The presentation and management of cesarean scar defects: an updated review on an evolving diagnosis.

PURPOSE OF REVIEW: The purpose of this review is to provide a clinically relevant synthesis of the current literature on cesarean scar defects, focusing on their epidemiology and clinical presentation, diagnosis, treatment, and prevention. RECENT FINDINGS: Cesarean scar defects (CSDs) are an emerging area of gynecologic research, with an influx of higher quality cohorts, randomized controlled trials, and systematic reviews published within the last decade. Recent developments of importance include the European Niche Taskforce consensus on the measurement and diagnosis of CSDs, the proposal of clinical criteria for Cesarean scar disorder (CSDi), as well as the publication of several systematic reviews, which provide enhanced support for clinical decision-making in treatment strategies. Areas for continued research include risks factors for CSDs and preventive strategies, as well as their role in obstetrical complications. SUMMARY: CSDs are a common sonographic finding. While those incidentally identified in an asymptomatic population require no treatment, CSDs can cause significant burden in the form of abnormal uterine bleeding, pelvic pain, and infertility. Their role in obstetrical complications has yet to be fully elucidated. Given the high incidence of cesarean sections, many - if not all - providers of uterine care will encounter their sequalae. As such, continued awareness amongst all providers regarding their evaluation and management is key. VIDEO ABSTRACT: http://links.lww.com/COOG/A91.

Minimally Invasive Management of Second Trimester Placenta Percreta.

STUDY OBJECTIVE: To describe the diagnostic and surgical challenges in the management of second trimester placenta percreta. DESIGN: Stepwise demonstration of the surgical technique with the use of an educational video. SETTING: Second trimester placenta percreta is a rare entity, with very few case reports in the literature. Our video demonstrates the challenges of a minimally invasive approach toward definitive surgical management with hysterectomy. A 39-year-old G7P3 (3 previous cesarean deliveries) female at 17 weeks and 2 days gestation presented with acute abdominal pain to a community hospital. This was a spontaneously conceived pregnancy. Her hemoglobin level on admission was 92 g/L. An ultrasound showed a normal uterus, and the appendix was not visualized. One unit of packed red blood cells was transfused, and she underwent exploratory laparoscopy for a possible retrocecal hematoma/mass seen on computerized tomography. In the operating room, acute hemoperitoneum was visualized with placenta-like tissue invading through the anterior lower uterine segment (Figures 2 & 3). A hemostatic agent (Floseal, Baxter) was placed over the bleeding, and she was then transferred to a tertiary academic center for further management. INTERVENTIONS: Magnetic resonance imaging was performed on the following day after transfer to our facility, which confirmed placenta percreta at the level of the bladder (Figure 1). Following counseling with a multidisciplinary team and given that there was ongoing bleeding from the invading placental tissue, pregnancy continuation and uterine conservation were not possible. The patient was offered preprocedure termination of pregnancy with intra-cardiac injection of potassium chloride and 350 cc of amniotic fluid was drained at that time. This was done to facilitate visualization for a minimally invasive approach. We describe 5 main challenges of minimally invasive hysterectomy for placental percreta and provide a stepwise approach to mitigating them: visibility, vascular control, bladder dissection, colpotomy, and specimen retrieval. We adapted the previously described laparotomy techniques of progressive uterine devascularization and approach to bladder dissection and colpotomy to laparoscopy [1,2]. In addition, we performed dilatation and evacuation to allow for vaginal specimen removal. The patient's postoperative course was uncomplicated, and she was discharged home in a stable condition. CONCLUSION: Midtrimester placenta percreta poses significant challenges in diagnosis and surgical management. Total laparoscopic hysterectomy for this condition poses unique challenges but is feasible and safe.

Closing the knowledge gap in pelvic neuroanatomy: assessment of a cadaveric training program.

