Port-site hernia recurrence at previous 5-mm laparoscopic access: case report and review of literature.

Port-site hernia (PSH) of less than 10 mm is an exceptionally rare complication of minimally invasive surgery (MIS). To date, there have been no cases in the literature reporting recurrence of PSH from a 5 mm incision. We present the first case of PSH recurrence in a woman who underwent surgery for benign gynaecological pathology via a MIS approach. Her post-operative course was complicated by an episode of symptomatic hernia arising from a 5 mm accessory trocar which was surgically managed. A few months later she re-presented with the same symptoms and had a PSH recurrence of the same port-site. Two corrective surgeries employing different techniques were performed. The first episode was managed laparoscopically using interrupted stitches. On the other hand, the PSH recurrence was managed by placement of a mesh. Ultrasound played a crucial role in diagnostics, especially in the recurrent setting. Due to the complete absence of similar cases in the literature, the decision making around the management of a PSH recurrence from a 5 mm trocar site proved to be challenging. As MIS is the current standard of care, more cases are likely to occur, however despite the increasing number of surgical procedures performed via MIS, no established guidelines for managing such complications have been proposed. Trying to bridge this gap, we present the case report of the first case of PSH recurrence from a 5 mm accessory port and a review of the most significant literature available to date. We finally summarise the reported cases of PSH and the types of surgical repair conducted to highlight the absence of a standard of care.

Simple hysterectomy versus radical hysterectomy in early-stage cervical cancer: A systematic review and meta-analysis.

BACKGROUND: This systematic review (SR) and meta-analysis aims to compare the surgery-related results and oncological outcomes between SH and RH in patients with early-stage cervical cancer. METHOD: We systematically searched databases including PubMed, Embase and Cochrane to collect studies that compared oncological and surgery-related outcomes between SH and RH groups in patients with stage IA2 and IB1 cervical cancer. A random-effect model calculated the weighted average difference of each primary outcome via Review Manager V.5.4. RESULT: Seven studies comprising 6977 patients were included into our study. For oncological outcomes, we found no statistical difference in recurrence rate [OR = 0.88; 95% CI (0.50, 1.57); P = 0.68] and Overall Survival (OS) [OR = 1.23; 95% CI (0.69, 2.19), P = 0.48]. No difference was detected in the prevalence of positive LVSI and lymph nodes metastasis between the two groups. Concerning surgery-related outcomes, the comprehensive effects revealed that the bladder injury [OR = 0.28; 95% CI (0.08, 0.94), P = 0.04] and bladder disfunction [OR = 0.10; 95% CI (0.02, 0.53), P = 0.007] of the RH group were higher compared to the SH group. CONCLUSION: This meta-analysis suggested there are no significant differences in terms of both recurrence rate and overall survival among patients with stage IA2-IB1 cervical cancer undergoing SH or RH, while the SH group has better surgery-related outcomes. These data confirm the need to narrow the indication for RH in early-stage cervical cancer.

Primary flap closure of perineal defects to avoid empty pelvis syndrome after pelvic exenteration in gynecologic malignancies: An old question to explore a new answer.

Pelvic exenteration (PE) is a radical oncological surgical procedure proposed in patients with recurrent or persistent gynecological cancers. The radical alteration of pelvic anatomy and of pelvic floor integrity can cause major postoperative complications. Fortunately, PE can be combined with reconstructive procedures to decrease complications and functional and support problems of pelvic floor, reducing morbility and mortality and increasing quality of life. Many options for reconstructive surgery have been described, especially a wide spectrum of surgical flaps. Different selection criteria have been proposed to select patients for primary perineal defect flap closure without achieving any strict indication of the best option. The aim of this review is to focus on technical aspects and the advantages and disadvantages of each technique, providing an overview of those most frequently used for the treatment of pelvic floor defects after PE. Flaps based on the deep inferior epigastric artery, especially vertical rectus abdominis musculocutaneous (VRAM) flaps, and gracilis flaps, based on the gracilis muscle, are the most common reconstructive techniques used for pelvic floor and vaginal reconstruction. In our opinion, reconstructive surgery may be considered in case of total PE or type II/III PE and in patients submitted to prior pelvic irradiation. VRAM could be used to close extended defects at the time of PE, while gracilis flaps can be used in case of VRAM complications. Fortunately, numerous choices for reconstructive surgery have been devised. As these techniques continue to evolve, it is advisable to adopt an integrated, multi-disciplinary approach within a tertiary medical center.

