Does an aptitude for surgery exist and can we predict it? An experimental study.

BACKGROUND: The selection and allocation of surgeons with a greater potential for high surgical performance are essential aspects of improving the quality, safety, and effectiveness of surgical procedures. Objective of this trial was to determine the existence of basic skills and traits that would predict better performance in surgery, and those predictive factors that constitute a driving force in different stages of training. MATERIALS AND METHODS: The randomized crossover training trial took place from January 2021 to December 2021 and was conducted at an educational training center for minimally invasive surgery. A total of n =87 physicians (residents and experts) from surgical disciplines and n =239 fifth-year medical students were studied. The participants underwent extensive neuropsychological testing and surgical training, which was performed with conventional as well as robot-assisted laparoscopy by way of identical brief tasks conducted six times in a randomized crossover setting. Main Outcome was the latent factor structure of 'psychomotor skills', 'personality', and 'motivation' based on structural equation modeling. RESULTS: The training performance of both students and physicians was significantly explained by the interaction of the three factors (explained variance: 8.2% for students, 23.8% for physicians). In students, motivation (explained variance 8.4%) and personality (explained variance 4.5%) revealed the highest contribution to surgical training performance (explained variance through psychomotor skills 1.1%). In physicians, psychomotor skills (explained variance 27.4%) made the greatest contribution to surgical training performance (explained variance through motivation 2.3%; explained variance through personality 10.5%). CONCLUSION: The study showed that surgical performance is sensitive to, and fragile in regard of nonsurgery-related general individual traits. This aligns with the notion that early selection of surgeons with prospects of high surgical performance is possible, and perhaps even necessary in order to keep up with future demands on the medical system.

The Feasibility of Practical Training in Minimally Invasive Surgery at Medical School-A Prospective Study on the Pelvitrainer.

Background and Objectives: The acquisition of practical skills at medical school is an important part of the multidimensional education program of future physicians. However, medical schools throughout the world have been slow in incorporating practical skills in their curriculum. Therefore, the aims of the present prospective study were (a) to demonstrate the feasibility of such surgical training, (b) to objectify its benefit in medical education, and (c) to investigate the impact of such training on subsequent career choices. Material and Methods: We introduced a two-day laparoscopy course on the pelvitrainer as part of the curriculum of the gynecological internship of fifth year medical students from 2019 to 2020. The results of the students' training were matched to those of surgeons who completed the same curriculum in a professional postgraduate laparoscopy course from 2017 to 2020 in a comparative study design. Additionally, we performed a questionnaire-based evaluation of the impact of the course on medical education and subsequent career choices directly before and after completing the course. Results: A total of 261 medical students and 206 physicians completed the training program. At baseline, the students performed significantly more poorly than physicians in a median of three of four exercises (p < 0.001). However, this evened out in the final runs, during which students performed more poorly than physicians only in one exercise and even better than physicians in one. The general integration of surgical training in medical school curricula was rated very low (12.4% on the VAS, IQR 3-16%) despite the high demand for such training. In the survey, the course was deemed very beneficial for medical education (median VAS 80.7%, IQR 73-98%), but did not appear to influence the students' subsequent career preferences. Conclusions: The acquisition of practical surgical skills during medical school is significantly under-represented in many medical faculties. The benefits of such training, as demonstrated in our study, would improve the education of future physicians.

Molecular Determinants of Uterine Receptivity: Comparison of Successful Implantation, Recurrent Miscarriage, and Recurrent Implantation Failure.

Embryo implantation is one of the most remarkable phenomena in human reproduction and is not yet fully understood. Proper endometrial function as well as a dynamic interaction between the endometrium itself and the blastocyst-the so-called embryo-maternal dialog-are necessary for successful implantation. Several physiological and molecular processes are involved in the success of implantation. This review describes estrogen, progesterone and their receptors, as well as the role of the cytokines interleukin (IL)-6, IL-8, leukemia inhibitory factor (LIF), IL-11, IL-1, and the glycoprotein glycodelin in successful implantation, in cases of recurrent implantation failure (RIF) and in cases of recurrent pregnancy loss (RPL). Are there differences at the molecular level underlying RIF or RPL? Since implantation has already taken place in the case of RPL, it is conceivable that different molecular biological baseline situations underlie the respective problems.

