Ovarian ectopic pregnancy after in vitro fertilisation treated by laparoscopic excision with ovarian preservation.

A 42-year-old woman presented with lower abdominal pain and fainting episodes 36 days after in vitro fertilisation and embryo transfer. Transvaginal ultrasound revealed a large amount of free fluid in the pouch of Douglas and no evidence of an intrauterine gestational sac or adnexal mass suggestive of ectopic pregnancy. A presumed haemorrhagic corpus luteal cyst was seen in the left ovary. Laparoscopic exploration revealed a left ovarian haemorrhagic mass, which was excised with preservation of the ovary. Histopathological examination confirmed an ovarian ectopic pregnancy (OEP). OEP is rare but potentially life-threatening, as it can lead to internal haemorrhage. Its diagnosis is challenging as preoperative and intraoperative findings can be evocative of the far more frequent haemorrhagic corpus luteal cyst and histopathology is often necessary to confirm the diagnosis. Early recognition of OEP is crucial to reduce maternal morbidity and mortality, and allow treatment that preserves fertility as much as possible.

Laparoscopic Myomectomy - Converting to Laparotomy for a Suspicious Intraoperative Appearance with Subsequent Benign Histology - a Pre- and Intra-Operative Dilemma.

BACKGROUND: Although the most common uterine tumour is leiomyoma, the differential diagnoses also include the rarer adenomyoma and leiomyosarcoma. A lack of clear reliable clinical and radiological features makes the triage of uterine masses to the appropriate surgical procedure difficult. In the case of suspicious appearance of a presumed leiomyoma, an open surgical approach is recommended and morcellation is avoided. CASE: We present a case of a woman undergoing an elective laparoscopic myomectomy for a fibroid that appeared benign on ultrasound but had suspicious features intraoperatively. The operation was converted to a laparotomy to avoid the risk of morcellation-related seeding in the event that the histology was malignant. The histology was subsequently a benign exophytic adenomyoma. CONCLUSION: The assessment of the nature of fibroids can be difficult both pre- and intraoperatively, and the need for difficult decision making to convert to open surgery during a laparoscopic myomectomy but with subsequent benign histology should be part of patient counselling.

Gynecologic endoscopy skills training and assessment: review.

Training in and assessment of endoscopic skills is currently undergoing a period of evolution. Several recognized factors driving this evolution include working pattern, training opportunities, cost, and patient safety. In addition, the need to continuously monitor competence is punctuated by the rapid technologic changes and rising consumer expectation. These challenges present an opportunity to positively enhance the learning and performance of surgical practice.

Psychomotor skills and cognitive load training on a virtual reality laparoscopic simulator for tubal surgery is effective.

OBJECTIVES: Validation of a virtual reality (VR) simulator for the training and assessment of laparoscopic tubal surgery and mapping of cognitive load. STUDY DESIGN: Prospective cohort study conducted at the Imperial College Virtual Reality Surgical Skills laboratory amongst 25 trainees and nine senior gynaecologists. Participants performed two sessions of salpingectomy and salpingotomy procedures on a VR simulator to assess construct validity. Nine novices performed ten such sessions to enable assessment of the learning curve. The relationship between cognitive load and the dexterity parameters was assessed. Simulator fidelity was reported by experienced and intermediate level gynaecologists. Statistical analyses utilised non-parametric tests, Kruskall-Wallis and Mann-Whitney U tests. Learning curves were assessed using the Friedman test and Wilcoxon Signed Ranks test. Relationship between dexterity metrics and cognitive load was performed using Spearman's rank order correlation. RESULTS: Salpingectomy demonstrated construct validity for time taken by experienced, intermediate and novice gynaecologists (median 170 vs. 191 vs. 313s (P=0.003) respectively) and movements (median 200 vs. 267 vs. 376s, P=0.045). Salpingotomy demonstrated construct validity for time taken (median 183 vs. 191 vs. 306s, P=<0.001) and movements (median 210 vs. 233 vs. 328s, P=0.005). Learning curve analysis for salpingectomy displayed a plateau for time taken after the eighth session, and the fourth session for movements. Salpingotomy displayed a plateau after the eighth session for both time taken and movements. Cognitive load correlated significantly with dexterity parameters. The fidelity scores were not significantly different between the two procedures (P=0.619). CONCLUSION: The LAP Mentor VR laparoscopic simulator is a valid and effective tool for training novice surgeons in ectopic pregnancy surgery. Reduction in cognitive load significantly correlates with the learning curves.

