Prevention of peritoneal adhesions after gynecological surgery: a systematic review.

IMPORTANCE: The formation of adhesions after gynecological surgery not only has detrimental impacts on those affected, including pain, obstruction, and infertility, but also imposes a high economic burden on healthcare systems worldwide. OBJECTIVE: The aim of this review was to evaluate the adhesion prevention potential of all currently available adhesion barriers for gynecological surgery. EVIDENCE ACQUISITION: We systematically searched MEDLINE and CENTRAL databases for randomized controlled trials (RCTs) on the use of adhesion barriers as compared with peritoneal irrigation or no treatment in gynecological surgery. Only RCTs with second-look surgery to evaluate adhesions in the pelvic/abdominal (but not intrauterine) cavity were included. RESULTS: We included 45 RCTs with a total of 4,120 patients examining a total of 10 unique types of barriers in second-look gynecological surgery. While RCTs on oxidized regenerated cellulose (significant improvement in 6 of 14 trials), polyethylene glycol with/without other agents (4/10), hyaluronic acid and hyaluronate + carboxymethylcellulose (7/10), icodextrin (1/3), dextran (0/3), fibrin-containing agents (1/2), expanded polytetrafluoroethylene (1/1), N,O-carboxymethylchitosan (0/1), and modified starch (1/1) overall showed inconsistent findings, results for expanded polytetrafluoroethylene, hyaluronic acid, and modified starch yielded the greatest improvements regarding adhesion reduction at 75%, 0-67%, and 85%, respectively. CONCLUSIONS AND RELEVANCE: Best results for adhesion prevention were reported after applying Gore-Tex Surgical Membrane, hyaluronic acid, and 4DryField®. As Gore-Tex Surgical Membrane is nonabsorbable, it is associated with a greater risk of new adhesion formation due to second-look surgery to remove the product. 4DryField® yielded the greatest improvement in adhesion score compared to all other barrier agents (85%). For better comparability, future studies should use standardized scores and put more emphasis on patient-reported outcome measures, such as pain and infertility.

The Feasibility of Practical Training in Minimally Invasive Surgery at Medical School-A Prospective Study on the Pelvitrainer.

Background and Objectives: The acquisition of practical skills at medical school is an important part of the multidimensional education program of future physicians. However, medical schools throughout the world have been slow in incorporating practical skills in their curriculum. Therefore, the aims of the present prospective study were (a) to demonstrate the feasibility of such surgical training, (b) to objectify its benefit in medical education, and (c) to investigate the impact of such training on subsequent career choices. Material and Methods: We introduced a two-day laparoscopy course on the pelvitrainer as part of the curriculum of the gynecological internship of fifth year medical students from 2019 to 2020. The results of the students' training were matched to those of surgeons who completed the same curriculum in a professional postgraduate laparoscopy course from 2017 to 2020 in a comparative study design. Additionally, we performed a questionnaire-based evaluation of the impact of the course on medical education and subsequent career choices directly before and after completing the course. Results: A total of 261 medical students and 206 physicians completed the training program. At baseline, the students performed significantly more poorly than physicians in a median of three of four exercises (p < 0.001). However, this evened out in the final runs, during which students performed more poorly than physicians only in one exercise and even better than physicians in one. The general integration of surgical training in medical school curricula was rated very low (12.4% on the VAS, IQR 3-16%) despite the high demand for such training. In the survey, the course was deemed very beneficial for medical education (median VAS 80.7%, IQR 73-98%), but did not appear to influence the students' subsequent career preferences. Conclusions: The acquisition of practical surgical skills during medical school is significantly under-represented in many medical faculties. The benefits of such training, as demonstrated in our study, would improve the education of future physicians.

Molecular Determinants of Uterine Receptivity: Comparison of Successful Implantation, Recurrent Miscarriage, and Recurrent Implantation Failure.

Embryo implantation is one of the most remarkable phenomena in human reproduction and is not yet fully understood. Proper endometrial function as well as a dynamic interaction between the endometrium itself and the blastocyst-the so-called embryo-maternal dialog-are necessary for successful implantation. Several physiological and molecular processes are involved in the success of implantation. This review describes estrogen, progesterone and their receptors, as well as the role of the cytokines interleukin (IL)-6, IL-8, leukemia inhibitory factor (LIF), IL-11, IL-1, and the glycoprotein glycodelin in successful implantation, in cases of recurrent implantation failure (RIF) and in cases of recurrent pregnancy loss (RPL). Are there differences at the molecular level underlying RIF or RPL? Since implantation has already taken place in the case of RPL, it is conceivable that different molecular biological baseline situations underlie the respective problems.

