Using Magnetic Resonance Imaging During Childbirth to Demonstrate Fetal Head Moldability and Brain Compression: Prospective Cohort Study.

BACKGROUND: Childbirth is a physiological process with significant medical risk, given that neurological impairment due to the birthing process can occur at any time. Improvements in risk assessment and anticipatory interventions are constantly needed; however, the birthing process is difficult to assess using simple imaging technology because the maternal bony pelvis and fetal skeleton interfere with visualizing the soft tissues. Magnetic resonance imaging (MRI) is a noninvasive technique with no ionizing radiation that can monitor the biomechanics of the birthing process. However, the effective use of this modality requires teamwork and the implementation of the appropriate safeguards to achieve appropriate safety levels. OBJECTIVE: This study describes a clinically effective and safe method to perform real-time MRI during the birthing process. We reported the experience of our team as part of the IMAGINAITRE study protocol (France), which aimed to better understand the biomechanics of childbirth. METHODS: A total of 27 pregnant women were examined with 3D MRI sequences before going into labor using a 1-Tesla open-field MRI. Of these 27 patients, 7 (26%) subsequently had another set of 3D MRI sequences during the second stage of labor. Volumes of 2D images were transformed into finite element 3D reconstructions. Polygonal meshes for each part of the fetal body were used to study fetal head moldability and brain compression. RESULTS: All 7 observed babies showed a sugarloaf skull deformity and brain compression at the middle strait. The fetus showing the greatest degree of molding and brain shape deformation weighed 4525 g and was born spontaneously but also presented with a low Apgar score. In this case, observable brain shape deformation demonstrated that brain compression had occurred, and it was not necessarily well tolerated by the fetus. Depending on fetal head moldability, these observations suggest that cephalopelvic disproportion can result in either obstructed labor or major fetal head molding with brain compression. CONCLUSIONS: This study suggests the presence of skull moldability as a confounding factor explaining why MRI, even with the best precision to measure radiological landmarks, fails to accurately predict the modality of childbirth. This introduces the fetal head compliance criterion as a way to better understand cephalopelvic disproportion mechanisms in obstetrics. MRI might be the best imaging technology by which to explore all combined aspects of cephalopelvic disproportion and achieve a better understanding of the underlying mechanisms of fetal head molding and moldability.

Three-dimensional magnetic resonance imaging of fetal head molding and brain shape changes during the second stage of labor.

To demonstrate and describe fetal head molding and brain shape changes during delivery, we used three-dimensional (3D) magnetic resonance imaging (MRI) and 3D finite element mesh reconstructions to compare the fetal head between prelabor and the second stage of labor. A total of 27 pregnant women were examined with 3D MRI sequences before going into labor using a 1 Tesla open field MRI. Seven of these patients subsequently had another set of 3D MRI sequences during the second stage of labor. Volumes of 2D images were transformed into finite element 3D reconstructions. Polygonal meshes for each part of the fetal body were used to study fetal head molding and brain shape changes. Varying degrees of fetal head molding were present in the infants of all seven patients studied during the second phase of labor compared with the images acquired before birth. The cranial deformation, however, was no longer observed after birth in five out of the seven newborns, whose post-natal cranial parameters were identical to those measured before delivery. The changing shape of the fetal brain following the molding process and constraints on the brain tissue were observed in all the fetuses. Of the three fetuses presenting the greatest molding of the skull bones and brain shape deformation, two were delivered by cesarean-section (one after a forceps failure and one for engagement default), while the fetus presenting with the greatest skull molding and brain shape deformation was born physiologically. This study demonstrates the value of 3D MRI study with 3D finite element mesh reconstruction during the second stage of labor to reveal how the fetal brain is impacted by the molding of the cranial bones. Fetal head molding was systematically observed when the fetal head was engaged between the superior pelvic strait and the middle brim.

Comparative anatomy on 3-D MRI of the urogenital sinus and the periurethral area before and during the second stage of labor during childbirth.

