Laparoscopic nerve lysis for deep endometriosis improves quality of life and chronic pain levels: A pilot study.

OBJECTIVES: To assess the benefit of surgical management of patients with endometriosis infiltrating pelvic nerves in terms of pain, analgesic consumption, and quality of life (QOL). METHODS: We conducted a retrospective cohort study In an Endometriosis referral center at a tertiary care university affiliated medical center. Patients diagnosed with endometriosis that underwent laparoscopic neurolysis for chronic pain were included. Patients rated their pain before and after surgery and differentiated between chronic pain and acute crises. Patients were requested to maintain a record of analgesic consumption and to evaluate their quality-of-life (QOL). RESULTS: Of the 21 patients in our study 15 (71.5 %) had obturator nerve involvement, 2 (9.5 %) had pudendal nerve involvement and 4 (19 %) had other pelvic nerve involvement. Median postoperative follow - up was of 8 months. All but 2 patients (9.6 %) had significant chronic pain improvement with a mean decrease of VAS of 3.05 (±2.5). Analgesic habits changed postoperatively with a significant decrease of 66 % of patients' daily consumption of any analgesics. Surgery improved QOL in 12 cases (57.1 %) and two patients (9.6 %) completely recovered with a high QOL. CONCLUSION: Neurolysis and excision of endometriosis of pelvic nerves could results in significant improvement of quality of life.

The association of endometrial closure during cesarean section to the risk of developing uterine scar defect: a randomized control trial.

PURPOSE: The surgical technique for uterine closure following cesarean section influences the healing of the cesarean scar; however, there is still no consensus on the optimal technique regarding the closure of the endometrium layer. The aim of this study was to compare the effect of closure versus non-closure of the endometrium during cesarean section on the risk to develop uterine scar defect and associated symptoms. METHODS: A randomized prospective study was conducted of women undergoing first elective cesarean section at a single tertiary medical center. Exclusion criteria included previous uterine scar, preterm delivery and dysmorphic uterus. Women were randomized for endometrial layer closure versus non-closure. Six months following surgery, women were invited to the ambulatory gynecological clinic for follow-up visit. 2-D transvaginal ultrasound examination was performed to evaluate the cesarean scar characteristics. In addition, women were evaluated for symptoms that might be associated with uterine scar defect. Primary outcome was defined as the residual myometrial thickness (RMT) at the uterine cesarean scar. Data are presented as median and interquartile range. RESULTS: 130 women were recruited to the study, of them follow-up was achieved in 113 (86.9%). 61 (54%) vs. 52 (46%) of the women were included in the endometrial closure vs. non-closure groups, respectively. Groups were comparable for patient's demographic, clinical characteristics and follow-up time for postoperative evaluation. Median RMT was 5.3 (3.0-7.7) vs. 4.6 (3.0-6.5) mm for the endometrial closure and non-closure groups, respectively (p = 0.38). Substantially low RMT (< 2.5 mm) was measured in four (6.6%) women in the endometrial closure group and three (5.8%) of the women in the non-closure group (p = 0.86). All other uterine scar sonographic measurements, as well as dysmenorrhea, pelvic pain and intermenstrual bleeding rates were comparable between the groups. CONCLUSION: Closure versus non-closure of the endometrial layer during cesarean uterine incision repair has no significant difference in cesarean scar characteristics and symptom rates at 6 months follow-up.

Findings on emergent magnetic resonance imaging in pregnant patients with suspected appendicitis: A single center perspective.

This study's aim is to describe the imaging findings in pregnant patients undergoing emergent MRI for suspected acute appendicitis, and the various alternative diagnoses seen on those MRI scans. This is a single center retrospective analysis in which we assessed the imaging, clinical and pathological data for all consecutive pregnant patients who underwent emergent MRI for suspected acute appendicitis between April 2013 and June 2021. Out of 167 patients, 35 patients (20.9%) were diagnosed with acute appendicitis on MRI. Thirty patients (18%) were diagnosed with an alternative diagnosis on MRI: 17/30 (56.7%) patients had a gynecological source of abdominal pain (e.g. ectopic pregnancy, red degeneration of a leiomyoma); 8 patients (26.7%) had urological findings such as pyelonephritis; and 6 patients (20%) had gastrointestinal diagnoses (e.g. abdominal wall hernia or inflammatory bowel disease). Our conclusions are that MRI is a good diagnostic tool in the pregnant patient, not only in diagnosing acute appendicitis, but also in providing information on alternative diagnoses to acute abdominal pain. Our findings show the various differential diagnoses on emergent MRI in pregnant patients with suspected acute appendicitis, which may assist clinicians and radiologists is patient assessment and imaging utilization.

