The Enzian score was correct in 60% of the classic group compared to 90% in the EQUSUM group (P = 0.03). EFI scores were calculated correctly in 25% of the classic group versus 85% in the EQUSUM group (P < 0.01). Finally, the usability measured with the SUS was significantly better in the EQUSUM group compared to the classic group: 80.8 ± 11.4 and 61.3 ± 20.5 (P < 0.01). Also the mental effort measured with the SMEQ was significant lower in the EQUSUM group compared to the classic group: 52.1 ± 18.7 and 71.0 ± 29.1 (P = 0.04). Future research should further develop and confirm these initial findings by conducting similar studies with larger study groups, to limit the possible role of chance.

LIMITATIONS REASONS FOR CAUTION

These first results are promising, however it is important to note that this is a preliminary result of experts in DE and needs further testing in daily practice with different types (complex and easy) of endometriosis cases and less experienced gynaecologists in endometriosis surgery.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first time that the rASRM, Enzian and EFI are combined in one web-based application to simplify correct and automatic endometriosis classification/scoring and surgical registration through infographics. Collection of standardized data with the EQUSUM could improve endometriosis reporting and increase the uniformity of scientific output. However, this requires a broad implementation.

STUDY FUNDING/COMPETING INTERESTS

To launch the EQUSUM application, a one-time financial support was provided by Medtronic to cover the implementation cost. No competing interests were declared.

TRIAL REGISTRATION NUMBER

N/A.

Crossroad decisions in deep endometriosis treatment options: a qualitative study among patients

OBJECTIVE

To study the experiences, considerations, and motivations of patients with endometriosis in the decision-making process for deep endometriosis (DE) treatment options.

DESIGN

Qualitative study using semi-structured in-depth focus group methodology.

SETTING

University medical center.

PATIENT(S)

A total of 19 Dutch women diagnosed with DE between 27 and 47 years of age.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Focus group topics were disease impact and motives for treatment, expectations of the treatment process, and important factors in the decision process.

RESULT(S)

Women reported that pain, fertility, and strong fear of complications are important decisive factors in the treatment process. The goal of conceiving a child is considered important, however, sometimes doctors emphasize this topic too much. It emerged that complication counseling is frequently about surgical complications, whereas side effects of hormonal treatments are neglected. Shared decision making and information about treatment options, complications, and side effects are not always optimal, making it difficult to make a well-considered choice. Despite negative experiences encountered after surgery, the positive effect of surgery ensures that most women do not regret their choice.

CONCLUSION(S)

In the treatment decision process for patients with DE, pain is almost always the most important decisive factor. The wish to conceive and strong fear of complications can change this choice. Doctors should understand the importance of fertility for the majority of women, but, also, if this is not considered paramount, respect that view. To improve shared decision making, exploration of treatment goals, training of healthcare providers, and better patient information provision are desirable.

Septum resection in women with a septate uterus: a cohort study

STUDY QUESTION

Does septum resection improve reproductive outcomes in women with a septate uterus?

SUMMARY ANSWER

In women with a septate uterus, septum resection does not increase live birth rate nor does it decrease the rates of pregnancy loss or preterm birth, compared with expectant management.

WHAT IS KNOWN ALREADY

The septate uterus is the most common uterine anomaly with an estimated prevalence of 0.2-2.3% in women of reproductive age, depending on the classification system. The definition of the septate uterus has been a long-lasting and ongoing subject of debate, and currently two classification systems are used worldwide. Women with a septate uterus may be at increased risk of subfertility, pregnancy loss, preterm birth and foetal malpresentation. Based on low quality evidence, current guidelines recommend removal of the intrauterine septum or, more cautiously, state that the procedure should be evaluated in future studies.

STUDY DESIGN, SIZE, DURATION

We performed an international multicentre cohort study in which we identified women mainly retrospectively by searching in electronic patient files, medical records and databases within the time frame of January 2000 until August 2018. Searching of the databases, files and records took place between January 2016 and July 2018. By doing so, we collected data on 257 women with a septate uterus in 21 centres in the Netherlands, USA and UK.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We included women with a septate uterus, defined by the treating physician, according to the classification system at that time. The women were ascertained among those with a history of subfertility, pregnancy loss, preterm birth or foetal malpresentation or during a routine diagnostic procedure. Allocation to septum resection or expectant management was dependent on the reproductive history and severity of the disease. We excluded women who did not have a wish to conceive at time of diagnosis. The primary outcome was live birth. Secondary outcomes included pregnancy loss, preterm birth and foetal malpresentation. All conceptions during follow-up were registered but for the comparative analyses, only the first live birth or ongoing pregnancy was included. To evaluate differences in live birth and ongoing pregnancy, we used Cox proportional regression to calculate hazard rates (HRs) and 95% CI. To evaluate differences in pregnancy loss, preterm birth and foetal malpresentation, we used logistic regression to calculate odds ratios (OR) with corresponding 95% CI. We adjusted all reproductive outcomes for possible confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

In total, 257 women were included in the cohort. Of these, 151 women underwent a septum resection and 106 women had expectant management. The median follow-up time was 46 months. During this time, live birth occurred in 80 women following a septum resection (53.0%) compared to 76 women following expectant management (71.7%) (HR 0.71 95% CI 0.49-1.02) and ongoing pregnancy occurred in 89 women who underwent septum resection (58.9%), compared to 80 women who had expectant management (75.5%) (HR 0.74 (95% CI 0.52-1.06)). Pregnancy loss occurred in 51 women who underwent septum resection (46.8%) versus 31 women who had expectant management (34.4%) (OR 1.58 (0.81-3.09)), while preterm birth occurred in 26 women who underwent septum resection (29.2%) versus 13 women who had expectant management (16.7%) (OR 1.26 (95% CI 0.52-3.04)) and foetal malpresentation occurred in 17 women who underwent septum resection (19.1%) versus 27 women who had expectant management (34.6%) (OR 0.56 (95% CI 0.24-1.33)).

