The impact of metronidazole on pain persistence after fertility-sparing endometriosis surgery: METROFERT randomized study.

BACKGROUND: Recent studies have shown that a disrupted microbiome is associated with endometriosis. Despite endometriosis affecting 1 in 10 reproductive-aged women, there is a lack of innovative and nonhormonal long-term effective treatments. Studies have reported an approximately 20-37.5% persistence of pain after fertility-sparing endometriosis surgery. Metronidazole has been shown to decrease inflammatory markers and the size of endometriosis lesions in animal studies. OBJECTIVE: To determine if modulating the microbiome with oral metronidazole for 14 days after fertility-sparing endometriosis surgery decreases pain persistence postoperatively. STUDY DESIGN: This was a randomized, multicenter, placebo-controlled, double-blind trial. Individuals 18-50 years old were prospectively randomized to placebo versus oral metronidazole for 14 days immediately after endometriosis fertility-sparing excision surgery. The primary outcome was binary, subjective pain persistence at six weeks postoperatively. Secondary outcomes of quality of life, sexual function, and endometriosis-associated pain scores according to the Endometriosis Health Profile-5, Female Sexual Function Index, and a visual analog scale. RESULTS: 152 participants were approached from October 2020 to October 2023 to enroll in the study. 64 participants were excluded either because they did not meet inclusion or exclusion criteria or because they declined to participate. 88 participants were randomized in a 1:1 ratio to receive either the oral placebo or metronidazole after endometriosis excision surgery. 18.2% of participants were lost to follow-up or discontinued treatment and this was not significantly different between the two arms, yielding a final cohort of 72 participants. Baseline demographics of the two study groups were similar. There was no statistically significant improvement in the primary outcome of binary subjective pain persistence between the metronidazole group compared to placebo (84% vs 88%, p=0.74) at 6 weeks postoperatively. Further, no significant differences between treatments were detected in the secondary outcomes. CONCLUSION: A postoperative 14-day regimen of oral metronidazole immediately after fertility-sparing endometriosis surgery was not associated with any significant differences between treatment groups in the in the persistence of endometriosis-related pain symptoms compared to placebo at 6 weeks.

Surgical Aspects of Adhesiolysis and Adhesion Barriers for Today's Surgeon: A Call for More Robust Research.

Adhesions can cause symptoms of pelvic pain, infertility, and bowel obstruction in reproductive and postmenopausal women. The topic of adhesiolysis and adhesion barriers in gynecology has been studied in small, heterogeneous studies with very low to moderate quality. The efficacy for prevention and treatment strategies of adhesive disease in the gynecologic population will be reviewed here.

Robotic Applications for Benign Gynecologic Procedures.

INTRODUCTION: Robotic systems provide a platform for surgeons to expand their capabilities, allowing them to perform complex procedures safely and efficiently. Within the field of benign gynecology, this has become an increasingly popular option since receiving Food and Drug Administration (FDA) approval in 2005. However, the appropriate indications for robotic versus laparoscopic surgery continue to be debated. MATERIALS AND METHODS: Literature was reviewed to provide a comprehensive, evidence-based evaluation of the advantages and pitfalls of robotic surgery, the applications of robotic surgery for benign gynecologic procedures in comparison to conventional laparoscopy, and the role of robotic surgery as an educational tool. RESULTS: Robotic surgery has favorable outcomes for surgeons in the areas of ergonomics, dexterity, and fatigue. Cost comparisons are widely varied and elaborate. Most patient outcomes are comparable between robotic and laparoscopic hysterectomies and endometriosis resections. In patients with a body mass index >30mg/m2 and uteri >750mg, hysterectomy outcomes are improved when surgery is done robotically. The use of the robotic system may be beneficial for patients undergoing myomectomy. Robotic surgery confers advantages for trainees and novice surgeons. There is no consensus on a standardized curriculum for robotic training or credentialing process for experienced surgeons. CONCLUSION: Robotic surgery has distinct features that make it a valuable tool for gynecologic surgeons. There are no clear indications regarding when a robotic route should be chosen but could be considered when above average complexity is anticipated and when training new surgeons.

