Inguinal endometriosis, a rare entity of which surgeons should be aware: clinical aspects and long-term follow-up of nine cases.

INTRODUCTION: Inguinal endometriosis is a rare disease and often misdiagnosed for other, more common groin pathology. We present nine cases of women with inguinal endometriosis with long-term follow-up. METHODS: In this retrospective case series, the Dutch PALGA system was searched for all patients diagnosed with extrapelvic endometriosis located in the groin in the OLVG hospital, Amsterdam, between 2000 and 2016. Relevant information regarding pre- and postoperative characteristics and symptoms was collected. Follow-up consisted of a telephone call from the attending surgeon. RESULTS: None of the patients had a history of pelvic endometriosis. Typically, they presented with a right-sided swelling in the groin. Preoperative ultrasound and MRI were in most cases inconclusive. In one of two patients fna indicated endometriosis. In only three patients the surgeon considered the diagnosis endometriosis preoperatively. Surgical removal was effective with no reported complications. A coexisting hernia sac was resected in four cases, and there was a suspicion of a persistent processus vaginalis (canal of Nuck) in three, suggesting that a persistent processus vaginalis is possibly an important key to the pathogenesis. In none of the cases there was an indication for mesh implantation. One patient was later diagnosed with pelvic endometriosis. CONCLUSION: Follow-up by a gynecologist is advised to check for intra-abdominal disease and inform patients on fertility perspective. Surgeons should be aware of the possibility of inguinal endometriosis in fertile women with a lump in the groin.

The HysNiche trial: hysteroscopic resection of uterine caesarean scar defect (niche) in patients with abnormal bleeding, a randomised controlled trial.

BACKGROUND: A caesarean section (CS) can cause a defect or disruption of the myometrium at the site of the uterine scar, called a niche. In recent years, an association between a niche and postmenstrual spotting after a CS has been demonstrated. Hysteroscopic resection of these niches is thought to reduce spotting and menstrual pain. However, there are no randomised trials assessing the effectiveness of a hysteroscopic niche resection. METHODS/DESIGN: We planned a multicentre randomised trial comparing hysteroscopic niche resection to no intervention. We study women with postmenstrual spotting after a CS and a niche with a residual myometrium of at least 3 mm during sonohysterography. After informed consent is obtained, eligible women will be randomly allocated to hysteroscopic resection of the niche or expectant management for 6 months. The primary outcome is the number of days with postmenstrual spotting during one menstrual cycle 6 months after randomisation. Secondary outcomes are menstrual characteristics, menstruation related pain and experienced discomfort due to spotting or menstrual pain, quality of life, patient satisfaction, sexual function, urological symptoms, medical consultations, medication use, complications, lost productivity and medical costs. Measurements will be performed at baseline and at 3 and 6 months after randomisation. A cost-effectiveness analysis will be performed from a societal perspective at 6 months after randomisation. DISCUSSION: This trial will provide insight in the (cost)effectiveness of hysteroscopic resection of a niche versus expectant management in women who have postmenstrual spotting and a niche with sufficient residual myometrium to perform a hysteroscopic niche resection. TRIAL REGISTRATION: Dutch Trial Register NTR3269 . Registered 1 February 2012. ZonMw Grant number 80-82305-97-12030.

Carboxyhaemoglobin formation and ECG changes during hysteroscopic surgery, transurethral prostatectomy and tonsillectomy using bipolar diathermy.

Diathermy is known to produce a mixture of waste products including carbon monoxide. During transcervical hysteroscopic surgery, carbon monoxide might enter the circulation leading to the formation of carboxyhaemoglobin. In 20 patients scheduled for transcervical hysteroscopic resection of myoma or endometrium, carboxyhaemoglobin was measured before and at the end of the surgical procedure, and compared with levels measured in 20 patients during transurethral prostatectomy, and in 20 patients during tonsillectomy. Haemodynamic data, including ST-segment changes, were recorded. Levels of carboxyhaemoglobin increased significantly during hysteroscopic surgery from median (IQR [range]) 1.0% (0.7-1.4 [0.5-4.9])% to 3.5% (2.0-6.1 [1.3-10.3]%, p < 0.001), compared with levels during prostatectomy or tonsillectomy. Significant ST-segment changes were observed in 50% of the patients during hysteroscopic surgery. Significant correlations were observed between the increase in carboxyhaemoglobin and the maximum ST-segment change (ρ = -0.707, p < 0.01), between the increase in carboxyhaemoglobin and intravasation (ρ = 0.625; p < 0.01), and between intravasation and the maximum ST-segment change (ρ = -0.761; p < 0.01). The increased carboxyhaemoglobin levels during hysteroscopic surgery appear to be related to the amount of intravasation and this could potentially be a contributing factor to the observed ST-segment changes.

A personalised eHealth programme reduces the duration until return to work after gynaecological surgery: results of a multicentre randomised trial.