Three-dimensional vision versus two-dimensional vision on laparoscopic performance of trainee surgeons: a systematic review and meta-analysis.

Laparoscopic surgery underwent great improvements during the last few years. This review aims to compare the performance of Trainee Surgeons using 2D versus 3D/4 K laparoscopy. A systematic review of the literature was done on Pubmed, Embase, Cochrane's Library and Scopus. The following words and key phrases have been searched: "Two-dimensional vision", "Three-dimensional vision", "2D and 3D laparoscopy", "Trainee surgeons". This systematic review was reported according to the PRISMA statement 2020. PROSPERO registration No. CRD42022328045. Twenty-two randomized controlled trials (RCTs) and two observational studies were included in the systematic review. Two trials were carried out in a clinical setting, and twenty-two trials were performed in a simulated setting. In studies involving the use of a box trainer, the number of errors in the 2D laparoscopic group was significantly higher than in the 3D laparoscopic group during the performance of FLS skill tasks: peg transfer (MD: -0.82; 95% CI - 1.17 to - 0.47; p < 0.00001), cutting (MD: - 1.09; 95% CI - 1.50 to - 0.69 p < 0.00001), suturing (MD: - 0.48; 95% CI - 0.83 to - 0.13 p = 0.007), However, in clinical studies, there was no significant difference in the time taken for laparoscopic total hysterectomy (MD: 8.71; 95% CI - 13.55 to 30.98; p = 0.44) and vaginal cuff closure (MD: 2.00; 95% CI - 0.72 to - 4.72; p = 0.15) between 2D group and 3D group. 3D laparoscopy facilitates learning for novice surgeons and shows improvements in their laparoscopic performance.

4K versus 3D total laparoscopic hysterectomy by resident in training: a prospective randomised trial.

Background: The introduction of ultra-high-definition laparoscopic cameras (4K), by providing stronger monocular depth perception, could challenge the existing 3D technology. There are few available studies on this topic, especially in gynaecological setting. Objectives: Prospective, single institution, randomised clinical trial (NCT04209036). Materials and Methods: The two laparoscopes utilised were the 0°ULTRA Telescopes with 4K technology and the 0°3D-HD by Olympus. The surgeons were all trainees and in their last year of residency and who had obtained the certificate of first or second level of the Gynaecological Endoscopic Surgical Education and Assessment program - GESEA program. Twenty-nine patients with benign uterine pathology were enrolled. Main outcome measures: To compare if the use three-dimensional (3D) versus ultra-high-definition laparoscopic vision system (4K) for total laparoscopic hysterectomy performed by trainees was associated with a shorter operative time. Results: The 3D vision system did not prove to be superior to the 4K vision system. Operators reported significantly more vision-related side effects when using 3D than 4K. Completing the GESEA training program was the only factor with a positive and statistically significant impact on the overall time of the procedure, especially when greater dexterity and tissue handling were required. Conclusions: Neither technology used proved superior to the other, although operators showed a preference for 4K over 3D due to the lower number of visual side effects. Attendance at courses on laparoscopic simulators and training programs allowed trainees to demonstrate excellent surgical skills.

Recurrent ectopic pregnancy on tubal remnant treated by laparoscopic resection: loop and stitch.

Ectopic pregnancies occur in about 1-2 % of all pregnancies, with a high rate of maternal mortality due to bleeding caused by the rupture of the ectopic pregnancy. Ipsilateral ectopic pregnancy on a tubal remnant after salpingectomy is rare and it is associated with a higher mortality rate when compared to other ectopic pregnancies. Diagnosis and treatment of these pregnancies can be difficult, requiring a multidisciplinary management to plan the best treatment for the patient. The objective of this video is to show the laparoscopic removal of a tubal pregnancy on the stump of a previous salpingectomy with the application of three laparoscopic rings/endoloops ® to isolate the tubal portion from the uterus.

