We live in a virtual world: Training the trainee using an integrated visual reality simulator curriculum.

BACKGROUND: Gynaecology trainees struggle to obtain adequate procedural experience. Training programs integrating virtual reality simulators (VRS) have been suggested as a solution. AIMS: The study aimed to assess if a VRS training program (LapSim® , Surgical Sciences, Göteborg, 2017) improved live operating performance at six months for novice and experienced trainees. Additional outcomes included the association between LapSim® logged time and live operating performance at six months, LapSim® scores and live operating performance at zero and sixmonths and the difference in benefit for novice and experienced gynaecology trainees. METHODS: A prospective intervention study was conducted. Novice and experienced trainees were enrolled, and comparisons made at zero- and six-month time points. The intervention groups were provided with a laparoscopic gynaecology curriculum incorporating VRS. Controls underwent routine training only. Assessment of live operating performance was conducted after six months training. RESULTS: Thirty-five trainees participated, and 25 had access to the VRS curriculum (17 novice and eight experienced trainees). Access to the VRS curriculum and time spent training on the LapSim® made no difference to live operating ability for either intervention group (P > 0.05). The median (interquartile range) hours of VRS usage were 7.9 (4.5-10.8) and 6.0 (4.0-6.8) for novice and experienced trainees respectively. The intervention group provided positive feedback on the utility of VRS in their laparoscopic skill development. CONCLUSION: Optimal utilisation of VRS in Australian training paradigms remains incompletely understood. Further research is required to establish the most effective integration of VRS into training models to ensure uptake and transferability to the operating theatre.

Endometriosis: Does the menstrual cycle affect magnetic resonance (MR) imaging evaluation?

PURPOSE: To determine if the menstrual cycle affects MR interpretation in patients with pelvic endometriosis. MATERIALS AND METHODS: Thirty-one patients with either laparoscopically proven endometriosis, or a high clinical suspicion of deep infiltrative endometriosis, were prospectively recruited from May 2008 to October 2009 and January to June 2012. Two pelvic MR scans were performed for pre-operative planning; during menses and the other mid-cycle. Two experienced radiologists independently assessed image quality and disease extent. Both were blinded to patient identity, previous imaging and menstrual status. Interobserver agreement was assessed using the Kappa (k) test. Descriptive statistics were prepared using chi-squared (or Fishers' exact) tests and Mann-Whitney (rank sum) tests to assess for significant differences between menstrual and non-menstrual imaging. RESULTS: Interobserver agreement for image quality was moderate for T2 weighted imaging (k=0.475, p-value <0.001) and substantial for T1 fat saturated imaging (k=0.733, p-value<0.001), with no significant difference in image quality between menstrual and non-menstrual scans (all p-values>0.255). Readers demonstrated at least moderate interobserver agreement for certainty level of endometriosis at site-specific locations, with median k 0.599 (IQR 0.488-0.807). No significant difference in disease extent was observed between menstruating and non-menstruating scans (all p-values>0.05). CONCLUSION: Findings suggest no significant differences in image quality, disease extent or disease severity between menstruating and non-menstruating MR; thus, timing of pelvic MR for assessment of endometriosis need not be influenced by the menstrual cycle.

The effect of heated humidified carbon dioxide on postoperative pain, core temperature, and recovery times in patients having laparoscopic surgery: a randomized controlled trial.

STUDY OBJECTIVE: To determine whether use of heated humidified carbon dioxide as insufflation gas during gynecologic laparoscopy reduced postoperative pain and hypothermia. DESIGN: A randomized controlled trial (Canadian Task Force classification 1). SETTING: A tertiary referral hospital. PATIENTS: Sixty women scheduled for gynecologic laparoscopy between 30 and 90 minutes' duration. INTERVENTIONS: Operative laparoscopic management of endometriosis, adhesions, or adnexal pathology. MEASUREMENTS AND MAIN RESULTS: Sixty patients were randomized into either receiving heated humidified carbon dioxide (study group) or standard cold dry gas (control group). Intraoperative and postoperative core temperature, total analgesic use, postoperative nausea, and recovery room time were recorded. Postoperative pain intensity was assessed using visual analog scale. Statistical analysis was performed using software. No significant difference was revealed between groups with regard to postoperative pain, analgesic requirements, recovery room time, or postoperative nausea. The control group had less postoperative hypothermia, suggesting that external warming blankets may be more effective than heated humidified gas at maintaining intraoperative normothermia. CONCLUSION: The use of heated humidified carbon dioxide insufflation for short-duration gynecologic laparoscopy up to 90 minutes' duration was not associated with any significant benefit with regard to postoperative pain, hypothermia, or time of recovery room stay.