A national survey of senior trainees surgical experience in hysterectomy and attitudes to the place of vaginal hysterectomy.

We set out to determine the current status of training in vaginal hysterectomy in the UK. In total, 255 year 4 or 5 'Calman' trainees were identified and sent an anonymous questionnaire assessing surgical experience, quality of training and attitudes towards vaginal hysterectomy. Our results demonstrate that senior trainees' experience in vaginal as opposed to abdominal hysterectomy is relatively poor. Despite this, trainees believed that the majority of hysterectomies should be done vaginally, and only a minority, laparoscopically.

Randomized, prospective, double-blind comparison of abdominal and vaginal hysterectomy in women without uterovaginal prolapse.

BACKGROUND: To determine under controlled conditions whether there are significant differences in the duration of hospitalization and recovery between abdominal and vaginal hysterectomy for indications other than uterovaginal prolapse. METHOD: In a two-center prospective, double-blind randomized trial, 36 women with dysfunctional uterine bleeding, uterine fibroids or pelvic pain scheduled for hysterectomy were randomized to abdominal or vaginal hysterectomy. The primary outcome measure was the duration of hospital stay. Secondary outcome measures included analgesic requirements and return to normal health and function. RESULTS: There were no significant differences in peri-operative patient or surgical characteristics. Vaginal hysterectomy was associated with a reduction in hospital stay compared to abdominal hysterectomy (median stay 3 days vs. 5 days, p = 0.01). In addition, patients undergoing vaginal hysterectomy had reduced analgesic requirements (mean 75.4 mg vs. 131.4 mg morphine equivalent, p = 0.002), shorter need for intravenous hydration (mean 25.3 h vs. 32.7 h, p = 0.05), and faster return of bowel action (median 3 days vs. 4 days, p = 0.002). They also returned to normal domestic activities (mean 4.6 weeks vs. 8.5 weeks, p = 0.01) and work (mean 7.0 weeks vs. 13.9 weeks, p = 0.005), and completed their recovery (mean 7.9 weeks vs. 16.9 weeks, p = 0.008) more quickly. CONCLUSIONS: Vaginal hysterectomy was associated with significant benefits in terms of reduced hospital stay and improved patient recovery. Vaginal hysterectomy should be the route of choice not only for women with genital tract prolapse but also those without.

The use of intrauterine insemination in Australia and New Zealand.

BACKGROUND: There is good evidence in the literature in favour of intrauterine insemination (IUI) as the most cost-effective treatment for unexplained and moderate male factor subfertility. However there is no published data on whether this evidence is being translated into clinical practice. METHODS: We identified fertility centres within Australia and New Zealand registered with the Reproductive Technology Accreditation Committee of the Fertility Society of Australasia. Thirty-seven of these units were then sent a postal survey to establish current clinical practice. RESULTS: Nearly a third of centres promote IVF as first-line treatment even in the presence of patent tubes and normal semen while, when semen parameters are reduced, IUI is rarely considered. One in five (20%) units remain unconvinced of the cost-effectiveness of IUI. When IUI is used, it is virtually always combined with ovarian stimulation with marginally more units using clomiphene citrate than gonadotrophins. CONCLUSIONS: Although it may take relatively more treatment cycles to achieve pregnancy, there are considerable advantages to the patient in terms of risk/benefit ratio and financial cost associated with IUI compared with IVF. In the current climate of evidence-based medicine, as clinicians we are obliged to translate this into our practice. It appears from our survey that in many units this is not happening.