Sentinel lymph node detection in endometrial cancer with indocyanine green: laparoscopic versus robotic approach.

BACKGROUND: The aims of the present study were to assess bilateral sentinel lymph node (SLN) mapping with laparoscopic versus robotic approach, to assess variables affecting bilateral detection rates and to assess survival difference in patients with no/unilateral, compared to bilateral SLN detection. METHODS: This is a retrospective, single-centre, observational cohort study, including patients with endometrial cancer FIGO stage IA-IVB, treated with minimally invasive primary surgery and undergoing indocyanine green (ICG) injection to detect SLN, between January 2015 and December 2019. RESULTS: Of the 549 included patients, 286 (52.1%) and 263 (47.9%) underwent the laparoscopic and robotic approach respectively. 387 (70.5%) patients had bilateral SLN mapping, 102 (18.6%) and 60 (10.9%) had unilateral and no mapping, respectively. Patients who underwent the robotic approach were older (median 61 versus 64 years, p=0.046) and had a higher BMI (median 26.0 versus 34.8 kg/m2, p<0.001). No difference in any SLN mapping or in SLN bilateral detection was evident between the laparoscopic or robotic approach (p=0.892 and p=0.507 respectively). Patients with bilateral SLN detection in the entire cohort were younger (p<0.001) and had a better 3-year disease-free survival (DFS) compared to patients with no/unilateral SLN mapping (77.0% versus 66.3%, respectively, p=0.036). No 3-year overall survival (OS) difference was reported (p=0.491). CONCLUSION: SLN mapping and bilateral SLN detection with ICG in endometrial cancer was not different in the laparoscopic and robotic approach, even though patients undergoing the robotic approach were older and more obese. Bilateral SLN detection was associated with improved 3-year DFS, but not with 3-year OS, compared to no and unilateral SLN detection.

Step-by-step surgical procedures for a correct identification of the sentinel lymph node in endometrial cancer.

BACKGROUND: In patients with endometrial cancer, the common method for assessing the status of lymph nodes (LN) is lymphadenectomy. The sentinel lymph node (SLN) biopsy is a revolutionary concept and it will play an increasingly important role in surgical practice. The surgical technique of the sentinel lymph node is less destructive than lymphadenectomy, and it requires less anatomical knowledge. METHODS: Step by step technique of cervical injection, the preparation of the anatomical spaces and the identification of the main structures to detect and remove the SLN safely in patients affected by endometrial cancer stage IA. RESULTS: We identify the three different lymphatic pathways drainage from the uterine cervix and show how anatomical retroperitoneal knowledge is essential for the safe dissection of anatomical spaces. In literature it is reported that in about 9% of cases the SLN is located at the lumbo-aortic level, so it is clear how important it is to know the anatomy to follow the highlighted lymph pathway to identify first lymph node absorber of the drainage. CONCLUSION: Anatomical knowledge and the correct preparation of the anatomical spaces make the identification of the sentinel lymph node safe and feasible.

Laparoscopic vs percutaneous hysterectomy in obese patients: a prospective evaluation.

