Does the experience of the first assistant affect organ injuries in laparoscopic hysterectomy for benign diseases?

PURPOSE: This study sought to explore whether the experience level of the first assistant surgeon influences perioperative organ injuries (ureteral, bladder, and intestinal injuries) in patients undergoing total laparoscopic hysterectomy (TLH) for benign diseases. We defined an experienced surgeon as a surgeon certified by the Skill Qualification Committee of the Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy or a surgeon with equivalent surgical skills. METHODS: We reviewed our surgical registry database of TLH for benign indications between 2014 and 2020 and only selected cases performed by an experienced primary surgeon. Patients were divided into two groups based on the experience level of the first assistant. Inverse probability of treatment weighting by propensity score, which was adjusted for patient and procedure characteristics, was used to examine differences in perioperative organ injuries according to the experience level of the first assistant. RESULTS: Among 1682 patients who underwent TLH, 18 organ injuries were found (0.83%). In the propensity score inverse probability of treatment weighting models, less experience of the first assistant had no significant impact on the occurrence of perioperative organ injuries (p = 0.348). CONCLUSION: In TLH for benign indications at our hospital, given an experienced primary surgeon, the inclusion of a less experienced first assistant does not negatively affect the occurrence of perioperative organ injuries.

Risk factors of vaginal cuff infection in women undergoing laparoscopic hysterectomy for benign gynecological diseases.

AIM: This study aimed to identify the risk factors for vaginal cuff infection after laparoscopic hysterectomy for benign gynecological diseases. METHODS: We conducted a retrospective cohort study among 1559 Japanese women who underwent total laparoscopic hysterectomy (TLH) for benign indications between 2014 and 2018 at Teine Keijinkai Hospital in Sapporo, Japan. All patients received preoperative antibiotics based on appropriate timing, choice, and weight-based dosing. We assessed the risk factors of vaginal cuff infection after TLH, including demographic and clinical variables, and patient- and surgery-related factors, using univariable and multivariable logistic regression analyses. RESULTS: Among all the patients who underwent TLH, 71 cases of vaginal cuff infections (4.6%) were recorded. Univariate analyses showed that current smoking, pathological result of adenomyosis, use of Seprafilm as an antiadhesive material, white blood cell counts on postoperative day (POD) 2, C-reactive protein (CRP) level on POD2 and postoperative vaginal cuff hematoma were significantly associated with an increased risk of vaginal cuff infection. In multivariate analysis, current smoking, use of seprafilm, CRP level on POD2 and vaginal cuff hematoma were significantly associated with an increased risk of vaginal cuff infection. CONCLUSION: Current smoking, use of seprafilm, CRP level on POD2 and vaginal cuff hematoma were identified as significant risk factors of vaginal cuff infection in the 30 days after surgery in Japanese women who underwent TLH for benign indications.

Analysis of risk factors of postlaparoscopic shoulder pain.

AIM: Postlaparoscopic shoulder pain (SP), mainly caused by pneumoperitoneum with CO2 , sometimes suffers patients. This study was aimed to analyze the backgrounds of SP after gynecologic laparoscopy to clarify the risk of SP. METHODS: We analyzed answers of questionnaire about the degree of SP from 696 patients undergoing gynecologic laparoscopic surgery since 2014-2018. The questionnaire asks the degree of SP with numeric rating scale from 0 to 10, before and 3 days after operation. We defined cases in which postoperative score elevated more than three compared to preoperative score as SP(+). Analyzed backgrounds were age, parity, body mass index, operative method, operative duration and amount of hemorrhage. Statistics was performed by Fisher exact analysis as univariate analysis, and with logistic regression as multivariate analysis. All laparoscopic surgeries were performed under 10-12 mmHg in pressure of pneumoperitoneum with CO2 . RESULTS: Univariate analysis revealed categories 'less than 50 years old', and 'over 2 h' and 'over 3 h' in operative duration resulted significant high rate of SP(+). For these three factors, multivariate analysis resulted that "less than 50 years old' and 'over 3 h in operative duration' were significantly high. CONCLUSION: This study suggests that 'less than 50 years' old and 'over 3 h in operative duration' were risk factors of postlaparoscopic SP. To protect from SP after laparoscopy, some countermeasures should be necessary especially for these patients.