Expanding Robotic-Assisted Surgery in Gynecology Using the Potential of an Advanced Robotic System.

Minimally invasive surgery (MIS) in gynecology was introduced to achieve the same surgical objectives as traditional open surgery while minimizing trauma to surrounding tissues, reducing pain, accelerating recovery, and improving overall patient outcomes. Minimally invasive approaches, such as laparoscopic and robotic-assisted surgeries, have become the standard for many gynecological procedures. In this review, we aim to summarize the advantages and main limitations to a broader adoption of robotic-assisted surgery compared to laparoscopic surgeries in gynecology. We present a new surgical system, the Dexter Robotic System™ (Distalmotion, Switzerland), that facilitates the transition from laparoscopy expertise to robotic-assisted surgery.

The global incidence, mortality, and burden of uterine cancer in 2019 and correlation with SDI, tobacco, dietary risks, and metabolic risk factors: An ecological study.

Background and Aim: Endometrial cancer (EC) is the sixth most common cancer among women worldwide. Since global studies are based on awareness of the incidence trend, mortality, geographical diversity, and level of social development and income of countries, this study was conducted to investigate the trend of uterine cancer (UC) in the world in 2019. Methods: Age-standardized rates (ASR) of incidence, deaths, prevalence, and disability-adjusted life years (DALYs) of UC, as well as targeted risk factors, were extracted from the Global Burden of Disease (GBD) online database 2019. Pearson correlation coefficient and SPSS 16 were used to calculate the correlation between risk factors and ASR of epidemiological indicators. Statistical significance was considered as p < 0.05. Results: In 2019, the age-specific incidence and death rate of UC was peaking at 60-64 and 65-69 years, respectively. The highest age-standardized incidence rate per 100,000 people for UC has been reported in the Northern Mariana Islands, high sociodemographic index (SDI) countries, World Bank High-Income category, Europe continent and among World Health Organization (WHO) regions were found in the European Region. The highest age-standardized death rate per 100,000 people for UC has been reported in Grenada, high SDI countries, the World Bank High-Income category, Europe continent, and among WHO regions found in the European Region. In 2019, the age-standardized DALYs rate was 53.54 per 100,000 inhabitants, of which 48.49 cases were related to years of life lost (YLLs) and 5.05 cases were related to years lived with disability. Conclusion: According to GBD-2019, the highest incidence, mortality, and DALY of UC are in Europe. The evidence and traces of diversity can be seen in the inequalities of UC. Race, ethnicity, economic status, level of education and awareness, co-morbidities, access, grade, and histological type of tumor are the most important causes of this inequality.

[Fostering young talents for surgery : Laparoscopy in preclinical education-Too early or exactly right?] / Nachwuchsförderung in der Chirurgie : Laparoskopie in der Vorklinik ­ zu früh oder genau richtig?

BACKGROUND: Due to the declining interest among medical students in pursuing a surgical career, the impact of demographic changes and the technical challenges, there is an increasing need to attract medical students to the surgical profession. Against this backdrop, a teaching project was developed to familiarize medical students with minimally invasive surgical techniques early in the preclinical education, thereby increasing the interest in surgery. MATERIAL AND METHODS: Within the framework of the regular anatomical dissection course the following modules on laparoscopic surgery were integrated: (1) clinical lecture on the technique and application of laparoscopy, (2) exploratory live laparoscopy on a body donor and (3) practical exercises on laparoscopic trainers. The impact of this teaching project on the interest in a surgical career and on the clinical anatomical understanding was evaluated among 295 participating medical students. RESULTS: The evaluation revealed a pronounced gender-independent interest in learning surgical skills early in the preclinical study phase. The teaching project led to a significantly increased interest in pursuing a surgical career. Moreover, the incorporation of laparoscopic teaching modules into the preclinical anatomy course enhanced the learning motivation and understanding of clinically relevant topographic anatomy. CONCLUSION: The integration of practical surgical content into preclinical anatomical education can increase the attractiveness of surgical disciplines and simultaneously optimize teaching of anatomy. Longitudinal studies are required to examine the sustainability of these clinical teaching modules in career decisions of medical students.