Improved Exposure in Minimally Invasive Excision of Endometriosis with Temporary Ovarian Suspension Using Carter-Thomason CloseSure System, a Novel Technique.

STUDY OBJECTIVE: To describe a novel technique for temporary ovarian suspension using the Carter-Thomason CloseSure system (CooperSurgical, Inc., Trumbull, CT). DESIGN: A narrated, stepwise in vivo demonstration of surgical technique. SETTING: Academic tertiary care hospital (University of Louisville Hospital, Louisville, KY). INTERVENTIONS: Laparoscopic temporary ovarian suspension using the Carter-Thomason CloseSure system for improved exposure of deep pelvis during a laparoscopic excision of deep pelvic endometriosis (including demonstration of previously used techniques at this institution). CONCLUSION: We have developed and used this technique at our institution for the last several years, reviewing 20 cases between August 2018 and September 2019, with improved intraoperative visualization and no observed intraoperative or postoperative complications. This technique has replaced the use of other forms of ovarian suspension at our institution owing to the accessibility of the device, stability of the suspension, and ease of the procedure. The Carter-Thomason technique of ovarian suspension provides excellent retraction of ovarian tissue to provide improved views of the deep pelvis, with ease of use and low cost.

Total Laparoscopic Hysterectomy of a 7400 g Uterus.

OBJECTIVE: To demonstrate improved techniques and safety measures for total laparoscopic hysterectomy for a severely enlarged uterus. DESIGN: Technical video of the surgery, which demonstrates various techniques for improved visualization, hemostasis, and manipulation for total laparoscopic hysterectomy for a 7400 g uterus. SETTING: Academic tertiary care hospital, University of Louisville Hospital, Louisville, Kentucky. INTERVENTIONS: A 44-year-old woman, gravida 0, presented with a severely enlarged myoma uterus, class III obesity with a body mass index of 40.4 kg/m2, and hypertension seeking minimally invasive hysterectomy. Magnetic resonance imaging demonstrated a uterus measuring 26 × 26 × 17 cm with multiple myomas. The patient was counseled in detail regarding minimally invasive surgery. She underwent total laparoscopic hysterectomy, bilateral salpingectomy, right oophorectomy, and cystoscopy. The total operative time was 4 hours 12 minutes, and the estimated blood loss was 700 mL. Pre- and postoperative hemoglobin was 13.3 g/dL and 11.3 g/dL, respectively. A 4-cm minilaparotomy incision was created as an extension of the umbilical port, and the specimen was extracted by scalpel morcellation using the extracorporeal C-incision tissue extraction technique. The patient was discharged home on postoperative day 1 and recovered without any complications. CONCLUSION: There is an increasing trend in performing laparoscopic hysterectomy for large uteri, which has a lower incidence of overall complications than laparotomy [1,2]. In addition, a cost analysis has demonstrated the superiority of laparoscopic hysterectomy for myomatous uterus accounting for the rare incidence of leiomyosarcoma [3]. Our video demonstrates improved hemostasis and visualization techniques through the use of high-cephalad camera and assistant ports, generous traditional bipolar desiccation, blunt retraction with suction irrigator in the midline umbilical port, and surgical bed rotation. We also describe in detail the scalpel morcellation technique. To date, we believe this is the largest uterine size removed laparoscopically that has been reported in the literature. In the hands of an experienced surgeon and with the demonstrated techniques, a laparoscopic approach to hysterectomy of a very enlarged uterus is safe and feasible.

Latest Advances in the Laparoscopic Treatment of Uterine Fibroids.

INTRODUCTION: Fibroids are highly prevalent among reproductive-aged women and have a significant impact on their wellbeing. Myomectomy is a fertility-sparing option for these patients. MATERIALS AND METHODS: This paper is a comprehensive, evidence-based and updated review of literature regarding myomectomy techniques. RESULTS: This paper provides general recommendations for myomectomy techniques, including patient selection and surgical planning. Strategies to overcome intraoperative challenges and prevent blood loss are highlighted. In addition, recommendations are provided for tissue extraction and laparoscopic suturing. CONCLUSION: Myomectomy is a safe and feasible alternative to hysterectomy for patients who wish to bear children.

