Ergonomics in the operating room and surgical training: a survey on the Italian scenario.

Introduction: Surgical-related injuries are frequent, in fact the reported percentage of musculoskeletal disorders in surgeons is between 47% and 87%. These conditions are caused by long periods of standing, incorrect postures, repeated movements, little rest between operations, the lack of integrated operator rooms, the correct number and arrangement of monitors and the use of non-ergonomic instruments. This survey aims to assess the Italian overview both highlighting how prevalent surgical-related injury is in our surgeons and whether there is an operating room ergonomics education program in Italian surgical specialty schools. Methods: An anonymous questionnaire was designed through SurveyMonkey© web application. This survey was composed of 3 different sections concerning the general characteristics of the participants, their surgical background and any training performed, and any injuries or ailments related to the surgical activity. The survey was carried out in the period 1th of December 2022 and the 6th of February 2023. Results: At the close of our survey, 300 responses were collected. Among the participants, the two most represented specialties were Gynecology and Obstetrics (42.3%) and General Surgery (39.7%) and surgeons were mainly employed in the Northern regions of Italy (54.8%). Analyzing the participants' background, 61.7% of the respondents had laparoscopic training during their training and only 53.1% had a pelvic trainer during their residency. In accordance with 98.7% of the respondents, during surgery we have the feeling of being in an uncomfortable position that causes discomfort or muscle pain, and regarding the frequency of these discomforts, the majority of our study population experiences these problems monthly (46.2%), while in 29.6% it is experienced weekly, 12.1% annually and finally 12.1% daily. The surgical approach that is most correlated with these disorders is laparoscopy (62.7%) while the one that causes the least discomfort is robotic surgery (1.4%). These discomforts cause 43.9% of our population to take a break or do short exercises to reduce pain during surgery, and the body areas most affected are the back (61.6%), neck (40.6%) and shoulders (37.8%). Conclusion: Despite this, our survey allows us to highlight some now-known gaps present in the surgical training program of our schools and the lack of protection toward our surgeons during their long career.

Employing the Aviation Model to Reduce Errors in Robotic Gynecological Surgery: A Narrative Review.

The operating room is the environment where harm to the patient is most likely. Robotic surgery was listed as one of the top 10 health hazards as late as 2020. Taking inspiration from other fields of application, such as aeronautics, checklists have been increasingly implemented in medical practice over the years, becoming essential components of the operating theatre. In addition to checklists, simulation has taken on a fundamental importance in reducing errors. This paper aims to provide a narrative review to assess the importance of checklists and training in robotic surgery and how they improve the outcome. A comprehensive literature search from January 2000 to September 2023 was conducted. A total of 97 articles were included in the initial search. Eleven studies were deemed relevant and were considered eligible for full-text reading. Among these, ten studies focused on the analysis of training effectiveness. An article in our review assessed the benefits of introducing checklists in the operating room. Innovations created in aviation, such as checklists and simulation, have entered the medical field to prevent human error. Developing dedicated checklist and surgical teams, through theoretical and practical training, has become essential in modern medicine. Tools such as checklists, training, and simulation are among the best methods to reduce adverse medical events.

Molecular classification of endometrial carcinoma on endometrial biopsy: an early prognostic value to guide personalized treatment.

OBJECTIVE: Molecular features are essential for estimating the risk of recurrence and impacting overall survival in patients with endometrial cancer. Additionally, the surgical procedure itself could be personalized based on the molecular characteristics of the tumor. This study aims to assess the feasibility of obtaining reliable molecular classification status from biopsy specimens collected during hysteroscopy to better modulate the appropriate surgical treatment. METHODS: This monocentric, retrospective, observational study was conducted on 106 patients who underwent a biopsy procedure followed by radical surgery for endometrial cancer, with concurrent molecular investigation. The molecular classification was determined through immunohistochemical staining for p53 and mismatch repair proteins, along with gene sequencing for POLE. RESULTS: Overall, 106 patients underwent molecular investigation, which was finally achieved on 99 patients (93.4%). Among these, the molecular analysis was conducted in 71 patients (67%) on the pre-operative endometrial biopsy and on the final uterine specimen in 28 patients (26.4%). Most of the endometrial biopsies were performed using Bettocchi hysteroscopy (66%). Molecular analysis was not possible in seven patients (6.6%), with six cases due to sample inadequacy and one case attributed to intra-mucosal carcinoma. The molecular results showed that the copy number low sub-group was the most common, and five cases of 'multiple classifiers' were observed in the low-risk category. CONCLUSION: Our experience in obtaining molecular information from biopsy samples underscores the feasibility and efficacy of this technique, even in small tissue samples. This capability helps define the prognostic group of patients, facilitates timely decision-making, and develops a personalized strategy for each patient.