BACKGROUND: Treatment of obese female patients represents a real challenge. Indeed, obesity among women has reached epidemic levels not only elevating the cardiovascular and endocrinological risks, but also increasing the incidence of various gynecological pathologies (e.g. endometrial cancer and hyperplasia, uterine fibroids, genital prolapse) which commonly require hysterectomy as a surgical solution. In the last decade, minimally invasive surgery has emerged as an approach reducing the invasiveness of the standard laparoscopic surgical procedures while maintaining efficacy and feasibility. As such, in this study we aimed to evaluate the feasibility of percutaneous hysterectomy (PSS-H) approach in obese patients by reporting the first prospective comparison between the PSS-H to laparoscopic hysterectomy (LPS-H). METHODS: In this multicentric comparative prospective study, 45 patients affected by benign and malignant gynecological conditions were considered eligible for minimally invasive surgery (MIS). Fifteen patients received PSS-H and 30 LPS-H. All patients enrolled received a total hysterectomy ± bilateral salpingo-oophorectomy, with or without lymph nodal staging. RESULTS: No statistically significant differences were noted in operative time and estimated blood loss between the two groups. Four patients in PSS-H group and 3 in LPS-H group received lymph node staging. A multifunctional energy device was used in all PSS-H and 73.3% of LPS-H procedures (p=0.038). There were no conversions to laparotomy in either group and similarly there were no conversions to conventional laparoscopy in the PSS-H group. In the LPS-H group, there was one (3.3%) case of major bleeding( ≥ 500 mls). We recorded one vaginal cuff bleeding in PSS-H, whereas for LPS-H we reported 4 (13.3%) 30-days complications (p=0.651). No differences in visual analogue scale (VAS) score were recorded. A significant disparity was noted in cosmetic outcome at discharge (p=0.001), but not after 30 days. CONCLUSION: We demonstrated for the first time, in a prospective comparison between PSS and LPS approaches, that PSS-H may represent a valid alternative to performing total hysterectomy in obese patients.

Optical characterization and adaptive optics correction of polymer adaptive lens aberrations.

Adaptive lenses based on fluid-filled polymer membranes allow for great simplification of optical systems providing large focal length variation and reduction of size, weight, and power consumption. However, aberrations can reduce their optical quality and, for some demanding applications, their correction by means of adaptive optics implies increased complexity, especially if reflective wavefront correctors are used. In this work, we characterize two adaptive lenses in terms of optical power and aberrations. We then correct the gravity-induced aberrations by means of a multiactuator adaptive lens in a closed-loop adaptive optics configuration, with a minimal increase in optical setup complexity. The improvements in the performance of an imaging system are shown.

Real-time multiplexed PCR using surface enhanced Raman spectroscopy in a thermoplastic chip.

Surface enhanced Raman spectroscopy (SERS) has the potential to enable point-of-care sensing across the spectrum of chemical and biological analytes. In diagnostic assays, SERS has been demonstrated to increase the multiplexing density while reducing the burden of fluorescence hardware. One particular application of interest is the use of SERS to provide a multiplexed optical read-out following polymerase chain reaction (PCR). To date, however, the reported PCR-SERS assays require endpoint mixing with a plasmonic nanoparticle solution for detection, thus adding manual steps and preventing real-time, quantitative PCR. In this work, we detail a real-time PCR-SERS thermoplastic microsystem that allows simultaneous nucleic acid amplification and product separation into a SERS-active silver colloid for real-time detection. Specifically, a laser cut thermoplastic fluidic chip has been devised to utilize a dialysis membrane capable of isolating a PCR reaction from the silver colloid. As the reaction progresses, a Raman-reporter-labeled DNA probe is degraded, liberating the reporter from probe DNA, allowing passage across the size-restricting dialysis membrane into the SERS-active colloid, where the accumulating reporter can be measured in real time. Here, we demonstrate that this system is capable of real-time and single-well multiplexed readout of a PCR reaction to simultaneously detect two biomarker genes for methicillin-resistant S. aureus (MRSA).

Restoration of images degraded by underwater turbulence using structure tensor oriented image quality (STOIQ) metric.

Recent advances in image processing for atmospheric propagation have provided a foundation for tackling the similar but perhaps more complex problem of underwater imaging, which is impaired by scattering and optical turbulence. As a result of these impairments underwater imagery suffers from excessive noise, blur, and distortion. Underwater turbulence impact on light propagation becomes critical at longer distances as well as near thermocline and mixing layers. In this work, we demonstrate a method for restoration of underwater images that are severely degraded by underwater turbulence. The key element of the approach is derivation of a structure tensor oriented image quality metric, which is subsequently incorporated into a lucky patch image processing framework. The utility of the proposed image quality measure guided by local edge strength and orientation is emphasized by comparing the restoration results to an unsuccessful restoration obtained with equivalent processing utilizing a standard isotropic metric. Advantages of the proposed approach versus three other state-of-the-art image restoration techniques are demonstrated using the data obtained in the laboratory water tank and in a natural environment underwater experiment. Quantitative comparison of the restoration results is performed via structural similarity index measure and normalized mutual information metric.