Complications Related to the Initial Trocar Insertion of 3 Different Techniques: A Systematic Review and Meta-analysis.

This systematic review aimed to investigate complications related to initial trocar insertion among 3 different laparoscopic techniques: Veress needle (VN) entry, direct trocar entry (DTE), and open entry (OE). A literature search was completed, and complications were assessed. Major vessel injury, gastrointestinal injury, and solid organ injury were defined as major complications. Minor complications were defined as subcutaneous emphysema, extraperitoneal insufflation, omental emphysema, trocar site bleeding, and trocar site infection. Arm-based network meta-analyses were performed to identify the differences in complications among the 3 techniques. Seventeen studies were included in the quantitative analysis. DTE resulted in fewer major complications when compared with VN entry although the difference was not significant (p = .23) as well as significantly fewer minor complications (p < .001). There were no significant differences in minor complications when comparing OE and DTE (p = .74). Fewer major complications were observed with OE compared with VN entry although the difference was not significant (p = .31). There were significantly fewer minor complications for patients who underwent OE (p = .01). DTE patients experienced the least number of minor complications followed by VN entry and OE. In conclusion, major complications are extremely rare, and all 3 insertion methods can be performed without mortality.

Recovery of quality of life after laparoscopic myomectomy.

AIM: It is commonly thought that laparoscopic surgery leads to faster postoperative recovery for its low invasiveness. We evaluated postoperative quality of life (QOL) after laparoscopic myomectomy (LM) by using the Euro-QOL 5 dimension (EQ-5D) score and analyzed its relationship to surgical factors. METHODS: Between 2014 and 2016, 541 patients underwent LM at our institution. We included 86 patients in the final analysis (16% response rate) who replied to the EQ-5D questionnaire, in order to investigate postoperative QOL. We evaluated patients' EQ-5D score before the operation and on the 3rd, 7th, 14th, 21st and 28th postoperative day (POD). We investigated the degree of correlation between the EQ-5D score and four surgical characteristics (operation time, intraoperative bleeding, number of resected myomas and weight of specimen). We examined correlation between EQ-5D scores and chief complaints such as hypermenorrhea, dysmenorrhea, other pain, myoma enlargement, palpable tumor and desire for childbearing. We also examined correlation between EQ-5D scores and other factors such as patient's age, infertility, history of abdominal surgery, marriage and body mass index. RESULTS: Full recovery, defined as an EQ-5D score of 1.0, was reported 2.3% of patients by POD3, 18.6% by POD7, 58.1% by POD14, 73.3% by POD21 and 86.0% by POD28. Longer duration of operation correlated weakly with poor recovery on POD3. Intraoperative bleeding, number of resected myomas and weight of the specimen did not significantly influence EQ-5D score. There was no correlation between chief complaints or other factors mentioned above and EQ-5D score. CONCLUSIONS: More than a half of the patients undergoing LM included in our study reported full recovery of QOL after 2 weeks. The time to recover QOL was slightly influenced by the operation time. However, when LM was finished without any complications, postoperative QOL eventually seemed to improve regardless of the surgical characteristics such as operation time, intraoperative bleeding, number of resected myomas and weight of specimen.

Pain-reducing anesthesia prevents oxidative stress in human term placenta.

