Dilute versus concentrated vasopressin administration during laparoscopic myomectomy: a randomised controlled trial.

OBJECTIVE: To determine if higher-volume, fixed-dose administration of vasopressin further reduces blood loss at the time of minimally invasive myomectomy. DESIGN: Randomised multicentre clinical trial. SETTING: Tertiary-care academic centres in the USA. POPULATION: Women undergoing conventional laparoscopic or robot-assisted laparoscopic myomectomy. METHODS: All participants received the same 10-unit (U) dose of vasopressin, but were randomly assigned to one of two groups: (i) received 200 ml of diluted vasopressin solution (20 U in 400 ml normal saline), and (ii) received 30 ml of concentrated vasopressin solution (20 U in 60 ml normal saline). MAIN OUTCOME MEASURES: The primary study outcome was estimated blood loss; the study was powered to detect a 100-ml difference. RESULTS: A total of 152 women were randomised; 76 patients in each group. Baseline demographics were similar between groups. The primary outcome of intraoperative blood loss was not significantly different, as measured by three parameters: surgeon estimate (mean estimated blood loss 178 ± 265 ml and 198 ± 232 ml, dilute and concentrated groups respectively, P = 0.65), suction canister-calculated blood loss, or change in haematocrit levels. There were no vasopressin-related adverse events. CONCLUSION: Both dilute and concentrated vasopressin solutions that use the same drug dosing demonstrate comparable safety and tolerability when administered for minimally invasive myomectomy; however, higher volume administration of vasopressin does not reduce blood loss. TWEETABLE ABSTRACT: This randomised trial failed to show benefit of high-volume dilute vasopression.

Effectiveness of abdominal cerclage placed via laparotomy or laparoscopy: systematic review.

Preterm delivery remains a primary cause of neonatal morbidity and mortality. One cause of preterm birth is cervical incompetence. In women with a shortened or absent cervix or in those in whom previous vaginal cerclage failed, abdominal cerclage may be recommended. We performed a systematic literature search of PubMed, EMBASE, and the Cochrane database. Thirty-one eligible studies were selected. Six studies (135 patients) reported on the laparoscopic approach, and 26 (1116 patients) on the abdominal approach. Delivery of a viable infant at 34 weeks of gestation or more varied from 78.5% (laparoscopic) to 84.8% (abdominal). Second-trimester fetal loss occurred in 8.1% (laparoscopic) vs 7.8% (abdominal), with no reported third-trimester losses (laparoscopic) vs 1.2% (abdominal). We conclude that abdominal cerclage is associated with excellent results as treatment of cervical incompetence, with high fetal survival rates and minimal complications during surgery and pregnancy. Further studies are needed to differentiate which method is superior.

Use of bidirectional barbed suture in laparoscopic myomectomy: evaluation of perioperative outcomes, safety, and efficacy.

STUDY OBJECTIVE: To compare perioperative outcomes during laparoscopic myomectomy using a bidirectional barbed suture vs conventional smooth suture. DESIGN: Retrospective analysis of 138 consecutive laparoscopic myomectomies performed by a single surgeon over 3 years (Canadian Task Force classification II-2). SETTING: Major university teaching hospital. PATIENTS: One hundred thirty-eight women with symptomatic uterine myomas. INTERVENTIONS: In women undergoing laparoscopic myomectomy from February 2007 through April 2010, conventional smooth sutures were used in 31 patients, and bidirectional barbed suture in 107 patients. MEASUREMENTS AND MAIN RESULTS: The primary indications for laparoscopic myomectomy in either group were pelvic pain or pressure and abnormal uterine bleeding. Use of bidirectional barbed suture was found to significantly shorten the mean (SD) duration of surgery (118 [53] minutes vs 162 [69] minutes; p <.05) and reduce the duration of hospital stay (0.58 [0.46] days vs 0.97 [0.45] days; p <.05). No significant differences were observed between the 2 groups insofar as incidence of perioperative complications, estimated blood loss, and number or weight of myomas removed during surgery. CONCLUSION: Use of bidirectional barbed suture seems to facilitate closure of the hysterotomy site in laparoscopic myomectomy.

Endometriosis classification, staging and reporting systems: a review on the road to a universally accepted endometriosis classification.

BACKGROUND: In the field of endometriosis, several classification, staging and reporting systems have been developed. However, endometriosis classification, staging and reporting systems that have been published and validated for use in clinical practice have not been systematically reviewed up to now. OBJECTIVES: The aim of the current review is to provide a historical overview of these different systems based on an assessment of published studies. MATERIALS AND METHODS: A systematic Pubmed literature search was performed. Data were extracted and summarised. RESULTS: Twenty-two endometriosis classification, staging and reporting systems have been published between 1973 and 2021, each developed for specific and different purposes. There is still no international agreement on how to describe the disease. Studies evaluating different systems are summarised showing a discrepancy between the intended and the evaluated purpose, and a general lack of validation data confirming a correlation with pain symptoms or quality of life for any of the current systems. A few studies confirm the value of the Enzian system for surgical description of deep endometriosis. With regards to infertility, the endometriosis fertility index has been confirmed valid for its intended purpose. CONCLUSIONS: Of the 22 endometriosis classification, staging and reporting systems identified in this historical overview, only a few have been evaluated, in 46 studies, for the purpose for which they were developed. It can be concluded that there is no international agreement on how to describe endometriosis or how to classify it, and that most classification/staging systems show no or very little correlation with patient outcomes. WHAT IS NEW?: This overview of existing systems is a first step in working towards a universally accepted endometriosis classification.