LIMITATIONS, REASONS FOR CAUTION

Our retrospective study has a less robust design compared with a randomized controlled trial. Over the years, the ideas about the definition of the septate uterus has changed, but since the 257 women with a septate uterus included in this study had been diagnosed by their treating physician according to the leading classification system at that time, the data of this study reflect the daily practice of recent decades. Despite correcting for the most relevant patient characteristics, our estimates might not be free of residual confounding.

WIDER IMPLICATIONS OF THE FINDINGS

Our results suggest that septum resection, a procedure that is widely offered and associated with financial costs for society, healthcare systems or individuals, does not lead to improved reproductive outcomes compared to expectant management for women with a septate uterus. The results of this study need to be confirmed in randomized clinical trials.

STUDY FUNDING/COMPETING INTEREST(S)

A travel for JFWR to Chicago was supported by the Jo Kolk Studyfund. Otherwise, no specific funding was received for this study. The Department of Obstetrics and Gynaecology, University Medical Centre, Groningen, received an unrestricted educational grant from Ferring Pharmaceutical Company unrelated to the present study. BWM reports grants from NHMRC, personal fees from ObsEva, personal fees from Merck, personal fees from Guerbet, other payment from Guerbet and grants from Merck, outside the submitted work. The other authors declare no conficts of interest.

TRIAL REGISTRATION NUMBER

N/A.

SOMA-trial: surgery or medication for women with an endometrioma? Study protocol for a randomised controlled trial and cohort study

STUDY QUESTIONS

The objective of this study is to evaluate the effectiveness and cost-effectiveness of surgical treatment of women suffering from pain due to an ovarian endometrioma when compared to treatment with medication (analgesia and/or hormones). The primary outcome is defined as successful pain reduction (-30% reduction of pain) measured by the numeric rating scale (NRS) after 6 months. Secondary outcomes include successful pain reduction after 12 and 18 months, quality of life, affective symptoms, cost-effectiveness, recurrence rate, need of adjuvant medication after surgery, ovarian reserve, adjuvant surgery and budget impact.

WHAT IS KNOWN ALREADY

Evidence suggests that both medication and surgical treatment of an ovarian endometrioma are effective in reducing pain and improving quality of life. However, there are no randomised studies that compare surgery to treatment with medication.

STUDY DESIGN SIZE DURATION

This study will be performed in a research network of university and teaching hospitals in the Netherlands. A multicentre randomised controlled trial and parallel prospective cohort study in patients with an ovarian endometrioma, with the exclusion of patients with deep endometriosis, will be conducted. After obtaining informed consent, eligible patients will be randomly allocated to either treatment arm (medication or surgery) by using web-based block randomisation stratified per centre. A successful pain reduction is set at a 30% decrease on the NRS at 6 months after randomisation. Based on a power of 80% and an alpha of 5% and using a continuity correction, a sample size of 69 patients in each treatment arm is needed. Accounting for a drop-out rate of 25% (i.e. loss to follow up), we need to include 92 patients in each treatment arm, i.e. 184 in total. Simultaneously, a cohort study will be performed for eligible patients who are not willing to be randomised because of a distinct preference for one of the two treatment arms. We intend to include 100 women in each treatment arm to enable standardization by inverse probability weighting, which means 200 patients in total. The expected inclusion period is 24 months with a follow-up of 18 months.

PARTICIPANTS/MATERIALS SETTING METHODS

Premenopausal women (age ≥ 18 years) with pain (dysmenorrhoea, pelvic pain or dyspareunia) and an ovarian endometrioma (cyst diameter ≥ 3 cm) who visit the outpatient clinic will make up the study population. Patients with signs of deep endometriosis will be excluded. The primary outcome is successful pain reduction, which is defined as a 30% decrease of pain on the NRS at 6 months after randomisation. Secondary outcomes include successful pain reduction after 12 and 18 months, quality of life and affective symptoms, cost-effectiveness (from a healthcare and societal perspective), number of participants needing additional surgery, need of adjuvant medication after surgery, ovarian reserve and recurrence rate of endometriomas. Measurements will be performed at baseline, 6 weeks and 6, 12 and 18 months after randomisation.

STUDY FUNDING/COMPETING INTERESTS

This study is funded by ZonMw, a Dutch organization for Health Research and Development, project number 80-85200-98-91041. The Department of Reproductive Medicine of the Amsterdam UMC location VUmc has received several research and educational grants from Guerbet, Merck KGaA and Ferring not related to the submitted work. B.W.J. Mol is supported by a NHMRC Practitioner Fellowship (GNT1082548) and reports consultancy for ObsEva, Merck KGaA and Guerbet. V. Mijatovic reports grants from Guerbet, grants from Merck and grants from Ferring outside the submitted work. All authors declare that they have no competing interests concerning this publication.

TRIAL REGISTRATION NUMBER

Dutch Trial Register (NTR 7447, http://www.trialregister.nl).

TRIAL REGISTRATION DATE

2 January 2019.

DATE OF FIRST PATIENT’S ENROLMENT

First inclusion in randomised controlled trial October 4, 2019. First inclusion in cohort May 22, 2019.

[Steps for reducing the carbon footprint of the operating room]

The healthcare sector contributes significantly to global warming due to carbon emissions; this sector is, therefore, partially responsible for the negative effects of climate change on public health. Carbon emissions by the healthcare sector amount to 7% of the total carbon footprint of the Netherlands. It is anticipated that measures to reduce carbon emissions in the operating room (OR) can make an important contribution to reducing carbonemissions in the hospital as a whole. The most important elements contributing to the carbon footprint of the OR are: energy consumption for heating, ventilation and air conditioning (HVAC); the emission of inhalation anaesthetics; the purchase of materials and equipment; and waste production. Direct carbon emissions by the OR can be reduced through the use of sustainable energy and setback of the HVAC outside office hours. Anaesthetists can dramatically reduce the carbon footprint of the OR by choosing for intravenous anaesthetics instead of inhalation anaesthetics. Indirect carbon emissions and waste production by the OR can be reduced through circular procurement, choosing reusable over disposable products and recycling.

