An Early Investigation into Possible Alternatives to Stapled Hysterotomy in Open Fetal Surgery.

PURPOSE: We hypothesized that surgical energy could be used to create hysterotomies in open fetal surgery. STUDY DESIGN: Initial studies compared the LigaSure Impact and Harmonic ACE + 7 Shears in the efficiency of hysterotomy and thermal damage. Pregnant ewes at an estimated gestational age (EGA) of 116 to 120 days (term = 145; n = 7) underwent hysterotomy using either device. Hysterotomy edges were resected, and thermal injury extent was determined by histopathological assessment. Upon determining a superior device, subsequent studies compared this to the AutoSuture Premium Poly CS*-57 Stapler in uterine healing. Pregnant ewes (n = 6) at an EGA of 87 to 93 days underwent 6-cm hysterotomy in each gravid horn with either the stapler (n = 5) or Harmonic (n = 5) followed by closure and animal recovery. After 37 to 42 days, uterine healing was assessed by evaluating tensile strength and histopathology. RESULTS: Thermal damage was more extensive with the LigaSure (n = 11 hysterotomies) than with the Harmonic (n = 11; 5.6 ± 1 vs. 3.1 ± 0.6 mm; p < 0.0001);therefore, the Harmonic was selected for healing studies. Gross scar appearance and tensile strength were the same between the Harmonic and stapler. The stapler caused more fibrosis (4/7 samples with "moderate" fibrosis vs. 0/8 with the Harmonic; p = 0.02). CONCLUSION: The Harmonic ACE + 7 caused less thermal injury than the LigaSure Impact and performed similar to the CS*-57 Stapler in uterine healing with continued gestation.

Hysteroscopic Intrauterine Adhesiolysis Using a Blunt Spreading Dissection Technique With Double-action Forceps.

STUDY OBJECTIVE: To demonstrate step-by-step the technique of hysteroscopic adhesiolysis (HA) by means of a blunt spreading technique using double-action forceps to dissect and restore the layer between the anterior and posterior uterine walls in a patient with severe intrauterine adhesions (IUAs), particularly in cases in which the endometrial lining is obscured on ultrasound imaging and the endometrial cavity is completely occluded on hysteroscopy. DESIGN: A step-by-step explanation of the technique using videos and pictures (educative video) (Canadian Task Force Classification III). SETTING: A university-affiliated hospital. PATIENT: A 36-year-old, gravida 3, para 1, abortus 2 woman presenting with amenorrhea for 5 months after surgical termination of a 53-day intrauterine pregnancy. She had no cyclic lower abdominal pain. Ultrasound revealed an obscure endometrial stripe and no obvious hematometra. Both the urine human chorionic gonadotropin test and the progesterone withdrawal test were negative. One month before admission, hysteroscopic adhesiolysis failed because the uterine cavity was inaccessible because of adhesions completely occluding the lower uterine cavity. Additionally, the uterine cavity could not be explored with a probe because the anatomic layer of the endometrial lining could not be easily identified by transabdominal ultrasound. INTERVENTION: HA using a blunt spreading dissection technique with double-action forceps to restore the uterine cavity followed by "ploughing" of the intrauterine scar tissue using cold scissors [1]. MEASUREMENTS AND MAIN RESULTS: An intraoperative technique with commentary highlighting tips for a successful dissection. The uterine cavity was successfully restored using the blunt spreading dissection technique. There were no complications, including false uterine wall passage, uterine perforation, or fluid overload. Postoperative hysteroscopy at 1 month revealed an almost normal uterine cavity. CONCLUSIONS: HA using a blunt spreading dissection technique to restore the uterine cavity is a simple, effective, and safe hysteroscopic skill, especially when the endometrial stripe is obscured on ultrasound imaging and exploring the uterine cavity by means of a probe has failed. Furthermore, this technique may serve as an alternative to resectoscopic techniques because it uses cold forceps and scissors, which provide better protection for the endometrium.

[Blunt or sharp expansion of cesarean section: a comparative study]. / Expansion instrumentale ou digitale de l'hystérotomie au cours d'une césarienne : étude comparative.

OBJECTIVE: The aim of this study was to determine if the method used to expand the hysterotomy during a cesarean section (c-section) could affect maternal blood loss and uterine laceration. MATERIAL AND METHODS: Prospective study including 214 c-sections divided into two groups. Hundred and thirty-six were assigned to have blunt expansion of the uterine incision (group 1) and 78 to have sharp expansion by scissors (group 2). Maternal blood loss, change in hemoglobin level, and uterine tears were studied. RESULTS: The median blood loss was (IQR) 475mL (300-700) and 500mL (300-800) (P=0.227) in groups 1 and 2 respectively. The decrease in hemoglobin level was 9.5g/L versus 6g/L (P=0.007) in groups 1 and 2. Nine lateral uterine extensions of uterine incision (5.88%) were found in the group 1, three of them were complicated by a wound of the uterine vascular pedicle. One lateral uterine tear with vascular wound was found in the group 2 (1.28%). CONCLUSION: Sharp expansions were associated with a lower shift in hemoglobin level and a trend to more uterine lacerations.