BACKGROUND: The objective of this study is to characterize participants in a laparoscopic cadaveric neuroanatomy course and assess knowledge of pelvic neuroanatomy before and after this course. METHODS: This is a survey-based cohort study with a setting in a university educational facility. The participants are surgeons in a multiday laparoscopic cadaveric pelvic neuroanatomy course. Participants completed a precourse survey, including demographics and comfort with laparoscopic surgery. They then completed an identical precourse and postcourse anatomic knowledge test. Main outcomes are scores on the anatomic knowledge test precourse and postcourse. RESULTS: 44 respondents were included: 25 completed fellowship, 15 completed residency, 2 were residents, and 2 were fellows. Participants were on average 11.09 years post training, with an average of 8.67 years from training if they completed fellowship and 18.62 years if they completed residency only. 22 of 42 respondents strongly agreed or agreed they are comfortable performing complex laparoscopic hysterectomies. The average precourse score was 32.18/50 points and the mean difference score (MDS, defined as mean of Postcourse scores minus Precourse scores) was 9.80, showing significant improvement (p <  0.001). Precourse and MDS scores were not significantly different when comparing country of practice, level of training, or time since training. CONCLUSION: Baseline knowledge of pelvic neuroanatomy was similar among groups when comparing fellowship status, place of training, or time since training. There was significant improvement in knowledge after training in this dissection method. This course garnered interest from surgeons with broad training backgrounds.

Retrograde Bladder Filling after Laparoscopic Gynecologic Surgery: A Double-blind Randomized Controlled Trial.

STUDY OBJECTIVE: To evaluate whether retrofilling the bladder on completion of elective laparoscopic gynecologic surgery for benign indications has an effect on the timing of the first postoperative void and the timing of discharge from the hospital. DESIGN: Double-blind randomized controlled trial. SETTING: Single academic surgical day hospital. PATIENTS: Patients undergoing outpatient laparoscopic gynecologic surgery, excluding hysterectomy or pelvic reconstructive surgery. INTERVENTIONS: On completion of surgery, patients were randomized to either retrograde filling of the bladder with 200 mL of saline before catheter removal or standard care (immediate catheter removal). Patients and postanesthesia care unit nurses (outcome assessors) were both blinded. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the time to first void. The secondary outcomes were time to hospital discharge, postoperative urinary tract infection, and patient satisfaction. Over a 3-month period, 47 patients were approached on the day of surgery, 42 consented and were randomized (21 to intervention and 21 to control). There were no significant differences in baseline demographics between the groups. The median time to first void was significantly shorter for patients in the intervention arm than controls (104 ± 75 minutes vs 162 ± 76 minutes, p <.001). Patients who had retrofilled bladders were discharged faster from post-anesthesia care unit compared to controls (155.0 ± 74 minutes vs 227 ± 58 minutes, p = .001). There were no urinary tract infections in either group, and the proportion of satisfied or very satisfied patients was high (93.8% vs 88.2%, p = .512). CONCLUSION: Retrograde filling of the bladder after outpatient laparoscopic gynecologic surgery is a safe, effective method that significantly reduces the length of hospital stay.

Essentials in Minimally Invasive Gynecology Manual Skills Construct Validation Trial.

OBJECTIVE: To establish validity evidence for the Essentials in Minimally Invasive Gynecology laparoscopic and hysteroscopic simulation systems. METHODS: A prospective cohort study was IRB approved and conducted at 15 sites in the United States and Canada. The four participant cohorts based on training status were: 1) novice (postgraduate year [PGY]-1) residents, 2) mid-level (PGY-3) residents, 3) proficient (American Board of Obstetrics and Gynecology [ABOG]-certified specialists without subspecialty training); and 4) expert (ABOG-certified obstetrician-gynecologists who had completed a 2-year fellowship in minimally invasive gynecologic surgery). Qualified participants were oriented to both systems, followed by testing with five laparoscopic exercises (L-1, sleeve-peg transfer; L-2, pattern cut; L-3, extracorporeal tie; L-4, intracorporeal tie; L-5, running suture) and two hysteroscopic exercises (H-1, targeting; H-2, polyp removal). Measured outcomes included accuracy and exercise times, including incompletion rates. RESULTS: Of 227 participants, 77 were novice, 70 were mid-level, 33 were proficient, and 47 were experts. Exercise times, in seconds (±SD), for novice compared with mid-level participants for the seven exercises were as follows, and all were significant (P<.05): L-1, 256 (±59) vs 187 (±45); L-2, 274 (±38) vs 232 (±55); L-3, 344 (±101) vs 284 (±107); L-4, 481 (±126) vs 376 (±141); L-5, 494 (±106) vs 420 (±100); H-1, 176 (±56) vs 141 (±48); and H-2, 200 (±96) vs 150 (±37). Incompletion rates were highest in the novice cohort and lowest in the expert group. Exercise errors were significantly less and accuracy was greater in the expert group compared with all other groups. CONCLUSION: Validity evidence was established for the Essentials in Minimally Invasive Gynecology laparoscopic and hysteroscopic simulation systems by distinguishing PGY-1 from PGY-3 trainees and proficient from expert gynecologic surgeons.