Immediate versus delayed removal of urinary catheter after laparoscopic hysterectomy: a randomised controlled trial

Objective

To evaluate if immediate catheter removal (ICR) after laparoscopic hysterectomy is associated with similar retention outcomes compared with delayed removal (DCR).

Study design

Non‐inferiority randomised controlled trial.

Population

Women undergoing laparoscopic hysterectomy in six hospitals in the Netherlands.

Methods

Women were randomised to ICR or DCR (between 18 and 24 hours after surgery).

Primary outcome

The inability to void within 6 hours after catheter removal.

Results

One hundred and fifty‐five women were randomised to ICR (n = 74) and DCR (n = 81). The intention‐to‐treat and per‐protocol analysis could not demonstrate the non‐inferiority of ICR: ten women with ICR could not urinate spontaneously within 6 hours compared with none in the delayed group (risk difference 13.5%, 5.6–24.8, P = 0.88). However, seven of these women could void spontaneously within 9 hours without additional intervention. Regarding the secondary outcomes, eight women from the delayed group requested earlier catheter removal because of complaints (9.9%). Three women with ICR (4.1%) had a urinary tract infection postoperatively versus eight with DCR (9.9%, risk difference −5.8%, −15.1 to 3.5, P = 0.215). Women with ICR mobilised significantly earlier (5.7 hours, 0.8–23.3 versus 21.0 hours, 1.4–29.9; P ≤ 0.001).

Conclusion

The non‐inferiority of ICR could not be demonstrated in terms of urinary retention 6 hours after procedure. However, 70% of the women with voiding difficulties could void spontaneously within 9 hours after laparoscopic hysterectomy. It is therefore questionable if all observed urinary retention cases were clinically relevant. As a result, the clinical advantages of ICR may still outweigh the risk of bladder retention and it should therefore be considered after uncomplicated laparoscopic hysterectomy.

Tweetable abstract

The advantages of immediate catheter removal after laparoscopic hysterectomy seem to outweigh the risk of bladder retention.

The advantages of immediate catheter removal after laparoscopic hysterectomy seem to outweigh the risk of bladder retention.

The randomised uterine septum transsection trial (TRUST): design and protocol

BACKGROUND

A septate uterus is a uterine anomaly that may affect reproductive outcome, and is associated with an increased risk for miscarriage, subfertility and preterm birth. Resection of the septum is subject of debate. There is no convincing evidence concerning its effectiveness and safety. This study aims to assess whether hysteroscopic septum resection improves reproductive outcome in women with a septate uterus.

METHODS/DESIGN

A multi-centre randomised controlled trial comparing hysteroscopic septum resection and expectant management in women with recurrent miscarriage or subfertility and diagnosed with a septate uterus. The primary outcome is live birth, defined as the birth of a living foetus beyond 24 weeks of gestational age. Secondary outcomes are ongoing pregnancy, clinical pregnancy, miscarriage and complications following hysteroscopic septum resection. The analysis will be performed according to the intention to treat principle. Kaplan-Meier curves will be constructed, estimating the cumulative probability of conception leading to live birth rate over time. Based on retrospective studies, we anticipate an improvement of the live birth rate from 35% without surgery to 70% with surgery. To demonstrate this difference, 68 women need to be randomised.

DISCUSSION

Hysteroscopic septum resection is worldwide considered as a standard procedure in women with a septate uterus. Solid evidence for this recommendation is lacking and data from randomised trials is urgently needed.

TRIAL REGISTRATION

Dutch trial registry ( NTR1676 , 18th of February 2009).

MRI-Ultrasound Fusion Imaging for Diagnosis of Deep Infiltrating Endometriosis - A Critical Appraisal

Purpose

It was the aim of our study to evaluate this procedure using pelvic anatomical landmarks in order to assess the accuracy of fusion imaging and to critically evaluate the applicability in daily practice.

Methods

In a prospective, single center study, 10 patients with clinical signs of deep infiltrating endometriosis (DIE) were selected. We measured the distance between the landmark organ and the target shown by the software system (measurement 1). Measurement 2 depicts the distance between the landmark and the nearest calibration point. The calibration inaccuracy was measured as a third type of measurement (measurement 3).

Results

Measurement 1: the average distance between the organ landmark to the target was 13.6 mm (range: 0–96 mm). Measurement 2: in 31 of the 40 attempts (77.5 %), we could measure the distance from the landmark organ to the nearest calibration point. The average distance was 34.4 mm (range: 0–69 mm).

Measurement 3: A perfect match was seen in 6 of 20 attempts (30.0 %). There was a deviation in 14 of the 20 attempts (70.0 %). The mean distance was 11.1 mm (range: 6–23 mm). Conclusion Although very promising, MRI-ultrasound fusion imaging (MUFI) currently cannot be readily implemented into daily practice as a routine evaluation of DIE.

Surgical phase modelling in minimal invasive surgery

Background

Surgical Process Modelling (SPM) offers the possibility to automatically gain insight in the surgical workflow, with the potential to improve OR logistics and surgical care. Most studies have focussed on phase recognition modelling of the laparoscopic cholecystectomy, because of its standard and frequent execution. To demonstrate the broad applicability of SPM, more diverse and complex procedures need to be studied. The aim of this study is to investigate the accuracy in which we can recognise and extract surgical phases in laparoscopic hysterectomies (LHs) with inherent variability in procedure time. To show the applicability of the approach, the model was used to automatically predict surgical end-times.

