RESUMO
Background: Laparoscopic surgery in the second trimester of pregnancy is a high risk and demanding operation. Especially when dealing with adnexal pathology, the surgeon should balance between the effort to establish adequate visualisation of the operating field with minimal uterine manipulation and use of energy application to avoid any potential adverse effects on the intrauterine pregnancy. Objective: The video shows laparoscopic surgery performed in the second trimester of pregnancy and highlights modifications to technique to ensure safety. Materials and Methods: We present a case report of spontaneous heterotopic tubal pregnancy that mimicked an ovarian tumour and was managed surgically with a laparoscopy in the second trimester. During surgery, a previously ruptured left tubal pregnancy (? ectopic) was the cause for a concealed hematoma in the pouch of Douglas, misdiagnosed as ovarian tumour. This is one of the few cases of heterotopic pregnancy treated by laparoscopy in the second trimester of pregnancy. Results: The patient was discharged the day 2 post-operatively, the intrauterine pregnancy progressed, and the patient delivered with a planned caesarean section on the 38th week. Conclusions: Laparoscopic surgery, with adjustments, is a safe and effective method to manage adnexal pathology during a second trimester pregnancy.
RESUMO
BACKGROUND: Training in hysteroscopy can be challenging, especially in conscious women as an office procedure. OBJECTIVE: To develop a realistic hysteroscopy training model for residents using human uteri. METHODS: Human uterine specimens were acquired immediately after hysterectomy, before they were sent for histological analysis and were used as a training model for hysteroscopy. RESULTS: We describe this new technique, which we have used for one year in our resident training programme. Each resident performs at least 20 simulated diagnostic hysteroscopies in extirpated uteri, before performing procedures on women in the operating room. CONCLUSIONS: Simulating hysteroscopy on human uterine models offers a novel and realistic way of training novices prior to conducting procedures under supervision on live patients. WHAT IS NEW: This is a novel model for training and offers a much more realistic training opportunity.
RESUMO
The traditional method of acquiring surgical skills by observing and assisting in surgical procedures involving human beings has been challenged during the past several years. Lessons obtained from aviation suggested that the use of simulators is related to reduced costs, increased efficiency in performing certain tasks and above all safety. A shift in paradigm is also required in modern surgical training. The development of endoscopic surgery allowed for the incorporation of medical simulators into training programmes. A review of the literature was conducted using specific inclusion and exclusion criteria, for articles published up to July 31th, 2018. Relevant studies were identified using computerized bibliographic searches of MEDLINE database. The keywords that were used in various combinations were: "Medical Simulators", "Surgical Training", "Laparoscopy", "Surgical Skills", "Box trainers", "Virtual reality simulators", "Surgical Education". Surgical training with box trainers and/or virtual reality simulators confers a significant benefit in terms of surgical skills development, increases patient safety and reduces costs. Nevertheless, the use of virtual reality simulators was significantly more expensive. Simulation training allows trainees to learn from their mistakes, to repeat surgical tasks multiple times so as to establish muscle memory, and enhance skill competency with the aid of informative feedback. Simulators are necessary for the development of the skills required to meet the specific needs of endoscopic surgery in the 21st century. Teaching hospitals should introduce simulation training programmes in order to increase efficiency, reduce costs and improve patient safety. As medical advancements continue to transform the way we perform surgery day by day, simulation training will play a pivotal role in every surgical specialty.
Assuntos
Simulação por Computador/tendências , Cirurgia Geral/educação , Laparoscopia/educação , Treinamento por Simulação/tendências , Cirurgiões/educação , Humanos , Realidade VirtualRESUMO
PURPOSE OF INVESTIGATION: To describe a novel approach for longitudinal vaginal septum (LVS) resection. Materials and Methods: Two cases of young girls with a uterus didelphys and a longitudinal vaginal septum. The technique consisted in grasping the vaginal septum with a laparoscopic 33-cm long bipolar cutting forceps, five-mm in diameter, and divided it to its midportion towards the two cervices. RESULTS: In both cases, the procedure was straightforward, uncomplicated, completed within three minutes and the patients were discharged four hours later. It was associated with minimal blood loss, short recovery time, absence of local ischemia, and optimum healing process. CONCLUSION: The authors believe that surgical safety, efficacy and operative result make bipolar cutting forceps a tailored option for LVS resection.