Keep Your Landmarks Close and the Hypogastric Nerve Closer: An Approach to Nerve-sparing Endometriosis Surgery.

OBJECTIVE: Excisional techniques used to surgically treat deep infiltrating endometriosis (DIE) can result in inadvertent damage to the autonomic nervous system of the pelvis, leading to urinary, anorectal, and sexual dysfunction [1-4]. This educational video illustrates the autonomic neuroanatomy of the pelvis, identifying the predictable location of the hypogastric nerve in relation to other pelvic landmarks, and demonstrates a surgical technique for sparing the hypogastric nerve and inferior hypogastric plexus. DESIGN: Using didactic schematics and medical drawings, we discuss and illustrate the autonomic neuroanatomy of the pelvis. With annotated laparoscopic footage, we demonstrate a stepwise approach for identifying, dissecting, and preserving the hypogastric nerve during pelvic surgery. SETTING: Tertiary care academic hospitals: Mount Sinai Hospital in Toronto, Ontario, Canada, and S. Orsola Hospital in Bologna, Italy. INTERVENTIONS: Radical excision of DIE with adequate identification and sparing of the hypogastric nerve and inferior hypogastric plexus bilaterally was performed, following an overview of pelvic neuroanatomy. The superior hypogastric plexus was described and the hypogastric nerve, the most superficial and readily identifiable component of the inferior hypogastric plexus, was identified and used as a landmark to preserve autonomic bundles in the pelvis. The following steps, illustrated with laparoscopic footage, describe a surgical technique developed to identify and preserve the hypogastric nerve and the deeper inferior hypogastric plexus without the need for more extensive pelvic dissection to the level of the sacral nerve roots: (1) transperitoneal identification of the hypogastric nerve, with a pulling maneuver for confirmation; (2) opening of the retroperitoneum at the level of the pelvic brim and retroperitoneal identification of the ureter; (3) medial dissection and identification of the hypogastric nerve; and (4) lateralization of the hypogastric nerve, allowing for safe resection of DIE. CONCLUSION: The hypogastric nerve follows a predictable course and can be identified, dissected, and spared during pelvic surgery, making it an important landmark for the preservation of pelvic autonomic innervation.

Returning to Work Following Minimally Invasive Hysterectomy.

This commentary presents data collected from one patient population and reviews the literature on returning to work following minimally invasive hysterectomy (MIH). Although MIH can reduce postoperative pain, decrease hospital stays, and accelerate return to activities of daily living, it has not consistently translated into a quicker return to work (RTW) for patients. A retrospective case series was performed assessing RTW times of 31 patients following elective MIH at Mount Sinai Hospital in Toronto in 2018. The median RTW time was 21 days. Patients returned to work significantly faster when they were counselled about an expected convalescence of 2 to 4 weeks (median 16 days) compared with a more traditional 4- to 8-week recovery (median 56 days). Surgeon recommendation can strongly affect when a patient returns to work following MIH. Most patients can RTW within 2 to 3 weeks. However, recommendations should be patient-centred and consider job description.

Surgical Management Algorithm for Caesarean Scar Pregnancy.

OBJECTIVES: To report our experience with the management of Caesarean scar pregnancy (CSP) in the first trimester and to develop a unique treatment algorithm allowing physicians to customize their management based on clinical patient characteristics. METHODS: A retrospective review of 12 patients diagnosed with CSP between December 2012 and June 2016 was conducted in a tertiary care hospital in Toronto. All patients were diagnosed with CSP by transvaginal ultrasound using radiologic criteria. Patients were initially treated with an ultrasound-guided embryocidal injection when fetal heart activity was present. Next, patients underwent medical management with systemic multidose methotrexate (MTX) or surgical management using a laparoscopic or transcervical approach depending on CSP characteristics. RESULTS: The mean age at diagnosis was 35.6 years. The median number of previous CSs was one. The mean serum human chorionic gonadotropin level was 59 938 IU/L. The mean GA at presentation was 8+1 weeks. Two-thirds of patients received medical management with systemic multidose methotrexate. Of these, 50% required additional surgical treatment for the resolution of their CSP. One-third of patients underwent primary surgical treatment, resulting in complete resolution of CSP with no complications. Given the improved outcomes of surgical management in our series, we suggest a treatment algorithm that tailors the surgical approach, either laparoscopic or transcervical, to the characteristics of the CSP. CONCLUSION: This constitutes the largest case series of CSP in Canada. Based on our results, CSP can be safely and effectively managed using the suggested surgical algorithm, which accounts for individual patient characteristics.