Methods

A dataset of 40 video-recorded LHs was manually annotated for instrument use and divided into ten surgical phases. The use of instruments provided the feature input for building a Random Forest surgical phase recognition model that was trained to automatically recognise surgical phases. Tenfold cross-validation was performed to optimise the model for predicting the surgical end-time throughout the procedure.

Results

Average surgery time is 128 ± 27 min. Large variability within specific phases is seen. Overall, the Random Forest model reaches an accuracy of 77% recognising the current phase in the procedure. Six of the phases are predicted accurately over 80% of their duration. When predicting the surgical end-time, on average an error of 16 ± 13 min is reached throughout the procedure.

Conclusions

This study demonstrates an intra-operative approach to recognise surgical phases in 40 laparoscopic hysterectomy cases based on instrument usage data. The model is capable of automatic detection of surgical phases for generation of a solid prediction of the surgical end-time.

Towards spill-free in-bag morcellation: a health failure mode and effects analysis

BACKGROUND

To assess potential risks of new surgical procedures and devices before their introduction into daily practice, a prospective risk inventory (PRI) is a required step. This study assesses the applicability of the Health Failure Mode and Effects Analysis (HFMEA) as part of a PRI of new technology in minimally invasive gynecologic surgery.

METHODS

A reference case was defined of a patient with presumed benign leiomyoma undergoing a laparoscopic hysterectomy or myomectomy including in-bag power morcellation; however, pathology defined a stage I uterine leiomyosarcoma. Using in-bag morcellation as a template, a HFMEA was performed. All steps of the in-bag morcellation technique were identified. Next, the possible hazards of these steps were explored and possible measures to control these hazards were discussed.

RESULTS

Five main steps of the morcellation process were identified. For retrieval bags without openings to accommodate instruments inside the bag, 120 risks were identified. Of these risks, 67 should be eliminated. For containment bags with openings 131 risks were identified of which 68 should be eliminated. Of the 10 causes most at risk to cause spillage, two can be eliminated by using appropriate bag materials. Myomectomy appears to be more at risk for residual tissue spillage compared to total hysterectomy.

CONCLUSION

The HFMEA has provided important new insights regarding potential weaknesses of the in-bag morcellation technique, particularly with respect to hazardous steps in the morcellation process as well as requirements that bags should meet. As such, this study has shown HFMEA to be a valuable method that identifies and quantifies potential hazards of new technology.

Urinary catheterisation management after laparoscopic hysterectomy: a national overview and a nurse preference survey

The aim of this study was to evaluate the catheterisation regimes after a laparoscopic hysterectomy (LH) in Dutch hospitals and to assess the nurses' opinion on this topic. This was particularly relevant as no consensus exists on the best moment to remove a urinary catheter after an LH. All 89 Dutch hospitals were successfully contacted and provided information on their catheterisation regime after LH: 69 (77.5%) hospitals reported removing the catheter the next morning after the LH, while nine hospitals (10.1%) removed it directly at the end of the procedure. The other 11 hospitals had different policies (four hours, up to two days). Additionally, all nurses working in the gynaecology departments of the hospitals affiliated to Leiden University were asked to fill in a self-developed questionnaire. Of the 111 nurses who completed the questionnaire (response rate 81%), 90% was convinced that a direct removal was feasible and 78% would recommend it to a family member or friend. Impact Statement What is already known on this subject? Although an indwelling catheter is routinely placed during a hysterectomy, it is unclear what the best moment is to remove it after an LH specifically. To fully benefit from the advantages associated with this minimally invasive approach, postoperative catheter management, should be, amongst others, optimal and LH-specific. A few studies have demonstrated that the direct removal of urinary catheter after an uncomplicated LH is feasible, but the evidence is limited. What the results of this study add? While waiting for the results of the randomised trials, this present study provides insight into the nationwide catheterisation management after an LH. Despite the lack of consensus on the topic, catheterisation management was quite uniform in the Netherlands: most Dutch hospitals removed the urinary catheter one day after an LH. Yet, this was not in line with the opinion of the surveyed nurses, as the majority would recommend a direct removal. This is interesting as nurses are closely involved in the patients' postoperative care. What are the implications of these findings for clinical practice and/or further research? Although randomised trials are necessary to determine an optimal catheterisation management, the findings of this present study are valuable if a new urinary catheter regime has to be implemented.

Surgical outcomes of laparoscopic hysterectomy with concomitant endometriosis without bowel or bladder dissection: a cohort analysis to define a case-mix variable

Background

Pelvic endometriosis is often mentioned as one of the variables influencing surgical outcomes of laparoscopic hysterectomy (LH). However, its additional surgical risks have not been well established. The aim of this study was to analyze to what extent concomitant endometriosis influences surgical outcomes of LH and to determine if it should be considered as case-mix variable.

Results

A total of 2655 LH’s were analyzed, of which 397 (15.0%) with concomitant endometriosis. For blood loss and operative time, no measurable association was found for stages I (n = 106) and II (n = 103) endometriosis compared to LH without endometriosis. LH with stages III (n = 93) and IV (n = 95) endometriosis were associated with more intra-operative blood loss (p = < .001) and a prolonged operative time (p = < .001) compared to LH without endometriosis. No significant association was found between endometriosis (all stages) and complications (p = .62).

Conclusions

The findings of our study have provided numeric support for the influence of concomitant endometriosis on surgical outcomes of LH, without bowel or bladder dissection. Only stages III and IV were associated with a longer operative time and more blood loss and should thus be considered as case-mix variables in future quality measurement tools.

Measuring surgical safety during minimally invasive surgical procedures: a validation study

BACKGROUND

During the implementation of new interventions (i.e., surgical devices and technologies) in the operating room, surgical safety might be compromised. Current safety measures are insufficient in detecting safety hazards during this process. The aim of the study was to observe whether surgical teams are capable of measuring surgical safety, especially with regard to the introduction of new interventions.

