Does Cost Influence the Choice of Disposable Versus Reusable Instruments? Mailed Survey of Obstetrician/Gynaecologists.

OBJECTIVE: A "cost-awareness" campaign was undertaken at a tertiary hospital from 2015 to 2016 to raise awareness about costs of disposable versus reusable instruments in laparoscopic procedures. We undertook a before and after survey of obstetrician/gynecologists (Ob/Gyns) to find out if the campaign had affected their attitudes about choosing disposable versus less expensive reusable instruments. METHODS: In 2015 (before the cost-awareness campaign) and 2017 (after the cost-awareness campaign), all full-time university-associated Ob/Gyns were mailed a cover letter, questionnaire, and coffee card ($5) with a postage-paid return envelope. Responses (with unique identification) from Ob/Gyns who perform laparoscopic procedures were entered into a password-protected REDCap database on a secure server. All statistical analyses were performed using SAS software version 9.4 (SAS Institute Inc, Cary, NC) (Canadian Task Force Classification II-3). RESULTS: A total of 35 of 42 eligible Ob/Gyns (85%) with a median 10 years in practice completed questionnaires before and after the intervention. The majority had undertaken minimally invasive surgery training, mainly during residency (80%) and conferences (71%). Before the intervention, the three most important qualities influencing their decision to use a particular instrument were safety (66%), effectiveness (57%), and personal experience (49%). After the intervention, the three most important qualities were effectiveness (57%), safety (57%), and ease of use (46%). Device cost was ranked sixth (26%) before and seventh (17%) after the intervention. The majority (57%) of participants did not change their choice of disposable or reusable instruments, or they would make the choice according to the specific procedure. CONCLUSION: Given the current economy, operative costs are constantly under review. Knowledge about Ob/Gyns' attitudes provides information to design more effective awareness campaigns to encourage use of less costly instruments. To change practice, a campaign increasing Ob/Gyns' exposure to less expensive but safe and effective instruments may help to increase uptake and potentially lead to cost reduction. Cost awareness alone is unlikely to change practice.

Experience in the use of non-pneumatic anti-shock garment (NASG) in the management of postpartum haemorrhage with hypovolemic shock in the Fundación Valle Del Lili, Cali, Colombia.

BACKGROUND: The aim of this case series is to describe the experience of using the non-pneumatic anti-shock garment (NASG) in the management of severe Postpartum hemorrhage (PPH) and shock, and the value of implementing this concept in high-complexity obstetric hospitals. METHODS: Descriptive case series of 77 women that received NASG in the management of PPH with severe hypovolemic shock from June 2014 to December 2015. Vital signs, shock index (SI), the lactic acid value and the base deficit were compared before and after NASG application. RESULTS: Fifty-six (77%) women had an SI > 1.1 at the time shock management was initiated; 96% had uterine atony. All women received standard does of uterotonics. The average time between the birth and NASG applications was 20 min. Forty-eight percent of women recovered haemodynamic variables in the first hour and 100% within the first 6 h; 100% had a SI < 1.0 in the first hour. The NASG was not removed until definitive control of bleeding was achieved, with an average time of use of 24 h. There were no mortalities. CONCLUSIONS: In this case series of women in severe shock, the NASG was an effective management device for the control of severe hypovolemic shock. It should be considered a first-line option for shock management.

The value of occlusive balloons in the management of abnormal placentation: A retrospective study.

Abnormal placentation is a potential cause of maternal morbidity and mortality from massive postpartum bleeding. The objective of this study was to investigate the efficacy of occlusive balloons when used as an adjunct to surgery in reducing blood loss and transfusion requirements. A retrospective study of 42 patients was performed involving consecutive cases of abnormal placentation who delivered with either conventional surgery with preoperatively placed occlusive balloons or conventional surgery alone. No differences were noted between the control group and the group of patients who had occlusive balloons with regard to estimated blood loss (P = 0.767), packed red blood cells transfused (P = 0.799), amount of crystalloids infused (P = 0.435), total procedure duration (P = 0.076), and length of ICU stay (P = 0.315) or total hospital stay (P = 0.254). Prophylactic intravascular balloon catheters did not benefit women with abnormal placentation when compared with conventional surgery alone.