Encouraging medical students to become surgeons? Impact of psychological and surgical factors on career choice at medical school.

Aim: Training decisions are viewed as a problem by the majority of medical students.In the present study we compared sociodemographic and psychological characteristics of students who are interested in surgical training to those who preferred a non-surgical specialty. Furthermore, we examined whether students who wish to be trained as surgeons performed better than their non-surgical counterparts in a course designed to acquire skills in minimally invasive surgery. Method: From October 2020 to January 2021 we performed a cross-sectional survey among 116 medical students prior to their year of practical training at Christian-Albrechts University in Kiel. Based on their intended field of specialization, the students were divided into a non-surgical and a surgical group. Sociodemographic and psychological characteristics such as self-efficacy expectations, resilience and stress perception were evaluated and compared between groups. Simultaneously, we compared their surgical performance in two laparoscopic exercises and their self-assessment as surgeons. Statistical differences between the training groups were determined by the Mann-Whitney U test or Pearson's Chi square test. Results: Ninety-two students participated in the study, of whom 64.1% intended to train in a non-surgical specialty and 35.9% in a surgical specialty. Students who wished to be trained as surgeons had higher general self-efficacy expectations (p<0.001) and greater resilience (p=0.009). However, on comparison they had a lower stress level (p=0.047). The inter-group comparison of training results and self-assessment as surgeons revealed no unequivocal differences in surgical performance. Conclusion: Interest in surgical specialties is correlated, among other factors, with the strength of psychological skills such as general self-efficacy expectations, resilience and stress perception. Early attention to these psychological resources in academic training might assist medical students in future career choices.

Deciphering resistance mechanisms and novel strategies to overcome drug resistance in ovarian cancer: a comprehensive review.

Ovarian cancer is among the most lethal gynecological cancers, primarily due to the lack of specific symptoms leading to an advanced-stage diagnosis and resistance to chemotherapy. Drug resistance (DR) poses the most significant challenge in treating patients with existing drugs. The Food and Drug Administration (FDA) has recently approved three new therapeutic drugs, including two poly (ADP-ribose) polymerase (PARP) inhibitors (olaparib and niraparib) and one vascular endothelial growth factor (VEGF) inhibitor (bevacizumab) for maintenance therapy. However, resistance to these new drugs has emerged. Therefore, understanding the mechanisms of DR and exploring new approaches to overcome them is crucial for effective management. In this review, we summarize the major molecular mechanisms of DR and discuss novel strategies to combat DR.

The Combination of Laparoscopic and Robotic Surgery: First Experience with the Dexter Robotic System™ in Visceral Surgery.

INTRODUCTION: For over two decades, abdominal surgical procedures have been safely performed robotically. After the first patent expiration, alternative robotic systems entered the market. The Dexter Robotic System™ is a small-format, modular, and robotic platform consisting of a surgeon's console, two patient carts with instrument arms, and one endoscope arm. We report our initial experiences with Dexter since its installation at our visceral surgery department. METHODS: The system and surgical setup are described. Demographic and perioperative data of all operated patients as well as the system docking times were analyzed. RESULTS: From 56 procedures performed with Dexter, the most common ones included cholecystectomy (n = 15), inguinal hernia repair (TAPP; unilateral n = 15; bilateral n = 3), and right oncologic hemicolectomy (n = 15). The median docking time was 6 min (2-16 min) and was reduced to 4 min in the last tertile of procedures performed. CONCLUSIONS: In our experience, Dexter can be implemented without any major challenges, and visceral surgical procedures of simple to medium complexity can be performed safely. The simplicity and accessibility of the system along with the ease of switching between robotics and laparoscopy could be particularly suitable for beginners in robotic surgery.

Peripartal management of dichorial twin pregnancy in a bicornuate bicollis uterus: a case report and review of the literature.