PURPOSE OF THE STUDY: To describe the observable MRI changes in the urogenital sinus during the second stage of labor and delivery by comparing the changes in the positions of the anatomical structures of the maternal perineum using MRI-based vector 3-D models. MATERIALS AND METHODS: Seven pregnant women underwent 3-D MRI sequences using a Philips 1 T Panorama open MRI during the pre-labor period and during the second stage of labor. A 3-D vector reconstruction platform (BABYPROGRESS, France) enabled the transformation of volumes of 2-D images into finite element meshes. The polygonal meshes labeled with the principal components of the urogenital sinus were used as part of a biomechanical study of the pressure exerted on the perineum during fetal descent. RESULTS: The expansion of the urogenital sinus was observed in all patients. Qualitative stretching was observed toward the rear and bottom of the iliococcygeus, pubococcygeus, puborectalis and obturator internus muscles. Significant length differences were measured along the iliococcygeus and pubococcygeus muscles but not along the tendinous arch of the levator ani or the puborectalis muscle. The inversion of the levator ani muscle curvature was accompanied by the transmission of pressure generated during fetal descent to the pubic muscle insertions and the descent of the tendinous arch of the levator ani. CONCLUSION: Mechanical pressures responsible for the tensioning of the constituent muscles of the urogenital sinus were qualitatively identified during the second stage of labor. MRI-based vector 3-D models allow the quantitative assessment of levator ani muscle stretching during labor, but 2-D MRI is not sufficient for describing perineal expansion. Vector 3-D models from larger scale studies have the potential to aid in the calibration of a realistic simulation based on the consideration of the reaction of each muscular element. These models offer perspectives to enhance our knowledge regarding perineal expansion during childbirth as a risk factor for postpartum perineal defects.

Surgical management of non-epithelial ovarian malignancies: advantages and limitations of laparoscopy.

OBJECTIVE: To compare open and laparoscopic surgery in the management of non-epithelial ovarian malignancies. STUDY DESIGN: Retrospective study from University Hospital of Clermont-Ferrand, France, of 20 patients undergoing surgery for non-epithelial ovarian malignancies. We compared the outcome of 13 open surgeries and 7 laparoscopic surgeries. The main outcome measures were stage and size of the tumor, surgical procedure, hospital stay, adjuvant treatment, follow-up and fertility. RESULTS: The mean age of the patients and the type of tumor at the time of diagnosis were similar in the two groups but the tumor size was significantly larger in the laparotomy group (14.0cm vs. 6.7cm; p<0.05). Treatment was conservative in 85.6% vs. 61.5% in the laparoscopy and laparotomy groups respectively. Tumor stages were not statistically different in the two groups. The hospital stay was shorter in the laparoscopy group (3.1 days vs. 6.9 days p=0.03) and there were no differences in terms of complications, surgical procedures, number of lymph nodes removed and adjuvant treatment. CONCLUSIONS: Laparoscopy respecting the usual oncologic principles appears to be a good alternative to laparotomy for the initial management of non-epithelial ovarian malignancies. The limiting factors of this technique remain the tumor size, the tumor stages and the surgeon's experience.

Surgery for deep infiltrating endometriosis: technique and rationale.

The surgical treatment of deep infiltrating endometriosis is challenging and complex. Currently, the gold standard for patient care is the referral to tertiary centers with a multidisciplinary team including gynecologists, colorectal surgeon and urologist with adequate training in advanced laparoscopic surgery. The surgical technique is essential to adequately manage the disease and to minimize the risk of complications; however, the technique is rarely taught and described in details. This paper reviews our current technique and all the tricks to allow the reproduction and even the improvement of this technique by other surgeons.

What's the impact of the obesity on the safety of laparoscopic hysterectomy techniques?

OBJECTIVE: To evaluate the impact of obesity in the safety of laparoscopic hysterectomy. STUDY DESIGN: A retrospective study was conducted using a database of 2271 women undergoing laparoscopic hysterectomy for benign diseases between January 1995 and December 2008 at the Centre Hospitalier Universitaire Estaing (Clermont-Ferrand, France). Patients were divided into two groups according to the body mass index: <30 kg/m(2) (n=2088) and ≥ 30 kg/m(2) (n=183). Primary outcomes were differences in conversion rates, operating time, estimated blood loss, intraoperative complications, and early postoperative complications. RESULTS: There was no difference in the operative time (121.3 versus 122.5 minutes; P=.71), in the difference between pre- and postoperative hemoglobin levels (1.8 versus 1.6 g/dL; P=.28), and in the conversion rate (4.6% versus 5.5%; P=.62) comparing the two groups. The overall intraoperative complication rate was 14.03% (n=293) and 13.66% (n=25) for nonobese and obese patients (P=.89), respectively. The overall postoperative complication rate was 8.81% (n=184) and 7.65% (n=14), respectively. CONCLUSIONS: Obesity does not have an adverse effect on the feasibility and safety of laparoscopic hysterectomy in experienced hands.