An International Terminology for Endometriosis, 2021.

BACKGROUND: Different classification systems have been developed for endometriosis, using different definitions for the disease, the different subtypes, symptoms and treatments. In addition, an International Glossary on Infertility and Fertility Care was published in 2017 by the International Committee for Monitoring Assisted Reproductive Technologies (ICMART) in collaboration with other organisations. An international working group convened over the development of a classification or descriptive system for endometriosis. As a basis for such system, a terminology for endometriosis was considered a condition sine qua non. OBJECTIVES: The aim of the current paper is to develop a set of terms and definitions on endometriosis that would be the basis for standardisation in disease description, classification and research. MATERIALS AND METHODS: The working group listed a number of terms relevant to be included in the terminology, documented currently used and published definitions, and discussed and adapted them until consensus was reached within the working group. Following stakeholder review, further terms were added, and definitions further clarified. Although definitions were collected through published literature, the final set of terms and definitions is to be considered consensus-based. After finalisation of the first draft, the members of the international societies and other stakeholders were consulted for feedback and comments, which led to further adaptations. RESULTS: A list of 49 terms and definitions in the field of endometriosis is presented, including a definition for endometriosis and its subtypes, different locations, interventions, symptoms and outcomes. Endometriosis is defined as a disease characterised by the presence of endometrium-like epithelium and/or stroma outside the endometrium and myometrium, usually with an associated inflammatory process. CONCLUSIONS: The current paper outlines a list of 49 terms and definitions in the field of endometriosis. The application of the defined terms aims to facilitate harmonisation in endometriosis research and clinical practice. Future research may require further refinement of the presented definitions. WHAT IS NEW?: A consensus based international terminology for endometriosis for clinical and research use.

COVID-19: A Surgical Perspective for when the curve flattens.

At the present time it is clear that our global healthcare community was not prepared to face the COVID-19 pandemic. Hospitals in the hardest hit areas have been transformed to COVID centres. Surgical societies have recommended postponing non-emergency surgery, and have given recommendations for triaging the ever- growing backlog of patients. However, simply resuming these non-emergency surgeries may lead the healthcare system into a second disaster. If healthcare policymakers around the world do not systematically consider how to resume normal surgical services, hospitals will be quickly overwhelmed, vital resources will be depleted, and patients and providers alike will face an increased exposure risk. This perspective serves to highlight certain aspects of returning to normal that physicians and hospital administrators alike must consider to avoid potential catastrophe.

Immature ovarian teratoma in an adolescent: a case report and review of the literature.

BACKGROUND: Benign cystic teratomas are relatively common tumors in reproductive age women, but can occur at any age. While the incidence of malignant elements in a teratoma is low (approximately 1-2%), the survival of patients with immature teratoma is poor. Definitive diagnosis is mandatory. CASE: We describe a case of a 13-year-old African American female, gravida 0, presenting with a large pelvic mass, determined to be a benign cystic teratoma by intra-operative frozen section. However, due to the size of the tumor and the preponderance of neural elements we performed a full surgical staging procedure (excluding hysterectomy and complete removal of adnexa). The final pathology report revealed foci of immature neural tissue, with a final diagnosis of an immature cystic teratoma Stage Ia. CONCLUSION: Foci of immature neural elements can be readily missed on frozen section, especially with a large tumor. Full surgical staging at the time of initial laparotomy is justified when encountering an apparently mature cystic teratoma with a preponderance of neural elements on frozen section.

Perceived proficiency in endoscopic techniques among senior obstetrics and gynecology residents.

STUDY OBJECTIVES: To assess current training methods in laparoscopic surgery employed in United States obstetrics and gynecology residency programs, level of proficiency in various minimally invasive surgery procedures amongst senior obstetrics and gynecology residents, and ways in which training in minimally invasive surgery can be improved. DESIGN: Survey (Canadian Task Force classification III). SETTING: Accredited obstetrics and gynecology programs in the United States. SUBJECTS: All fourth-year residents in accredited obstetrics and gynecology programs in the United States. INTERVENTION: Residents received a survey regarding their perceived proficiency performing various laparoscopic procedures and the type of training they received in these techniques. MEASUREMENTS AND MAIN RESULTS: Responses were received from 133 programs (52.4%) and 295 residents (26.8%). Of these, 67% of residents thought emphasis on laparoscopic surgery training should be increased or greatly increased; 87% thought laparoscopic skills were important for building a successful practice. Formal teaching methods were clearly associated with improved perception of proficiency, and those with higher perception of proficiency expected to perform more laparoscopic procedures after graduation. Residents lacked perceived competency in most advanced laparoscopic procedures. CONCLUSION: Residents seem to benefit significantly from a formal curriculum in minimally invasive surgery, but they do not feel competent performing some advanced procedures on graduation. In our opinion, more emphasis should be placed on training in laparoscopic surgery in United States obstetrics and gynecology programs.