Training of young medical professionals: implementation of modern training concepts, taking into account the changed framework conditions for training-a pilot project for operational subjects.

INTRODUCTION: For years, generations of medical students have complained that practice-oriented learning is neglected in medical studies. Further training assistants also complain about limited opportunities to learn subject-specific practical activities. MATERIAL AND TECHNIQUES: We are presenting a pilot project at the University Women's Hospital in Homburg, in which medical students complete an endoscopic hands-on course as part of the block internship gynaecology and obstetrics. During the course the students perform classic skills training and hand-eye coordination exercises and learn the first steps in endoscopic suturing (suture and rows of knots). The training concepts used can be implemented on simple boxing trainers and can therefore also be reproduced in clinics or in a private setting. OUTCOME: Altogether, 73 medical students did participate in the laparoscopy course. We were able to prove that the knotting time for a simple knot can be reduced from an average of 247 s to 40 s (80%) after completing our training programme. Based on the evaluation sheet that the students filled out after the course, we found a very-high acceptance for surgical simulation training within the student cohort. DISCUSSION: Practical surgical exercises can complement the curriculum well and, as we can show with our work, are rated very positively by the students. For students in higher semesters, such practical courses can also provide an insight into the respective subject area and thus counteract the lack of skilled workers in surgical subjects. The practical year should not be the first contact with these practical courses, as at this timepoint a certain favoured subject has often already being chosen by the students.

Vaginal operative delivery in Germany: a national survey about experience and self-reported competency.

BACKGROUND: To determine German obstetricians' self-perceived experience with vacuum and forceps deliveries. PATIENTS AND METHODS: Using a web-based survey, German obstetricians were invited to participate in a survey. This survey was approved by the German society of obstetrics and gynecology. RESULTS: Surveys of 635 obstetricians were received. All obstetricians reported performing significantly less forceps than vacuum deliveries. Almost all obstetricians want to perform more delivery, which indicates the willingness to learn both. More obstetricians felt confident to perform vacuum than forceps. In a similar obstetrical indication, most of the obstetricians would prefer to perform a vacuum assisted delivery. The majority of the obstetricians wished to receive more training in vaginal operative deliveries. CONCLUSION: Most of the German obstetricians prefer to use vacuum-assisted vaginal deliveries and feel less confident to perform forceps deliveries. Standardized training to improve the quality of care is recommended.

Intraoperative and postoperative complications of gynecological laparoscopic interventions: incidence and risk factors.

PURPOSE: The aims of this study were to determine the incidence of intraoperative and postoperative complications of laparoscopic gynecological interventions and to identify risk factors for such complications. METHODS: All patients who underwent laparoscopic interventions from September 2013 to September 2017 at the Department of Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital were identified retrospectively using a prospectively compiled clinical database. Binary logistic regression analysis was used to identify independent risk factors for intra- and postoperative complications. RESULTS: Data from 3351 patients were included in the final analysis. Overall, 188 (5.6%) intraoperative and 219 (6.5%) postoperative complications were detected. On multivariate analysis, age [odds ratio (OR), 1.03; 95% confidence interval (CI) 1.01-1.04], surgery duration (OR, 1.02; 95% CI 1.02-1.03), carbon dioxide use (OR, 0.99; 95% CI 0.99-1.00), and surgical indication (all p ≤ 0.01) were independent risk factors for intraoperative and duration of surgery (OR, 1.01; 95% CI 1.01-1.02; p ≤ 0.01), carbon dioxide use (OR, 0.99; 95% CI 0.99-1.00; p ≤ 0.01), hemoglobin drop (OR, 1.41; 95% CI 1.21-1.65; p ≤ 0.01), and ASA status (p = 0.04) for postoperative complications. CONCLUSION: In this large retrospective analysis with a generally low incidence of complications (5.6% intraoperative and 6.5% postoperative complications), a representative risk collective was identified: Patients aged > 38 years, surgery duration > 99 min, benign or malignant adnex findings were at higher risk for intraoperative and patients with surgery duration > 94 min, hemoglobin drop > 2 g/dl and ASA status III at higher risk for postoperative complications.

Teaching breast ultrasound skills including core-needle biopsies on a phantom enhances undergraduate student's knowledge and learning satisfaction.