Management for Cervical Cancer Patients: A Comparison of the Guidelines from the International Scientific Societies (ESGO-NCCN-ASCO-AIOM-FIGO-BGCS-SEOM-ESMO-JSGO).

Cervical cancer continues to have a significant incidence, despite global efforts in HPV vaccination campaigns. Managing this condition involves a diverse team of healthcare professionals. Research in this field is undergoing a period of great revolution in multiple areas, and international guidelines will soon have to adapt to new scientific evidence. This could be true mainly in locally advanced stages, and it could also be true for minimal invasive surgery. This paper aims to summarize and compare the most recent recommendations published by international gynecological oncological societies for patients with cervical cancer. From their comparison, common aspects and disagreements emerged, especially in the diagnostic pathway and follow-up strategies. Several issues that remain to be debated in the literature were addressed and compared, highlighting similarities and differences, from the role of the sentinel lymph node in early stages to that of the adjuvant hysterectomy in locally advanced tumors. On the surgical side, for this last subset of patients, currently, a laparotomic approach is recommended. At the same time, the advent of immunotherapy has just opened up new and promising scenarios in systemic treatment for locally advanced cervical cancer, and international guidelines will soon introduce it into their algorithms.

"Water or not water: That is the question." Analysis of costs and consumption of the operating theaters in a greener perspective.

OBJECTIVE: To compare the amounts of water and plastic used in surgical hand washing with medicated soaps and with alcohol-based products and to compare costs and consumption in a year, based on scheduled surgical activity. METHOD: This retrospective study was carried out at Udine's Gynecology Operating Block from October to November 2022. We estimated the average amount of water with a graduated cylinder and the total cost of water usage based on euros/m3 indicated by the supplier; for each antiseptic agent we collected the data relevant to wash time, amount of water and product used per scrub, number of handscrubs made with every 500 mL bottle and cost of a single bottle. We put data into two hypothetical contexts, namely WHO guidelines and manufacturers' recommendations. Data were subjected to statistical analysis. RESULTS: The daily amount of water using povidone-iodine, chlorhexidine-gluconate and alcohol-based antiseptic agents was 187.6, 140.7 and 0 L/day (P value = 0.001), respectively; A total of 69 000 L/year of water would be saved if alcohol-based products were routinely used. A single unit of an alcohol-based product allows three times as many handscrubs as any other product (P value = 0.001) with consequent reduction in plastic packaging. CONCLUSION: Despite the cost saving being negligible, choosing alcohol-based handrub over medicated soap handrub - on equal antiseptic efficacy grounds - could lead to a significant saving of water and plastic, thus making our operating theaters more environmentally friendly.

Is It Time to Reassess the Role of Radiotherapy Treatment in Ovarian Cancer?

With a 5-year survival rate of fewer than 50%, epithelial ovarian carcinoma is the most fatal of the gynecologic cancers. Each year, an estimated 22,000 women are diagnosed with the condition, with 14,000 dying as a result, in the United States. Over the last decade, the advent of molecular and genetic data has enhanced our understanding of the heterogeneity of ovarian cancer. More than 80% of women diagnosed with advanced illness have an initial full response to rigorous therapy at diagnosis, including surgery and platinum-based chemotherapy. Unfortunately, these responses are infrequently lasting, and the majority of women with ovarian cancer suffer recurrent disease, which is often incurable, despite the possibility of future response and months of survival. And what therapeutic weapons do we have to counter it? For many years, radiation therapy for ovarian tumors was disregarded as an effective treatment option due to its toxicity and lack of survival benefits. Chemotherapy is widely used following surgery, and it has nearly completely supplanted radiation therapy. Even with the use of more modern and efficient chemotherapy regimens, ovarian cancer failures still happen. After receiving first-line ovarian cancer chemotherapy, over 70% of patients show evidence of recurrence in the abdomen or pelvis. It is necessary to reinterpret the function of radiation therapy in light of recent technological developments, the sophistication of radiation procedures, and the molecular and biological understanding of various histological subtypes. This review article focuses on the literature on the use of radiation in ovarian tumors as well as its rationale and current indications.