Lactobacillus plantarum P17630 for preventing Candida vaginitis recurrence: a retrospective comparative study.

BACKGROUND: Recurrence is a frequent complaint of patients with vulvovaginal candidiasis (VVC). Although the pathogenesis of VVC remains a controversial issue, disruption of the balance between the vaginal microbiota may facilitate overgrowth by Candida. Some probiotic bacterial strains can suppress Candida albicans; Lactobacillus plantarum P17630 is able to attach to vaginal epithelial cells and significantly reduce the adhesion of C. albicans. OBJECTIVE: To evaluate the effect of the application of Lactobacillus plantarum P17630 in restoring the vaginal microbiota and prevention of relapses among women with acute VVC undergoing conventional (azole) local and main therapy. METHODS: Retrospective comparative study. We recruited 89 women with a diagnosis of VVC, who were placed into two groups on the basis of reported treatment. The control group was treated with a daily dose of 2% clotrimazole vaginal cream at bedtime for 3 days, followed by vaginal application of a capsule containing lubricant once a day for 6 days and then once a week for another 4 weeks. The probiotic group was treated with the same azole-based protocol but followed by vaginal application of a capsule containing Lactobacillus plantarum P17630 (>108 CFU) once a day for 6 days and then once a week for another 4 weeks beginning the day following clotrimazole discontinuation. Clinical and diagnostic patterns were monitored for three months of follow-up. RESULTS: At the end of study the probiotic-treated women showed a statistically significant increase in Lactobacillus values "+++" (80% versus 40%, p<0.001) and a better subjective resolution of symptoms such as vaginal discomfort described as burning or itching (90% versus 67.5%, p<0.03). Among controls there was a non-significant increase at 3 months of recurrence of infection, but a significant increase of women with value of pH=5 or >5. CONCLUSION: Although the results of different studies are controversial, most have suggested use of probiotics in the prevention or treatment of VVC, and no adverse effects have been reported. Our data with L. plantarum P17630 (Gyno-Canesflor - Bayer) confirm the role of this specific strain as a potential empirical preventive agent for reducing vaginal discomfort after conventional treatment of acute VVC and shifting the vaginal milieu toward a predominance of lactobacilli with an improvement of the vaginal pH value.

Pelvic inflammatory disease (PID) from Chlamydia trachomatis versus PID from Neisseria gonorrhea: from clinical suspicion to therapy.

Pelvic inflammatory disease (PID) is the most significant complication of sexually transmitted infections in childbearing-age women and it represents an important public health problem because of its long-term sequelae (chronic pelvic pain, tubal infertility, ectopic pregnancy). Prior to the mid 1970s PID was considered a monoetiologic infection, due primarily to Neisseria gonorrhea. Now it is well documented as a polymicrobial process, with a great number of microrganisms involved. In addition to Neisseria gonorrhea and Chlamydia trachomatis, other vaginal microrganisms (anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric Gram negative rods, Streptococco agalactie, Mycoplasma genitalium) also have been associated with PID. There is a wide variation in PID clinical features; the type and severity of symptoms vary by microbiologic etiology. Women who have chlamydial PID seem more likely than women who have gonococcal PID to be asymptomatic. Since clinical diagnosis is imprecise, the suspicion of PID should be confirmed by genital assessment for signs of inflammation or infection, blood test and imaging evaluation. Laparoscopic approach is considered the gold standard. According to the polymicrobial etiology of PID, antibiotic treatment must provide broad spectrum coverage of likely pathogens. Early administration of antibiotics is necessary to reduce the risk of long-term sequelae.