Fertility preservation for women with ovarian endometriosis: results from a retrospective cohort study.

RESEARCH QUESTION: What is the outcome of fertility-preservation treatments in women with endometrioma, especially those with endometrioma larger than 4 cm? DESIGN: Retrospective cohort study. Women with definitive diagnosis of ovarian endometriosis (by histology or ultrasound), who underwent fertility-preservation treatment in two IVF units between 2016 and 2021, were included. As some women cryopreserved oocytes and other embryos, the primary outcome was the number of metaphase II (MII) oocytes retrieved. RESULTS: Seventy-one women with ovarian endometriosis (OMA) underwent 138 fertility-preservation cycles. The median age of patients was 31 years. Forty out of 71 (56%) women underwent at least one surgery for OMA before fertility-preservation treatment. Multivariate analysis of each patient's first cycle was used. Women who underwent OMA surgery before fertility-preservation treatment had a 51.7% reduction (95% CI 26.1 to 68.5, P = 0.001) in the number of MII oocytes compared with women with OMA who did not undergo surgery. Among a subgroup who did not undergo surgery, those with an endometrioma larger than 4 cm had similar anti-Müllerian hormone concentration (2.6 ng/ml versus 2.1 ng/ml), number of oocytes retrieved (9 versus 9) and number of MII oocytes (7.6 versus seven 7) compared with women with an endometrioma of 4 cm or less. CONCLUSIONS: Discussing fertility-preservation treatment options with patients with OMA is recommended, especially if surgery is planned.

Pregnancy-Associated Ovarian Torsion - a Single-Center Case-Control Study.

The etiology of OT is largely unknown. Any predisposition to rotation of the infundibulopelvic ligament and utero-ovarian ligament should be considered a possible etiology. Information with respect to ovarian torsion (OT) among pregnant is underreported and based on small studies. We aim to compare characteristics of confirmed OT to laparoscopies performed for the indication of suspected OT, in which no OT was found among pregnant women. This is a retrospective case-control study. We included pregnant women who underwent laparoscopy for a suspected OT between March 2011 and August 2020. Pregnant women with confirmed OT (torsion group) were compared to those without (no torsion group). There were 169 women with suspected OT. OT was confirmed in 140 (82.8%) women. There was higher proportion of assisted reproductive technology (ART) gestation in the torsion group [76 (54.3%) vs. 5 (17.2%), p < 0.001]. The rate of pregnant approaching evaluation within 8 h of symptoms onset was higher in the torsion group [57 (40.7%) vs. 2 (6.9%), p < 0.001]. The mean visual analogue score (VAS) was higher in the torsion group (8.5 vs. 7.1, p = 0.002). The mean pulse was lower in the torsion group (79 vs. 88 bpm, p < 0.001). From sonographic characteristics examined, the following was higher in the torsion group; mean maximal size of the ovary (70 mm in the torsion group vs. 54 mm in the no torsion group, p = 0.011). In a multivariable logistic regression analysis, number of hours of symptoms was negatively associated with AT [aOR, 95% CI 0.95 (0.91-0.98)] and pulse was negatively associated with OT [aOR, 95% CI 0.78 (0.63-0.95)]. Among the 29 cases in which no OT was found during laparoscopy, the following findings were noted: 16 (55.2%) no abnormality at all, 5 (17.2%) functional ovarian cyst, 2 (6.9%) mature teratoma and 6 cases of peritoneal adhesions (20.7%). The time from pain onset to approaching evaluation and women's pulse should be considered and acknowledged in the evaluation of OT during pregnancy.