Expression of interleukin-1ß and its receptor in human granulosa cells and their association with steroidogenesis.

This study aimed to investigate whether interleukin 1ß (IL-1ß) and soluble IL-1 receptor 2 (sIL-1R2) are expressed in human granulosa cells (GCs) and relate to ovarian steroidogenesis. Ninety-six women undergoing in vitro fertilization (IVF) were recruited. RT-PCR and immunocytochemistry were used to detect mRNAs and proteins of IL-1ß and IL-1R2, respectively. The steroidogenesis of primary cultured GCs was evaluated following treatment with either IL-1ß alone or IL-1ß and FSH in combination. There were positive correlations between serum IL-1ß and serum progesterone (r = 0.220, p = 0.032) and follicular fluid (FF) estradiol (r = 0.242, p = 0.018). Additionally, serum and FF sIL-1R2 were negatively and positively correlated with FF estradiol (r = -0.376, p = 0.005) and FF progesterone (r = 0.434, p = 0.001), respectively. The mRNA and protein expression of IL-1ß and IL-1R2 became evident in GCs. IL-1ß alone significantly increased estradiol secretion from GCs, but in the presence of FSH, it could notably promote progesterone secretion in addition to estradiol. In conclusion, IL-1ß and sIL-1R2 are expressed in human GCs and substantially contribute to ovarian steroidogenesis, suggesting that the IL-1ß system may be a potential target for optimizing ovarian hyperstimulation and steroidogenesis in IVF cycles.

Factors influencing surgical performance and learning progress in minimally invasive surgery - results of an interdisciplinary multicenter study.

BACKGROUND: Advancing surgical techniques require a high level of adaptation and learning skills on the part of surgeons. The authors need selection procedures and decision support systems for the recruitment of medical students and young surgeons. The authors aimed to investigate factors influencing the surgical performance and learning abilities of surgeons and medical students. MATERIALS AND METHODS: The training scores of persons attending 16 standardized training courses (at three training centers) of the German Working Group for Gynecological Endoscopy (AGE e.V.) from 2017 to 2020, individual characteristics, and the results of psychomotor tests of three-dimensional imagination and hand-eye coordination were correlated. Similar analyses were performed for medical students in their final clinical year from 2019 to 2020. The training concept was evaluated in a prospective, multicenter, interdisciplinary, multinational setting. RESULTS: In all, 180 of 206 physicians (response rate 87.4%) and 261 medical students (response rate 100%) completed the multistage training concept successfully. Of personal characteristics, the strongest correlation was noted for good surgical performance and learning success, and the absolute number of performed laparoscopic surgeries ( r =0.28-0.45, P <0.001/ r =0.1-0.28, P <0.05). A high score on the spatial visualization ability test was also correlated with good surgical performance ( r =0.18-0.27, P <0.01). Among medical students with no surgical experience, however, age was negatively correlated with surgical performance, that is the higher the age, the lower the surgical performance ( r =0.13/ r =0.22, P <0.05/ P <0.001). CONCLUSION: Individual factors (e.g. surgical experience, self-assessment, spatial visualization ability, eye-hand coordination, age) influence surgical performance and learning. Further research will be needed to create better decision support systems and selection procedures for prospective physicians. The possibilities of surgical training should be improved, promoted, and made accessible to a maximum number of surgical trainees because individual learning curves can be overcome even by less talented surgeons. Training options should be institutionalized for those attending medical school.

Fertility Preservation in Endometrial Cancer-Treatment and Molecular Aspects.

Endometrial cancer is one of the most common gynecological malignancies worldwide; incidences are rising, with 417,367 new cases registered in 2020. Of these, the proportion of women that are of reproductive age is around 4-14% and the number is increasing. Thus, in addition to oncological therapy and safety, the preservation of fertility plays a central role in therapeutic strategies. Molecular genetic patient data provide a robust supplementary benefit that improves primary risk assessment and can help design personalized treatment options to curtail over- and undertreatment and contribute to fertility preserving strategies. The aim of our review is to provide an overview of the latest significant recommendations in the diagnosis and therapy of endometrial cancer during reproductive age. In this paper the most recent groundbreaking molecular discoveries in endometrial cancer are highlighted and discussed as an opportunity to enhance the prognostic and therapy options in this special patient collective.