OBJECTIVE: To evaluate the effectiveness of an eHealth intervention on recovery and return to work, after gynaecological surgery. DESIGN: Randomised multicentre trial that ran from March 2010 until September 2011. SETTING: Secondary care in seven general and university hospitals in The Netherlands. POPULATION: A cohort of 215 women (aged 18-65 years) who had a hysterectomy and/or laparoscopic adnexal surgery for a benign indication. METHODS: The women were randomly assigned to the intervention group (n = 110) or the control group (n = 105). The intervention group received an eHealth programme that provided personalised tailor-made pre- and postoperative instructions on the resumption of daily activities, including work, and tools to improve self-empowerment and to identify recovery problems. The control group was provided with access to a control website. MAIN OUTCOME MEASURES: The primary outcome was the duration of sick leave until a full sustainable return to work. Secondary outcome measures were quality of life, general recovery, and pain intensity. RESULTS: In intention-to-treat analysis the eHealth intervention was effective on time to return to work (hazard ratio 1.43; 95% confidence interval 1.003-2.040; P = 0.048). The median duration of sick leave until a full sustainable return to work was 39 days (interquartile range 20-67 days) in the intervention group and 48 days (interquartile range 21-69 days) in the control group. After 26 weeks pain intensity was lower (visual analogue scale, cumulative odds ratio 1.84; 95% confidence interval 1.04-3.25; P = 0.035) and quality of life was higher (Rand-36 health survey, between-group difference 30, 95% confidence interval 4-57; P = 0.024) in the intervention group, compared with the control group. CONCLUSIONS: The use of the eHealth intervention by women after gynaecological surgery results in a faster return to work, with a higher quality of life and less pain.

Cervical tourniquet in case of uncontrollable haemorrhage during caesarean section owing to a placenta accreta.

This case report describes a 38-year-old woman in whom a primary caesarean section for placenta previa was complicated by postpartum haemorrhage due to a placenta accreta. Despite tamponade with a Bakri balloon and placement of a B-Lynch suture, the amount of blood loss could not be effectively reduced. The blood loss was eventually minimised by the placement of a Penrose drain around the cervix as a cervical tourniquet. We think that a cervical tourniquet is an effective method of stopping haemorrhage during caesarean section, as shown in this case report, and we consider this technique to be a valuable addition to several existing methods through which fertility is preserved by preventing emergency hysterectomy.

Perioperative outcomes using LigaSure compared with conventional bipolar instruments in laparoscopic hysterectomy: a randomised controlled trial.

OBJECTIVE: To compare the effects of LigaSure versus the conventional bipolar technique on operating time and blood loss during laparoscopic hysterectomy. DESIGN: A randomised controlled trial. SETTING: Three teaching hospitals. POPULATION: Women undergoing a laparoscopic hysterectomy for benign indications. METHODS: 140 women undergoing a laparoscopic hysterectomy were randomised for LigaSure or conventional bipolar instruments. MAIN OUTCOME MEASURES: Primary outcome was operating time from initial skin incision till detachment of the uterus. Secondary outcome measures were total operating time (from initial skin incision till final skin closure), time to dissect the adnexal ligaments, intra-operative blood loss and subjective evaluation by the surgeon of the instrument used. RESULTS: No differences in operating time (from initial skin incision till uterine detachment and initial skin incision till final skin closure) using LigaSure versus conventional bipolar instruments: 97.6 versus 91.8 minutes (P = 0.39, 95% CI - 7.6 to 19.2), and 148.1 versus 142.1 minutes (P = 0.46, 95% CI - 10.1 to 22.3), respectively. The mean blood loss using LigaSure versus conventional bipolar was 234.1 versus 273.1 ml (P = 0.46, 95% CI -39.1 to 52.7). Various subjective efficacy and instrument handling parameters were significantly different between the two instruments and between the different participating centres. CONCLUSIONS There were no significant differences in operating time and blood loss between the use of LigaSure and the use of conventional bipolar instruments during laparoscopic hysterectomy, even after correction for potential confounders. User satisfaction parameters were assessed as significantly different by surgeons of the participating centres.

How safe is the intravasation limit in hysteroscopic surgery?

BACKGROUND: Transcervical resection of myomas (TCR-M) is considered a safe hysteroscopic procedure if intravasation is limited. Complications may occur if gas formation during myoma resection leads to gaseous embolism. However, the incidence of emboli during transcervical myoma resection is unknown. Therefore in this study the occurrence of physiological changes that indicate the formation of emboli was retrospectively determined in patients undergoing hysteroscopic myoma resection. In addition, these changes were related to the amount of fluid intravasation. METHODS: The anesthesia records and operation files of 234 patients were screened for physiological changes that indicate embolism, as measured with standard intraoperative monitoring. These patients underwent surgery for intrauterine myomas with either a monopolar resectoscope with electrolyte-free distension fluid containing 3% sorbitol (limited to 1500-mL intravasation) or a bipolar resectoscope with normal saline solution (limited to 2500-mL intravasation). The patients were grouped according to the amount of fluid intravasation during the operation: Group 1: 500 mL or less, group 2: 500-1000 mL, group 3: 1000-1500 mL, and group 4: 1500-2500 mL. RESULTS: Physiological changes that could be attributed to gaseous embolism were observed in 33% to 43% of patients with 1000 to 2500 mL fluid intravasation during transcervical myoma resection. Nearly half of those patients had cardiovascular disturbances that indicated the formation of emboli. CONCLUSION: During transcervical resection of myomas, physiological changes that could be attributed to gaseous embolism frequently occurred. Therefore cardiovascular disturbances that indicate gaseous embolism during transcervical resection of myomas may occur despite the limitation of intravasation according to current view.