Pregnancy following cesarean scar defect (niche) repair: a cohort study.

PURPOSE: The aim of the study is to learn the obstetrical outcome of women after laparoscopic niche repair. METHODS: A retrospective cohort study including all women after laparoscopic niche repair done by a single high-skilled surgeon, from July 2014 to March 2019. Data were collected from women's medical records and a telephone interview was performed to assess further symptoms and attempts to conceive, including pregnancy outcomes. RESULTS: During the study period, 48 women underwent laparoscopic niche repair, of them complete follow-up was achieved for 37 (78.7%) women. The median residual myometrial thickness measured by ultrasound before the repair was 2.0 mm (IQR 1.4-2.5). Attempts to conceive were reported by 81% (n = 30) of the women, while 18 (60%) achieved pregnancy in median time of 6 month (IQR 5-12) post-niche repair. 14 (78%) of the women conceived spontaneously. No placental abnormalities were reported in any of the women. All gave birth by cesarean delivery at a median of 38.4 gestation week (IQR 37.0-39.5). No dehiscence or rupture was reported. CONCLUSIONS: Pregnancy following niche repair can be achieved with low pregnancy complication rate and good pregnancy outcomes. Further studies need to be done to strengthen our findings.

Clinical features of isolated Fallopian tube torsion: evidence from a large series.

We aimed at studying isolated Fallopian tube torsion (IFTT) in a relatively large cohort of women and to evaluate different features of IFTT in comparison to a large cohort of women with non-IFTT adnexal torsion (NIAT). This was a retrospective cohort study. We included women with surgically confirmed ovarian and/or Fallopian tube torsion between March 2011 and June 2020. Fifty-four cases of IFTT were surgically confirmed during the study period and were compared to 422 surgically confirmed NIAT. The rate of controlled ovarian hyperstimulation treatments, current pregnancy, and vomiting was lower in the IFTT group compared with the NIAT group. Cervical tenderness and vaginal discharge were more common in the IFTT group. Oedematous and enlarged ovaries were less common in the IFTT group. In multivariate regression analysis, the following factors were independently associated with IFTT: (i) vaginal discharge [adjusted odds ratio (aOR) 95% CI 8.16, 1.98-33.55]; (ii) cervical motion tenderness (aOR 95% CI 2.71, 1.01-7.29); (iii) fertility treatments (aOR 95% CI 0.26, 0.70-0.77); (iv) previous abdominal surgery (aOR 95% CI 0.46, 0.22-0.96); (v) vomiting (aOR 95% CI 0.38, 0.19-0.76); and (vi) enlarged ovary (aOR 95% CI 0.34, 0.18-0.65). In conclusion, we have identified factors positively and negatively associated with IFTT in a large cohort of women with adnexal torsion.

Pediatric and adolescent females are at higher risk of adnexal torsion recurrence-A large-scale retrospective study.

AIM: Recurrence of adnexal torsion (rAT) is reported mainly in small series. Normal and small appearing ovaries are associated with an increased risk for rAT. Nevertheless, updated data of larger cohorts is lacking. We aimed to investigate the predictors for rAT in a cohort of women who had surgical intervention for primary adnexal torsion (pAT). METHODS: A retrospective case-control study from a single institution between 2011 and 2020. Women with a primary occurrence of surgically proven adnexal torsion were included. We compared those who had experienced rAT to those who had not. Univariate and multivariate analysis were performed to study independent predictors for rAT. RESULTS: Overall, 358 women were included. Of those, 35 (9.8%) had a rAT. Women who experienced rAT were younger (mean age 26 vs. 30 years, p = 0.01). Women experiencing rAT had smaller mean ovarian cyst diameter in the pAT episode (42 vs. 59 mm. p < 0.001). Performance of laparoscopic detorsion was only associated with rAT (odds ration [OR] 95% confidence interval [CI] 2.13 [1.02-4.42], p = 0.03), while the performance of additional cystectomy was negatively associated with rAT (OR 95% CI 0.10 [0.01-0.79], p = 0.006). Multivariate analysis demonstrated that age ≤15 and smaller cyst diameter at pAT were independently associated with the risk for rAT (aOR 95% CI 5.0 [1.09-23.2] and 1.47 [1.08-2.0], for every 10 mm decrease in cyst diameter, respectively). CONCLUSIONS: Adolescents and pediatric females and women with smaller ovarian cysts at pAT are at higher risk for future recurrence of adnexal torsion.