Impact of Adenomyosis on Infertile Patients-Therapy Options and Reproductive Outcomes.

Adenomyosis is associated with a negative impact on reproductive outcomes. Although adenomyosis is detected more frequently in women of late reproductive age, its impact on pregnancy rates is important because, in today's world, family planning has shifted towards the late reproductive phase of life for many women. Although the diagnostic indications for imaging studies are well-known, we lack strict diagnostic criteria and classification systems concerning the extent of the disease. Selecting the optimal evidence-based treatment option for adenomyosis is difficult because of the paucity of evidence concerning the association between fertility and the degree and composition of adenomyosis. Furthermore, the treatment of infertility might interfere with the treatment of adenomyosis due to the presence of pain. The aim of this review is to analyze the association between adenomyosis and infertility, and describe treatment options to enhance reproductive outcomes. The following aspects will be addressed in detail: (a) prevalence and causes of adenomyosis, (b) diagnostic tools with imaging techniques, (c) clinical symptoms, (d) proposed pathomechanism of adenomyosis and infertility, and (e) different treatment approaches (pharmacological, surgical, others) and their impact on reproductive outcomes.

Is Blastocyst Culture Responsible for Higher Pregnancy Rates? A Critical Analysis of the Day of Optimal Embryo Transfer and Embryo Quality.

OBJECTIVE: A prolonged culture of embryos beyond day 2-3 to day 5 (blastocyst culture) after fertilization might be an alternative, simple way of selecting suitable embryos for transfer. Extending embryo culture to day 5/6 is a selection tool to choose an embryo with a greater likelihood of implantation rather than improve embryo quality. METHODS: This retrospective study analyzed 1126 fresh IVF/ICSI cycles performed between February 1, 2014 and December 30, 2018 at the University Fertility Center in Kiel, Germany, to determine the impact of blastocyst culture on pregnancy rates and the association between embryo quality and pregnancy rates. RESULTS: Clinical pregnancy was achieved in 154 cases (19.5%) after day 2/3 transfer and in 76 cases (22.7%) after day 5 transfer. Pearson's two-sided chi-squared test yielded no statistical significance (p=0.221). The analysis of clinical pregnancy rates in relation to the quality of transferred embryos yielded the following results: 49 (10.7%) pregnancies in cases of no ideal embryo(s); 122 (27.2%) in cases of at least one ideal embryo; and 59 (26.7%) for both quality groups. Pearson's two-sided Chi-squared test was statistically significant (p<0.001). CONCLUSIONS: Our data revealed no improvement of pregnancy rates after blastocyst transfer compared with day 2/3 transfers. However, we noted higher pregnancy rates when an embryo of good quality was transferred.

The pelvitrainer for training in laparoscopic surgery - A prospective, multicenter, interdisciplinary study: Experimental research.

BACKGROUND: Minimally invasive surgical procedures have a flat learning curve, especially in the initial period of a surgeon's training. Pelvitrainers enable the prospective surgeon to drill the surgical technique, including camera navigation, instrument manipulation, and the individual steps of the operation, on a model rather than a patient. Integrating the pelvitrainer into standardized surgical training programs is challenging, but would be essential to achieve optimum effects of long duration in surgical education. MATERIAL AND METHODS: The pelvitrainer Realsimulator 2.0 (Endodevelop) was evaluated in 16 standardized training courses (at three training centers) of the German Working Group for Gynecological Endoscopy (AGE e.V.) from 2017 to 2020, The training concept was implemented and evaluated in a prospective, multicenter, interdisciplinary, multinational setting. RESULTS: One hundred and eighty of 206 physicians (response rate 87.4%) completed the multi-stage training concept successfully. A significant (p < 0.001) objective improvement (positive learning curve) was observed for all exercises on the pelvitrainer. The trainer's subjective evaluation revealed positive ratings for design (median 82%, IQR 71-91%), camera navigation (87%, IQR 76-95%), and instrument manipulation (median 87%, IQR 77-94%). A follow-up survey performed six months after the course confirmed its sustainable and high benefits in clinical routine (median 82%, IQR 70-97%). CONCLUSION: The present investigation proved the high educational value of pelvitrainers, which can be enhanced by using a structured training concept. The benefit of training courses for health care justifies their incorporation into a standardized training curriculum. The completion of such training courses should be regarded as a prerequisite for a doctor to qualify as an independent surgeon.