Uterine sparing robotic-assisted laparoscopic sacrohysteropexy for pelvic organ prolapse: safety and feasibility.

BACKGROUND AND PURPOSE: The aim of this study was to describe the surgical technique and report the safety and feasibility of robotic-assisted laparoscopic sacrohysteropexy, a uterine sparing procedure to correct pelvic organ prolapse (POP). Hysterectomy at the time of POP surgery has yet to be proven to improve the durability of repair. Nevertheless, the leading indication for hysterectomy in postmenopausal women is POP. PATIENTS AND METHODS: We reviewed the medical records of a consecutive case series of uterine sparing prolapse repair procedures from 2005 to 2011. Fifteen women were identified. Procedures utilized a type I polypropylene mesh securing the posterior uterocervical junction to the sacral promontory. This was later modified to utilize a Y-shaped strip that was inserted through the broad ligaments to include the anterior uterocervical junction. RESULTS: Objective success was defined as Baden Walker grade 0 uterine prolapse and subjective success was defined as no complaint of vaginal bulge or pressure. The mean age of women was 51.8 years (28-64 years). No intraoperative complications were noted. The mean operating time was 159.4 minutes (130-201 minutes) and mean estimated blood loss was 35 mL (0-100 mL). The mean length of stay was 1.6 days (1-4 days) and mean length of follow-up was 10.8 months. Uterine prolapse improved in all 15 patients. Objective success was 93% (14/15) and subjective success was 80% (12/15). CONCLUSION: Robotic-assisted laparoscopic sacrohysteropexy was found to be a safe and feasible surgical treatment option for POP patients who desire uterine preservation.

The comparison of an inexpensive-modified transobturator vaginal tape versus TVT-O procedure for the surgical treatment of female stress urinary incontinence.

OBJECTIVE: To compare the safety and efficacy of an inexpensive-modified transobturator vaginal tape procedure with the transobturator tension-free vaginal tape (TVT-O) procedure for the surgical treatment of female stress urinary incontinence (SUI). MATERIALS AND METHODS: Patients with SUI were randomly allocated to either the test group receiving the inexpensive-modified transobturator vaginal tape procedure or the control group receiving the GYNECARE TVT-O procedure. Treatment outcomes and Quality-of-life scores were recorded and analyzed between two groups. RESULTS: A total of 156 patients were enrolled in this trial. Eighty patients underwent the modified transobturator vaginal tape procedure. Among them 75(93.8%) were cured and 5(6.2%) were improved. The rest of the 76 patients underwent the GYNECARE TVT-O procedure with a 92% (70 of 76) cure rate and an 8% (6 of 76) improvement rate. No inefficient or aggravated cases occurred in both groups. The success rates between groups had no significant statistic difference (p > 0.05). The operative time, blood loss, hospital stay, and medical cost were significantly lower in the test group (p < 0.01); the increases in Quality-of-life scores were comparable between groups. CONCLUSIONS: The modified transobturator vaginal tape procedure is an efficacious and economic surgical treatment for female SUI.

Simultaneous correction of anterior and apical vaginal prolapse with the modified placement of the transobturator-guided mesh (Anterior Prolift™) set.

AIM: Modified placement of the Anterior Prolift™ (MODAP) in patients with prolapse of the anterior and middle vaginal compartment is described. It was performed in order to achieve simultaneous tension-free correction of the anterior and middle vaginal compartment without excessive use of the mesh. MATERIAL AND METHODS: MODAP was performed in 32 patients. The anterior part of the mesh was placed transobturatorily. Surplus of the central part of the mesh was longitudinally divided and fixed around the cervix. Posterior mesh arms were passed through the sacrospinous ligament. All patients were analyzed regarding anatomy and symptoms 1 year after surgery. RESULTS: Cure of pelvic organ prolapse was achieved in 28 of 32 (87.5%) patients. The position of Ba and C points was significantly corrected (p = 0.00). Deterioration of the posterior compartment occurred in 1 case. Symptoms of pelvic organ prolapse were significantly corrected (p = 0.05 up to p = 0.00) except for rectal emptying. CONCLUSION: MODAP makes an improvement of both anatomy support and symptoms in cases with mixed insufficiency of the anterior vaginal wall and apical vaginal support.