METHODS

A Surgical Safety Questionnaire was developed that had to be filled out directly postoperative by three surgical team members. A potential safety concern was defined as at least one answer between (strongly) disagree and indifferent. The validity of the questionnaire was assessed by comparison with the results from video analysis. Two different observers annotated the presence and effect of surgical flow disturbances during 40 laparoscopic hysterectomies performed between November 2010 and April 2012.

RESULTS

The surgeon reported a potential safety concern in 16% (85/520 questions). With respect to the scrub nurse and anesthesiologist, this was both 9% (46/520). With respect to the preparation, functioning, and ease of use of the devices in 37.5-47.5% (15-19/40 procedures) a potential safety concern was reported by one or more team members. During procedures after which a potential safety concern was reported, surgical flow disturbances lasted a higher percentage of the procedure duration [9.3 ± 6.2 vs. 2.9 ± 3.7% (mean ± SD), p < .001]. After procedures during which a new instrument or device was used, more potential safety concerns were reported (51.2 vs. 23.1%, p < .001).

CONCLUSIONS

Potential safety concerns were especially reported during procedures in which a relatively high percentage of the duration consisted of surgical flow disturbances and during procedures in which a new instrument or device was used. The Surgical Safety Questionnaire can act as a validated tool to evaluate and maintain surgical safety during minimally invasive procedures, especially during the introduction of a new intervention.

Human cadavers to evaluate prototypes of minimally invasive surgical instruments: A feasibility study

BACKGROUND

New technology should be extensively tested before it is tried on patients. Unfortunately representative models are lacking. In theory, fresh frozen human cadavers are excellent models.

OBJECTIVE

To identify strengths and weaknesses of fresh frozen human cadavers as research models for new technology prior to implementation in gynecological surgery.

METHODS

During pre-clinical validation studies regarding the MobiSep uterine manipulator, test procedures were performed on fresh frozen cadavers. Both the experimental setup as the performance of the prototype were assessed.

RESULTS

Five tests including six human cadavers were performed. Major changes were made to the MobiSep prototype design. The cadavers of two tests closely resembled surgical experiences as found in live patients. The anatomy of 4 of the 6 cadavers was not fully representative due to atrophy of the internal genitalia caused by age and due to the presence of pathology such extensive tumorous tissue.

CONCLUSION

The cadaver tests provided vital information regarding design and functionality, that failed to emerge during the in-vitro testing. However, experiments are subject to anatomical uncertainties or restrictions. Consequently, the suitability of a cadaver should be carefully assessed before it is used for testing new technology.

Laparoscopic hysterectomy for benign indications: clinical practice guideline

Purpose

Since the introduction of minimally invasive gynecologic surgery, the percentage of advanced laparoscopic procedures has greatly increased worldwide. It seems therefore, timely to standardize laparoscopic gynecologic care according to the principles of evidence-based medicine. With this goal in mind—the Dutch Society of Gynecological Endoscopic Surgery initiated in The Netherlands the development of a national guideline for laparoscopic hysterectomy (LH). This present article provides a summary of the main recommendations of the guideline.

Methods

This guideline was developed following the Dutch guideline of medical specialists and in accordance with the AGREE II tool. Clinically important issues were firstly defined and translated into research questions. A literature search per topic was then conducted to identify relevant articles. The quality of the evidence of these articles was rated following the GRADE systematic. An expert panel consisting of 18 selected gynecologists was consulted to formulate best practice recommendations for each topic.

Results

Ten topics were considered in this guideline, including amongst others, the different approaches for hysterectomy, advice regarding tissue extraction, pre-operative medical treatment and prevention of ureter injury. This work resulted in the development of a clinical practical guideline of LH with evidence- and expert-based recommendations. The guideline is currently being implemented in The Netherlands.

Conclusion

A guideline for LH was developed. It gives an overview of best clinical practice recommendations. It serves to standardize care, provides guidance for daily practice and aims to guarantee the quality of LH at an (inter)national level.

Endometrial scratching in women with implantation failure after a first IVF/ICSI cycle; does it lead to a higher live birth rate? The SCRaTCH study: a randomized controlled trial (NTR 5342)

BACKGROUND

Success rates of assisted reproductive techniques (ART) are approximately 30%, with the most important limiting factor being embryo implantation. Mechanical endometrial injury, also called 'scratching', has been proposed to positively affect the chance of implantation after embryo transfer, but the currently available evidence is not yet conclusive. The primary aim of this study is to determine the effect of endometrial scratching prior to a second fresh in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycle on live birth rates in women with a failed first IVF/ICSI cycle.

METHOD

Multicenter randomized controlled trial in Dutch academic and non-academic hospitals. A total of 900 women will be included of whom half will undergo an endometrial scratch in the luteal phase of the cycle prior to controlled ovarian hyperstimulation using an endometrial biopsy catheter. The primary endpoint is the live birth rate after the 2^nd fresh IVF/ICSI cycle. Secondary endpoints are costs, cumulative live birth rate (after the full 2^nd IVF/ICSI cycle and over 12 months of follow-up); clinical and ongoing pregnancy rate; multiple pregnancy rate; miscarriage rate and endometrial tissue parameters associated with implantation failure.

DISCUSSION

Multiple studies have been performed to investigate the effect of endometrial scratching on live birth rates in women undergoing IVF/ICSI cycles. Due to heterogeneity in both the method and population being scratched, it remains unclear which group of women will benefit from the procedure. The SCRaTCH trial proposed here aims to investigate the effect of endometrial scratching prior to controlled ovarian hyperstimulation in a large group of women undergoing a second IVF/ICSI cycle.

TRIAL REGISTRATION

NTR 5342 , registered July 31^st, 2015.

PROTOCOL VERSION

Version 4.10, January 4th, 2017.