Assuntos
Procedimentos Médicos e Cirúrgicos sem Sangue/métodos , Procedimentos Cirúrgicos em Ginecologia/métodos , Vagina/anormalidades , Doenças Vaginais/cirurgia , Perda Sanguínea Cirúrgica , Feminino , Humanos , Anormalidades Urogenitais/complicações , Anormalidades Urogenitais/cirurgia , Útero/anormalidades , Vagina/cirurgia , Doenças Vaginais/complicações , Cicatrização , Adulto JovemRESUMO
Colorectal infiltration by endometriotic implants accounts about 90% of all intestinal location and is difficult to be assessed preoperatively by means of history taking and clinical examination. During the last decade, a number of studies are trying to assess various minimally invasive procedures in order to establish a therapeutic plan that is efficacious and produces acceptable clinical outcomes, preventing the morbidity that results from open surgery. The study aims to review the efficacy of these procedures as therapeutic options of endometriosis infiltrating the bowel. Thirty five observational studies were finally included in the present review involving 3490 women. Intraoperative complications were observed in 4.3% of women and postoperative complications in 7.8%. Quality of life was statistically significantly improved, wherever recorded. Postoperative pain reduction and fertility scores were also improved among cases that received either segmental resection or less radical operations. The various techniques described seem to be efficacious, with acceptable intraoperative and postoperative complication rates. Laparoscopic disc shaving or disc resection in cases of minimal bowel involvement seem to be sufficient alternatives to segmental bowel resection, resulting in high rates of fertilization.
Assuntos
Doenças do Colo/cirurgia , Endometriose/cirurgia , Laparoscopia/métodos , Doenças Retais/cirurgia , Doenças do Colo/patologia , Endometriose/patologia , Feminino , Fertilidade , Humanos , Complicações Intraoperatórias/epidemiologia , Dor Pós-Operatória/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Qualidade de Vida , Doenças Retais/patologiaRESUMO
Postoperative ascites is a rare complication of laparoscopic surgery. Life-threatening and serious etiologies such as unrecognized bowel or urinary tract injury should be excluded promptly to avoid prolonged morbidity and even mortality. Occasionally, no definitive cause can be identified after an extensive diagnostic work-up. In such cases, idiopathic allergic or inflammatory peritoneal reaction may be the final diagnosis.
Assuntos
Ascite/etiologia , Infertilidade Feminina/cirurgia , Laparoscopia/efeitos adversos , Complicações Pós-Operatórias/diagnóstico , Adulto , Ascite/diagnóstico por imagem , Ascite/terapia , Feminino , Seguimentos , Humanos , Infertilidade Feminina/diagnóstico , Laparoscopia/métodos , Monitorização Fisiológica , Período Pós-Operatório , Medição de Risco , UltrassonografiaRESUMO
OBJECTIVE: To analyze the value of second trimester ultrasound examination among those women whose fetuses were indicated to be at low risk of chromosomal anomalies on the basis of both first trimester nuchal translucency measurement and second trimester biochemical screening. METHODS: A retrospective study of 5500 pregnancies carried out at the fetal medicine unit, Royal Free Hospital. During a period of over 3 years 5500 pregnancies underwent a first trimester scan and nuchal translucency measurement which enabled the detection of 62% (20 of 32) of all chromosomal anomalies. From the remaining pregnancies that underwent second trimester biochemical screening, 3548 were considered negative (risk < 1:250; using maternal serum free beta human chorionic gonadotrophin and alpha fetoprotein). The ultrasound markers that were examined were: shortened femur length, echogenic bowel, pyelectasis, choroid plexus cysts and echogenic intracardiac foci. The likelihood ratios for chromosomal aneuploides for each of these markers were calculated. RESULTS: Of the 3548 screen negative pregnancies, 3541 (99.8%) had a normal karyotype. Seven (0.2%) fetuses had an abnormal karyotype including four (0.11%) with trisomy 21, one with trisomy 18 and two with 47XXY. Second trimester ultrasound markers were found in two of the five (40%) with severe chromosomal anomalies compared to 184 of 3541 (5.2%) with normal karyotypes. Detection of one or more ultrasound markers in a screen negative pregnancy increased the possibility of chromosomal aneuploidy and a negative ultrasound decreased the risk by a likelihood ratio of 0.6 (95% confidence interval, 0.3-1.3). The risk was considerably increased when two or more markers were detected and we would recommend karyotyping under these circumstances. CONCLUSION: This preliminary data indicates a possible role for abnormal ultrasound markers in assessing the risk of chromosomal abnormalities in patients considered to be at low risk by nuchal translucency and serum screening. However analysis of a much larger study group will have to be conducted to assess the significance of individual markers.
