[THE ROLE OF SIMULATION IN SURGICAL TRAINING--A NEW ERA].

Surgical training, which was traditionally based on the apprentice model, is undergoing a fundamental change since the introduction of virtual reality simulators into the training program of surgical residents. With the introduction of these simulators we can expect to see an improvement in the surgical abilities of new surgeons and a decrease in costs--as seen in the aviation world. Virtual reality simulators include a visual and tactile interface which is meant to train young surgeons in full procedure before the actual surgery. The available operation encompasses a multitude of surgical disciplines--gynecology, urology, orthopedics, vascular surgery, general surgery and more. The simulator allows the surgeon to practice complicated procedures and to be exposed to emergency situations without risking the patient's life. We opened in the Carmel Medical Center a multi disciplinary simulation center 18 months ago. The center includes simulators for gynecology, orthopedics, urology, general surgery, vascular surgery and advanced cardiac life support. The center cooperates with the Faculty of Medicine at the Technion in order to train young surgeons in all surgical disciplines. In this period of time we followed the improvement in the endoscopic abilities of the basic skills course participants.

Symptomatic pelvic hematoma following transvaginal reconstructive pelvic surgery: incidence, clinical presentation, risk factors, and outcome.

OBJECTIVE: To assess the incidence, clinical presentation, risk factors and outcome of symptomatic pelvic hematomas following transvaginal pelvic reconstructive surgery. MATERIALS AND METHODS: We reviewed the medical records of all women undergoing transvaginal reconstructive pelvic surgery in our institution between January 2006 and July 2009. RESULTS: 462 patients underwent pelvic reconstructive surgery, of whom 28 (6%) presented with symptomatic pelvic hematomas. All cases occurred after transvaginal hysterectomy, 25 (90%) presented with fever, 20 (71%) with pelvic pain and 5 (20%) with urinary retention. All hematomas were diagnosed by ultrasound. They were located at the vaginal cuff in 18 (64%), anterior vaginal wall in six (21%) and posterior vaginal wall in four patients (14%), and had a mean volume of 590 ± 140 cm(3). Laboratory data included leukocytosis (71%), thrombocytosis (57%) and elevated liver enzymes (18%). Nine patients (33%) required ultrasound-guided drainage of the hematoma, which resulted in marked clinical improvement. Surgical outcome was not affected by the presence of pelvic hematoma. CONCLUSIONS: A postoperative symptomatic pelvic hematoma is not rare and is closely related to transvaginal hysterectomy. Its clinical presentation includes fever, pelvic pain, leukocytosis, thrombocytosis and occasionally liver dysfunction. Surgical outcome is generally unaffected.

Displacement of ureteral orifices following anterior colporrhaphy.

INTRODUCTION AND HYPOTHESIS: It is currently unknown whether ureteral orifices maintain their anatomic location after reconstructive pelvic surgeries. We therefore aimed to assess ureteral orifices' location after anterior colporrhaphy. METHODS: Between August and December 2007, patients undergoing anterior colporrhaphy for advanced cystocele in our institution underwent cystoscopy with intravenous dye injection and placement of ureteral catheters before and after the surgery. Each ureteral orifice location was marked on an X-Y coordinate on the posterior bladder wall before and after surgery. RESULTS: Thirteen women aged 44-80 years were included in the study. Postoperatively, ureteral orifices were noted to migrate 0.65 +/- 0.3 cm caudally (closer to the urethrovesical junction) (p = 0.002) and 0.32 +/- 0.5 cm laterally (p < 0.05). CONCLUSIONS: Anterior colporrhaphy is associated with significant caudal and lateral displacement of both ureteral orifices. These findings are of potential importance for pelvic reconstructive surgeons and may facilitate faster cystoscopic evaluation of ureteral patency postoperatively. They may also have implications on the angle of the preferred optical equipment to be used.

Are women with pelvic organ prolapse at a higher risk of developing hernias?

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse and hernia are common disorders which share several pathopysiological and epidemiological features. We therefore aimed to assess whether women with advanced pelvic organ prolapse have a higher prevalence of hernia. METHODS: We reviewed charts of women undergoing surgery for advanced pelvic organ prolapse and compared them to age-matched controls with mild or no prolapse. RESULTS: We identified 60 patients who underwent surgery for advanced pelvic organ prolapse and 60 controls. The total prevalence of hernias was significantly higher among patients with pelvic organ prolapse (31.6% vs. 5%, p = 0.0002), attributed to hiatal (16.6% vs. 1.6%, p = 0.004) and inguinal (15% vs. 3.3%, p = 0.04) hernias. CONCLUSIONS: Patients with advanced pelvic organ prolapse have a higher prevalence of hiatal and inguinal hernias. This finding may be explained by similar pathophysiological mechanisms shared by both disorders.