Educational value of an intensive and structured interval practice laparoscopic training course for residents in obstetrics and gynecology: a four-year prospective, multi-institutional recruitment study.

OBJECTIVE: To assess the educational value of an ongoing interval practice laparoscopy training program among obstetrics and gynecology residents. DESIGN: Prospective cohort, multi-institutional recruitment study. We conducted structured laparoscopic training sessions for residents, using both inanimate and porcine models. The 6-day course was separated into two 3-day long modules conducted 2 months apart. A prospective evaluation of standardized tasks was performed using validated scales. Resident's performance was compared using the Student t test and Wilcoxon signed-rank test when appropriate. SETTING: International Center of Endoscopic Surgery (CICE), Clermont-Ferrand, France. PARTICIPANTS: 191 PGY2 or PGY3 residents from different institutions. RESULTS: Significant improvement in time and technical scores for both laparoscopic suturing and porcine nephrectomy was noted (p < 0.0001). After 2 months, we found no improvement in suturing time (p = 0.59) or technical scores (p = 0.62), and significant technical deterioration was observed for the right hand (p = 0.02). Porcine nephrectomy improvement remained significant after 2 months (p < 0.0001). CONCLUSIONS: Despite significant short-term educational value of interval practice in laparoscopic performance, some acquired skills seem to deteriorate faster than anticipated.

Long-term follow-up after laparoscopic management of endometrial cancer in the obese: a fifteen-year cohort study.

STUDY OBJECTIVE: To assess the surgical outcomes and long-term results of laparoscopic treatment of endometrial cancer in obese patients, and compare these results with those of nonobese women. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Two referral cancer centers. PATIENTS: Fifty-two obese and 155 nonobese women with clinical stage I endometrial cancer managed by laparoscopy from 1990-2005 in two referral centers. INTERVENTIONS: Demographic, surgical, perioperative and pathological characteristics of obese women and nonobese women with endometrial cancer treated by laparoscopy were analyzed and then compared. Recurrence-free and overall survival was calculated by use of Kaplan-Meier method. MEASUREMENTS AND MAIN RESULTS: Median BMI of the study population was 26.2 Kg/m(2). Median BMI among obese patients was 34.2 Kg/m(2). The conversion rate was independent from the BMI of the patient (3.8% vs 4.5%, p = .80). Neither mean operative time (187.5 vs 172 min, p = .11) neither hospital stay (5.2 vs 4.9 days, p = .44) were related with BMI. Lymphadenectomy was considered not feasible in 7 obese (17%) and 8 nonobese (7%) women (p = 0.09). Fewer lymph nodes were retrieved among obese women (8 versus 11, p <.0002). No differences were found between the groups in terms of perioperative complications. Median follow-up was 69 and 71 months for the obese and nonobese, respectively (p = .59). Overall and disease-free 5-year survival rates did not differ between obese and nonobese patients (90.3% and 87.5% versus 88.5% and 89.8%, respectively). CONCLUSION: Despite some limitations, the laparoscopic approach seems to be particularly useful for obese patients with endometrial cancer, with similar survival and recurrence rates and without any more complications compared to the nonobese population.

Is laparoscopic hysterectomy feasible for uteri larger than 1000 g?