Office Operative Hysteroscopy for the Management of Retained Products of Conception.

The aim of this study was to compare office to conventional operative hysteroscopy for the treatment of retained products of conception (RPOC). This retrospective cohort study included all women who underwent hysteroscopy due to RPOC between January 2018 and December 2019, in a single tertiary medical care center. Exclusion criteria for hysteroscopy included the following: (1) proximity to delivery (up to 3 weeks); (2) hemodynamic instability; (3) active massive bleeding; and (4) genital tract infection. See-and-treat hysteroscopy (study group) outcomes were compared to operative hysteroscopy (controls). Data were collected from women's medical records. Primary outcome was defined as successful removal of all suspected RPOC with no need for additional intervention. Data are presented as median and interquartile range. During the study period, 222 women underwent hysteroscopy due to RPOC. Of them, 138 (62%) and 84 (38%) underwent see-and-treat and operative hysteroscopy, respectively. Symptomatic women were more commonly referred to operative hysteroscopy (60 (71%) vs. 54 (39%); p = 0.001). Maximal diameter of the suspected finding was smaller both by ultrasound examination (13 (10-18) vs. 18 (13-32) mm; p = 0.001) and by surgeon estimation during diagnostic hysteroscopy (12 (8-20) vs. 20 (14-30) mm; p = 0.001), in the see-and-treat compared to the operative hysteroscopy group, respectively. While comparing success rate between groups, no difference was observed. Sub-analysis by the maximal diameter of RPOC findings revealed that see-and-treat success rate is reduced as the RPOC is larger. Success rate was high and comparable to operative hysteroscopy for findings ≤ 2 cm (102/117 (87%) vs. 49/54 (91%); p = 0.79). Nevertheless, for RPOC > 2 cm, success was significantly more frequent in the operative hysteroscopy group (28/30 (93%) vs. 9/16 (57%); p = 0.002). This finding was supported by logistic regression analysis that found maximal diameter of RPOC as the only parameter associated with success rate (B = 0.96; p = 0.03). Office operative hysteroscopy is a feasible treatment option for the removal of RPOC when maximal diameter is taken under consideration due to its association to success rate.Clinical trial registration: The study protocol was approved by the "Sheba Medical Center" Review Board (ID 5200-18 SMC) on June 24, 2018.

Placenta accreta spectrum in subsequent pregnancy following myomectomy.

PURPOSE: To compare the prevalence of placental abnormalities in pregnancy following different modes of operative myomectomy. METHODS: A retrospective cohort study, including all women after myomectomy that gave birth in a single tertiary care center from February 2011 to January 2019. Data was collected from the patients' medical files and completed by telephone questionnaire. Patients were stratified to 3 groups, according to the mode of operative myomectomy (laparotomy, laparoscopy, hysteroscopy). Groups were compared for women demographics, fibroid's characteristics, operative management, post-operative placental evaluation and delivery characteristics. Primary outcome was defined as the need for any intervention for placental separation during the third phase of the delivery. RESULTS: Two hundred forty one women met inclusion criteria. Complete follow-up was achieved in 199 (82.57%) women, of whom 82, 89, and 28 underwent laparoscopic, laparotomy and hysteroscopic myomectomy, respectively. There were no in-between groups differences in women's age, BMI, and gravidity. Disruption of the endometrial cavity during laparoscopy and laparotomy was reported in 3 (3.6%) and 7 (7.8%) cases, respectively (p = .21). During the subsequent pregnancy following myomectomy, placenta accreta spectrum disorder was suspected in only one woman in each of the study groups (p = .63). Placenta previa was low and comparable between groups. Vaginal delivery rate was significantly higher in the hysteroscopy group, as compared to the laparoscopy or the laparotomy groups [11 (36.3%) vs. 5 (6.1%) vs. 4 (4.5%); p = .001], with significantly lower need for manual lysis of the placenta [11(39.0%) vs. 51 (62.1%) vs. 62 (69.7%); p = .01] and further interventions for blood loss control. CONCLUSIONS: Subsequent pregnancy following surgical myomectomy was not found to be associated with higher prevalence placental abnormality. Furthermore, other than manual lysis, the different modes of myomectomy did not necessitate any further intervention for complications associated with abnormal placentation requiring intervention. KEY MESSAGE: Subsequent pregnancy following surgical myomectomy is not associated with higher prevalence of placental abnormality.