[The effect of uterine incision expansion at caesarean delivery on perioperative haemorrhage: a prospective randomised clinical trial]. / Impact de la technique d'hystérotomie au cours de la césarienne sur le saignement périopératoire: un essai prospectif randomise.

To determine if blunt or sharp expansion of the uterus at caesarean delivery is associated with increased maternal peripartum haemorrhage as estimated by the drop in hematocrit. Prospective randomised intention to treat clinical trial of women undergoing elective or urgent caesarean delivery at at least 36 weeks gestation. Two study groups were formed; after an initial hysterotomy which consisted in a transverse uterine incision of the lower segment, in the blunt group, the surgeon's indexes expanded the initial incision bilaterally and cephalad; in the sharp group, expansion of the initial incision was made using scissors. The primary outcome measure was the mean drop in hematocrit and p < 0.05 was considered significant. Three hundred women were randomised: 153 to the sharp group and 147 to the blunt group. The demographic and clinical characteristics of the two populations were similar. There were no statistically significant differences between the groups in estimated blood loss as assessed by the mean drop in hematocrit (%) (respectively 1.71 +/- 3.18 versus blunt group 1.91 +/- 3.28 p = 0.58 non significant). Our findings support that sharp or blunt expansion of hysterotomy during caesarean section equally affect blood loss as estimated by drop in hematocrit.

The Almodin-Moron trocar for uterine entry during fetal surgery.

OBJECTIVE: Compare the use of a newly designed and reusable metal trocar for initial uterine entry with the disposable Tulipan-Bruner trocar in creation of a hysterotomy for fetal surgery. METHODS: Six consecutive patients undergoing hysterotomy for intrauterine repair of myelomeningocele were randomized to uterine entry either with the Tulipan-Bruner trocar or with the Almodin-Moron trocar. Blood loss was estimated by the primary surgeon. RESULTS: There was no statistically significant difference in the uterine entry times between the trocars. Blood loss was estimated to be approximately the same. The Almodin-Moron trocar was judged to provide easy handling with good safety. CONCLUSIONS: The Almodin-Moron trocar provides a uterine entry during creation of a hysterotomy that is as quick and causes as little trauma as the Tulipan-Bruner trocar.

La cesárea / Caesarean section

En los últimos años estamos viviendo un aumento en la tasa de cesáreas. Por ello realizamos una valoracion de suó distintas indicaciones médicas y paramédicas con el fin de intentar acercarnos a tomar las decisiones que supongan un mayor beneficio materno-fetal. La cesárea a demanda supone uno de los aspectos más polémicos en este momento

In the past 20 years we are attending to a continuous increase in the rate of caesarean section. Because of this we try to analize the different clinical and non clinical indications for caesarean section in order to decide the best for mother and fetus. Moreover we discuss the actual controversy of caesarean section “on maternal request”

The Tulipan-Bruner trocar for uterine entry during fetal surgery.

OBJECTIVE: Our goal was to compare the use of a specially designed trocar for initial uterine entry with standard entry by electrocautery in creation of a hysterotomy for fetal surgery. STUDY DESIGN: Ten consecutive patients undergoing hysterotomy for intrauterine repair of myelomeningocele were randomized to initial uterine entry with electrocautery or with the Tulipan-Bruner trocar. Timing of initial uterine entry with electrocautery began with incision into the uterine serosa and ended with incision of the chorioamnionic membranes. Timing of initial uterine entry with the Tulipan-Bruner trocar began with placement of stay sutures and ended with removal of the central introducer from the peel-away sheath. Blood loss was estimated by the primary surgeon. All of the participating surgeons judged the convenience and ease of each technique. The times required for initial uterine entry were compared with an unpaired t test. Statistical significance was set at P <.05. RESULTS: The time required for initial uterine entry with electrocautery was 231 +/- 63 (mean +/- SD) seconds compared with 146 +/- 51 seconds with the trocar (P <.05). The total blood loss for all 10 cases was <50 mL, but the presence of blood in the wound was judged much more inconvenient when electrocautery was used. Finally, electrocautery required 2 surgical assistants in every case, whereas the trocar was readily placed with only a single assistant. CONCLUSION: The Tulipan-Bruner trocar provides quicker, less traumatic uterine entry during creation of a hysterotomy, as compared with electrocautery.