A rare case of Asherman's syndrome after open myomectomy: sonographic investigations and possible underlying mechanisms.

AIMS: To present a study on severe Asherman's syndrome after open myomectomy and investigate the possible reasons for this outcome. METHODS: This study involves a rare case of a 38-year-old nulliparous woman who underwent a relatively minor and straightforward open myomectomy in a university hospital setting, during which the uterine cavity was not entered and there were no post-operative complications. Post-operatively the patient had oligomenorrhoea for over a year. The patient was investigated with three-dimensional power Doppler angiography of the uterus and underwent diagnostic/operative hysteroscopy. Main outcome measures were to sonographically assess the blood flow and vascularisation throughout the uterus and to hysteroscopically confirm diagnosis of Asherman's syndrome and treat the patient at the same time. RESULTS: Sonographically there was reduced perfusion in the outer part of the uterus and the scarred areas of the endometrium. Upon hysteroscopic confirmation of diagnosis, the division of adhesions led to a normal sized uterine cavity. CONCLUSIONS: Among the predisposing and causal factors that have been implicated in post-operative adhesion formation, endometrial trauma, infection and tissue hypoxia are considered the most important. This case supports a role for tissue hypoxia in the development of Asherman's syndrome after open myomectomy.

The management of Asherman syndrome: a review of literature.

Asherman syndrome is a debatable topic in gynaecological field and there is no clear consensus about management and treatment. It is characterized by variable scarring inside the uterine cavity and it is also cause of menstrual disturbances, infertility and placental abnormalities. The advent of hysteroscopy has revolutionized its diagnosis and management and is therefore considered the most valuable tool in diagnosis and management. The aim of this review is to explore the most recent evidence related to this condition with regards to aetiology, diagnosis management and follow up strategies.

An unusual case of cervical diverticulum identified by presence of 3 cavities at diagnostic hysteroscopy.

Herein is presented the case report of a patient who had severe dysmenorrhea since menarche, known right unicornuate uterus with a left rudimentary horn, and recurrent hematometra. Previous hysteroscopic drainage of the hematometra temporarily alleviated the symptoms. At subsequent hysteroscopy, 3 cavities were identified, 2 corresponding to the uterine horns and the other to a cervical diverticulum. Hysteroscopic metroplasty with drainage of the rudimentary horn hematometra provided long-term relief of the symptoms. The diagnosis was verified at diagnostic laparoscopy.

The "Ruston Stretch": a simple way to get a large specimen out through a small hole.

The balance between port-site size and ease of specimen removal is often a challenge in laparoscopic surgery. Herein we describe a simple technique that circumvents this dilemma by means of port-site dilation using Hegar dilators.

Surgical videos for accident analysis, performance improvement, and complication prevention: time for a surgical black box?

Conventional audit of surgical records through review of surgical results provides useful knowledge but hardly helps identify the technical reasons lying behind specific outcomes or complications. Surgical teams not only need to know that a complication might happen but also how and when it is most likely to happen. Functional awareness is therefore needed to prevent complications, know how to deal with them, and improve overall surgical performance. The authors wish to argue that the systematic recording and reviewing of surgical videos, a "surgical black box," might improve surgical care, help prevent complications, and allow accident analysis. A possible strategy to test this hypothesis is presented and discussed. Recording and reviewing surgical interventions, apart from helping us achieve functional awareness and increasing the safety profile of our performance, allows us also to effectively share our experience with colleagues. The authors believe that those potential implications make this hypothesis worth testing.

Digital video recordings for training, assessment, and revalidation of surgical skills.

Surgical training is undergoing drastic changes, and new strategies should be adopted to keep quality standards. The authors review and advocate the use of surgical recordings as a useful complement to current training, assessment, and revalidation modalities. For trainees, such recordings would promote quality-based and competence-based surgical training and allow for self-evaluation. Video logbooks could be used to aid interaction between trainer and trainee, and facilitate formative assessment. Recordings of surgery could also be integrated into trainees' portfolios and regular assessments. Finally, such recordings could make surgeons' revalidation more sensible. The routine use of records of surgical procedures could become an integral component of the standard of care. This would have been an unattractive suggestion until recently, as analogue recording techniques are inconvenient, cumbersome, and time consuming. Today, however, with the advent of inexpensive digital technologies, such a concept is realistic and is likely to improve patient care.

The mini-resectoscope: a new instrument for office hysteroscopic surgery.