Clinical Performance of Radiofrequency Ablation for Treatment of Uterine Fibroids: Systematic Review and Meta-Analysis of Prospective Studies.

Background: Radiofrequency ablation (RFA) has emerged as a safe and effective treatment option for women with symptomatic uterine fibroids and can be delivered by laparoscopic, transvaginal, or transcervical approaches. The evidence regarding typical patient outcomes with RFA has not previously been examined in a comprehensive fashion. Materials and Methods: We performed a systematic review of prospective studies for treatment of uterine fibroids with RFA. Main outcomes were procedure time, patient recovery metrics, change in fibroid volume, symptom severity score (SSS), health-related quality of life (HRQL), and reinterventions. Data were analyzed with random effects meta-analysis and metaregression. Results: We identified 32 articles of 1283 unique patients (median age: 42 years) treated with laparoscopic RFA (19 articles), transvaginal RFA (8 articles), or transcervical fibroid ablation (5 articles). Mean procedure time was 49 minutes, time to discharge was 8.2 hours, time to normal activities was 5.2 days, and time to return to work was 5.1 days. At 12 months follow-up, fibroid volume decreased by 66%, HRQL increased by 39 points, and SSS decreased by 42 points (all P < .001 versus baseline). The annual cumulative rate of reinterventions due to fibroid-related symptoms was 4.2%, 8.2%, and 11.5% through 3 years. Conclusions: RFA of uterine fibroids significantly reduces fibroid volume, provides significant durable improvements in fibroid-related quality of life, and is associated with favorable reintervention rates.

Comparison of Industry-Leading Energy Devices for Use in Gynecologic Laparoscopy: Articulating ENSEAL versus LigaSure Energy Devices.

STUDY OBJECTIVE: To compare 2 laparoscopic bipolar electrosurgical devices used in total laparoscopic hysterectomy (TLH). An articulating advanced bipolar device (ENSEAL G2; Ethicon Endo-Surgery, Cincinnati, OH) and an electrothermal bipolar vessel sealer (LigaSure; Medtronic, Minneapolis, MN) were analyzed for differences in surgeon perception of ease of instrument use and workload using the NASA Raw Task Load Index (RTLX) scale. A second objective was to examine differences in operative time, estimated blood loss (EBL), and perioperative complication rates between the 2 devices. DESIGN: Single-institution, single-blinded, randomized controlled trial (Canadian Task Force classification I). SETTING: Division of Minimally Invasive Gynecologic Surgery in a university hospital. PATIENTS: Eligibility required planned TLH, over age 18 years, and able to give informed consent; exclusions were stage III or IV endometriosis, known gynecologic malignancy, and early decision for conversion to laparotomy. One hundred seventy-eight patients screened, 142 enrolled, 2 withdrew, and 140 completed the study. Patients were followed 1 month postoperatively. INTERVENTIONS: Preoperative randomization to articulating advanced bipolar device or electrothermal bipolar vessel sealer to be used during TLH. MEASUREMENTS AND MAIN RESULTS: At the end of each hysterectomy the primary surgeon completed an ergonomic assessment tool, the RTLX. Results were analyzed to detect differences in workload between the 2 devices. For each case the time to ligation of the bilateral uterine arteries, EBL, and complications (including device failure, blood transfusion, or other injury) were recorded. Statistical analysis was performed using the t test for normally distributed data, χ2 test for categorical data, and Mann-Whitney U-test for nonparametric data. There were no differences in age, body mass index, parity, prior surgery, uterine weight, race, indication, pathology, and comorbidities between the 2 groups. A statistically significant increase in RTLX scores (p < .0001), device failures (p = .0031), and time to ligation of bilateral uterine arteries (p = .0281) was noted in the articulating device group. No significant differences in EBL or complication rates were noted between the groups. CONCLUSIONS: The articulating advanced bipolar device was shown to have a statistically significant increase in surgeon-perceived workload and rate of device failure when used in TLH; however, clinical and surgical outcomes were equivalent.