Assuntos
Aberrações Cromossômicas/sangue , Aberrações Cromossômicas/diagnóstico por imagem , Testes Genéticos/métodos , Segundo Trimestre da Gravidez/sangue , Ultrassonografia Pré-Natal/métodos , Adolescente , Adulto , Transtornos Cromossômicos , Intervalos de Confiança , Feminino , Sangue Fetal/química , Marcadores Genéticos , Humanos , Cariotipagem , Pessoa de Meia-Idade , Pescoço/diagnóstico por imagem , Pescoço/embriologia , Gravidez , Primeiro Trimestre da Gravidez , Estudos Retrospectivos , Sensibilidade e EspecificidadeRESUMO
OBJECTIVE: To determine the value of early pregnancy sonography in detecting fetal abnormalities in an unselected obstetric population. DESIGN Prospective cross-sectional study. All women initially underwent transabdominal sonography and when the anatomical survey was considered to be incomplete, transvaginal sonography was also performed (20.1%). Nuchal translucency was measured and karyotyping was performed as appropriate. SETTING: University Department of Obstetrics and Gynaecology. PARTICIPANTS: 6634 sequential unselected women (mean maternal age 29.9 years, range 13-50; mean gestational age 12+4 weeks, range 11+0-14+6), carrying 6443 live fetuses participated in this study. MAIN OUTCOME MEASURE: Detection rate of fetal anomalies and the associated cost per case detected in early pregnancy. RESULTS: The incidence of anomalous fetuses was 1.4% (92/6443) including 43 chromosomal abnormalities. The detection rate for structural abnormalities was 59.0% (37/63, 95% CI 46.5-72.4) and the specificity was 99.9% in early pregnancy. When the first and second trimester scans were combined, the detection for structural abnormalities was 81.0% (51/63, 95% CI 67.7-89.2). Seventy-eight percent (31/40) of chromosomal abnormalities (excluding three cases of XXY) were diagnosed at 11-14 weeks, either because of a nuchal translucency greater than or equal to the 99th centile for gestational age (43%; 17/40, 95% CI 27.4-60.4), or due to the presence of structural abnormalities (35%; 14/40, 95% CI 21.2-52.8). Sixty-five percent (15/23) of cases of trisomy 21 were also diagnosed either because of having a nuchal translucency greater than or equal to the 99th centile (57.0%; 13/23) or due to the presence of a structural abnormality (9.0%; 2/23). Overall, the detection rate of structurally abnormal fetuses was 59% (37/63) in early pregnancy and 81% in combination with the second trimester scan. The cost per abnormality diagnosed in early pregnancy is estimated to be pound sterling 6258 per structurally abnormal fetus, pound sterling 7470 per chromosomal abnormality and pound sterling 4453 per anomalous fetus. CONCLUSION: The majority of fetal structural and chromosomal abnormalities can be detected by sonographic screening at 11-14 weeks, but the second trimester scan should not be abandoned.
Assuntos
Feto/anormalidades , Ultrassonografia Pré-Natal/métodos , Aberrações Cromossômicas , Custos e Análise de Custo , Estudos Transversais , Feminino , Humanos , Gravidez , Primeiro Trimestre da Gravidez , Segundo Trimestre da Gravidez , Estudos Prospectivos , Sensibilidade e Especificidade , Ultrassonografia Pré-Natal/economiaRESUMO
The increasing use of laparoscopic surgery with more complicated procedures means that the use of multiple and larger ports is becoming commonplace. One well-known risk associated with the use of ports more than 10 mm in diameter is the development of an incisional hernia unless the deep fascia is closed adequately. This complication is estimated to follow 3% of major laparoscopic procedures. Closure of trocar incisions is therefore recommended for large sites. We have developed a closure technique using standard sutures with straight needles, a 5-mm laparoscopic grasper, and a 4-mm hysteroscope which we have found simple and fast, with the added advantage of low cost.