Medical malpractice claims in laparoscopic gynecologic surgery: a Dutch overview of 20 years

BACKGROUND

The success of newly introduced surgical techniques is generally primarily assessed by surgical outcome measures. However, data on medical liability should concomitantly be used to evaluate provided care as they give a unique insight into substandard care from patient's point of view. The aim of this study was to analyze the number and type of medical claims after laparoscopic gynecologic procedures since the introduction of advanced laparoscopy two decades ago. Secondly, our objective was to identify trends and/or risk factors associated with these claims.

METHODS

To identify the claims, we searched the databases of the two largest medical liability mutual insurance companies in The Netherlands (MediRisk and Centramed), covering together 96% of the Dutch hospitals. All claims related to laparoscopic gynecologic surgery and filed between 1993 and 2015 were included.

RESULTS

A total of 133 claims met our inclusion criteria, of which 54 were accepted claims (41%) and 79 rejected (59%). The number of claims remained relatively constant over time. The majority of claims were filed for visceral and/or vascular injuries (82%), specifically to the bowel (40%) and ureters (20%). More than one-third of the injuries were entry related (38%) and 77% of the claims were filed after non-advanced procedures. A delay in diagnosing injuries was the primary reason for financial compensation (33%). The median sum paid to patients was €12,000 (500-848,689). In 90 claims, an attorney was defending the patient (83% for the accepted claims; 57% for the rejected claims).

CONCLUSION

The number of claims remained relatively constant during the study period. Most claims were provoked by bowel and ureter injuries. Delay in recognizing injuries was the most encountered reason for granting financial compensation. Entering the abdominal cavity during laparoscopy continues to be a potential dangerous step. As a result, gynecologists are recommended to thoroughly counsel patients undergoing any laparoscopic procedure, even regarding the risk of entry-related injuries.

[Optimising postoperative recovery at home; individualised discharge policy and task division between GP and medical specialist]

In the last decennia, the length of hospital stay of admitted patients has significantly decreased in all medical fields. As a result, postoperative recovery mainly takes place at home, inherently leading to new challenges. Here, two patients are being discussed for whom the postoperative period was substandard. To guarantee optimal quality of care in the home situation, the medical specialist and the general practitioner need to make the necessary arrangements. We would first of all recommend providing each discharged patient with specific, structured and individualised advices regarding postoperative recovery but also regarding alarm symptoms and logistics (e.g. who to call in case of emergency). Finally, we believe that, as (serious) complications are rare, it should be agreed on the fact that the responsible medical specialist is the coordinator of the postoperative period and the first contact point for postoperative patients.

A dynamic quality assessment tool for laparoscopic hysterectomy to measure surgical outcomes

BACKGROUND

The current health care system has an urgent need for tools to measure quality. A wide range of quality indicators have been developed in an attempt to differentiate between high-quality and low-quality health care processes. However, one of the main issues of currently used indicators is the lack of case-mix correction and improvement possibilities. Case-mix is defined as specific (patient) characteristics that are known to potentially affect (surgical) outcome. If these characteristics are not taken into consideration, comparisons of outcome among health care providers may not be valid.

OBJECTIVE

The objective of the study was to develop and test a quality assessment tool for laparoscopic hysterectomy, which can serve as a new outcome quality indicator.

STUDY DESIGN

This is a prospective, international, multicenter implementation study. A web-based application was developed with 3 main goals: (1) to measure the surgeon's performance using 3 primary outcomes (blood loss, operative time, and complications); (2) to provide immediate individual feedback using cumulative observed-minus-expected graphs; and (3) to detect consistently suboptimal performance after correcting for case-mix characteristics. All gynecologists who perform laparoscopic hysterectomies were requested to register their procedures in the application. A patient safety risk factor checklist was used by the surgeon for reflection. Thereafter a prospective implementation study was performed, and the application was tested using a survey that included the System Usability Scale.

RESULTS

A total of 2066 laparoscopic hysterectomies were registered by 81 gynecologists. Mean operative time was 100 ± 39 minutes, blood loss 127 ± 163 mL, and the complication rate 6.1%. The overall survey response rate was 75%, and the mean System Usability Scale was 76.5 ± 13.6, which indicates that the application was good to excellent. The majority of surgeons reported that the application made them more aware of their performance, the outcomes, and patient safety, and they noted that the application provided motivation for improving future performance.

CONCLUSION

We report the development and test of a real-time, dynamic, quality assessment tool for measuring individual surgical outcome for laparoscopic hysterectomy. Importantly, this tool provides opportunities for improving surgical performance. Our study provides a foundation for helping clinicians develop evidence-based quality indicators for other surgical procedures.

Identification of risk factors in minimally invasive surgery: a prospective multicenter study

Background

Since the introduction of minimally invasive surgery (MIS), concerns for patient safety are more often brought to the attention. Knowledge about and awareness of patient safety risk factors are crucial in order to improve and enhance the surgical team, the environment, and finally surgical performance. The aim of this study was to identify and quantify patient safety risk factors in laparoscopic hysterectomy and to determine their influence on surgical outcomes.

Methods

A prospective multicenter study was conducted from April 2014 to January 2016, participating gynecologists registered their performed laparoscopic hysterectomies (LHs). If deemed necessary, gynecologists could fill out a checklist with validated patient safety risk factors. Association between procedures with and without an occurred risk factor(s) and the surgical outcomes (blood loss, operative time, and complications) were assessed, using multivariate logistic regression and generalized estimation equations.

Results

Eighty-five gynecologists participated in the study, registering a total of 2237 LHs. For 627(28 %) procedures, the checklist was entered (in total 920 items). The most reported risk factors were related to the surgeon (19.6 %), the surgical team (14.4 %), technology (16.6 %), and the patient (26.8 %). The procedures where a risk factor was registered had significantly less favorable outcomes, higher complication rate (10.5 vs. 4.8 % (p = 0.002), longer operative time [114 vs. 95 min (p < 0.001)], and more blood loss [110 vs. 168 mL (p = 0.047)], which was mainly due to the technological and patient-related risk factors.