A clinical prediction model for adnexal torsion in pediatric and adolescent population.

PURPOSE: To describe the clinical characteristics of children and adolescents that underwent diagnostic laparoscopy for suspected adnexal torsion (AT), and to develop a prediction model for preoperative detection of AT among young women. METHODS: A retrospective cohort study. We included all girls ≤18 years old with clinically suspected AT who underwent a diagnostic laparoscopy between 3/2011 and 6/2020. We compared patients with AT to those without AT and constructed a prediction model. RESULTS: Overall, 120 children and adolescents with suspected AT were included in the study. Of those, AT was identified in 83 (69.2%). In a multivariate analysis, the following risk factors were independently associated with AT and included in the prediction model: absence of right lower quadrant tenderness upon examination [adjusted odds ratio (aOR) (95% Confidence interval (CI)) 3.23 (1.23-8.47), p = 0.017], platelets level >240 K [aOR (95% CI) 3.15 (1.19-8.36), p = 0.021], and neutrophils level >5.4 [aOR (95% CI) 2.71 (1.02-7.52), p = 0.046]. The rate of AT was 12.5% in cases without risk factors for AT, 56.7% with one, 68.8% with two, and 94.1% with three risk factors present, respectively. CONCLUSIONS: We have identified preoperative indicators independently associated with surgically confirmed AT in a large cohort of young women. Level of evidence- III.

Pregnancy outcomes following laparoscopy for suspected adnexal torsion during pregnancy.

OBJECTIVE: To evaluate pregnancy outcomes of women with surgically confirmed adnexal torsion (AT) as compared to those in whom AT was ruled out. METHODS: A retrospective cohort study in a tertiary medical center. All pregnant women who underwent diagnostic laparoscopy due to suspected AT between 3/2011 and 4/2020 were included. We compared maternal, delivery and neonatal outcomes of both groups. We further compared women with confirmed AT to a control group of women who did not undergo laparoscopy during pregnancy. RESULTS: During the study period, 112 women met the inclusion criteria. AT was confirmed in 93 cases (83.0%). Baseline characteristics did not differ between groups, excluding the rate of previous AT [5.4% in the torsion vs. 26.3% in the no-torsion group, odds ratio (OR) 0.15, 95% confidence interval (CI) 0.04-0.62, p = .004], and nulliparity rate (57.0% in the torsion vs. 31.6% in the no-torsion group, OR 2.41, 95%CI 1.004-8.21, p = .043). Pregnancies conceived by assisted reproductive technology were more common in the AT group compared to the no-AT group (46.2% vs. 10.5%, OR 7.21, 95%CI 1.59-33.45, p = .002). Miscarriage and stillbirth rates, gestational age at delivery, delivery characteristics and neonatal outcomes were favorable and did not differ between groups. Outcomes of pregnancies with confirmed AT did not differ from a control group of women who did not undergo laparoscopy during pregnancy. CONCLUSION: Pregnancy outcomes among women who underwent laparoscopy for a suspected AT during pregnancy were reassuring, irrespective of the surgical findings and gestational week. Outcomes did not differ when compared to pregnant women who did not undergo laparoscopy. SYNOPSIS: Maternal, fetal and neonatal outcomes among women who underwent laparoscopy for suspected adnexal torsion during pregnancy are reassuring, irrespective of the surgical findings and gestational week.

Surgically confirmed adnexal torsion during pregnancy: Does the trimester make a difference?