Assuntos
Fasciotomia , Laparoscopia , Peritônio/cirurgia , Técnicas de Sutura , Humanos , Agulhas , PunçõesRESUMO
OBJECTIVES: To assess the sonographic screening for anencephaly in the first trimester in a low-risk obstetric population. METHODS: Since 1994, 5388 women attended our clinic for a first-trimester scan (11-14 weeks of gestation) and screening for structural and chromosomal abnormalities. The patients underwent transabdominal scanning, and transvaginal scanning if necessary. RESULTS: The ultrasonographic appearances of anencephaly in the first trimester are different from the familiar second-trimester signs. The cerebral hemispheres are present and exposed to the surrounding amniotic fluid. The ultrasound appearances in the coronal section of the head are best described as 'Mickey Mouse face'. There were six cases of anencephaly (incidence 1.1:1000). All cases were diagnosed in the first trimester and five demonstrated this sign. There were no false-positive diagnoses. The crown-rump length was significantly reduced in all affected fetuses. CONCLUSION: First-trimester ultrasonographic diagnosis of anencephaly is accurate, but sonographers should be familiar with the ultrasound appearances that are different from those in the second trimester.
Assuntos
Anencefalia/diagnóstico por imagem , Doenças Fetais/diagnóstico por imagem , Ultrassonografia Pré-Natal , Adolescente , Adulto , Líquido Amniótico/diagnóstico por imagem , Encéfalo/embriologia , Aberrações Cromossômicas/diagnóstico por imagem , Transtornos Cromossômicos , Anormalidades Congênitas/diagnóstico por imagem , Estatura Cabeça-Cóccix , Ecoencefalografia , Feminino , Idade Gestacional , Humanos , Pessoa de Meia-Idade , Gravidez , Resultado da Gravidez , Primeiro Trimestre da Gravidez , Segundo Trimestre da Gravidez , Sensibilidade e EspecificidadeRESUMO
Vaginal hysterectomy has been demonstrated to be the cheapest route to perform a hysterectomy but no detailed costing has been performed in the United Kingdom. In this study the costs incurred by a UK teaching hospital for 30 women aged between 40 and 50 years of age undergoing either abdominal (AH), laparoscopically assisted vaginal hysterectomy (LH) were compared with vaginal hysterectomy (VH). VH was significantly the cheapest procedure (993.00 Pounds, 95th Cl 883.20 Pounds to 1124.80 Pounds) and there was a tendency for LH (1148.00 Pounds, 95th Cl 1006.80 Pounds to 1289.20 Pounds) to be less expensive than AH (1340.00 Pounds, 95th CI 1080.80 Pounds to 1595.20 Pounds); this difference may be reversed if disposable laparoscopic instruments were to be used for LH. Our study agrees with data from other countries showing that VH is the cheapest type of hysterectomy. With the added benefits of shorter hospital stay, convalescence and return to work, effort should be directed towards increasing the proportion of hysterectomies performed vaginally in the UK.
RESUMO
BACKGROUND: To facilitate extraction and avoid intra-abdominal spillage during laparoscopic removal of adnexal masses, various designs and sizes of endopouches (bags) have been used. We describe a simple technique using a special laparoscopic bag that requires no additional instruments to hold, open, or close the bag. TECHNIQUE: The laparoscopic bag can be prepared from the sterile wrapping of disposable surgical items (eg, suction tubing) and two long sutures. The bag is introduced through the cannula of the laparoscope and is unfurled. By manipulation of the two long sutures threaded through the neck of the bag, the surgeon can easily open and close it. EXPERIENCE: We have performed this procedure "in vitro" on many occasions to ensure that the drawstring technique works. The laparoscopic bag has been used successfully in three patients undergoing oophorectomy and salpingo-oophorectomy. Our experience shows that this type of laparoscopic bag is easy to use and safe, reduces operative time, and is cost effective. Because the bag can be large, operating inside the bag is also possible. CONCLUSION: Our drawstring design allows easy manipulation of a laparoscopic bag to facilitate its opening and closure.