OBJECTIVE: To evaluate the feasibility of laparoscopic hysterectomy for uteri weighing more than 1000 g. STUDY DESIGN: A retrospective study was conducted in a tertiary center of laparoscopic surgery including 38 women submitted to hysterectomy for uteri weighing more than 1000 g. Patients submitted to open hysterectomy were compared to those submitted to laparoscopic hysterectomy. The primary statistical endpoint was the complication rate. Secondary endpoints were operating time, estimated blood loss, length of hospital stay, and conversion to laparotomy. RESULTS: The patients' mean age was 49.4 years and mean BMI was 25.2 kg/m(2). The surgical intent was laparoscopic hysterectomy in 23 patients (60.5%) and laparotomy in 15 patients (39.5%). Conversion to open surgery was required in 4 patients (17.4%) due to inaccessibility of the pelvis at the beginning of surgery (n=2), technical difficulties during surgery (n=1), and intraoperative bleeding (n=1). One patient in the laparotomy group had an intraoperative ureteral injury. Despite longer operative time (130 vs. 80 min, p=0.002), laparoscopic surgery was associated with reduced length of hospital stay (3 vs. 6 days, p<0.001). Intraoperative bleeding was evaluated by the difference of pre- and post-operative hemoglobin and was equivalent in both groups (2.2 vs. 1.6g/dL; p=0.84). There was a tendency for more postoperative complications in the laparotomic group (33.4% vs. 8.7%; p=0.05). CONCLUSION: Laparoscopic hysterectomy is feasible for selected patients with uteri weighing more than 1000 g.

Surgical outcomes of laparoscopic hysterectomy for enlarged uteri.

STUDY OBJECTIVE: To compare surgical outcomes of laparoscopic hysterectomy for benign diseases according to the uterine weight. DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: Teaching and research hospital, a tertiary center. PATIENTS: Women undergoing laparoscopic hysterectomy for benign diseases. INTERVENTIONS: Patients were divided into three groups according to the uterine weight: <250 g (n = 1300), 250 to 500 g (n = 614), and >500 g (n = 178). MEASUREMENTS AND MAIN RESULTS: Primary outcomes were differences in conversion rates, operating time, and blood loss. Secondary outcomes were differences in length of hospital stay, time to first bowel movement, time of bladder catheterization, and complications. Operating time increased according to the uterine weight (116.5 vs 124.1 vs 133 minutes; p <.001). The rate of conversion was statistically higher only for patients with uteri >500 g (3.3% vs 5% vs 13.5%; p <.001). However, the difference between preoperative and postoperative hemoglobin levels was equivalent for the three groups, as well as the overall rates of minor and major intraoperative complications. There was no difference in the time of bladder catheterization, time to first bowel movement, length of hospital stay, and incidence of minor and major postoperative complications among the three groups. CONCLUSION: Despite longer operating time, there is no increase in the intraoperative or postoperative complication rates in those patients with enlarged uteri undergoing laparoscopic hysterectomy. Only conversion is higher in patients with uteri >500 g.

Impact of intraperitoneal pressure and duration of surgery on levels of tissue plasminogen activator and plasminogen activator inhibitor-1 mRNA in peritoneal tissues during laparoscopic surgery.

BACKGROUND: Our objective was to evaluate the impact of intraperitoneal pressure (IPP) and duration of a CO(2) pneumoperitoneum on the peritoneal fibrinolytic system during laparoscopic surgery. METHODS: Human study: Patients undergoing laparoscopic surgery were divided into two groups: low (8 mmHg, n= 32) or standard (12 mmHg, n= 36) IPP. Normal peritoneum was collected from the parietal wall at the beginning of surgery and every 60 min thereafter. Mouse study: Mice were divided into three groups: low (2 mmHg) or high (8 mmHg) IPP or laparotomy. Peritoneal tissue was collected at 0, 4, 8, 24, 48 and 72 h, and 5 and 7 days after surgery. Real-time RT-PCR was performed in humans and mice to measure the levels of tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) mRNA in peritoneal tissues. RESULTS: Human study: The tPA/PAI-1 mRNA ratio was significantly decreased in the 12 mmHg group at 1 h [P < 0.0001 versus matched initial peritoneal biopsies (MI)]. The tPA/PAI-1 mRNA ratio decreased in both groups at 2 h (P < .0.01 versus MI). Mouse study: The tPA/PAI-1 ratio was decreased at 0 h, and the difference was significant at 4 h in both the laparotomy (P < 0.001 versus controls, 0 h, 5 and 7 days) and high-IPP (P < 0.0001 versus 0, 48 and 72 h, 5 and 7 days) groups. No changes in tPA/PAI-1 ratio were observed in the low-IPP group. CONCLUSIONS: A low IPP and shorter duration of surgery appear to minimally impact the fibrinolytic system during a CO2 pneumoperitoneum.