Conclusion

Technological incidents are the most important and clinically relevant risk factors affecting surgical outcomes of LH. Future improvements of MIS need to focus on this. As awareness of safety risk factors in MIS is important, embedding of a safety risk factor checklist in registration systems will help surgeons to evaluate and improve their individual performance. This will inherently improve the surgical outcomes and thus patient safety.

Hospital versus individual surgeon's performance in laparoscopic hysterectomy

Purpose

To compare hospital versus individual surgeon’s perioperative outcomes for laparoscopic hysterectomy (LH), and to assess the relationship between surgeon experience and perioperative outcomes.

Methods

A retrospective analysis of all prospective collected LHs performed from 2003 to 2010 at one medical center was performed. Perioperative outcomes (operative time, blood loss, complication rate) were assessed on both a hospital level and surgeon level using Cumulative Observed minus Expected performance graphs.

Results

A total of 1618 LHs were performed, 16 % total laparoscopic hysterectomies and 84 % laparoscopic supracervical hysterectomies. Overall outcomes included mean (SD±) blood loss 108.9 ± 69.2 mL, mean operative time 95.4 ± 39.7 min and a complication occurred in 76 (4.7 %) of cases. Suboptimal perioperative outcomes of an individual surgeon were not always detected on a hospital level. However, collective suboptimal outcomes were faster detected on a hospital level compared to individual surgeon’s level. Evidence of a learning curve is seen; for the first 100 procedures, a decrease in operative time is observed as individual surgeon experience increases. Similarly, the risk of conversion decreases up to the first 50 procedures.

Conclusion

An individual outlier (i.e., surgeon with consistently suboptimal performance) will not always be detected when monitoring outcome measures only on a hospital level. However, monitoring outcome measures on a hospital level will detect suboptimal performance earlier compared to monitoring only on an individual surgeon’s level. To detect performance outliers timely, insight into an individual surgeon’s outcome and skills is recommended. Furthermore, an experienced surgeon is no guarantee for acceptable surgical outcomes.

Gamification to Engage Clinicians in Registering Data: A Randomized Trial

<p><strong>OBJECTIVE: </strong>To determine the effect of additional gamification elements in a web-based registry system in terms of engagement and involvement to register outcome data, and to determine if gamification elements have any effect on clinical outcomes.</p><p><strong>METHODS:</strong> Randomized controlled trial for gynecologists to register their performed laparoscopic hysterectomies (LH) in an online application. Gynecologists were randomized for two types of registries.<strong> </strong>Both groups received access to the online application; after registering a procedure, direct individual feedback on surgical outcomes was provided by showing three proficiency graphs. In the intervention group, additionally gamification elements were shown. These gamification elements consisted of points and achievements that could be earned and insight in monthly collective scores. All gamification elements were based on positive enforcement.</p><p><strong>RESULTS: </strong>A total of<strong> </strong>71 gynecologists were randomized and entered a total of 1833 LH procedures. No significant difference was found between the groups in terms of engagement and involvement on a 5-point Likert scale, respectively 2.34±0.87 versus 2.56±1.05 and 3.63±0.57 versus 3.33±1.03 for the intervention versus the control group (p&gt;0.05). The intervention group showed longer operative time than the control group (108±42 vs. 101±34 minutes, p=0.04), no other differences were found in terms of surgical outcomes.</p><p><strong>CONCLUSIONS: </strong>The addition of gamification elements in a registry system did not enhance the engagement and involvement of clinicians to register their clinical data. Based on our results, we advise that registry systems for clinical data should be as simple as possible with the focus on the main goal of the registry.</p>

A dynamic quality assessment tool for laparoscopic hysterectomy to measure surgical outcomes

BACKGROUND

The current healthcare system has an urgent need for tools to measure quality. A wide range of quality indicators have been developed in an attempt to differentiate between high-quality and low-quality healthcare processes. However, one of the main issues of currently used indicators is the lack of case-mix correction and improvement possibilities. Case-mix is defined as specific (patient) characteristics that are known to potentially affect (surgical) outcome. If these characteristics are not taken into consideration, comparisons of outcome among healthcare providers may not be valid OBJECTIVE: To develop and test a quality assessment tool for laparoscopic hysterectomy, which can serve as a new outcome quality indicator STUDY DESIGN: This is a prospective international multicenter implementation study. A web-based application (.www.qusum.org) was developed with three main goals: to measure the surgeon's performance using three primary outcomes (blood loss, operative time, and complications); to provide immediate individual feedback using cumulative Observed-minus-Expected graphs; and to detect consistently suboptimal performance after correcting for case-mix characteristics. All gynecologists who perform laparoscopic hysterectomies were requested to register their procedures in the application. A patient safety risk factor checklist was used by the surgeon for reflection. Thereafter, a prospective implementation study was performed, and the application was tested using a survey that included the System Usability Scale.

RESULTS

A total of 2066 laparoscopic hysterectomies were registered by 81 gynecologists. Mean operative time was 100±39 minutes, blood loss 127±163ml, and the complication rate 6.1%. The overall survey response rate was 75%, and the mean System Usability Scale was 76.5±13.6, which indicates that the application was good to excellent. The majority of surgeons reported that the application made them more aware of their performance, the outcomes, and patient safety, and they noted that the application provided motivation for improving future performance.

CONCLUSIONS

We report the development and test of a real-time, dynamic quality assessment tool for measuring individual surgical outcome for laparoscopic hysterectomy. Importantly, this tool provides opportunities for improving surgical performance. Our study provides a foundation for helping clinicians develop evidence-based quality indicators for other surgical procedures.

Surgical flow disturbances in dedicated minimally invasive surgery suites: an observational study to assess its supposed superiority over conventional suites

Background

Minimally invasive surgery (MIS) is frequently compromised by surgical flow disturbances due to technology- and equipment-related failures. Compared with MIS in a conventional cart-based OR, performing MIS in a dedicated integrated operating room (OR) is supposed to be beneficial to patient safety. The aim of this study was to compare a conventional OR with an integrated OR with regard to the incidence and effect of equipment-related surgical flow disturbances during an advanced laparoscopic gynecological procedure [laparoscopic hysterectomy (LH)].

