Very Low Rates of Ureteral Injury in Laparoscopic Hysterectomy Performed by Fellowship-trained Minimally Invasive Gynecologic Surgeons.

STUDY OBJECTIVE: The objective of this case series is to evaluate the rates of ureteral injury at the time of laparoscopic hysterectomy among high-volume fellowship-trained surgeons. DESIGN: A retrospective chart review was performed, evaluating laparoscopic hysterectomy cases between 2009 and 2019 performed exclusively by fellowship-trained surgeons. SETTING: Division of Minimally Invasive Gynecologic Surgery (MIGS) at the Brigham and Women's Hospital and Brigham and Women's Faulkner Hospital, a Harvard Medical School teaching hospital in Boston. PATIENTS: All patients undergoing laparoscopic hysterectomy by one of 5 surgeons with fellowship training in MIGS. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 5160 cases were handled by MIGS surgeons between 2009 and 2019 at our institution. Of these cases, 2345 were laparoscopic hysterectomy cases with available intraoperative and postoperative documentation. Most patients had undergone previous surgeries, and the most common indications for hysterectomy included uterine myomas, pelvic pain/endometriosis, and abnormal uterine bleeding. At the time of hysterectomy, 1 ureteral injury (0.04%) was noted. No additional delayed ureteral injuries were observed. Most patients were discharged home the same day (64.9%) and did not have any postoperative complications (63.9%) as designated by the Clavien-Dindo classification. CONCLUSION: Ureteral injury, although rare, is more prevalent in gynecologic surgery than in other surgical disciplines that have some focus on the pelvis. No study to date has evaluated the effect of surgical training and volume on rates of ureteral injuries. This study retrospectively examined ureteral injury rates for one group of high-volume fellowship-trained surgeons and found their rates to be lower than the national average. Proposals are presented for optimizing training and delivery of gynecologic surgical care to minimize complications.

Laparoscopic Abdominal Cerclage.

Cervical insufficiency is a well-established cause of infant morbidity and mortality. Recommended treatment of cervical insufficiency includes a procedure in which a stitch, termed a cerclage, is placed around the cervix to keep it closed. Abdominal cerclage is the preferred approach for patients with refractory cervical insufficiency or anatomic limitations to vaginal cerclage placement. Laparoscopic abdominal cerclage has many benefits over an open approach and has been increasingly performed over the last 20 years due to surgeon skillset and improved neonatal survival compared with repeat vaginal cerclage. Laparoscopic abdominal cerclage is a highly effective, well-tolerated surgical treatment of selected patients.

Deep Pelvic Side Wall Anatomy: A Case of Laparoscopic Management of Vaginal Vault Fistula to the Presacral Area.

STUDY OBJECTIVE: Video presentation showing retroperitoneal dissection and deep pelvic side wall anatomy [1-3]. DESIGN: Case presentation with showing anatomic structures in detail. SETTING: Tertiary academic teaching hospital. INTERVENTIONS: A 74-year-old female with history of type 2 diabetes, hypertension, and a vaginal hysterectomy with left sacrospinous ligament suspension 9 years ago presented with fever and was found to have bacteremia. Abdomen and pelvic magnetic resonance imaging showed a presacral and precoccygeal loculated collections, sacral osteomyelitis, and fistula from the left superior vaginal vault to one of the presacral collections. Transgluteal drain placed with cultures growing Streptococcus constellatus and Gemella morbillorum. Blood cultures grew same bacteria. She was started on vancomycin, cefepime, and metronidazole and was transitioned to ceftriaxone with a plan for 6-week antibiotic course. Her blood sugar levels were well controlled during hospitalization with baseline insulin and moderate sliding scale. Physical therapy started preoperative and continued postoperative. She was managed with an interdisciplinary team of gynecologists, urogynecologists, orthopedic doctors, neurosurgeons, nutritionists, infectious disease doctors, endocrinologists, hematologists, rehabilitation specialists, and physical therapists. This video showcases laparoscopic resection of sacrospinous fistula tract. Postoperative pathology result showed squamous mucosa, submucosa, and deep soft tissue with a submucosal abscess surrounded by fibrosis, consistent with a fistula tract. CONCLUSION: Preoperative planning is of paramount importance in cases with multiple comorbidities. Gentle dissection with maintained hemostasis, creating windows, and starting from less distorted anatomy are key points in retroperitoneal dissection. Knowing the precise anatomy of critical structures close to the area of interest is crucial.

Analysis of COVID-19 Response and Impact on Gynecologic Surgery at a Large Academic Hospital System.

BACKGROUND AND OBJECTIVES: The COVID-19 pandemic dramatically impacted gynecologic surgery. In March 2020, the American College of Surgeons recommended delay of all nonessential invasive procedures. This study characterizes the number and types of procedures performed during the peak pandemic. METHODS: A retrospective cohort study was performed. All patients undergoing gynecological surgery at a large academic hospital system from March 16, 2019 to July 31, 2019 and from March 16, 2020 to July 31, 2020 were evaluated. Data was stratified by three time periods corresponding to state and hospital policy changes. During period 1, no nonessential procedures were advised. During period 2, urgent procedures resumed. During period 3, full surgical reopening was achieved. RESULTS: In 2019, 1,545 gynecologic cases were performed compared with 942 cases in 2020 (39.0% decrease). There was a 73.6% decrease in cases over period 1, a 20.1% decrease over period 2, and a 2.9% increase over period 3. Cases performed by gynecologic oncologists in 2020 accounted for 58.1% of all gynecologic cases over period 1, 29.4% of cases over period 2, and 33.3% of cases over period 3. In 2020, hysterectomy was the most commonly performed procedure, while surgery for endometriosis and uterine fibroids had the greatest decrease in volume. Among emergency procedures, more surgery for ectopic pregnancy was performed in 2020 compared with 2019. CONCLUSION: Many patients had significant delays in receiving gynecologic surgical care during the peak pandemic period. Further studies are indicated to determine the impact of delayed care on patients' quality of life and disease process.