Systematic Review of Topical Hemostatic Agent Use in Minimally Invasive Gynecologic Surgery.

BACKGROUND AND OBJECTIVES: To perform a systematic review of articles evaluating hemostatic effectiveness and peri-operative outcomes when topical hemostatic agents (HA) are used in minimally invasive gynecologic surgeries (MIGS) for benign conditions. METHODS: Studies published through March 31, 2017 were retrieved through PubMed, EMBASE, Cochrane, and ClinicalTrials.gov to identify all eligible studies. No studies were excluded based on publish date. All comparative studies or case series with >10 participants reporting use of at least one topical HA in MIGS for benign conditions were included as long as full-text articles were available and written in English. Studies were excluded if surgery was done for malignancy or completed via an open approach. Articles that included multiple surgical subspecialties were excluded if data related to MIGS was unable to be isolated. Evaluation for eligibility and data extraction was performed by three independent reviewers. Quality of evidence was also assessed by each reviewer. RESULTS: From 132 articles, a total of 8 studies were included in this systematic review. We found that use of fibrin sealant decreased time to hemostasis, postoperative hemoglobin drop, and estimated blood loss (EBL) compared with bipolar energy and reduced the overall operative time in laparoscopic myomectomy. When fibrin sealant use at time of myomectomy was compared to bipolar energy there was no significant difference in the rate of postoperative complications. Furthermore, there was less of a decrease in anti-Mullerian hormone (AMH) level when a thrombin-gelatin matrix was used compared to bipolar energy on ovarian tissue. CONCLUSION: Application of topical HA in MIGS can reduce operative time, blood loss, and ameliorate damage to ovarian function. However, more data needs to be gathered for use of HA during different types of gynecologic procedures (adnexal surgery, myomectomy, and hysterectomy) to provide better quality evidence to guide their use.

Pelvic Retroperitoneal Dissection: A Hands-on Primer.

This article is a personal perspective of female surgical pelvic anatomy and recommended surgical dissection techniques.

Identifying the Rate-Limiting Step in Total Laparoscopic Hysterectomy in a Training Hospital.

STUDY OBJECTIVE: To identify the lengthiest step of total laparoscopic hysterectomy (TLH) in a teaching hospital and to determine which clinical factors affect the duration of this step. SETTING: The University of Louisville Hospital. DESIGN: Single institution retrospective case series. METHODS AND MAIN RESULTS: This is a retrospective chart and video review that included 135 benign, elective TLHs performed at The University of Louisville. TLH was divided into 5 steps: (1) insertion of laparoscopic ports and adhesiolysis to restore normal anatomy; (2) identification of the ureter and resection of adnexal structures to transection of the round ligament; (3) transection of the round ligament to transection of the uterine artery; (4) lateralization of the uterine vessel pedicle to completion of colpotomy; and (5) completion of vaginal cuff closure. The random intercept and slope model was used to identify the lengthiest step of TLH, and the backward elimination procedure was used to evaluate which clinical factors affected this step. Mean ± SD total length of TLH was 81 ± 30 min. The lengthiest step was colpotomy, with a mean duration of 24 ± 13 min. Uterine weight significantly increased the length of time required for colpotomy (p = .001). The primary energy source (ultrasonic scalpel vs monopolar hook) used to perform colpotomy did not influence the length of time (p = .539 vs p = .583). Uterine weight (p < .001) and adhesiolysis (p = .003) significantly increased the total time of TLH. CONCLUSIONS: At a teaching institution where surgeries are performed by residents and fellows, colpotomy is the lengthiest step of TLH and is influenced by uterine weight. This finding may reflect the training levels of the surgeons performing these cases and the learning curve associated with a challenging surgical skill. Further research should focus on simulation models and/or tools for colpotomy that may result in greater efficiency in the operating room.

First Trimester Laparoscopic Cerclage.