A Rare Case of Hepatocellular Carcinoma Recurrence in Ovarian Site after 12 Years Mimicking a Hepatoid Adenocarcinoma: Case Report.

Hepatoid carcinoma of the ovary (HCO) is a tumor that resembles, both histologically and cytologically, hepatocarcinoma (HCC) in a patient with a non-cirrhotic liver not involved by the disease. Hepatoid carcinoma is an extremely rare histologic subtype of ovarian cancer and should be distinguished from metastatic HCC. Here, we report the rare case of a 67-year-old woman with ovarian recurrence of HCC 12 years after first diagnosis. The patient was being followed by oncologists because she had been diagnosed with HCV-related HCC (Edmonson and Stainer grade 2, pT2 N0 M0, G2, V1) in 2009. She had undergone surgery for enlarged left hepatectomy to the 4th hepatic segment with cholecystectomy and subsequent placement of a Kehr drain. The preoperative alpha-fetoprotein (AFP) level was 8600 ng/mL, while the postoperative value was only 2.7 ng/mL. At the first diagnosis, no other localizations of the disease, including the genital tract, were found. At the time of recurrence, however, the patient was completely asymptomatic: her liver function was within normal limits with negative blood indices, except for an increased blood dosage of AFP (467 ng/mL), and CA125, which became borderline (37.4 IU/mL). The oncologist placed an indication for a thoracic abdominal CT scan, which showed that the residual liver was free of disease, and the presence of a formation with a solid-cystic appearance and some calcifications at the left adnexal site. The radiological findings were confirmed on level II gynecological ultrasound. The patient then underwent a radical surgery of hysterectomy, bilateral oophorectomy, pelvic peritonectomy, and omentectomy by a laparotomic approach, with the sending of intraoperative extemporaneous histological examination on the annexus site of the tumor mass, obtaining RT = 0. Currently, the patient continues her gyneco-oncology follow-up simultaneously clinically, in laboratory, and instrumentally every 4 months. Our study currently represents the longest elapsed time interval between first diagnosis and disease recurrence, as evidenced by current data in the literature. This was a rather unique and difficult clinical case because of the rarity of the disease, the lack of scientific evidence, and the difficulty in differentiating the primary hepatoid phenotype of the ovary from an ovarian metastasis of HCC. Several multidisciplinary meetings for proper interpretation of clinical and anamnestic data, with the aid of immunohistochemistry (IHC) on histological slides were essential for case management.

Mesonephric-Like Adenocarcinomas a Rare Tumor: The Importance of Diagnosis.

Mesonephric-like adenocarcinomas (MLA) are rare neoplasms that arise in the uterine body and ovary and have been added to the World Health Organisation's recent 2020 classification of female genital cancers. The pathogenesis of MLA is unknown and it remains debated whether they represent mesonephric carcinomas (Wolffian) arising in the endometrium/ovary or endometrioid carcinomas (Müllerian) closely mimicking mesonephric carcinomas. Here we report the case of a 57-year-old woman with an initial misdiagnosis of endometrioid adenocarcinoma on diagnostic biopsy. The patient came to our clinical evaluation for the appearance of menometrorrhagia complicated by anemia for several months. Therefore, she underwent pelvic echo-flowmetry, with indication for diagnostic hysteroscopy with endometrial biopsy, which yielded a positive result for endometrioid endometrial adenocarcinoma. Following staging CT scan and targeted examinations on pulmonary findings, the patient underwent surgery with surprise of definitive diagnosis deponent for endometrial MLA. Our intention is to establish a brief review of the scientific evidence in the literature and the tools available for a correct histological diagnosis, in the light of the scant anatomopathological evidence. Our question gives rise to the motive for the publication: is immunohistochemistry the right way to resolve the diagnostic error at histology, which is usually the only source of diagnostic certainty? This case is intended to alert of diagnostic error that risked having the patient treated as a neoplasm with a favorable prognosis and low degree of aggressiveness instead of for a very aggressive and poor prognosis tumor such as MLA.