Comparison between standard and reverse laparoscopic techniques for rectovaginal endometriosis.

BACKGROUND: This study was designed to compare the surgical outcomes of standard and reverse laparoscopic techniques for the treatment of rectovaginal endometriosis. METHODS: A retrospective study was conducted in a teaching and research hospital (tertiary center), which included 75 women subjected to laparoscopic treatment of rectovaginal endometriosis that required both vaginal resection and rectal surgery. Standard and reverse laparoscopic techniques were compared in 35 and 40 women, respectively. Student's t test, Mann-Whitney test, and Fisher's exact test were performed to compare groups when needed; p < 0.05 was considered statistically significant. RESULTS: There was no statistically significant difference in operating time, blood loss, conversion rate, major intraoperative complications, length of hospital stay, and minor postoperative complications between the two techniques. The rate of major postoperative complications for the standard technique was 22.9%, whereas only 5% for the reverse technique (p = 0.02). The rate of postoperative rectovaginal fistula was the same for both techniques. CONCLUSIONS: Major postoperative complications were reduced by using the reverse technique.

Do patients manage to achieve pregnancy after a major complication of deeply infiltrating endometriosis resection?

OBJECTIVE: To evaluate the fertility status in women suffering from major postoperative complications following deep endometriosis surgery. STUDY DESIGN: A retrospective study in teaching and research hospitals (tertiary centers) including 23 women submitted to the surgical treatment for deep endometriosis and presenting a major postoperative complication. Postoperatively, women desiring pregnancy who conceived were compared to those who did not conceive using Mann-Whitney test and Fisher's exact test. Main outcome measure included the pregnancy rate among these women. RESULTS: The overall intrauterine pregnancy rate was 47.8% and the live birth rate was 30.4%. There were 10 spontaneous conceptions and 3 IVF conceptions among 11 patients. Women who did not conceive were older than those who conceived (33.9 vs. 29.3 years; p = 0.02). The pregnancy rate after intestinal complications was lower than after urinary complications (33.3% vs. 83.3%; p = 0.04). CONCLUSION: Fertility remains preserved among women experiencing a major complication after removal of deep endometriosis with a live birth rate of 30.4%. Women experiencing bowel complications have a reduced probability of conception compared with those who experience a urologic complication.

Proximal ectopic pregnancy: a descriptive general population-based study and results of different management options in 86 cases.

OBJECTIVE: To describe different approaches for diagnosis and management of proximal ectopic pregnancies (PP) in general population. DESIGN: Observational population based-study. SETTING: Regional ectopic pregnancy registry. PATIENT(S): Eighty-six PP registered from 1992 to 2008. INTERVENTION(S): Surgical (radical or conservative), medical, or combined therapies. MAIN OUTCOME MEASURE(S): Epidemiologic characteristics, clinical presentation, hCG level, treatments performed, failure rate, and recurrence. RESULT(S): Mean gestational age was 48.2 days. Estimated incidence of PP was 2.7%. Abdominal pain and vaginal bleeding were the commonest symptoms. Two patients were admitted in hypovolemic shock. Diagnostic modalities included transvaginal ultrasound, abdominal ultrasonography, and laparoscopy in 38 (44%), 7 (8%), and 39 (45%) cases, respectively. Mean hCG level was 10,759 IU/L. Thirty-four patients underwent primary cornual resection (39.5%) by laparoscopy (n = 32) or laparotomy (n = 2). Twenty-seven patients (31.4%) underwent primary conservative surgery by laparoscopy: cornuostomy (n = 18) or extended salpigostomy (n = 9). Primary medical treatment with methotrexate was attempted in 14 patients (16.3%). Expectant management was attempted in one case (1.2%). Eleven cases received combined therapies (11.6%). Failure rates for medical and surgical treatments were 35.7% and 28%, respectively. No failures were noted among patients who received combined therapies. CONCLUSION(S): Proximal ectopic pregnancy remains a life-threatening condition. Diagnosis is challenging and requires a high index of suspicion. Despite available conservative strategies, management of PP remains heterogeneous.