AIM: To investigate the clinical and the sonographic characteristics of adnexal torsion (AT) during pregnancy and to underline differences in AT manifestation between pregnancy trimesters. METHODS: This is a retrospective cohort study in a tertiary medical center. The study included all pregnant women with surgically confirmed AT between March 2011 and April 2020. The patients were divided into three groups according to pregnancy trimesters, and the clinical and sonographic characteristics were compared between the groups. RESULTS: The study cohort included 140 cases of AT. Ninety-nine (70.7%) of the cases occurred during the 1st trimester, and 31 (22.1%) and 10 (7.1%) occurred during the 2nd and the 3rd trimesters, respectively. Conception by assisted-reproductive technologies (ART), nausea, and finding of enlarged ovary on ultrasound scan were all more common among patients in the 1st trimester group as compared to the 3rd trimester group (p = 0.001, 0.015, and 0.024, respectively). The mean time from admission to surgery was significantly shorter in the 1st trimester group as compared to late pregnancy (p = 0.001). The majority of cases were right-sided. There was a significant difference in the organs involved in every trimester of pregnancy-ovary only, ovary and fallopian tube, and fallopian tube only (p = 0.023). CONCLUSIONS: Most AT cases during pregnancy occurred during the 1st trimester. Conception by ART and enlarged ovary on ultrasound scan were also more common in AT cases during early pregnancy. Time from admission to surgery was longer as pregnancy progressed and organs involved differed between trimesters. Understanding the difference in manifestation of AT in every trimester might improve the preoperative evaluation of AT in pregnancy.

External Validation of the IOTA Classification in Women with Ovarian Masses Suspected to Be Endometrioma.

The study aimed to perform external validation of the International Ovarian Tumor Analysis (IOTA) classification of adnexal masses as benign or malignant in women with suspected endometrioma. A retrospective study including women referred to an endometriosis tertiary referral center for dedicated transvaginal ultrasound (TVUS). Adnexal masses were evaluated using the IOTA classification simple descriptors, simple rules and expert opinion. The reference standard was definitive histology after mass removal at laparoscopy. In total, 621 women were evaluated and divided into four groups: endometrioma on TVUS and confirmed on surgery (Group 1 = 181), endometrioma on TVUS but other benign cysts on surgery (Group 2 = 9), other cysts on TVUS but endometrioma on surgery (Group 3 = 2), masses classified as other findings or suspicious for malignancy on TVUS and confirmed on surgery (Group 4 = 5 potentially malignant, 11 benign). This gave a sensitivity 98.9%, specificity 64%, positive 95.3% and negative 88.9% predictive values, positive 2.74 and negative 0.02 likelihood ratios and 94.7% overall accuracy. The surgical diagnosis for the five masses suspected to be malignant was: borderline serous tumor (2), borderline mucinous tumor (2), and endometrioid lesion with complex hyperplasia without atypia (1). The conclusions were that the IOTA classification simple descriptors, simple rules and expert opinion performs well for classifying adnexal masses suspected to be endometrioma. The most common potentially malignant masses in these women were borderline ovarian tumors.

Optimal Isthmocele Management: Hysteroscopic, Laparoscopic, or Combination.

