Clinical Perspective Concerning Abdominal Entry Techniques.

OBJECTIVE: Entry into the abdomen during operative laparoscopy is a source of some controversy regarding the safest and most useful method. The objective of this review is to describe, compare, and contrast the most popular entry techniques. DATA SOURCES: Data were collected from the historical starting point until present day from English language journal articles and book chapters. METHODS OF STUDY SELECTION: Descriptive accounts dating back to the start of laparoscopy in the 1970s and spanning to present day well-designed randomized controlled trials and Cochrane reviews were compiled to evaluate the evidence for the effectiveness and safety of abdominal entry techniques. TABULATION, INTEGRATION, AND RESULTS: The most common sites of entry are the umbilicus and the left upper quadrant. Between the Veress needle, direct trocar insertion, and open entry there is no high-quality evidence to suggest that any of these offers a universal safety advantage. The Veress needle is still the most used among gynecologists and facilitates primary trocar placement. Direct trocar entry under laparoscopic visualization may be underused, is faster, and may result in fewer failed entries. Open (Hasson) entry can be more technically challenging, but may be best for patients with suspected intra-abdominal adhesions. CONCLUSION: Surgeon comfort is critical in choosing the entry site, method, and equipment. Surgeon familiarity with entry-failure troubleshooting, possible complications, and management is essential because major entry complications are rare in modern laparoscopy but critical because the essential steps of recognition and management can be lifesaving.

Is ovarian cancer surgery stuck in the dark ages?: a commentary piece reviewing surgical technologies.

Ovarian cancer surgery endeavours to remove all visible tumour deposits, and surgical technologies could potentially facilitate this aim. However, there appear to be barriers around the adoption of new technologies, and we hope this article provokes discussion within the specialty to encourage a forward-thinking approach to new-age surgical gynaecological oncology.

Surgical training in gynecologic oncology: Past, present, future.

The purpose of this paper is to review the surgical care related to training in gynecologic oncology, from past, present and future perspectives. A marked decline in the incidence of cervical cancer as well as improvements in radiation therapy have led to a reduction in the numbers of radical hysterectomies and exenterations being performed. Utilization of neoadjuvant chemotherapy is reducing the extent of cytoreductive operations, including intestinal surgery. The incorporation of sentinel lymphatic mapping has reduced the number of pelvic, paraaortic and inguinal lymphadenectomies being performed. Coupled with these changes are other factors limiting time for surgical training including an explosion in targeted anticancer therapies and more individualized options beyond simple cytotoxic therapy. With what is likely to be a sustained impact on training, gynecologic oncologists will still provide a broad range of care for women with gynecologic cancer but may be quite limited in surgical scope and rely on colleagues from other surgical disciplines. Enhancement of surgical training by off-service rotations, simulation, attending advanced surgical training courses and/or a longer duration of training are currently incorporated into some programs. Programs must ensure that fellows take full advantage of the clinical materials available, particularly those related to the potential deficiencies described. Changing required research training to an additional elective year could also be considered. Based on the perspectives noted, we believe it is time for our subspecialty to reevaluate its scope of surgical training and practice.

Henry van Roonhuyse and the first repair of a vesico-vaginal fistula (~1676).

INTRODUCTION AND HYPOTHESIS: Obstetric vesico-vaginal fistula is a traumatic complication of prolonged obstructed labor in which pressure necrosis from the impacted fetal head destroys portions of the vesico-vaginal septum, resulting in continuous and uncontrollable urinary incontinence. Ancient evidence suggests that fistula cases have probably been occurring since the development of rotational delivery mechanics in anatomically modern humans hundreds of thousands of years ago. It is likely that attempts to repair such injuries also have a long history. The early history of vesico-vaginal fistula surgery was investigated to determine the earliest credible report of successful cure of this condition. METHODS: Historical review of vesico-vaginal fistula surgery was undertaken, focusing on the work of Henry Van Roonhuyse, a seventeenth century Dutch surgeon living in Amsterdam. RESULTS: Van Roonhuyse's clinical treatise entitled Medico-Chirurgical Observations (1676) was reviewed in detail and is described in this article. His technique for vesico-vaginal fistula repair included six essential steps that are still recognizable today: (1) use of the lithotomy position; (2) exposure of the fistula with a speculum; (3) sharp paring of the fistula edge prior to attempted closure; (4) careful approximation of the denuded edges of the fistula; (5) dressing of the wound with absorbent vaginal packing; (6) immobilization of the patient in bed until the repair has healed. CONCLUSIONS: Henry Van Roonhuyse is the most credible candidate presently known for having successfully repaired a vesico-vaginal fistula in the pre-modern era.

The Greek Surgeon-Gynecologist Savvas Georgiadis (1857-1942) and the First Vaginal Reconstruction in Smyrna.