Perioperative considerations in the treatment of endometriosis

Endometriosis is one of the most common benign diseases in women of reproductive age. Nearly all gynecological offices and clinics will contain patients with endometriosis; the frequency and severity of the disease will vary from one setting to another. Adjoining specialties, such as internal medicine, general medicine, surgery, urology, orthopedics, neurology and psychosomatic medicine, will be challenged directly or indirectly by various forms of endometriosis and its sequelae. The disease is characterized by pelvic pain, dysmenorrhea, dyspareunia and sterility. Even now, several years may elapse between the onset of the disease and its diagnosis. The diagnosis of endometriosis is complicated by the diversity of the symptoms. A precise documentation of the patient's medical history and thorough diagnostic procedures are essential to establish a robust diagnosis. This article will discuss the perioperative considerations, diagnosis and treatment of endometriosis.

Video Feedback and Video Modeling in Teaching Laparoscopic Surgery: A Visionary Concept from Kiel.

Learning curves for endoscopic surgery are long and flat. Various techniques and methods are now available for surgical endoscopic training, such as pelvitrainers, virtual trainers, and body donor surgery. Video modeling and video feedback are commonly used in professional training. We report, for the first time, the application of video modeling and video feedback for endoscopic training in gynecology. The purpose is to present an innovative method of training. Attendees (residents and specialists) of minimally invasive surgery courses were asked to perform specific tasks, which were video recorded in a multimodular concept. Feedback was given later by an expert at a joint meeting. The attendees were asked to fill a questionnaire in order to assess video feedback given by the expert. The advantages of video feedback and video modeling for the development of surgical skills were given a high rating (median 84%, interquartile ranges (IQR) 72.5-97.5%, n = 37). The question as to whether the attendees would recommend such training was also answered very positively (median 100%, IQR 89.5-100%, n = 37). We noted a clear difference between subjective perception and objective feedback (58%, IQR 40.5-76%, n = 37). Video feedback and video modeling are easy to implement in surgical training setups, and help trainees at all levels of education.

The Development of Laparoscopy-A Historical Overview.

The advent of laparoscopy marked a fundamental change in the evolution of medicine. The procedure progressed consistently after the first time it was performed in a human being nearly a hundred years ago. The 1960's and 1980's witnessed groundbreaking changes. During this time, laparoscopy evolved from a purely diagnostic procedure into an independent surgical approach. Outstanding pioneers of the times were Palmer, Frangenheim and Semm. Laparoscopy advanced rapidly and influenced gynecology as well. The procedure was initially attacked most vociferously by the surgical fraternity. However, within a short period of time the pendulum shifted: laparoscopy became the preferred surgical approach for a variety of diseases-whether benign or malignant-in several medical disciplines. Laparoscopy has become a routine approach in the twenty-first century. Technical advancements have led to robot-assisted surgery. Future developments will include artificial intelligence and augmented reality. In the present article we address past milestones, current practices, and future challenges in laparoscopy.

Establishment and evaluation of a training course in advanced laparoscopic surgery based on human body donors embalmed by ethanol-glycerol-lysoformin fixation.