OBJECTIVE: To conduct a systematic review of the literature on the hysteroscopic and laparoscopic repair of isthmocele. DATA SOURCES: A thorough search of the PubMed/Medline, Embase, and Cochrane databases was performed. (PROSPERO registration number CRD42020190668). METHODS OF STUDY SELECTION: Studies from the last 20 years that addressed isthmocele repair were collected. Both authors screened for study eligibility and extracted data. All prospective and retrospective studies of more than 10 women were included. TABULATION, INTEGRATION, AND RESULTS: The initial search identified 666 articles (Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart) (see Supplemental Fig.). We excluded duplicates, case reports, reviews, video articles, and technique articles. We also excluded studies describing only laparotomy or vaginal repair as these were not in the scope of this review. A total of 31 articles met the inclusion criteria, 21 for hysteroscopic resection and 13 for laparoscopic or combined repair (4 articles tested both modalities and appear in both Tables 1 and 2).For abnormal uterine bleeding, hysteroscopic remodeling relived symptoms in 60% to 100% of cases and laparoscopy in 78% to 94%. Secondary infertility was not evaluated in all studies. After hysteroscopic and laparoscopic treatment, 46% to 100% and 37.5% to 90% of those who wished to conceive became pregnant, after the procedure, respectively. Pain and dysmenorrhea seem to be uncommon. All studies that tested improvement of pain had fewer than 10 women. However, between 66% and 100% of women who complain of pain or dysmenorrhea will note a marked improvement to full resolution. CONCLUSION: Patients with an isthmocele or cesarean scar defect are usually asymptomatic. For symptomatic women, a repair is a valid option. For those with residual myometrial thickness >2 to 3 mm, hysteroscopic remodeling is the modality of choice with an improvement in abnormal uterine bleeding, secondary infertility, and pain. Women with a residual myometrial thickness <2- to 3-mm laparoscopic repair with simultaneous hysteroscopic guidance show similar results. Because available data are limited, no cutoff for the correct choice between hysteroscopy and laparoscopy can be concluded. We recommend 2.5 mm as the cutoff value based on common practice and expert opinion, although no significance between hysteroscopic and laparoscopic treatment was shown.

Uterine Artery Pseudoaneurysm in a Pregnant Patient with Retrocervical Endometriosis.

A pseudoaneurysm of the uterine artery or its branches is usually a result of vascular trauma during invasive procedures such as a cesarean section, vaginal delivery, myomectomy, hysterotomy, or dilatation and curettage. A uterine artery pseudoaneurysm rupture is a rare, yet life-threatening event. Deep infiltrating endometriosis usually involves a decrease in symptoms and imaging findings throughout pregnancy, with the notable exception of the phenomenon of decidualization. We present the case of a pregnant woman with a recent diagnosis of endometriosis, who conceived spontaneously and presented with disabling pain at 13 weeks' gestation. She was diagnosed with a left, huge (and rapidly growing) retrocervical endometriosis nodule encompassing a uterine artery pseudoaneurysm. Selective transarterial embolization was performed at 22 weeks' gestation owing to enlargement of the pseudoaneurysm sac, and the pseudoaneurysm was obliterated successfully. The patient was followed intensively throughout the pregnancy and the baby was delivered at term by cesarean section. After delivery, the nodule returned to the pregestational size.

Urgent Laparoscopic Surgeries during the Third Trimester of Pregnancy: A Case Series.

STUDY OBJECTIVE: Laparoscopic management of nonobstetric acute abdominal pain in the third trimester of pregnancy remains controversial with limited data regarding procedure safety and feasibility. This study aimed to investigate the feasibility, immediate complications, and short-term outcomes of laparoscopic surgery at an advanced gestational age. DESIGN: Case-series. SETTING: Sheba Medical Center, a tertiary referral center. PATIENTS: Pregnant women who underwent urgent laparoscopic surgery at 27 weeks of gestation and above. INTERVENTION: Emergent laparoscopic surgery. MEASUREMENTS AND MAIN RESULTS: Clinical data were retrospectively collected and analyzed. A telephone questionnaire was administered in cases of missing data. Clinical information obtained included detailed medical and obstetric history; preoperative, intraoperative, and postoperative data; complications; and pregnancy outcomes. Between January 2010 and July 2017, 12 patients underwent emergent laparoscopic surgeries during the third trimester of pregnancy. The gestational age at the time of the surgery ranged between 27 and 38 weeks. All women had singleton pregnancies. Laparoscopic surgeries included 7 appendectomies, 4 adnexal surgeries, and 1 diagnostic laparoscopy. No complications related to the access route for any of the 12 laparoscopic surgeries occurred. The laparoscopic surgical procedure was successfully completed in 11 patients; only 1 laparoscopic appendectomy for perforated acute appendicitis with purulent peritonitis at 30 weeks of gestation was converted to laparotomy because of a limited operative field. Two patients had preterm labor at 35 and 36 weeks of gestation, respectively. None of the women was complicated with intrauterine fetal demise or low Apgar scores. CONCLUSION: Our results demonstrate that urgent laparoscopic surgeries in the third trimester of pregnancy are feasible and can be safely performed with minimal risk for the patient and fetus. Larger prospective studies are required to validate these recommendations.