Anesthesia is sometimes used for the reduction of maternal pain in normal human term labor, but whether the drugs affect oxidative stress remains unclear. The placenta serves as an interface between the maternal and fetal vasculature. In this study, we immunohistochemically analyzed two markers for oxidative stress, namely 8-hydroxy-2'-deoxyguanosine (8-OHdG) and 4-hydroxy-2-nonenal-modified proteins (HNE), using placentas from 21 cases of normal tansvaginal delivery (V group), 20 Caesarean sections (C group), and 17 normal transvaginal deliveries with epidural anesthesia (E group). 8-OHdG staining in the nuclei of trophoblasts lining the chorionic villi was significantly stronger in the V group either compared with the C or E group (p<0.001), without significant differences in the C and E groups (p = 0.792). Moderate to intense staining by HNE of the intravascular serum of chorionic villi vasculature was frequently observed in the placentas from the V group, but less frequently of those in either C or E groups (p<0.001), nor the p value comparing the C and E groups was significant (p = 0.128) for HNE staining. Our results suggest that although the role of oxidative stress and its influences on fetal state in the placenta in labor remains unclear, it seems to be lessened by epidural anesthesia.

May-Thurner syndrome resulting in acute iliofemoral deep vein thrombosis during the second trimester of pregnancy.

Described is a 27-year-old pregnant woman with May-Thurner syndrome who experienced extensive pelvic and lower extremity thromboses during the antepartum period. The patient was referred for a symptomatic deep venous thrombosis at 23 weeks of gestation. Ultrasonography demonstrated a massive thrombus in the left iliofemoral vein. Heparin was given intravenously. Due to the possibility of pulmonary embolism during or immediately after delivery, a temporary inferior vena cava filter was inserted at 36 weeks of gestation. Labor was induced at 37 + 5 weeks of gestation; labor proceeded uneventfully and a male infant was born. Postpartum computed tomography (CT) demonstrated compression of the left common iliac vein by the right common iliac artery and lumbar vertebra. CT venogram demonstrated poor flow through the common iliac vein and well-developed collateral vessels. Critical stenosis at the origin of the left common iliac vein was consistent with a diagnosis of May-Thurner syndrome.

Influence of Uterine Cavity Breach in Laparoscopic Myomectomy on the Risk of Obstetric Complications.

Objectives: Prepregnancy myomectomy is effective for the treatment of infertility or prevention of obstetric complications and is usually performed with laparoscopy. However, pregnancies following myomectomy have risks of obstetric complications, especially in cases with uterine cavity breaches, but the evidence remains unclear. We investigated how uterine cavity breach in laparoscopic myomectomy influenced the occurrence of obstetric complications. Patients and Methods: One hundred and eighty women who underwent a cesarean section from 2014 to 2020 in pregnancies following laparoscopic myomectomy were included. They were divided into two groups: 25 women in the uterine cavity breach group and 155 in the nonbreach group. Obstetric complications, including placenta accreta spectrum (PAS), uterine rupture, placental malposition, abruption placenta, preterm delivery, threatened premature labor, premature rupture of membranes, and massive intrapartum hemorrhage, were assessed. Results: Multivariate analysis revealed that the frequency of PAS in the breach group (24.0%) was statistically significantly higher than in the nonbreach group (5.2%, P < 0.05). Conclusion: This study demonstrated that women who experienced uterine cavity breach in laparoscopic myomectomy had an increased risk of PAS in subsequent pregnancies.

Perinatal outcomes associated with the positional relationship between the placenta and the adenomyosis lesion.