INTRODUCTION: The management of a pregnancy in a bicornuate uterus is particularly challenging. A bicornuate uterus is a rare occurrence and a twin pregnancy in a bicornuate uterus even more rare. These pregnancies call for intensive diagnostic investigation and interdisciplinary care. CASE PRESENTATION: We report on a 27-year-old European woman patient (gravida I, para 0) with a simultaneous pregnancy in each cavity of a bicornuate bicollis uterus after embryo transfer. The condition was confirmed by hysteroscopy and laparoscopy. Several unsuccessful in vitro fertilization (IVF) attempts had been performed earlier before embryo transfer in each cornus. After a physiological course of pregnancy with differential screening at 12 + 6 weeks and 22 + 0 weeks of gestation, the patient presented with therapy-resistant contractions at 27 + 2 weeks. This culminated in the uncomplicated spontaneous delivery of the leading fetus and delayed spontaneous delivery of the second fetus. DISCUSSION: Only 16 cases of twin pregnancy in a bicornuate unicollis uterus have been reported worldwide and only 6 in a bicornuate bicollis uterus. The principal risks in such pregnancies are preterm labor, intrauterine growth restriction, malpresentation and preeclampsia. These typical risk factors of a twin pregnancy are greatly potentiated in the above mentioned setting. CONCLUSION: A twin pregnancy in the presence of a uterine malformation is rare and difficult to manage. These rare cases must be collected and reported in order to work out algorithms of monitoring and therapy as well as issue appropriate recommendations for their management.

Inositols in treating polycystic ovary syndrome and non-insulin dependent diabetes mellitus: now and the future.

INTRODUCTION: This Expert Opinion covers recent updates in the use of Inositol in polycystic ovary syndrome (PCOS) and type II diabetes and gives support to researchers and clinicians. AREAS COVERED: This article discusses the role of Myo-Inositol (MI) and D-Chiro-Inositol (DCI) in physiological function, the use of MI in PCOS, the risks of using DCI in reproductive conditions, the 40:1 combination of MI/DCI in PCOS. Furthermore, we discuss the issues of insulin resistance and how α-lactalbumin may increase the intestinal bioavailability of MI. The paper then transitions to talk about the use of inositols in diabetes, including type II diabetes, Gestational Diabetes Mellitus (GDM), and double diabetes. Literature searches were performed with the use of PubMed, Google Scholar, and Web of Science between July and October 2023. EXPERT OPINION: Inositol therapy has grown in the clinical field of PCOS, with it demonstrating an efficacy like that of metformin. The use of α-lactalbumin has further supported the use of MI, as issues with intestinal bioavailability have been largely overcome. In contrast, the effect of inositol treatment on the different PCOS phenotypes remains an outstanding question. The use of inositols in type II diabetes requires further study despite promising analogous data from GDM.

Does an aptitude for surgery exist and can we predict it? An experimental study.

BACKGROUND: The selection and allocation of surgeons with a greater potential for high surgical performance are essential aspects of improving the quality, safety, and effectiveness of surgical procedures. Objective of this trial was to determine the existence of basic skills and traits that would predict better performance in surgery, and those predictive factors that constitute a driving force in different stages of training. MATERIALS AND METHODS: The randomized crossover training trial took place from January 2021 to December 2021 and was conducted at an educational training center for minimally invasive surgery. A total of n =87 physicians (residents and experts) from surgical disciplines and n =239 fifth-year medical students were studied. The participants underwent extensive neuropsychological testing and surgical training, which was performed with conventional as well as robot-assisted laparoscopy by way of identical brief tasks conducted six times in a randomized crossover setting. Main Outcome was the latent factor structure of 'psychomotor skills', 'personality', and 'motivation' based on structural equation modeling. RESULTS: The training performance of both students and physicians was significantly explained by the interaction of the three factors (explained variance: 8.2% for students, 23.8% for physicians). In students, motivation (explained variance 8.4%) and personality (explained variance 4.5%) revealed the highest contribution to surgical training performance (explained variance through psychomotor skills 1.1%). In physicians, psychomotor skills (explained variance 27.4%) made the greatest contribution to surgical training performance (explained variance through motivation 2.3%; explained variance through personality 10.5%). CONCLUSION: The study showed that surgical performance is sensitive to, and fragile in regard of nonsurgery-related general individual traits. This aligns with the notion that early selection of surgeons with prospects of high surgical performance is possible, and perhaps even necessary in order to keep up with future demands on the medical system.