Removal of an eroded transobturator tape from the bladder using laser cystolithotripsy and cystoscopic resection.

This case presentation describes a unique minimally invasive technique of treating transobturator tape erosion into the urinary bladder with calculus growth. A 42-year-old woman was admitted for recurrent urinary tract infections, 9 months after a transobturator tape procedure. Pelvic sonography, followed by cystourethroscopy, demonstrated an eroded tape in the bladder with heavy calculus growth and diffuse mucosal inflammation. The calculus was fragmented by using laser cystolithotripsy, and the tape was excised and removed by using cystoscopic resection. Intravesical tape erosion with calculus growth can complicate transobturator tape procedures, and is amenable to transurethral laser cystolithotripsy and cystoscopic resection.

[Post hysterectomy vaginal vault prolapse: diagnosis prevention and treatment].

Post-hysterectomy vaginal vault prolapse is a common disorder which generally manifests as a protrusion of the vagina through the genital hiatus, sometimes accompanied by urinary and gastrointestinal symptoms as well as sexual dysfunction. Risk factors for this condition include vaginal deliveries, obesity and previous hysterectomy, although genetic predisposition leading to reduced connective tissue and muscle strength may also play a role. Surgical correction of this disorder can be performed through either the abdominal or transvaginal approaches. Two prospective randomized trials have compared these approaches demonstrating better anatomic success rates for the abdominal approach as opposed to faster recovery and lower morbidity for the transvaginal approach. Laparoscopic and other transvaginal minimal access techniques for vaginal vault suspension have recently been advocated utilizing synthetic or biological adjuvant grafts. These techniques have been associated with high success rates albeit substantial graft complications such as erosion, contraction and dyspareunia. Suspension of the vaginal apex to the uterosacral ligaments (McCall culdoplasty) or to the sacrospinous ligaments at the time of vaginal hysterectomy is the mainstay for prevention of post hysterectomy vaginal vault prolapse. Our knowledge of the pathophysiology of post hysterectomy vaginal vault prolapse is quickly being refined, leading to more efficient surgical therapies for prevention and treatment of this disorder.

Pain relief by continuous intraperitoneal nebulization of ropivacaine during gynecologic laparoscopic surgery--a randomized study and review of the literature.

STUDY OBJECTIVE: To evaluate the efficacy of intraperitoneal nebulization of ropivacaine on pain relief during and after gynecologic laparoscopic procedures including a review of the literature. DESIGN: Double-blinded, randomized, controlled, clinical trial (Canadian Task Force classification I). SETTING: University hospital ambulatory gynecoendoscopic department. PATIENTS: Forty patients (20 patients in each arm) undergoing elective gynecologic same-day outpatient laparoscopic surgery including unilateral/bilateral salpingo-oophorectomy or unilateral/bilateral ovarian cystectomy. INTERVENTIONS: The study group received 10 mL of 1% ropivacaine and the control group received 10 mL of sterile water by intraperitoneal nebulization. During surgery, vital signs were recorded and summarized. Postoperatively patients were followed up for 24 hours including visual analog scale scores and analgesic use. MEASUREMENTS AND MAIN RESULTS: No significant differences existed between the groups during surgery and at the recovery department in terms of arterial blood pressure (p=.42) or heart rate (p=.60). Regarding postoperative analgesia, no difference existed between the groups in terms of morphine consumption (p=.52) or other analgesics (p=.53). No significant difference existed between the groups in postoperative visual analog scale scores including visceral, abdominal wall, and shoulder pain during rest and during cough at the different time frames (30, 60, and 120 minutes and 6 and 24 hours after surgery). CONCLUSION: Our study is the first to examine the effects of intraperitoneal nebulization of ropivacaine throughout laparoscopic gynecologic procedures on patients undergoing general anesthesia. Nebulization of 100 mg of ropivacaine under our specific regimen of anesthesia does not improve patients' outcome in terms of intraoperative and postoperative pain along with consumption of analgesics. Further research with other regimens is required.

Primary repair of advanced obstetric anal sphincter tears: should it be performed by the overlapping sphincteroplasty technique?