The Greek surgeon-gynecologist Savvas Georgiadis from Phocaea in Asia Minor had performed in 1897 an innovative surgical operation in a young female patient, reconstructing her vagina. Having been educated both in Greece and France, specialized in gynecology, he became a famous surgeon in the Hellenic Hospital of Smyrna "Agios Charalampos," where the operation was masterfully executed. Although among the pioneers in neovagina techniques, Georgiadis still is searching his place among the important figures in the history of plastic surgery.

Meigs to modern times: The evolution of debulking surgery in advanced ovarian cancer.

Joe V. Meigs was a visionary clinician and an early adopter of radical techniques in the surgical treatment of ovarian cancer. His 1934 textbook "Tumors of the Female Pelvic Organs", consolidated his approach to this "hopeless" disease, with pearls on diagnosis, outcomes, and even speculations about the benefits of minimally invasive surgery. Decades before adjuvant chemotherapy would prove of value, and in an era when sophisticated statistics were unheard of, he nonetheless tried to eke out what benefits he could using the methods available in his time. We transition his original findings and observations through the advent of platinum-based chemotherapy, retrospective cohort studies supporting the benefits of primary debulking, and finally the long-awaited randomized controlled trial. We aim to provide historical context for the underpinnings of how cytoreductive surgery has evolved into its current role in the treatment of advanced ovarian cancer.

Transvaginal mesh: a historical review and update of the current state of affairs in the United States.

INTRODUCTION: Transvaginal mesh usage has been at the forefront of popular media and academic debate for the past 10 years. Several US Food and Drug Administration (FDA) communications, society statements, and research articles have been written in an attempt to define and articulate the classification system, safety data, and efficacy of this approach to transvaginal surgery. In this review, we explore the history of transvaginal mesh surgery for pelvic organ prolapse (POP), review FDA and society statements, and research current practice in the United States. METHODS: We searched the English language literature using PubMed for articles related to safety and monitoring of transvaginal mesh and reviewed all FDA publication and notices and gynecology and urogynecology society statements on its use in the United States. We then reviewed 22 articles and grouped them into several sections. RESULTS: Mesh used to augment transvaginal repair of POP was introduced in the United States in 2005 without clinical safety and efficacy data. In the subsequent years of use, both major and minor complications were increasingly reported, leading to several FDA notifications and warnings. The type of mesh used, reporting and classifications systems, and provider usage has varied widely over time. CONCLUSION: We present a historical review of transvaginal mesh use for pelvic organ prolapse in the United States from 2005 to 2016. There continues to be heated debate among practitioners about balancing the efficacy of mesh use to decrease recurrent prolapse and complications. Research into safety and efficacy, along with tighter FDA regulations, is ongoing.

Hallmarks in the evolution of gynaecological cancer surgery: the famous pioneers in children.

At the beginning of the 19th century, gynaecological cancer, mainly cancer of the uterus and cervix was a dreadful, incurable affection. However, the popularization of the three fundamentals in surgery, anesthesia, asepsis and haemostasis, ushered the golden age of operative gynaecology. During that period distinguished surgeons/gynaecologists such as Friedrich Benjamin Osiander (1759-1822), Elias von Siebold (1775-1828) and Joseph-Claude-Anthelme Récamier (1774-1852) contributed to the development of the operative techniques, providing a therapeutic solution in gynaecological cancer.

Surgical treatment of pelvic organ prolapse: a historical review with emphasis on the anterior compartment.

INTRODUCTION AND HYPOTHESIS: The objective of this work was to collect and summarize a detailed historical review of the surgical treatment of pelvic organ prolapse (POP) in which we specifically focused on the anterior compartment. METHODS: A literature search in English, Dutch, and German was carried out using the keywords pelvic organ prolapse, anterior colporrhaphy, cystocele, and interposition operations in several databases (e.g., PubMed and HathiTrust Digital Library). Other relevant journal and textbook articles were found by retrieving references cited in previous articles and textbooks. RESULTS: Probably the first explanation of the treatment of POP dates from 1500 B.C. The Egyptians gave a description to "falling of the womb" in the Kahun Papyrus. More than a millennium later, Euryphon, a contemporary of Hippocrates (400 B.C.) described some interesting therapeutic options, from succussion (turning a women upside down for several minutes) to irrigating the displaced uterus with wine. A wide range of techniques has been attempted to repair the prolapsing anterior vaginal wall. By 1866, Sim had already performed a series of operations very similar to a modern anterior repair. The first reviews about the abdominal approach to correcting a cystocele were in 1890. The first description of using mesh to cystoceles was the use of tantalum mesh in 1955. In 1970, the first report of collagen mesh in urogynecology was described. Nowadays, robot-assisted surgery and cell-based tissue engineering are the latest interventions. CONCLUSION: Many surgeons have tried to find the ideal surgical therapy for anterior compartment prolapse, but to date, this has not been achieved.