Assuntos
Tubas Uterinas/cirurgia , Laparoscópios , Laparoscopia/métodos , Ovariectomia/métodos , Desenho de Equipamento , Feminino , HumanosRESUMO
OBJECTIVE: To determine the influence of the position of the fetal neck on nuchal translucency measurement. DESIGN: A prospective cross-sectional study. POPULATION: One hundred and ninety-six. METHODS: Nuchal translucency was measured in the mid-sagittal plane, with the fetal neck in the flexed, neutral and extended positions. Measurements were made to the nearest 0.1 mm. Statistical analysis used the paired t-test for differences between the extended and neutral positions, [delta extended nuchal translucency] and the flexed and neutral positions [delta flexed nuchal translucency]. RESULTS: The mean extended nuchal translucency was 0.62 mm greater than the mean neutral nuchal translucency value [95% confidence interval 0.53 to 0.70, T = 14.33, P < or = 0.00001]. The mean flexed nuchal translucency was 0.40 mm less than the mean neutral nuchal translucency value [95% CI 0.34 to 0.47, T = 11.99; P = < 0.00001]. The repeatability coefficient was lower in the case of neutral nuchal translucency measurements [0.48] and was higher in the other groups [extended = 1.04, flexed = 0.70]. CONCLUSION: Fetal neck position can make a significant difference to nuchal translucency measurements. Repeatability of measurements are more accurate with the fetal neck in the neutral position. These findings have important implications for clinicians using nuchal translucency to screen the general obstetric population.
Assuntos
Pescoço/diagnóstico por imagem , Pescoço/embriologia , Ultrassonografia Pré-Natal/métodos , Estudos Transversais , Feminino , Idade Gestacional , Humanos , Postura , Gravidez , Primeiro Trimestre da Gravidez , Estudos ProspectivosAssuntos
Apendicectomia/métodos , Laparoscopia , Dor Pélvica , Adulto , Apêndice , Doenças do Ceco/complicações , Doenças do Ceco/cirurgia , Feminino , Procedimentos Cirúrgicos em Ginecologia , Humanos , Dor Pélvica/etiologia , Dor Pélvica/prevenção & controle , Aderências Teciduais/complicações , Aderências Teciduais/cirurgiaRESUMO
OBJECTIVE: To determine the significance of certain soft ultrasonographic markers for chromosomal abnormalities in the first trimester. DESIGN: This was a prospective cross-sectional study. SETTING: University Department of Obstetrics and Gynaecology, London, UK. METHODS: A total of 5385 women from an unselected population underwent a detailed assessment of fetal anatomy at 11-14 weeks of gestation (confirmed by crown-rump length) by transabdominal sonography (5.0 MHz) and transvaginal sonography (6.0 MHz) when necessary. RESULTS: In normal fetuses, the prevalences of choroid plexus cysts, pyelectasis and echogenic heart foci were 2.2, 0.9 and 0.6%, respectively in the first trimester and 2.0, 0.8 and 0.8%, respectively in the second trimester. Pyelectasis (likelihood ratio = 8.0, p = 0.03) and echogenic heart foci (likelihood ratio = 10.3, p = 0.02) were found to be associated significantly with fetal aneuploidy, while choroid plexus cysts were not. CONCLUSIONS: Although the majority of aneuploidies were detected by increased nuchal translucency and/or the presence of structural abnormalities (78%; 25/32), the use of soft ultrasonographic markers in the first trimester would have increased the overall detection by a further 3%. These data are preliminary and many thousands of pregnancies will need to be examined to determine the significance of the individual markers in different chromosomal abnormalities.
Assuntos
Encefalopatias/diagnóstico por imagem , Plexo Corióideo/diagnóstico por imagem , Cistos/diagnóstico por imagem , Coração Fetal/diagnóstico por imagem , Nefropatias/diagnóstico por imagem , Ultrassonografia Pré-Natal , Adolescente , Adulto , Aberrações Cromossômicas/diagnóstico por imagem , Transtornos Cromossômicos , Estudos Transversais , Feminino , Doenças Fetais/diagnóstico por imagem , Humanos , Pelve Renal/diagnóstico por imagem , Pessoa de Meia-Idade , Gravidez , Primeiro Trimestre da Gravidez , Estudos ProspectivosRESUMO
Trauma to the inferior epigastric artery during insertion of ports for laparoscopic surgery can be associated with major hemorrhage. Several techniques have been developed to deal with this emergency, but most require special and expensive instrumentation that may not be readily available. We describe a simple and quick method to deal with this complication using only standard sutures and a laparoscopic needle holder. Two sutures with straight needles are inserted below laterally and medially to the vessels and pulled out via a contralateral port. The sutures are tied together and pulled back into the abdominal cavity and tied to secure the vessels. The procedure is repeated above the vessels to produce complete hemostasis. The technique also can be applied easily to repair the rectus sheath after using large trocars and cannulas and thereby prevent herniation.