INTRODUCTION: Although various perinatal complications have been reported to be increased in the pregnant patients with adenomyosis, it is not clear what type of patients with adenomyosis is more likely to cause obstetric complications. In this study, we focused on the positional relationship between the placenta and adenomyosis lesion in evaluating perinatal prognosis of pregnant patients with adenomyosis. MATERIAL AND METHODS: This retrospective cohort study was carried out between 1 January 2005 and 31 December 2019 in a single institution. Adenomyosis was diagnosed by magnetic resonance imaging (MRI) and/or transvaginal ultrasonography (TVUS). To evaluate the influence of adenomyosis on perinatal outcomes, we classified the positional relationship between the placenta and the adenomyosis lesion into two groups and examined the perinatal prognosis of the patients with adenomyosis by analyzing their clinical records. Group I (n = 9) was defined when the placenta was not overlaid on adenomyosis lesion. Group II (n = 11) was defined when a part of the placenta was overlaid on adenomyosis lesion. RESULTS: Twenty pregnant patients with adenomyosis were analyzed. There were no differences in clinical backgrounds between group I and group II. There was a significant increase in the obstetric morbidity in group II than that of Group I(group I: 6.3%, 4/63 vs group II: 18.6%, 26/77; P < 0.001). In group II, fetal growth restriction (FGR) was more frequent (0%, 0/9 vs 45.5%, 5/11; P = 0.042) and the birth weight was significantly lower than that in group I (2951.1 g ± 326.5 g vs 2318.9 ± 656.1 g; P = 0.037). There was a trend of lighter weight of the placenta in group II (550.6 ± 66.5 g vs 437.5 ± 117.8 g; P = 0.063) and the volume of bleeding during delivery was a higher trend in group II than that in group I (845.1 ± 367.1 g vs 1356 ± 604.8 g; P = 0.083). Group II was furtherly subdivided into group IIa (less than half the major axis of the placenta overlaid on adenomyosis lesion) and group IIb (more than half the major axis of placenta overlaid on adenomyosis lesion). The obstetric morbidity tended to be higher in group IIb than in group IIa (group IIa: 22.9%, 8/35 vs group IIb: 42.9%, 18/42); P = 0.09). In group IIb, the frequency of FGR was significantly higher (group IIa: 0%, 0/5 vs IIb: 83.3%, 5/6; P = 0.020) and the birth weight was significantly lower than those in group IIa (2656.8 ± 231.9 g vs 2037 ± 780.1 g; P = 0.040). All cases of FGR, hypertensive disorder of pregnancy (HDP), and oligohydramnios were observed in group IIb. CONCLUSION: Placental localization near adenomyosis may increase the risk of perinatal complications.

Laparoscopic-extracorporeal surgery performed with a fixation device for adnexal masses complicating pregnancy: Report of two cases.

The potential complications associated with an adnexal mass discovered during early pregnancy call for surgical treatment. Ideally, surgery is performed after gestational week 12, but uterine expansion after the first trimester makes surgery difficult. We report two pregnancies complicated by adnexal masses for which we used an organ fixation device for safe performance of single-site umbilical laparoscopic surgery. Pelvic magnetic resonance imaging depicted a dichorionic, diamniotic twin pregnancy and 60-mm right adnexal mass in the first patient and bilateral adnexae in the second. All three masses were suspected mature cystic teratomas. Both patients underwent laparoscopic surgery during gestational week 14. With use of an organ fixation device, traction was applied until the mass reached the umbilicus; tumor resection was performed extracorporeally. In the second patient, the second mass was simply aspirated because adhesions were encountered. Our single-site laparoscopic-extracorporeal technique proved to be a safe approach to an otherwise high-risk situation.

A Case Report: Ovarian Sertoli-Leydig Cell Tumor With Hyperestrogenism and Endometrial Hyperplasia in a Postmenopausal Woman.

The patient was a 66-year-old woman, G2P2. The patient presented a chief complaint of irregular postmenopausal bleeding 1 month ago. A transvaginal ultrasonography showed that bilateral ovaries were not enlarged and uterine endometrium was thickened, measuring at 9 mm. As a result of endometrial curettage, the simple endometrial hyperplasia was revealed. A blood examination showed an elevated estradiol level of 67 pg/mL, an elevated level of testosterone 0.64 ng/mL, and a slightly suppressed follicle-stimulating hormone (FSH) level of 34.86 mIU/mL. We conducted laparoscopic hysterectomy and bilateral salpingo-oophorectomy because the patient strongly suggested less invasive surgery. The result of pathological diagnosis was Sertoli-Leydig cell tumor (SLCT) in moderately differentiation. A blood examination after a month postoperatively revealed an elevated FSH level of 85.59 mIU/mL, depressed estradiol level of less than 10 pg/mL, and testosterone level of less than 0.03 ng/mL. There was no evidence of recurrence in the first year of follow-up.