Ectopic pregnancy treatment by laparoscopy, a short glimpse.

Ectopic pregnancy is a life-threatening emergency, the incidence of which is increasing globally. There are a number of factors predisposing to this condition; today, the most common of these is salpingitis. Due to advancements in diagnostic technology it is possible to diagnose this condition early and thus try to achieve a favourable outcome for the patient. Treatment options in the form of medical and surgical modalities are widely available. As minimally invasive therapy techniques are rapidly advancing, laparoscopic treatment has become the most popular and preferred method for treating ectopic pregnancy. Both salpingotomy as well as salpingectomy can be performed through the laparoscope. This paper gives a short glimpse at the predisposing factors and the diagnostic investigations available for ectopic pregnancy and an insight into its laparoscopic treatment. It also reviews the pregnancy outcome and laparoscopic treatment of cases at the Department of Obstetrics and Gynaecology, Campus Kiel, University Hospitals Schleswig-Holstein.

[Operative position suitable for transvaginal excision of urethral diverticulum or closure of urethrovaginal fistula].

Among the various surgeries in female urology, transvaginal excision of urethral diverticulum needs careful and meticulous procedures in order to avoid some operative complications, such as urethral stricture or urethrovaginal fistula. In the present report, we present a woman with urethral diverticulum who initially underwent transvaginal excision of diverticulum in the dorsal lithotomy position, but she was complicated with urethrovaginal fistula postoperatively. Unfortunately, we failed to repair her fistula when she underwent excision of the fistula in the dorsal lithotomy position. With reconsideration of an operative position useful for transvaginal surgery, we succeeded in fistula closure in the Jackknife prone reverse-lithotomy position, and thereafter, two subsequent patients with urethral diverticulum were successfully treated with transvaginal excision of diverticulum in this operative position. In the transvaginal approach to the peri-urethral disorders, the Jackknife prone reverse-lithotomy position was notably superior to the dorsal lithotomy position with the following advantages: (1) the surgeons can easily operate in a bright and large surgical site without any blind view. (2) the surgeons can dissect and suture safely and accurately. (3) the assistants also can help in the operation bimanually in the same view as the surgeon when the posterior vaginal wall is fixed with a retractor.

Technical description of the B-Lynch brace suture for treatment of massive postpartum hemorrhage and review of published cases.

Massive uncontrolled hemorrhage after childbirth is a leading cause of the pregnancy-related death and resulting morbidity. Uterine atony is the most common cause (75-90%) of primary postpartum hemorrhage. When simple massage of the uterus and uterotonics such as oxytocins, syntometrine and prostaglandins failed to manage this condition, various surgical solutions have been sought, including uterine artery ligation, more complicated stepwise devascularization of the uterus, internal iliac artery ligation and, ultimately, hysterectomy. All these procedures require above average surgical skill. In contrast, the B-Lynch suturing technique (brace suture) is particularly useful because of its simplicity of application, life saving potential, relative safety and capacity for preserving the uterus and subsequent fertility. The adequacy of haemostasis can be assessed both before and immediately after application of the suture. Only if it fails need other more radical surgical methods be considered. The special advantage of this innovative technique is that it presents an alternative to major surgical procedures for controlling pelvic arterial pulse pressure or hysterectomy. To date, this suturing technique, when applied correctly, has been successful with no problems and no apparent complications. This review provides an update on the B-Lynch brace suturing technique, including choice of suture material, use of the technique in early and late gestation, and comparison with other uterine compression surgical techniques. It also includes a comprehensive review and analysis of all published cases and their postoperative follow-up.

Surgical management of severe obstetric hemorrhage: experience with an obstetric hemorrhage equipment tray.