BACKGROUND: Outpatient hysteroscopy has become well-established for the investigation abnormal uterine bleeding. Although "See and Treat" clinics have been widely introduced, the types of procedures offered are limited, and many patients with intrauterine pathology continue to be admitted as in-patients for hysteroscopic surgery. We wanted to investigate the feasibility and acceptability of surgery for small intrauterine lesions without the need for general anesthesia by using a miniature resectoscope. METHODS: This was a prospective observational study on 30 women with abnormal uterine bleeding associated with endometrial polyps or small (<3 cm) type 0 or 1 submucous fibroids. Hysteroscopic polypectomy (n=26) or myomectomy (n=4) was carried out using a 16 Fr gauge mini-resectoscope. RESULTS: Ten procedures were carried out in the outpatient clinic and 20 in the operating theatre. Sixteen procedures were done without any anaesthesia and 14 after intra-cervical local anesthetic injections. The polyps and fibroids ranged in size from 1 to 5 cm, and all procedures took less than 15 minutes from the time the vagina was instrumented to the end of surgery. All procedures were completed successfully and were well tolerated with little discomfort. There were no complications. CONCLUSIONS: The mini-resectoscope appears to be an efficient and acceptable instrument for hysteroscopic surgery and can be used without general anesthesia for minor procedure such as polypectomy and the resection of small submucous fibroids.

NEST (network enhanced surgical training): a PC-based system for telementoring in gynaecological surgery.

OBJECTIVES: To develop and describe NEST (network enhanced surgical training), an affordable and easily reproducible telementoring system. STUDY DESIGN: We have developed the system around two standard personal computers: a desktop computer for the surgeon in the operating room (OR), equipped with a digital video-capture system; and a laptop computer for a mentor outside the OR. In an attempt to reduce the costs, freeware software has been tested and chosen to allow visual and audio interaction between the two computers. No IT technicians were involved in the process at any stage. RESULTS: Following 6 months of hardware and software testing, we have successfully developed NEST (network enhanced surgical training), an affordable telementoring system based on two standard personal computers connected through an Ethernet cable. We tried NEST during the whole range of gynaecologic interventions performed in our unit, including abdominal, vaginal and laparoscopic surgery. We also successfully used NEST to provide visual access to the operative field to medical students and endoscopy workshop delegates. In addition, we also used NEST to simulate telementoring during pelvi-trainer sessions in our endoscopy skills laboratory. Surgeons' interaction through NEST seems reliable since the mentor's instructions, both vocal and visual (by pointing at landmarks), were always followed on time by the surgeon during our tests. CONCLUSIONS: We believe that surgical telementoring deserves attention and our NEST system could be an ideal tool for studies on telementoring in safe environments. In its simplest incarnation with the mentor "next-door", just outside the operating theatre, he/she could intervene at any stage if necessary. Moreover, NEST is affordable and reproducible as it is based solely on two standard personal computers, a video-capture system, an Ethernet cable, and two freeware computer programs.

Do patients want to see recordings of their surgery?

OBJECTIVE: In an effort to improve patients' understanding and perception of their surgery and communication between doctors and patients we have evaluated the use of a mobile digital video recorder in the case of women undergoing gynaecological surgery. STUDY DESIGN: Patients scheduled for endoscopic or open surgery were asked if they would allow their surgery be recorded on a dedicated computer system. Those who agreed were offered the opportunity to have real-time edited highlights of their surgery recorded simultaneously on a miniature digital video recorder. They were shown the edited recording before discharge from hospital, and their reaction was assessed using a structured questionnaire. RESULTS: 51/54 (94.4%) women agreed to their surgery being recorded on the computer system, and 37/54 (68.5%) asked to see the edited highlights. The median duration of the computer and portable recordings for the 37 patients was 90 min (range 2-280) and 3.3 min (range 1-13.6) respectively. Thirty-four (91.9%) reported that the edited recording gave them a better understanding of their medical condition and surgery. Thirty (81.1%) would have liked a copy of the recording. CONCLUSIONS: Portable video recorders are a convenient tool for recording surgical procedures. In our experience, about two-third of patients are interested in reviewing their surgery and find it provides useful information and a perceived better understanding of their condition. As these recording devices are small and fit into a pocket, their use could easily become a routine part of post-operative ward rounds. For the surgeon, such recordings have an educational value and provide the basis for a library of surgery as well as being useful when planning future management or for referral purposes.

Female sterilization.

There has been considerable development and implementation of new contraceptive methods over the last 15 years. However, sterilization has remained the most widely used method around the world. Ideally, the procedure should be safe, have a high efficacy, be readily accessible, and be personally and culturally acceptable. The cost for each procedure would be low and the method would be simple, quick, easily learned and be able to be performed in an outpatient setting without general anesthesia. A transuterine method of female sterilization has long been the ideal for the gynecologist. The Essure system fulfils many of the criteria, and is the first one to be approved by the US FDA. However, there is still a need for further research to find a device with the success rate of the Essure but without its irreversibility.

A new technique for temporary ovarian suspension: temporarily displacing the ovaries anterior to the uterus facilitates pelvic side wall access in the laparoscopic treatment of endometriosis.

The adnexa frequently hinder access to the pelvic side wall during laparoscopic surgery for endometriosis. An innovative tactic can facilitate dissection.

First-generation endometrial ablation: roller-ball vs loop vs laser.