Clinical Success Rate of Extensive Hysteroscopic Cesarean Scar Defect Excision and Correlation to Histologic Findings.

STUDY OBJECTIVE: Cesarean scar defect (CSD) is often associated with postmenstrual bleeding, infertility, and pain. Hysteroscopic CSD repair was described in the past, mainly as excision of the proximal edge of the defect to allow continuous blood flow during menstruation. In this study we aimed to evaluate the efficacy of extensive hysteroscopic cesarean scar niche excision in symptomatic patients. DESIGN: A retrospective cohort study. PATIENTS: Symptomatic patients treated with hysteroscopic CSD excision who were considered eligible for the procedure when myometrial thickness of 2 mm or more was observed on sonohysterography. SETTING: Tertiary referral center. INTERVENTIONS: Extensive CSD excision was performed using a cutting loop and pure cutting current. The proximal and distal edges of the defect were resected. This was followed by resection of tissue at the base of the niche, until underling muscular tissue was evident. Tissue sampled from the base of the CSD was collected for histologic examination. Patients were followed for a minimum of 1 year after hysteroscopic CSD excision. Clinical information obtained included detailed obstetric history and preoperative and postoperative menstruation pattern. MEASUREMENTS AND MAIN RESULTS: Between 2011 and 2016, 95 patients underwent extensive hysteroscopic niche excision; 67 were included in the study, whereas the remaining were lost to follow-up. Patient mean age at the time of the procedure was 38 ± 5.5 years. Twenty-nine patients (43%) had a history of high-order repeat cesarean surgeries. Sixty-six patients (98.5%) presented with postmenstrual bleeding, 26 with secondary infertility (38.8%), and 2 with pelvic pain (2.9%). After hysteroscopic niche excision, 63.4% of patients reported significant improvement or resolution of postmenstrual bleeding. A statistically significant reduction in number of bleeding days per cycle (15.5 ± 4.8 vs 9.8 ± 4.7, p < .001) was also noted. Histologic evidence for myometrial tissue within the obtained samples was associated with better outcomes. A histologic specimen from patients who experienced significant improvement or resolution of postmenstrual bleeding was more likely to reveal myometrial tissue (p = .04). Of the 26 patients who suffered from infertility, 19 attempted to conceive spontaneously after CSD excision. Of those, 10 patients (52.6%) conceived and 9 delivered at least once (47.36%). CONCLUSION: Extensive hysteroscopic surgical excision of cesarean scar niche should be considered in symptomatic patients suffering from irregular menstrual bleeding. The quality of the excision at the apex of the niche could be associated with a higher success rate. The role of niche excision to overcome secondary infertility should be further evaluated.

Experienced surgeons versus novice surgery residents: Validating a novel knot tying simulator for vessel ligation.

BACKGROUND: Vessel ligation with a knot is one of the most fundamental tasks surgeons must master. We developed a simulator designed to enable novices to acquire and refine gentle knot tying capabilities. METHODS: A bench-top, knot-tying simulator with computer-acquired assessment was tested on expert surgeons and surgery residents at an academic medical center during the years 2016 to 2018. Each participant tied a total of 8 knots in different settings (superficial versus deep) and techniques (1-handed versus 2 hands). The simulator measured vertical forces and task completion time. RESULTS: Fifteen experienced surgeons and 30 surgery residents were recruited. The expert group exerted considerably less total force during placement of the knots than the novice residents (3.8 ± 2.0 vs 9.2 ± 6.1 N, respectively; P = .0005) and the peak force exerted upward was less in the expert group (1.31 ± 0.6 vs 1.75 ± 0.84 N; P = .02). The experts also completed the task in less time (10.9 ± 3.4 vs 18.3 ± 7.2 seconds; P = 0.001). CONCLUSION: The simulator can offer residency programs a low-cost, bench-top platform to train and assess objectively the knot-tying capabilities of surgery residents.