Prevention and management of urologic injury during gynecologic laparoscopy.

PURPOSE OF REVIEW: This article provides an update on the best practices for the prevention, recognition, and management of urinary tract injuries that may occur during gynecologic laparoscopic surgery. RECENT FINDINGS: Higher surgical volume is directly associated with improved surgical outcomes, denoted by consistently lower rates of complications for commonplace procedures such as hysterectomy. As a result, expert opinion on prevention of iatrogenic urologic injury suggests a real need for improved education and training of gynecologic surgeons. Discontinued manufacturing of indigo carmine has led to the utilization of alternative methods to assess ureteral patency during cystoscopy, such as phenazopyridine or sodium fluorescein. Intraoperative cystoscopy has been shown to detect approximately 50% of urinary tract injuries during hysterectomy, but has limited accuracy and does not necessarily decrease delayed postoperative complications. When identified, most urologic injuries can be managed in a minimally invasive fashion. SUMMARY: A thorough understanding of pelvic anatomy and early recognition of urinary tract injuries can significantly reduce surgical morbidity for women undergoing laparoscopic surgery.

Safety, efficiency and learning curves in robotic surgery: a human factors analysis.

BACKGROUND: Expense, efficiency of use, learning curves, workflow integration and an increased prevalence of serious incidents can all be barriers to adoption. We explored an observational approach and initial diagnostics to enhance total system performance in robotic surgery. METHODS: Eighty-nine robotic surgical cases were observed in multiple operating rooms using two different surgical robots (the S and Si), across several specialties (Urology, Gynecology, and Cardiac Surgery). The main measures were operative duration and rate of flow disruptions-described as 'deviations from the natural progression of an operation thereby potentially compromising safety or efficiency.' Contextual parameters collected were surgeon experience level and training, type of surgery, the model of robot and patient factors. Observations were conducted across four operative phases (operating room pre-incision; robot docking; main surgical intervention; post-console). RESULTS: A mean of 9.62 flow disruptions per hour (95 % CI 8.78-10.46) were predominantly caused by coordination, communication, equipment and training problems. Operative duration and flow disruption rate varied with surgeon experience (p = 0.039; p < 0.001, respectively), training cases (p = 0.012; p = 0.007) and surgical type (both p < 0.001). Flow disruption rates in some phases were also sensitive to the robot model and patient characteristics. CONCLUSIONS: Flow disruption rate is sensitive to system context and generates improvement diagnostics. Complex surgical robotic equipment increases opportunities for technological failures, increases communication requirements for the whole team, and can reduce the ability to maintain vision in the operative field. These data suggest specific opportunities to reduce the training costs and the learning curve.

Does Laparoscopic Hysterectomy Increase the Risk of Vaginal Cuff Dehiscence? An Analysis of Outcomes from Multiple Academic Centers and a Review of the Literature.

Vaginal cuff dehiscence represents a serious, but infrequent complication after hysterectomy, with a reported increased incidence following a laparoscopic approach. Various risk factors have been proposed including laparoscopically placed suture, surgical experience, use of electrosurgery, surgical indication, and obesity. Technical aspects of the procedure itself have also been questioned such as the variable use of monopolar electrosurgery during colpotomy and the suture type or number of layers chosen to reapproximate the vaginal cuff. Nothwithstanding the tendency for cuff dehiscence to occur following laparoscopic approach, there remains a paucity of high-quality data that supports or refutes this finding or clearly defines the mechanism(s) by which this event occurs allowing for the proposal of objective guidelines for reducing risk. Various techniques have been proposed to decrease the risk of vaginal cuff dehiscence during endoscopic hysterectomy, including use of monopolar current on cutting mode, achievement of cuff hemostasis with sutures rather than electrocoagulation, use of a two-layer cuff closure with polydioxanone suture, and use of bidirectional barbed suture for cuff closure. The authors experience at three university-based minimally invasive gynecologic surgery programs showed a low rate of vaginal cuff dehiscence in their own practices. Large randomized controlled trials are needed to truly determine whether there is a difference in vaginal cuff dehiscence between surgical modalities for hysterectomy as well as to determine the true risk factors.