BACKGROUND: Education of clinical anatomy and training of surgical skills are essential prerequisites for any surgical intervention in patients. Here, we evaluated a structured training program for advanced gynecologic laparoscopy based on human body donors and its impact on clinical practice. METHODS: The three-step training course included: (1) anatomical and surgical lectures, (2) demonstration and hands-on study of pre-dissected anatomical specimens, and (3) surgical training of a broad spectrum of gynecological laparoscopic procedures on human body donors embalmed by ethanol-glycerin-lysoformin. Two standardized questionnaires (after the course and 6 months later) evaluated the effectiveness of each of the training modules and the benefits to surgical practice. RESULTS: Eighty participants took part in 6 training courses using a total number of 24 body donors (3 trainees/body donor). Based on a 91.3% (73/80) response rate, participants rated high or very high the tissue and organ properties of the body donors (n = 72, 98.6%), the technical feasibility to perform laparoscopic surgery (n = 70, 95.9%), and the overall learning success (n = 72, 98.6%). Based on a 67.5% (54/80) response rate at 6 months, participants rated the benefit of the course to their daily routine as very high (mean 80.94 ± 24.61%, n = 53), and this correlated strongly with the use of body donors (r = 0.74) and the ability to train laparoscopic dissections (r = 0.77). CONCLUSIONS: This study demonstrates the technical feasibility and didactic effectiveness of laparoscopic training courses in a professional and true-to-life setting by using ethanol-glycerol-lysoformin embalmed body donors. This cost-efficient fixation method offers the option to integrate advanced surgical training courses into structured postgraduate educational curricula to meet both the technical demands of minimal invasive surgery and the ethical concerns regarding patients´ safety.

Challenges Posed by Embryonic and Anatomical Factors in Systematic Lymphadenectomy for Endometrial Cancer.

Lymph node involvement has been shown to be one of the most relevant prognostic factors in a variety of malignancies; this is also true of endometrial cancer. The determination of the lymph node status is crucial in order to establish the tumor stage, and to consider adjuvant treatment. A wide range of surgical staging practices are currently used for the treatment of endometrial cancer. The necessity and extent of lymph node dissection is an ongoing controversial issue in gynecological oncology. Lymph node surgery in endometrial cancer is technically challenging, and can be time consuming because of the topographic complexity of lymphatic drainage as such, and the fact that the lymph nodes are directly adjacent to both blood vessels and nerves. Therefore, profound and exact knowledge of the anatomy is essential. Sentinel lymph node mapping was recently introduced in surgical staging with the aim of reducing morbidity, whilst also obtaining useful prognostic information from a patient's lymph node status. The present review summarizes the current evidence on the role of lymph node surgery in endometrial cancer, focusing on the embryological, anatomical, and technical aspects.

Management of a Thin Endometrium by Hysteroscopic Instillation of Platelet-Rich Plasma Into The Endomyometrial Junction: A Pilot Study.

In patients whose embryo transfer has been previously canceled due to a thin endometrium, the injection of platelet-rich plasma (PRP) guided by hysteroscopy into the endomyometrial junction improves endometrial thickness and vascularity. This may well serve as a novel approach for the management of these patients. In this study, 32 patients aged between 27 and 39 years, suffering from primary or secondary infertility, were selected for hysteroscopic instillation of PRP. This cross-sectional study included a retrospective assessment of the improvement of endometrial thickness (>7 mm) on the commencement of progesterone treatment in 24 of 32 patients (75%) after hysteroscopy-guided injections of PRP into the subendometrial zone. After PRP instillation, the endometrium was 7 mm or thicker in 24 of 32 patients, and all 24 patients underwent frozen embryo transfer. Moreover, 12 of 24 patients who underwent embryo transfer conceived, whereas 10 had a clinical pregnancy with visualization of cardiac activity at 6 weeks and two had a biochemical pregnancy. Our approach of PRP injection into the subendometrial region is consistent with the histologically proven regeneration of the endometrium from the endomyometrial junction. We observed an improvement of endometrial thickness and higher pregnancy rates in cases of previously canceled embryo transfer due to a thin endometrium.

Didactic Benefits of Surgery on Body Donors during Live Surgery Events in Minimally Invasive Surgery.