Role of high molecular weight hyaluronic acid in postmenopausal vaginal discomfort.

AIM: Aim of the present study was to quantify the intensity of vulvovaginal symptoms before and after treatment with high molecular weight hyaluronic acid (HA), to test the tolerability and safety of the product, to evaluate the effect on the quality of life and the compliance to the treatment. METHODS: This was a double-blind randomized placebo-controlled study. In seven months we enrolled 36 post-menopausal women, equally distributed in placebo and active group. The evaluation was based on at least three atrophy-related signs and on the patient reported symptoms. After the written informed consent, the participants were instructed to apply the gel (drug or placebo) daily. Three days after the end of the treatment the patients received a final examination to evaluate the progress of symptoms, the presence of any adverse events and their correlation with the treatment. RESULTS: Self-evaluation scales and investigator evaluation showed that the vaginal dryness was significantly reduced both in placebo and in the active group; however, high molecular weight HA was the only active treatment in reducing significantly itching and burning (P<0.02 and <0.04 respectively). Both treatments significantly reduced vaginal atrophy (P<0.001), erythema (P<0.01 placebo and P<0.001 HA) and vaginal dryness (P<0.001), but HA treatment was significantly more effective on the first two symptoms. Both treatments were very well tolerated and compliance of the treatment was very high. CONCLUSION: High molecular weight HA could be effective in subjective and objective improvement of postmenopausal vaginal atrophy providing a good compliance. No adverse events occurred during the entire period of the study.

Adaptive optics performance model for optical interferometry.

The optical interferometry community has discussed the possibility of using adaptive optics (AO) on apertures much larger than the atmospheric coherence length in order to increase the sensitivity of an interferometer, although few quantitative models have been investigated. The aim of this paper is to develop an analytic model of an AO-equipped interferometer and to use it to quantify, in relative terms, the gains that may be achieved over an interferometer equipped only with tip-tilt correction. Functional forms are derived for wavefront errors as a function of spatial and temporal coherence scales and flux and applied to the AO and tip-tilt cases. In both cases, the AO and fringe detection systems operate in the same spectral region, with the sharing ratio and subaperture size as adjustable parameters, and with the interferometer beams assumed to be spatially filtered after wavefront correction. It is concluded that the use of AO improves the performance of the interferometer in three ways. First, at the optimal aperture size for a tip-tilt system, the AO system is as much as ~50% more sensitive. Second, the sensitivity of the AO system continues to improve with increasing aperture size. And third, the signal-to-noise ratio of low-visibility fringes in the bright-star limit is significantly improved over the tip-tilt case.

Characterization and control of a multielement dual-frequency liquid-crystal device for high-speed adaptive optical wave-front correction.

Multielement nematic liquid-crystal devices have been used by others and ourselves for closed-loop adaptive control of optical wave-front distortions. Until recently the phase retardance of available devices could be controlled rapidly in only one direction. The phase retardance of the dual-frequency device can be controlled rapidly in both directions. Understanding the dynamics of the phase retardance change is critical to the development of a high-speed control algorithm. We describe measurements and experiments leading to the closed-loop control of a multielement dual-frequency liquid-crystal adaptive optic.

Foveated, wide field-of-view imaging system using a liquid crystal spatial light modulator.

The field-of-view (FOV) of a simple imaging system can be dramatically improved using a liquid crystal spatial light modulator (SLM). A SLM can be used to correct the off-axis aberrations that often limit the useful FOV of an imaging system giving near diffraction-limited performance at much larger field angles than would otherwise be possible. Foveated imaging refers to the variation in spatial resolution across the image caused by using the SLM in this application, and it is useful in reducing bandwidth requirements for data transmission.

On the use of dual frequency nematic material for adaptive optics systems: first results of a closed-loop experiment.

The use of liquid crystal devices for wavefront control has been suggested and implemented by several authors. In this paper we report some preliminary results on the use of Nematic based liquid crystal devices. Several experimental efforts have been carried out in the past few months. One of the main aims was to characterize a new device that uses dual frequency nematic material in a closed loop arrangement.