Methods

Using video recording, 40 LHs performed between November 2010 and April 2012 (20 in a conventional cart-based OR and 20 in an integrated OR) were analyzed by two different observers. Outcome measures were the number, duration and effect (on a seven-point ordinal scale) of the surgical flow disturbances (e.g., malfunctioning, intraoperative repositioning, setup device).

Results

A total of 103 h and 45 min was observed. The interobserver agreement was high (kappa .85, p < .001). Procedure time was not significantly different (NS) [conventional OR vs. integrated OR, minutes ± standard deviation (SD), mean 161 ± 27 vs. 150 ± 34]. A total of 1651 surgical flow disturbances were observed (mean ± SD per procedure 40.8 ± 19.4 vs. 41.8 ± 15.9, NS). The mean number of surgical flow disturbances per procedure with regard to equipment was 6.3 ± 3.7 versus 8.5 ± 4.0, NS. No clinically relevant differences in the mean effect of these disturbances on the surgical flow between the two OR setups were observed.

Conclusions

Performing LH in an integrated OR did not reduce the number of surgical flow disturbances nor the effect of these disturbances. Furthermore, in the integrated OR, repositioning of the monitors was a frequent and time-consuming source of disturbance. In order to maintain the high standard of surgical safety, the entire surgical team has to be aware that by performing surgery in an integrated OR different potential source for disruption arise.

Trocar types in laparoscopy

BACKGROUND

Laparoscopic surgery has led to great clinical improvements in many fields of surgery; however, it requires the use of trocars, which may lead to complications as well as postoperative pain. The complications include intra-abdominal vascular and visceral injury, trocar site bleeding, herniation and infection. Many of these are extremely rare, such as vascular and visceral injury, but may be life-threatening; therefore, it is important to determine how these types of complications may be prevented. It is hypothesised that trocar-related complications and pain may be attributable to certain types of trocars. This systematic review was designed to improve patient safety by determining which, if any, specific trocar types are less likely to result in complications and postoperative pain.

OBJECTIVES

To analyse the rates of trocar-related complications and postoperative pain for different trocar types used in people undergoing laparoscopy, regardless of the condition.

SEARCH METHODS

Two experienced librarians conducted a comprehensive search for randomised controlled trials (RCTs) in the Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, CDSR and DARE (up to 26 May 2015). We checked trial registers and reference lists from trial and review articles, and approached content experts.

SELECTION CRITERIA

RCTs that compared rates of trocar-related complications and postoperative pain for different trocar types used in people undergoing laparoscopy. The primary outcomes were major trocar-related complications, such as mortality, conversion due to any trocar-related adverse event, visceral injury, vascular injury and other injuries that required intensive care unit (ICU) management or a subsequent surgical, endoscopic or radiological intervention. Secondary outcomes were minor trocar-related complications and postoperative pain. We excluded trials that studied non-conventional laparoscopic incisions.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted the study selection, risk of bias assessment and data extraction. We used GRADE to assess the overall quality of the evidence. We performed sensitivity analyses and investigation of heterogeneity, where possible.

MAIN RESULTS

We included seven RCTs (654 participants). One RCT studied four different trocar types, while the remaining six RCTs studied two different types. The following trocar types were examined: radially expanding versus cutting (six studies; 604 participants), conical blunt-tipped versus cutting (two studies; 72 participants), radially expanding versus conical blunt-tipped (one study; 28 participants) and single-bladed versus pyramidal-bladed (one study; 28 participants). The evidence was very low quality: limitations were insufficient power, very serious imprecision and incomplete outcome data. Primary outcomesFour of the included studies reported on visceral and vascular injury (571 participants), which are two of our primary outcomes. These RCTs examined 473 participants where radially expanding versus cutting trocars were used. We found no evidence of a difference in the incidence of visceral (Peto odds ratio (OR) 0.95, 95% confidence interval (CI) 0.06 to 15.32) and vascular injury (Peto OR 0.14, 95% CI 0.0 to 7.16), both very low quality evidence. However, the incidence of these types of injuries were extremely low (i.e. two cases of visceral and one case of vascular injury for all of the included studies). There were no cases of either visceral or vascular injury for any of the other trocar type comparisons. No studies reported on any other primary outcomes, such as mortality, conversion to laparotomy, intensive care admission or any re-intervention. Secondary outcomesFor trocar site bleeding, the use of radially expanding trocars was associated with a lower risk of trocar site bleeding compared to cutting trocars (Peto OR 0.28, 95% CI 0.14 to 0.54, five studies, 553 participants, very low quality evidence). This suggests that if the risk of trocar site bleeding with the use of cutting trocars is assumed to be 11.5%, the risk with the use of radially expanding trocars would be 3.5%. There was insufficient evidence to reach a conclusion regarding other trocar types, their related complications and postoperative pain, as no studies reported data suitable for analysis.

AUTHORS' CONCLUSIONS

Data were lacking on the incidence of major trocar-related complications, such as visceral or vascular injury, when comparing different trocar types with one another. However, caution is urged when interpreting these results because the incidence of serious complications following the use of a trocar was extremely low. There was very low quality evidence for minor trocar-related complications suggesting that the use of radially expanding trocars compared to cutting trocars leads to reduced incidence of trocar site bleeding. These secondary outcomes are viewed to be of less clinical importance.Large, well-conducted observational studies are necessary to answer the questions addressed in this review because serious complications, such as visceral or vascular injury, are extremely rare. However, for other outcomes, such as trocar site herniation, bleeding or infection, large observational studies may be needed as well. In order to answer these questions, it is advisable to establish an international network for recording these types of complications following laparoscopic surgery.