BACKGROUND: Live surgery events serve as a valuable tool for surgical education, but also raise ethical concerns about patient safety and professional performance. In the present study, we evaluate the technical feasibility and didactic benefits of live surgery on body donors compared to real patients. METHODS: A live surgery session performed on a body donor's cadaver embalmed in ethanol-glycerol-lysoformin was integrated into the live surgery program presented at a major gynecological convention of minimally invasive surgery. Surgical procedures carried out in real patients were paralleled in the body donor, including the dissection and illustration of surgically relevant anatomical landmarks. A standardized questionnaire was filled by the participants (n = 208) to evaluate the appropriateness, effectiveness, and benefits of this novel concept. RESULTS: The live surgery event was appreciated as a useful educational tool. With regard to the use of body donors, authenticity was rated high (85.5%), and the overall value of body donors for surgical education and training was rated very high (95.0%). The didactic benefit of simultaneous operations performed on body donors and real patients was considered particularly useful (95.5%), whereas complete replacement of real patients by body donors was not favored (14.5%). CONCLUSIONS: The study demonstrated both the technical feasibility and didactic benefits of performing minimally invasive surgery in body donors as part of live surgery events. This novel concept has the potential to enhance anatomical knowledge, providing insights into complex surgical procedures, and may serve to overcome yet unresolved ethical concerns related to live surgery events.

Postoperative Telephone-Based Questionnaire on Quality of Life after Robotic-Assisted Laparoscopic Hysterectomy versus Conventional Total Laparoscopic Hysterectomy.

Aim: The objective of the study was to evaluate the benefits of robotic-surgery for hysterectomy compared to conventional laparoscopy for benign indications. A specially prepared telephone-based questionnaire was used postoperatively. Method: All women (n = 155) undergoing total laparoscopic hysterectomy for benign indications either by the robotic-assisted procedure (RALH) or conventional laparoscopy (CL) between 1 January 2013 and 31 December 2017 at the Department of the Gynecology, University Hospitals, Campus Kiel, Germany, were eligible for analysis. Intra-operative and postoperative parameters affecting the patients' quality of life were assessed by a telephone-based questionnaire. The latter addressed postoperative pain, limitations of basic hygiene, daily activity, active pursuit of hobbies, sexual intercourse, and days of sick leave. All patients received the questionnaire by post at least three weeks prior to being contacted on the phone. Results: 78% of the contacted patients responded to the questionnaire; 96% (n = 115) of the patients said they would recommend the operation to other patients. Both groups needed 42 days to resume their regular hobbies. In whole 90.8% (n = 108) were total satisfied with the cosmetic result of the abdominal incision; the numbers in the respective groups were 80% (80% n = 36) in RALH and 97.3% (n = 72) in CL. The difference was significant on the Chi-square test (p = 0.002). 5% (n = 7) were dissatisfied with the scar (13.3%; n = 6) in the RALH group, and 1.4% (n = 1) in CL. In all 1.7 % of patients were dissatisfied with the position of the incisions; the respective numbers were 4.4 % (n = 2) in the RALH group and no patient in the CL group. 33% of patients experienced no limitations in regard of sexual intercourse after the operation. The median number of days taken to resume sexual intercourse after the operation was 56 days in the CL group, and 49 days in the RALH group. Nearly 30% (n = 25) were hesitant to resume intercourse. The median operating time was 145 min in the RALH group, which was significantly longer than the 117 min taken in the CL group (p < 0.001). Conclusions: The RALH procedure was associated with some minor advantages for the patients according to the results, however it does not have major significant advantages, especially in regard of early restoration of sexual function, while the CL shows shorter operating times and similar limitation. Postoperative counseling of patients should be aligned to their fears and expectations in regard of sexual function.