Advanced obstetric anal sphincter tears are often associated with a high incidence of fecal and flatus incontinence. We aimed to assess the clinical outcome of these repairs when done by the overlapping sphincteroplasty technique with reconstruction of the internal anal sphincter and perineum. Between August 2005 and December 2006, all grades 3 and 4 obstetric anal sphincter tears in our department were repaired by a reconstructive pelvic surgeon, primarily using the overlapping sphincteroplasty technique with reconstruction of the internal anal sphincter and perineum. All women were followed every 6 months using the Colorectal Anal Distress Inventory and Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire, a physical examination of the anal sphincter, anal manometry, and transperineal anal sonography. There were 3,478 deliveries of which 22 (0.63%) anal sphincter tears were repaired in women aged 22-41 years. Two women were diagnosed with Royal College of Obstetricians and Gynecologists grade 3a, eight with grade 3b, nine with grade 3c, and three with grade 4 anal sphincter tears. Postoperatively, 21 patients attended the outpatient clinic, with an average follow-up time of 9.2+/-1.4 months. Only two women (9.5%) complained of flatus incontinence and fecal urgency and had mildly decreased anal sphincter squeeze pressure and a small sonographic anal sphincter defect. None of the women complained of fecal incontinence. Two women (9.5%) reported on transient perineal pain and one (4.8%) on transient dyspareunia. All other women were asymptomatic and had normal anal manometry and sonographic evaluation. Repair of obstetric anal sphincter tears using the overlapping sphincteroplasty technique with reconstruction of the internal anal sphincter and perineum seems to carry favorable clinical outcome and reduced risk for anal incontinence, perineal pain, and sexual dysfunction.

Oxidative stress indices in follicular fluid as measured by the thermochemiluminescence assay correlate with outcome parameters in in vitro fertilization.

OBJECTIVE: To evaluate oxidative stress indices in follicular fluid (FF) by a novel thermochemiluminescence (TCL) assay and investigate the correlation between TCL and i.v.f. cycle parameters. DESIGN: Prospective, cross-sectional study. SETTING: I.v.f. Unit of an Obstetrics and Gynecology Department in a university-affiliated hospital. PATIENT(S): One hundred eighty-nine women undergoing consecutive i.v.f. treatment cycles during 2001. INTERVENTION(S): After oocyte retrieval, pooled FF was centrifuged and the supernatant was tested in the TCL assay. MAIN OUTCOME MEASURE(S): Maximal serum E2 levels, number of gonadotropin ampoules, retrieved oocytes, mature oocytes, fertilization and cleavage rates, number of available embryos and cryopreserved embryos, and clinical pregnancy rates and correlation with TCL indices. RESULT(S): The TCL curve slope of FF positively correlated with maximal serum E2 levels, number of mature oocytes, and number of cleaved embryos and was inversely correlated with the women's ages and the number of gonadotropin ampoules. Follicular fluid TCL amplitude at 50 seconds ranged from 294 to 711 cps, but all pregnancies (n = 50; 28.1%) occurred within the range of 347-569 cps. With 385 and 569 cps as cutoff levels for the occurrence of pregnancy, the negative predictive value beyond this range was 96% and the positive predictive value within this range was 32%. CONCLUSION(S): The TCL results may reflect the age-related increase in free radical activity and is associated with parameters of ovarian responsiveness and IVF outcome. A certain threshold of oxidative stress may be required for the occurrence of conception in i.v.f. TCL is a potential tool to evaluate, treat, and monitor antioxidant therapy in i.v.f. treatments.

Oxidative stress indices in seminal plasma, as measured by the thermochemiluminescence assay, correlate with sperm parameters.

OBJECTIVE: To examine the effect of oxidation of proteins and lipids, as measured by a novel thermochemiluminescence (TCL) analyzer, and to evaluate the correlation between TCL indices in seminal plasma and sperm parameters. DESIGN: Experimental and prospective clinical studies. SETTING: An infertility unit. PATIENT(S): One hundred forty-eight men undergoing semen analysis. INTERVENTION(S): Bovine serum albumin (BSA) and linolenic acid were oxidized and tested by TCL, protein carbonyls, and conjugated dienes assays. All participants underwent semen analysis. Seminal plasma was tested by TCL and conjugated dienes. MAIN OUTCOME MEASURE(S): Thermochemiluminescence indices before and after oxidation of BSA and linolenic acid, compared with protein carbonyl and conjugated dienes indices. Correlation between semen parameters and TCL and conjugated dienes indices in seminal plasma. RESULT(S): Oxidation of BSA and linolenic acid was marked by characteristic changes in their TCL curve pattern and an increase in the levels of protein carbonyls and conjugated dienes. Among 125 sperm-containing semen samples, the TCL curve exhibited two patterns: a positive relative ratio curve (group A, 87 patients) and a negative relative ratio curve (group B, 38 patients). Sperm concentration was lower and total motile sperm and rapid motile sperm were fewer in group B. A significant correlation was found between TCL indices, conjugated dienes, and sperm quality in group B. CONCLUSION(S): Oxidation affects TCL curve pattern of proteins and lipids in a characteristic manner. Thermochemiluminescence indices in seminal plasma closely correlate with sperm characteristics among patients with sperm disturbances, and it might serve as a tool in the evaluation, treatment, and monitoring of subfertile men.