Deliberate practice improves obstetrics and gynecology residents' hysteroscopy skills.

INTRODUCTION: Development of surgical skills is an integral component of residency education in obstetrics and gynecology. OBJECTIVE: We report data from a supervised, deliberate, dry lab practice in hysteroscopy for junior obstetrics-gynecology residents, undertaken to evaluate whether simulation training improved hysteroscopy performance to a skill level similar to that of senior residents. METHODS: A prospective, comparative, multicenter trial compared Objective Structured Assessment Of Technical Skills (OSATS) performance of 2 groups: 19 postgraduate year (PGY)-1 and PGY-2 and 18 PGY-3 and PGY-4 Ob-Gyn residents. PGY-1 and PGY-2 participants underwent 4 sessions of brief, deliberate, focused training in hysteroscope assembly and operative hysteroscopic polypectomy using uterine models. Subsequently, all participants completed a simulated hysteroscopic polypectomy OSATS, and procedure times and structured assessment scores were compared among groups. RESULTS: PGY-1 and PGY-2 residents who had completed OSATS training performed at or above the level of untrained PGY-3 and PGY-4 residents. Junior residents had better assembly times and scores, resection scores, and global skills scores (P < .05). Resection times did not differ between groups but differed among institutions. DISCUSSION: Brief, hands-on training sessions, which were task-specific and repetitive facilitated short-term gains in learning operative hysteroscopy and increased the dry lab skill level of junior residents compared to that of senior residents. This curriculum was effectively implemented at 3 institutions and generated comparable results, suggesting generalizability.

Group A streptococcal peritonitis and ruptured tubo-ovarian abscess three years after Essure® insertion: a case report.

We describe a complicated ruptured Streptococcus pyogenes tubo-ovarian abscess (TOA) and peritonitis in a 24-year-old woman, necessitating eventual hysterectomy and a prolonged intensive care unit (ICU) admission 3 years after successful tubal occlusion with Essure® (Conceptus, Inc., Mountain View, CA) microinsert devices. The patient is a 24-year-old gravida 3, para 2, aborta 1 (G3P2Ab1) who had a 1-day history of worsening right lower quadrant pain without associated fever or cervical motion tenderness. Patient's medical history was complicated by mitochondrial neurogastrointestinal encephalopathy (MNGIE). Upon her admission to the hospital, an exploratory laparoscopy was performed. Intraoperative findings revealed a ruptured right-sided TOA. S. pyogenes was isolated from the peritoneal fluid and cervicovaginal cultures. After the laparoscopy, the patient experienced initial improvement but abruptly worsened and on postoperative day 7 was returned to the operating room for a planned repeat exploration and total abdominal hysterectomy. Gross pathological examination of the uterus showed appropriate Essure insert placement. Based on this case, tubal occlusion by induced fibrosis may not be a sufficient obstacle in preventing ascending pelvic infections.

Promoting residents' professional development and academic productivity using a structured faculty mentoring program.

BACKGROUND: The importance of effective mentoring in career success is universally accepted but has not been well studied in academic medicine. PURPOSES: The purpose was to describe a formal mentoring program of residents by faculty in obstetrics and gynecology and assess professional and educational outcomes. METHODS: In 2006, a formal mentoring program was developed. Faculty and residents were provided instruction. Residents selected their mentors and met regularly. Resident-mentor contracts were signed. Mentors developed corrective plans and monitored residents with problems. Outcomes were measured prospectively. RESULTS: Twenty-five residents and 18 faculty participated. After 2 years, 7 residents (28%) had scientific publications as compared to 10% in the year preceding the mentoring program. Eleven (44%) presented oral or poster presentations, and 17 (68%) were conducting scientific research. Mentors' effectiveness was rated between 4.3 and 4.7 (Likert scale of 1-5). Three of 4 residents in remediation fulfilled their educational requirements. Four residents noted insufficient meeting time. CONCLUSION: A simple but well-organized mentoring system can be an effective means of improving resident learning and enhancing their academic portfolio. Mentoring should be strongly encouraged for residents, especially those with specific deficiencies.