BACKGROUND: Hemorrhage remains a leading cause of severe maternal morbidity and death. In addition to the appropriate use of oxytocic agents for uterine atony, surgical techniques, including uterine tamponade, major vessel ligation, compression sutures, and hysterectomy, may be required. On the rare occasions they are needed, the instruments and equipment required for these surgical techniques may not be readily available. OBJECTIVE: To record our experience with an obstetric hemorrhage equipment tray for surgical management of severe obstetric hemorrhage. METHODS: A severe obstetric hemorrhage equipment tray was established and included packing (5-yard roll) and balloon device for uterine tamponade, straight (10 cm) eyed-needles and large curved eyed-needles for use with No. 1 suture, 3 Heaney vaginal retractors, 4 sponge forceps, and diagrams and instructions for the various types of compression sutures and tamponade techniques. RESULTS: Of the 4400 deliveries that occurred at 1 tertiary maternity hospital during 2002, the obstetric hemorrhage tray was used on 9 occasions: 3 Caesarean sections with placenta previa (uterine tamponade used in 2 cases, compression sutures in 1); 2 Caesarean sections with uterine atony (compression sutures); 1 Caesarean section with placenta previa accreta (major vessel ligation and compression sutures); and 3 vaginal deliveries (suturing of cervical and vaginal lacerations in 2 of the cases, uterine tamponade used in the third case). In all cases, hysterectomy was avoided. CONCLUSION: The ready availability of an obstetric hemorrhage equipment tray on the labour ward facilitates prompt surgical management of severe obstetric hemorrhage, and may reduce the need for blood transfusion and hysterectomy.

The role of covering gowns in reducing rates of bacterial contamination of scrub suits.

OBJECTIVE: This study was undertaken to determine whether covering gowns reduce the rates of contamination of surgical scrubs. STUDY DESIGN: Seventy-five clinicians had pieces of fabric from clean scrubs attached to two areas of their scrub suits. Participants wore a covering garment when wearing scrub suits off of designated areas (n = 25), did not wear a covering garment (n = 25), or wore scrub suits outside the hospital (n = 25). Subsequently, the fabric was assessed with culture in enhanced broth media and blood agar. RESULTS: Although there was a trend toward lower rates of contamination in the group that did not wear a covering garment, the difference was not significant. At no point, and at neither site of fabric attachment, did those who wore a covering garment demonstrate any advantage in regard to levels or frequency of contamination. CONCLUSION: Wearing covering garments over scrub suits does not reduce rates of contamination.

Complicaciones Urologicas en Cirugia Ginecologica y Obstetrica / Urologicas complications in cirugia ginecologica and obstetrica

Comunicamos nuestra experiencia en sesenta (60) pacientes con lesiones del aparato urinaio secundarias a procedimientos ginecológicos y obstetricos quirúrgicos, destacando sus etiologías más frecuentes, las caracteristicas de las lesiones estudiadas, la metodología que consideramos adecuada para su diagnóstico y estadificación, las técnicas seguidas para solucionar cada lesión en particular y finalmente, para informar los excelentes resultados obtenidos con los procedimientos descritos.

Colored illustrations of obstetrics manipulations and instrumentation techniques of a Turkish surgeon Serafeddin Sabuncuoglu in the 15th century.

Serafeddin Sabuncuoglu (1385-1470) was the author of the first illustrated surgical textbook Cerrahiyyet'ül Haniyye (Imperial Surgery) in the Turkish-Islamic literature. In the obstetric section he gave detailed descriptions of normal and abnormal presentation, surgical manipulation of intrauterine foetal death and retained placenta. He wrote about previously described procedures and the obstetric culture of his time. Some authors have claimed that he only translated Abu Kasim-al Zahrawa (Albucasis)'s Al-Tasrif (Textbook of Surgery) and added the illustrations of the surgical techniques. Even if this is accepted, the illustrations are enough to entitle this work as a milestone. In this paper, we describe the contributions of this pioneer in obstetrics and compare his recommendations with the current practice.