[Optical biopsy: the surgical perspective]. / Biopsie optique: le point de vue du chirurgien.

Several new intraoperative imaging techniques, often described under the generic term "optical biopsy", have been developed over the last twenty years. The term optical biopsy in fact covers two distinct approaches. The first is endomicroscopy, which provides the surgeon with histologic images comparable to those obtained by the pathologist in the laboratory. The second is image-guided surgery, which includes a variety of techniques, from fluorescence to sentinel node biopsy and real-time image fusion (enhanced reality). The diagnostic value of intraoperative histology, and the reproducibility of these methods outside the expert centers where they were initially developed, remains to be determined In particular, it remains to be seen whether they can avoid the need for conventional biopsy. The main issue will probably be to decide who is qualified to read these images: a surgeon with training in pathology, or a pathologist who examines images transmitted to the lab or directly in the operating room? Pathologic diagnosis may require several readings of the same slides, additional biopsy sections, or even additional staining procedures. The ability to examine living tissue in situ is a very attractive prospect and will probably represent a major step forward in diagnosis and treatment evaluation. It is difficult to know which of the many candidate techniques will finally be adopted, but the future seems to lie in a combination of image-guided surgery and endomicroscopy.

"Iatrogenic" parasitic myomas: unusual late complication of laparoscopic morcellation procedures.

STUDY OBJECTIVE: To describe our experience in diagnosing and managing parasitic myomas developing as an unexpected late complication of laparoscopic morcellation. DESIGN: Observational study (Canadian Task Force classification II-3). SETTING: University hospital. PATIENTS: Retrospective chart review of all patients found to have parasitic myomas that developed after previous morcellation. INTERVENTION: Laparoscopic morcellation. Review of the recent literature correlated with clinical, surgical, and pathologic features of our cases. MEASUREMENTS AND MAIN RESULTS: Four patients had heterogeneous pelvic masses after morcellation. In 3 patients, symptoms developed between 2 and 16 years after the primary surgery. One patient had no symptoms, and was referred because of a suspect pelvic mass. Vaginal examination revealed painful pelvic masses in the pouch of Douglas in 2 patients, and painless masses fixed to the vaginal vault and anterior vaginal wall, respectively, in the other 2 patients. Laparoscopic examination confirmed the presence of parasitic masses in 3 patients. In 1 patient, the mass was excised vaginally. Histologic analysis confirmed leiomyoma fragments in all patients. A well-differentiated endometrial carcinoma was incidentally found in 1 patient after hysterectomy. CONCLUSION: These masses probably resulted from growth of missed fragments of uterine tissue after previous morcellation, culminating in development of symptomatic iatrogenic parasitic myomas. If morcellation is anticipated or required, exclusion of malignancy is mandatory. Meticulous inspection of the abdominal cavity is necessary after morcellation. In patients with a history of morcellation who have pelvic masses, iatrogenic parasitic myomas should be considered in the differential diagnosis.

Incidence of intraabdominal adhesions in a continuous series of 1000 laparoscopic procedures.

OBJECTIVE: The objective of the study was the laparoscopic evaluation of the incidence of intraabdominal adhesions related to prior abdominal surgery. STUDY DESIGN: This was a prospective monocentric study including a continuous series of 1000 gynecologic laparoscopic procedures. Data were collected on history of abdominal surgery. A precise initial description of intraoperative adhesions was performed. RESULTS: Six hundred thirty-seven of the 1000 procedures (63.7%) were performed in patients with a history of 1 or more than 1 abdominal surgery. Intraoperative adhesions were found in 211 of the 1000 subjects (21.10%). Fifty-nine of the 211 cases (28%) involved bowel loops. The prior indication for surgery did not seem to influence adhesion formation. The rate of intestinal adhesions significantly increased with the number of prior abdominal surgeries. The rate of intestinal adhesions was significantly higher in cases of prior midline incisions in comparison with the other incisions. CONCLUSION: Extensive preoperative knowledge of prior surgery is essential to evaluate the risk of adhesion formation.