Advanced cytoreductive surgery workshop report.

The Advanced Course in Cytoreductive Surgery for Ovarian Cancer and Gynecologic Peritoneal Surface Malignancies was held at the University of California Irvine Medical Center on November 4-5, 2011. The course director was Dr Robert E. Bristow, the Philip J. DiSaia Chair and Division Director of Gynecologic Oncology. Meeting information was distributed via e-mail blasts by the International Gynecologic Cancer Society. The workshop was comprised of didactic modules, a cadaver laboratory, and heated intraperitoneal chemotherapy demonstration. This was a not-for-profit workshop, and registration fees were used to support course faculty travel to UC Irvine and pay for the cadavers.

The portrayal of J. Marion Sims' controversial surgical legacy.

PURPOSE: In the mid 1800s Dr. J. Marion Sims reported the successful repair of vesicovaginal fistulas with a technique he developed by performing multiple operations on female slaves. A venerated physician in his time, the legacy of Dr. Sims is controversial and represents a significant chapter in the mistreatment of African-Americans by the medical establishment. This review compares the modern debate surrounding his legacy with the presentation of his operation in widely consulted urological texts and journals. MATERIALS AND METHODS: A literature review was performed of medical, sociological and periodical sources (1851 to the present) regarding J. Marion Sims and vesicovaginal fistula repair. RESULTS: During the last several decades, while the controversy around Dr. Sims' surgical development has produced a steady stream of articles in the historical and popular literature, relatively little mention is found in standard urology textbooks or journals. With increased public attention, some have debated the removal or modification of public tributes to Dr. Sims. This move has been countered by arguments against the validity of judging a 19th century physician by modern standards. CONCLUSIONS: While historians, ethicists and the popular press have debated Dr. Sims' legacy, medical sources have continued to portray him unquestionably as a great figure in medical history. This division keeps the medical profession uninformed and detached from the public debate on his legacy and, thus, the larger issues of ethical treatment of surgical patients.

Establishing specialty jurisdictions in medicine: the case of American obstetrics and gynaecology.

The profession of medicine has evolved into an extremely specialised occupation. Yet, recent research has neglected the intra-occupational processes influencing medical specialisation. This article aims to correct this oversight. It develops an historical account of intra-occupational factors influencing the decision to establish gynaecologic oncology as American ob/gyn's surgical subspecialty in 1972. Working within the framework initially developed by Everett C. Hughes and his students, the article examines this development as the outcome of a three-party relationship among gynaecologic oncologists, American ob/gyns, and gynaecologic pelvic surgeons. Aggressive movement by the gynaecologic pelvic surgeons challenging the established élite's identity definition for the ob/gyn specialty helped spur official recognition of gynaecologic oncology, a less threatening subspecialty. The article draws theoretical implications from the case regarding the role of a threatening other in influencing the specialisation process.

Joseph-Claude-Anthelme Récamier (1774-1852): forerunner in surgical oncology.

Professor J.C.A. Récamier (1774-1852), the undisputed founder of modern gynecologic surgery, had also excelled in the field of oncology. In particular, he performed the first successful vaginal hysterectomy for cancer; he conducted extensive research on cancer metastatic process and he was the proponent of a cancer treatment method by compression.

Anterior Vaginal Wall Prolapse Repair and the Rise and Fall of Transvaginal Mesh. Did We Come Full Circle? A Historical Perspective.

OBJECTIVE: To present a brief historical review of treatment options for pelvic organ prolapse with a focus on anterior vaginal wall defects and highlight changing practice patterns in the era of synthetic mesh controversy. METHODS: A MEDLINE and PubMed search was performed using the keywords pelvic organ prolapse, anterior colporrhaphy, and cystocele followed by a manual search of bibliographies. RESULTS: Ancient treatments included Hippocratic succession, local astringent, and use of pomegranates as crude pessaries. More sophisticated surgical techniques evolved in the 19th century with further refinement in the early 20th century. Numerous native tissue apposition techniques were popularized by Kelly, Kennedy, Burch, and Raz. Due to poor durability, surgeons sought alternate approaches including biologic and synthetic grafts. Synthetic transvaginal mesh (TVM) initially included use of Tantalum and Marlex to repair anterior wall defects. Both were eventually abandoned due to complications. TVM was re-designed, re-marketed, and re-introduced. Type 1 polypropylene monofilament TVM use became ubiquitous in female pelvic surgery peaking between 2004 and 2008. Initial promising outcomes were soon eclipsed by a surge of adverse events leading to multiple FDA warnings, reclassification to Class III, high-risk medical device, and ultimately a complete recall in 2019. CONCLUSION: The bidirectional pendulum swing on use of synthetic TVM has been occurring since its introduction 50 years ago. In the current era of mesh controversy, more practitioners are now revisiting previously described native tissue and biologic graft techniques. It appears that history has repeated itself.