STUDY OBJECTIVE: To review the indications, rationale, and technique for abdominal cerclage, specifically focusing on a laparoscopic approach to this procedure during the first trimester of pregnancy. DESIGN: This is an educational video directed toward gynecologic surgeons. Patient consent was obtained for use of surgical video footage, and Institutional Review Board exemption was granted. A patient case is discussed and a step-by-step description of the technique used to perform laparoscopic cerclage in the first trimester of pregnancy is demonstrated using surgical footage. SETTING: The estimated incidence of cervical insufficiency affecting pregnancy is as high as 1%. Cervical cerclage placement is the treatment for this condition. Although most cerclages are placed transvaginally via the Shirodkar or McDonald technique, abdominal cerclage is necessary in women with a previous failed transvaginal cerclage or in those with minimal cervical tissue accessible vaginally [1,2]. Both laparoscopic and robotic approaches to this procedure have been developed, allowing patients to enjoy a more rapid recovery as well as to avoid an unnecessary laparotomy[3-6]. The observational studies reporting outcomes for laparoscopic-assisted abdominal cerclage quote fetal survival rates of >85%, which is comparable to the rates for abdominal cerclage[7-18]. Complication rates are low, also congruent with the laparotomic approach[12-18]. INTERVENTION: The patient, a 35-year-old gravida 3, para 1, 0, 1, 1, at 11 weeks gestation, had a history of a full-term vaginal delivery followed by an excisional procedure for cervical dysplasia, and then an early second trimester pregnancy loss. She was referred for laparoscopic-assisted abdominal cerclage after a severely shortened cervix was noted on examination. Laparoscopic cerclage placement was uncomplicated, with minimal blood loss encountered. The patient did well in the immediate postoperative period and was discharged home on postoperative day 1. The remainder of the pregnancy was uneventful, and she delivered via scheduled cesarean section at term. CONCLUSION: With proper patient selection and operative planning, the technique of laparoscopic cerclage is both safe and advantageous in terms of faster recovery. Obstetric outcomes are equivalent, if not superior, to an open abdominal approach to this procedure.

The anatomical outcome of robotic sacrocolpopexy for treatment of pelvic organ prolapse: a comparison of obese and non-obese patients.

The purpose of this study is to compare the anatomical outcome of robotic sacrocolpopexy for pelvic organ prolapse in women with a body mass index (BMI) of 30 and higher to those with a BMI under 30. This is a retrospective chart review. POP-Q measurements preoperatively and 12 months postoperatively were evaluated using non-parametric statistical analysis. The primary outcome was to compare postoperative POPQ measurements at 12 months following surgery. Secondary outcomes were age at the time of surgery, mesh erosion rate, blood loss, length of hospital stay, and baseline anatomical support. A total of 71 patients were identified: 44 patients had a BMI below 30, and 27 had a BMI equal to or greater than 30. We found no significant relationship between BMI and anatomical support at 12 months post operation. However, obese patients were younger at the time of prolapse surgery (53.6 versus 60.6 years of age, p=0.0022). In regards to the ICS prolapse stage, no difference was found between obese and non-obese patients (2.81 versus 2.95, p=0.17).

Evaluation of surgical instrument handling on polypropylene mesh using scanning electron microscopy.

INTRODUCTION AND HYPOTHESIS: To evaluate the effect of surgical instruments handling on polypropylene mesh using scanning electron microscopy (SEM). METHODS: We applied different surgical instruments, including a few robotic ones, to pieces of polypropylene mesh. SEM was used to evaluate the morphological changes with this intervention. RESULTS: Straight hemostat, laparoscopic atraumatic grasper, laparoscopic needle driver, and robotic instruments (Bipolar forceps, Cadiere forceps, PK dissecting forceps and SutureCut) were applied to the mesh. SEM images of tool-affected mesh regions in specimens handled by different instruments along with the images of intact mesh were obtained. Average mesh fiber diameters, as well as the average parameters characterizing instrument-affected regions, were measured. There was substantial widening of the fibers in specimens handled by hemostat or a needle holder. An elliptical but much longer and narrower tool marking with more surface roughness was observed in mesh handled by a grasper. A ∼25-µm-wide and ∼200-µm-long strap was split on one side from the core of the fiber caused by Cadiere. CONCLUSIONS: There are morphological changes to polypropylene mesh caused by instrument handling. These changes are different depending on the instrument used. These alterations vary from changes in the surface creating roughness of the fiber, compression of the mesh with narrowing of the fiber in at least one direction or actual splitting or pitting of the fiber. Since there are no data regarding the effect of these morphological changes to the ultimate functioning of the mesh, surgeons should minimize mesh handling by instruments.