Long-term outcome of endometrial ablation therapy with Cavaterm Thermal Balloon in patients with abnormal uterine bleeding

Objective: The purpose of this study was to evaluate the long-term outcome of endometrial ablation (EA) therapy with Cavaterm Thermal Balloon in patients with abnormal uterine bleeding (AUB). Material and Methods: The retrospective cross-sectional study was performed on 209 patients who referred to Shahid Sadoughi Hospital in Yazd, Iran between March 2010 and September 2017 with AUB undergoing EA therapy. The data was collected by a questionnaire from the medical records of patients and phone call. The primary and secondary outcomes post EA therapy (from six months to seven years post-operatively) were assessed in patients. Results: The mean age of participants was 45.9±5.9 years and the mean follow-up duration was 21.2±13.2 months. The rate of treatment response was 95% in the first six months and 92.1% thereafter. The prevalence of amenorrhea was 41.2%. The patient satisfaction rate at the end of follow-up duration was 81.3%. Dysmenorrhea completely resolved in 32.6%. Moreover, 1.4% of patients became pregnant during follow-up. By the end of follow-up, four (1.9%) patients had a hysterectomy due directly to treatment failure. Conclusion: This study showed that EA surgery with Cavaterm Thermal Balloon was an effective treatment for AUB. The procedure was safe and was associated with a very low rate of postoperative adverse events. The patient satisfaction rate was favorable.

Uterine anomalies and endometriosis.

INTRODUCTION: Endometriosis is a common disease in women of reproductive age. In addition to causing pain, it may also reduce fertility. The coexistence of endometriosis and congenital uterine anomalies (CUA) has been frequently reported in the published literature. The present report is a review of existing studies on the subject and our own hitherto unpublished data. EVIDENCE ACQUISITION: The electronic search was conducted using the Pubmed database with specific keyword combinations including endometriosis, adenomyosis, infertility, Müllerian malformations/anomalies, and septate uterus. The principal aspects addressed in the present study were: diagnosis, management, and classification of CUA, their impact on fertility and coexistence with endometriosis. EVIDENCE SYNTHESIS: Endometriosis and CUA are frequently detected in the exploration of infertility, because both of these are liable to impair fertility. Endometriosis is associated with obstructive anomalies and nonobstructive malformations, especially those concerning the septate uterus. The diagnosis and management of CUA have been discussed for several years. Various classification systems have been proposed. CONCLUSIONS: The analysis of the existing literature has revealed the absence of any consensus about the management, diagnosis, and classification of CUA, especially with regard to the septate uterus. We need to find and speak a common language in order to avoid inappropriate or unnecessary surgery and optimize the individual patient's treatment. The combined presence of endometriosis or adenomyosis and CUA is a reason to perform precise diagnostic imaging investigations and early surgery for the purpose of enhancing the chances of pregnancy in infertile patients. Further research is needed on the subject.

Educational training in laparoscopic gynecological surgery based on ethanol-glycerol-lysoformin-preserved body donors.

PURPOSE: Educational training of laparoscopic skills performed on body donors is considered the gold standard prior to surgery in living patients. Appropriate, safe, and feasible fixation of body donors, reflecting true-to-life conditions of tissues, is an essential prerequisite for training workshops. MATERIALS AND METHODS: Here we describe and evaluate a modified ethanol-glycerol-lysoformin-based fixation technique. Body donors were fixed by perfusion (70% ethanol, 30% glycerol, 0.3% lysoformin; ca. 20l) via femoral artery and stored in a humid atmosphere (1% thymol) at 4°C. Technical equipment included a mobile operating table, endoscopy system with gas insufflation, suction/irrigation pump, standard and electrosurgical instruments. The tissue properties of ethanol-glycerol-lysoformin-fixed body donors and their suitability for laparoscopic surgery were tested and compared to the in vivo situation. RESULTS: Modified ethanol-glycerol-lysoformin fixation was a simple, cost-efficient and hazard-free procedure, resulting in near-to-life tissue conditions regarding consistency and flexibility, with moderate discoloration and greater viscosity of organs. Key laparoscopic procedures (trocar handling, pneumoperitoneum, blunt/sharp dissection, partial/total removal of organs, bi- or monopolar electrosurgery, suturing techniques) could be performed without difficulty. Multiple reuse of body donors was feasible over one year. Compared to the in vivo situation, the investigation of body donors required a greater degree of gas insufflation and more energy for electrosurgery. CONCLUSIONS: Modified ethanol-glycerol-lysoformin fixation applied to body donors permitted laparoscopic surgery in a realistic and practical manner. Due to its logistic advantages, this technique provides appropriate conditions to train laparoscopic skills and implement novel minimally invasive approaches.