Uterine bioimpedance combined with artificial intelligence as a means of cancer detection.

This study hypothesised that benign and tumour-bearing uterine tissue could be differentiated by their unique electrical bioimpedance patterns, with the aid of artificial intelligence. Twenty whole, ex-vivo uterine specimens were obtained at the time of hysterectomy. A total of 11 benign and 9 malignant specimens were studied. A uterine bioimpedance probe was designed to measure the tissue between the endometrial and serosal layers of the uterus. The impedance data was then analysed with multiple instance learning and principal component analysis, forms of artificial intelligence. Final pathology results for the specimens included uterine sarcoma, adenocarcinoma, carcinosarcoma, and high-grade serous carcinoma. The analysis correctly identified 78% (7/9) of the malignant specimens and 82% (9/11) of the benign specimens. The overall accuracy of our analysis was 80%. Our results demonstrate distinction between electrical impedance properties of malignant and benign uterine specimens. Bioimpedance and artificial intelligence may have potential implications in risk assessment of patients and may subsequently guide surgical decision-making regarding route of organ removal.

Atypical Presentation of Cervical Carcinoma With Cerebral Metastasis.

BACKGROUND: Cervical cancer is a leading cause of morbidity and mortality in women, but cerebral metastasis from cervical carcinoma is a rare event with a reported incidence of 0.57%. CASE REPORT: We describe a case of brain metastasis from primary cervical adenocarcinoma with several distinct features. This case illustrates uncommon presenting neurologic symptoms, a rare combination of histopathologic features, and atypical findings on radiographic evaluation. CONCLUSION: Clinicians must maintain a high index of suspicion for cerebral metastasis to make an accurate diagnosis and initiate appropriate management of advanced cervical cancer.

Characteristics of United States Emergency Department Visits for Traumatic Amputations in the Elderly Adult from 2010 to 2013.

BACKGROUND: Elderly adults (65 years of age and older) are of particular concern for traumatic amputations due to age-related changes in vision and coordination, making them more susceptible to injury. OBJECTIVES: The objective of this study is to describe the epidemiology of traumatic amputations in the elderly adults treated in United States emergency departments (ED). DESIGN: A retrospective analysis using data from the National Electronic Injury Surveillance System from 2010 to 2013. PARTICIPANTS: People aged 65 years and older treated in U.S. hospital EDs for traumatic amputations from 2010 to 2013. RESULTS: There were 15,611 elderly patients treated for amputations from 2010 to 2013, averaging 3,902 amputations per year in the United States. The frequency of amputations declined with increasing age. The mean age was 74 years old. Males represented 84% of the cohort. The majority of the injuries that were recorded took place at home (71%). The most common associated consumer products were saws, lawnmowers, and doors. Saws accounted for approximately 45% of amputations. In females, doors were the most common consumer product associated with amputations. Approximately 45% of amputations were complete amputations. The most common digit to be amputated was the thumb (24%). Approximately 72% of the cases in the cohort were treated and released from the ED. CONCLUSION: Traumatic amputations in elderly adults were frequently due to saws and lawnmowers. An increase in injury prevention efforts in this patient population is warranted.

Tricycle Injuries Presenting to US Emergency Departments, 2012-2013.

OBJECTIVE: To investigate the characteristics of tricycle-related injuries in children presenting to US emergency departments (EDs). METHODS: Data regarding tricycle injuries in children younger than 18 years of age were obtained from the National Electronic Injury Surveillance System for calendar years 2012 and 2013. Data included body regions injured, ED disposition, and demographics. RESULTS: There were an estimated 9340 tricycle-related injuries treated in US EDs from 2012 to 2013. The average age was 3 years. Children 2 years of age had the highest frequency of injuries. Boys accounted for 63.6% of all injuries. Children 1 to 2 years of age represented 51.9% of all injuries. Lacerations were the most common type of injury. Internal organ damage was the most common type of injury in 3- and 5-year-olds. Contusions were the most common type of injury in 1- and 7-year-olds. The head was the most commonly injured region of the body and the most common region to endure internal damage. The elbows were the most commonly fractured body part. The upper extremity was more frequently fractured than the lower extremity. Approximately 2.4% of all injured children were admitted to the hospital. CONCLUSIONS: The upper extremity of children, particularly the elbow, was more frequently fractured than the lower extremity. The head was the most common body part to endure internal damage. By elucidating the characteristics of tricycle-related injuries, preventive measures can be implemented to decrease the incidence of tricycle-related injuries and ED visits.

Crohn's disease: a review of treatment options and current research.

Crohn's disease is an autoimmune disorder that affects nearly 1.4 million Americans. The etiology of Crohn's disease is not completely understood, however, research has suggested a genetic link. There is currently no known cure for Crohn's disease and, as a result, most government-funded research is being conducted to increase the quality of life of afflicted patients (i.e. reducing chronic inflammation and alleviating growth impairment in pediatric patients). A number of treatment options are available including an alpha-4 integrin inhibitor and several TNF-alpha inhibitors. Furthermore, research is being conducted on several alternative treatment options to help understand exactly which cellular mechanisms (i.e. inducing apoptosis in leukocytes) are required for clinical efficacy. This review seeks to chronicle the current available treatment options for patients affected by Crohn's disease to aid in understanding potential cellular mechanistic requirements for an efficacious drug, and shed light on potential options for future treatment.