Stepwise approach to laparoscopic hysterectomy: evaluation of technique and cost benefit.

This article examines factors associated with performing a laparoscopic hysterectomy in a stepwise fashion and addresses the technique and cost effectiveness of this procedure compared with abdominal hysterectomy. We review techniques of the laparoscopic hysterectomy as well difficulties that may be encountered throughout the procedure. The hysterectomy is profiled in a method that provides a reproducible system that allows surgeons to increase their surgical numbers and comfort level. When assessing cost-benefit analysis, the cost of hysterectomy is primarily influenced by the operative time, length of hospital stay, equipment, and complications. Robotic and laparoscopic hysterectomy had the highest mean hospital charges. The laparoscopic approach to hysterectomy provides better rates of recovery, length of stay, and hospital cost. The use of the stepwise approach to hysterectomy may allow surgeons to readily perform the procedure and also identify areas and techniques that need improvement. Regardless of age, body mass index (BMI), comorbities, and other nonclinical factors, the laparoscopic hysterectomy compared with abdominal hysterectomy and vaginal hysterectomy has been shown to be better for the patient's recovery and quality of life.

Global endometrial ablation.

Abnormal uterine bleeding (AUB) is a significant health problem for many women. Surgical treatment of AUB often follows failed attempts with first-line medical therapy. Hysterectomy, while being a definitive treatment, is a major surgical procedure with potential for significant complications and economic costs. Endometrial ablation was developed as an alternative to hysterectomy. The first-generation endometrial ablation devices required extensive training and experience to be performed effectively and safely. As a result, newer ablative devices were developed addressing the need for less technical knowledge and improved safety. Since 1997, the United States FDA has approved 5 global endometrial ablation devices for treatment of AUB attributable to benign causes. This review will focus on the technical aspects of these second- generation devices and their applications for treatment of AUB.

Comparing robot-assisted with conventional laparoscopic hysterectomy: impact on cost and clinical outcomes.

OBJECTIVE: To compare clinical and economic outcomes (hospital costs) in women undergoing laparoscopic hysterectomy performed with and without robotic assistance in inpatient and outpatient settings. METHODS: Using the Premier hospital database, we identified women >18 years of age with a record of minimally invasive hysterectomy performed in 2007 to 2008. Univariable and multivariable analyses examined the association between robot-assisted hysterectomy and adverse events, hospital costs, surgery time, and length of stay. RESULTS: Of 36,188 patient records analyzed from 358 hospitals, 95% (n = 34,527) of laparoscopic hysterectomies were performed without robotic assistance. Inpatient and outpatient settings did not differ substantively in frequency of adverse events. For cardiac, neurologic, wound, and vascular complications, frequencies were <1% for robot and non-robot procedures. In inpatient and outpatient settings alike, use of robotic assistance was consistently associated with statistically significant, higher per-patient average hospital costs. Inpatient procedures with and without robotic assistance cost $9640 (95% confidence interval [CI] = $9621, $9659) versus $6973 (95% CI = $6959, $6987), respectively. Outpatient procedures with and without robotic assistance cost $7920 (95% CI = $7898, $7942) versus $5949 (95% CI = $5932, $5966), respectively. Inpatient surgery times were significantly longer for robot-assisted procedures, 3.22 hours (95% CI = 3.21, 3.23) compared with non-robot procedures at 2.82 hours (95% CI = 2.81, 2.83). Similarly, outpatient surgery times with robot averaged 2.99 hours (95% CI = 2.98, 3.00) versus 2.46 hours (2.45, 2.47) for non-robot procedures. CONCLUSION: Our findings reveal little clinical differences in perioperative and postoperative events. This, coupled with the increased per-case hospital cost of the robot, suggests that further investigation is warranted when considering this technology for routine laparoscopic hysterectomies.