Hysteroscopic guided or first generation endometrial ablation methods include transcervical endometrial resection, and rollerball and laser ablation. These techniques have been shown to be effective and safe alternatives to hysterectomy for dysfunctional uterine bleeding resulting in reduction in menstrual blood loss and dysmenorrhoea, correction of anaemia and improvement in quality of life. Compared with hysterectomy, treatment is associated with lower morbidity, shorter hospitalisation and faster recovery, and reduced treatment costs. As a result, the 1st generation ablation techniques are recognized as the "gold standard" ablation methods. There are many similarities between the three techniques with respect to surgical principles and effectiveness. Certainly, menstrual improvement and patient satisfaction are similar with all three methods. In contrast, the complication profile of the three techniques is different, but surgical experience is arguably a much more important arbiter of patient safety than the technique itself.

Digital recording of surgical procedures using a personal computer.

OBJECTIVE: To develop a system for recording surgical procedure digitally using a personal computer with real-time compression of the video signal. STUDY DESIGN: We built the system around a modern personal computer with a large hard disk to allow recording of over 250 h of continuous surgery. Digital capture from the camera was achieved using a standard external analogue-digital converter linked to the computer via a firewire cable. The software for capturing, compressing and editing movie files were obtained free of charge from the internet. The optimal settings for the software was determined. RESULTS: We have successfully used this system to record over 100 major and minor hysteroscopic, laparoscopic, vaginal and open gynaecological. Despite compression, the quality of the movies was judged to be very good and still images excellent. The recordings could be integrated in to standard presentation. Still pictures could be printed to provide hard copies for patients and medical notes, and movies burnt on to CDs or DVDs. CONCLUSIONS: A digital recording system built around a standard personal computer is relatively cheap, versatile and has a huge capacity to record surgical procedures.

Currently available devices for female sterilization.

Sterilization is now the method of family planning most commonly used in the world. Over the last 150 years, research has evolved in the search for the ideal method of female sterilization. The procedure should ideally have high efficacy, be readily accessible and be personally and culturally acceptable. The method should be simple, quick, easily learned and be able to be performed in an outpatient setting without general anesthesia. The most common and effective method for sterilization has, thus far, been via the laparoscopic route. Hysteroscopic sterilization, however, potentially fulfills many of these ideal criteria, but until recently has remained more of a concept than a reality.

Techniques to reduce blood loss during open myomectomy: a qualitative review of literature.

Open myomectomy is the most adopted surgical strategy in the conservative treatment of uterine fibroids. According to several studies, the likelihood that a woman could develop uterine myomas is estimated around 75% by the age of 50. Open myomectomy is nonetheless a complicated surgery in terms of blood loss and need for transfusion. Many strategies have been published with the aim of limiting intra and post-operative bleeding complications. The scope of this review is to describe in detail the different techniques reported in literature focusing on their validity and safety.

Culdoscopy using an optical cannula.

OBJECTIVE: To describe a technique for inserting an endoscope through the posterior vaginal fornix under direct vision using an optical cannula. DESIGN: Prospective case study. SETTING: University Department of Obstetrics & Gynecology. PATIENT(S): Patients with infertility referred for investigation in secondary care. INTERVENTION(S): Insertion of culdoscope using an optical cannula. MAIN OUTCOME MEASURE(S): Successful introduction of the culdoscope. RESULT(S): Sixteen of 20 patients had successful introduction of the optical cannula. There were no reported complications. CONCLUSION(S): Insertion of a culdoscope into the cul-de-sac can be done under visual control and this may reduce the risks of complications associated with blind insertion using a modified Veress needle.

Endometriosis arising during estrogen and testosterone treatment 17 years after abdominal hysterectomy: a case report.

OBJECTIVE: To report the possible association between the use of oestrogen replacement therapy and endometriosis in a postmenopausal woman. METHODS: We present a case of a postmenopausal, previously hysterectomised, woman who received hormonal replacement therapy and developed a large broad ligament cyst. Two years prior to her presentation she had been complaining of pelvic pain and deep dyspareunia. RESULTS: Pelvic ultrasound showed an adnexal cyst that was increasing in size. CA-125 was normal. Laparoscopy revealed multiple endometriotic deposits and a broad ligament cyst. Cystectomy and oophorectomy were done. Histology confirmed a diagnosis of endometriosis including the broad ligament cyst. CONCLUSIONS: Hormonal replacement therapy can be associated with de novo endometriosis including at sites, which are unusual.

Hysteroscopic tubal sterilization.

This article provides an overview of the history of hysteroscopic sterilization including the current state of the art and future ideals. Unlike laparoscopic techniques, sterilization by hysteroscopy can be performed in an outpatient setting without general anesthesia. Many attempts have been made to develop a safe and effective method, but until recently, without success. The Essure system is the first one that seems to be a realistic alternative to laparoscopic sterilization, but is irreversible. The search is still on for the optimum method of hysteroscopic sterilization.