Surgical adhesions: a timely update, a great challenge for the future.

Damage to the peritoneum during abdominal surgery triggers a cascade of events aimed at repairing the damage. As part of this process, fibrin is deposited, which is the precursor to the formation of an adhesion between 2 damaged peritoneal surfaces. This can have a significant impact on morbidity and even mortality as well as large cost implications. Strategies to reduce adhesion formation include improving surgical techniques, optimizing laparoscopy conditions, using pharmacologic interventions targeted at the inflammatory response and/or fibrin deposition, and using agents that provide a physical barrier to adhesion formation. While these strategies have provided some success, none have yet proved totally successful in abolishing adhesions. Further research to ensure that adhesion prevention is optimal is therefore essential.

Pain relief and outpatient hysteroscopy: a literature review.

Our early experience in setting up an ambulatory hysteroscopy service provoked a review of the literature, due to an unacceptably high failure rate. A literature review has been undertaken to establish the accepted success rates and reasons for failure, and to assess evidence for various analgesic protocols through randomized controlled trials. The data suggest the procedure is acceptable to most patients, with a completion success rate over 90%, and the use of analgesia may enhance the success rate. Analgesic protocols studied were nonsteroidal anti-inflammatory drugs, intracervical block, paracervical block, transcervical block, and topical analgesia. Failures are due predominantly to pain, stenosis, and poor view.

Intraperitoneal ropivacaine and a gas drain: effects on postoperative pain in laparoscopic surgery.

STUDY OBJECTIVE: To assess the benefits of the combination of a gas drain and the instillation of local anesthetic on the incidence of pain after operative gynecologic laparoscopy. DESIGN: Randomized control trial (Canadian Task Force classification I). SETTING: Tertiary referral center. PATIENTS: One hundred twenty-eight patients undergoing operative gynecologic laparoscopy procedures lasting less than 105 minutes. INTERVENTIONS: Postoperatively, one group received a blocked drain and saline placed intraperitoneally; a second group was given a blocked drain and ropivacaine; a third group received a patent drain and saline; and a fourth was given a patent drain and ropivacaine. MEASUREMENTS AND MAIN RESULTS: Visual analogue pain scores (VAS) were measured at 1, 2, 4, and 12 hours and day 1 to day 7. Also measured was opioid consumption at 4 hours, nausea, and activity scores. We found a statistically significant improvement in pain scores at 2 and 4 hours in the group allocated to receive a patent drain and ropivacaine. CONCLUSION: We recommend the use of a gas drain and ropivacaine to reduce postoperative pain.

The effect of intraperitoneal ropivacaine on pain after laparoscopic excision of endometriosis.

STUDY OBJECTIVE: To compare the effects of ropivacaine and saline on pain after laparoscopic excision of endometriosis. DESIGN: Randomized, double-blind, controlled trial (Canadian Task Force classification I). SETTING: Women's hospital. PATIENTS: Ninety-three women undergoing excision of endometriosis. INTERVENTION: Laparoscopic excision of endometriosis, after which saline 100 mg (46 women) or ropivacaine 200 mg dissolved in 100 ml saline (47) was instilled intraperitoneally for postoperative analgesia. MEASUREMENTS AND MAIN RESULTS: No differences were seen between groups during the first 7 hours after surgery with respect to pain scores, analgesic requirements, postoperative nausea and vomiting, or time to discharge. CONCLUSION: We found no difference between ropivacaine and saline, instilled intraperitoneally, in their effects on pain after extensive excision of endometriosis.