CUP-syndrome: Inguinal high grade serous ovarian carcinoma lymph node metastases with unknown primary origin - a case report and literature review.

Objective: High-grade serous ovarian carcinoma (HGSC) often presents lymph node involvement. According to the paths of lymphatic drainage, the most common site of nodal metastasis is in the aortic area. However, pelvic lymph nodes are also involved and inguinal metastases are less frequent. Methods: Our report concerns the case of a 78-year-old woman with an inguinal lymph node relapse of HGSC, with the prior positivity of a right inguinal lymph node, after the primary surgery. Ovaries and tubes were negative on histological examination. A comprehensive search of the literature published from January 2000 to October 2021 was conducted on PubMed and Scopus. The papers were selected following the PRISMA guidelines. Nine retrospective studies were evaluated. Results: Overall, 67 studies were included in the initial search. Applying the screening criteria, 36 articles were considered eligible for full-text reading of which, after applying the exclusion criteria, 9 studies were selected for the final analysis and included in the systematic review. No studies were included for a quantitative analysis. We divided the results according to the relapse location: loco-regional, abdominal, and extra-abdominal recurrence. Conclusions: Inguinal node metastasis is a rare but not unusual occurrence in HGSC. A reasonable level of suspicion should be maintained in patients with inguinal adenopathy and high CA125 values, especially in women with a history of gynecologic surgery, even in the absence of negative imaging for an ovarian origin.

Scar-Free Laparoscopy in BRCA-Mutated Women.

Background and Objectives: BRCA 1 and 2 mutations have a cumulative risk of developing ovarian cancer at 70 years of 41% and 15%, respectively, while a cumulative risk of breast cancer by 80 years of age was 72% for BRCA1 mutation carriers and 69% for BRCA2 mutation carriers. The NCCN recommends risk-reducing salpingo-oophorectomy (RRSO), typically between 35 and 40 years, and upon completion of childbearing in BRCA1 mutation, while it is reasonable to delay RRSO for management of ovarian cancer risk until age 40-45 years in patients with BRCA2. In recent years there have been two main lines of evolution in laparoscopy. The former concerning the development of a single-site laparoscopic and the latter concerning the miniaturisation of laparoscopic instruments (mini/micro-laparoscopy). Materials and Methods: In this case report, we show our experience in prophylactic adnexectomy, on a mutated-BRCA patient, using the MiniLap® percutaneous surgical system. Results: This type of technique is safe and effective and does not require a particular learning curve compared to single-port laparoscopy. Conclusions: The considerable aesthetic advantage of the scars, we believe, albeit to a lesser extent, is useful to find in these patients burdened by an important stress load.

Reconstructive surgery after Female Genital Mutilation: a multidisciplinary approach.

BACKGROUND AND AIM: Female Genital Mutilations (FMGs) are all interventions involving partial or total removal of external female genital apparatus, perpetrated not for therapeutic purposes. This review aims to describe a multidisciplinary approach to clinical management of women with FGM, requiring reconstructive surgery and therapeutic deinfibulation. Furthermore, these traditional procedures are harmful to women's physical integrity, being able to result in severe psychological damage with strong inhibitions in sexual and emotive life. METHODS: Clinical management followed internal protocol implemented at the obstetric Pathology of IRCCS Burlo Garofolo of Trieste, in the framework of the regional project "Female genital mutilation and women immigrants: a draft integrated training and support person," supported by Regione Friuli Venezia Giulia, Italy. We have enrolled in our protocol 15 women that came in our Hospital spontaneously. Here, we present a case of a 38-year-old woman, who had undergone ritual FGM type III with a deep groove scar. She had suffered pain and limitations to sexual intercourses. RESULTS: We performed a reconstructive surgery of the mutilated genital tissue and a therapeutic deinfibulation. The deep groove scar was successfully removed with a multidisciplinary approach. We achieved careful evaluation, both clinical and psychological, of the patient, before surgery. CONCLUSIONS: Reconstructive surgery for women who suffer sexual consequences from FGM is feasible. It restores women's natural genital anatomy, allowing to improve female sexuality.