PURPOSE: To investigate whether a training program on breast ultrasound skills including core-needle biopsies to undergraduate students can improve medical knowledge and learning satisfaction. METHODS: Medical students attending mandatory classes at the Medical School of the University of Saarland received a supplemental theoretical and hands-on training program on ultrasound (US) breast screening and on US-guided core-needle biopsy using an agar-agar phantom. Experienced breast specialists and ultrasound examiners served as trainers applying Peyton's 4-step training approach. The students' theoretical knowledge and hands-on skills were tested before and after the training program, using a multiple-choice questionnaire (MCQ), the Objective Structured Clinical Examination (OSCE) and a student curriculum evaluation. RESULTS: The MCQ results showed a significant increase of the student's theoretical knowledge (50.2-75.2%, p < 0.001). After the course, the OSCE showed a mean total of 17.3/20 points (86.5%), confirming the practical implementation of the new skills. The student curriculum evaluation in general was very positive. A total of 16/20 questions were rated between 1.2 and 1.7 (very good) and 3 questions were rated as 2.1 (good). CONCLUSION: Undergraduate student's medical education can be enhanced by teaching breast US skills.

Survey of current practices and opinions of German Society of Gynecologic Endoscopy members regarding the treatment of ovarian neoplasia by robotic surgery.

PURPOSE: As data on this topic are sparse and contradictory, we aimed to ascertain the opinions of the members of the German Society of Gynecologic Endoscopy (AGE) regarding the use of robotic surgery in the treatment of ovarian malignancies. METHODS: In 2015, an anonymous questionnaire was sent to AGE members to assess their views on the treatment of ovarian malignancies by robotic surgery according to T stage and the current treatment practices in their facilities. RESULTS: Of the 228 respondents, 132 (58%) were fellows or attending physicians and 156 (68%) worked at university hospitals or tertiary referral centers. Most [n = 218 (96%)] respondents reported treating < 10% of their patients using robotic surgery. Respondents felt that T1 and borderline ovarian tumors, but not T2 (51%) or T3/4 (76%) tumors, should and could be treated by robot surgery. 162 (71%) respondents considered the currently available data on this subject to be insufficient, and 42% indicated their willingness to participate in clinical studies on the applicability of robotic surgery to the treatment of T1/2 ovarian tumors. CONCLUSION: The majority of AGE members surveyed considered robotic surgery to be an option for the treatment of T1 ovarian malignancies and borderline ovarian tumors. However, prospective randomized studies are needed to determine the relevance of robotic surgery in this context.

Teaching undergraduate students gynecological and obstetrical examination skills: the patient's opinion.

INTRODUCTION: Our study assesses the patients' opinion about gynecological examination performed by undergraduate students (UgSts). This assessment will be used in improving our undergraduate training program. A positive opinion would mean a lower chance of a patient refusing to be examined by a tutor or student, taking into account vaginal examination (VE). MATERIALS AND METHODS: We performed a prospective cross-sectional survey on 1194 patients, consisting of outpatient and inpatient at the departments of obstetrics and gynecology from November 2015 to May 2016. The questionnaire consisted of 46 questions. Besides demographic data, we assessed the mindset of patients regarding the involvement of undergraduate student (UgSt) in gynecological and obstetrical examinations. We used SPSS version 23 for the statistical analysis. For reporting the data, we followed the STROBE statement of reporting observational studies. RESULTS: The median age was 38 years having a median of one child. 34% presented due to obstetrical problems, 38% due to gynecological complaints, and 19% due to known gynecological malignancies. Generally, we retrieved a positive opinion of patients towards the involvement of students in gynecological and obstetrical examination under supervision in 2/3 of the cases. CONCLUSIONS: There is no reason to exclude medical UgSts from gynecological and obstetrical examinations after obtaining a written or oral consent.

Efficacy and safety of two post-operative drains: results of a prospectively randomized clinical study in breast cancer patients after breast conserving surgery.

OBJECTIVE: To compare the efficacy and safety of two post-operative drains in breast cancer patients after breast conserving surgery. METHODS: This was a prospectively randomized comparative study of two drains investigated in breast cancer patients after breast conserving therapy. The Redon drain ends in a tip with 28 double perforations while the Quadrain drain features 4 flexible flaps of about 0.15 m length. The drains cost 0.28 € and 3.54 €, respectively. Primary target parameter was the duration of the drains staying in the surgical site. Secondary target parameters were pain post-surgery, seroma volume, final cosmetic result and surgical site infections. RESULTS: A total of 88 patients were randomized, 47 and 41 received the Redon drain and the Quadrain drain, respectively. The mean duration of the drains staying in the surgical site was not different between the Redon and the Quadrain drain, 42.6 h (± 25.8 h) and 50.1 h (± 28.5 h), respectively (p = 0.1959). The post-operative pain score, seroma size, cosmetic result and surgical site infections were not different for both systems. CONCLUSION: The Redon drain and the new Quadrain drain were not significantly different with respect to duration in the surgical site, post-operative pain, seroma volume and cosmetic result.

Introduction of a student tutor-based basic obstetrical ultrasound screening in undergraduate medical education.

BACKGROUND: While there is an increasing interest in incorporating ultrasound in undergraduate medical education and the use of student tutors in conveying this medical skill to assist faculty members, little is known about undergraduate ultrasound teaching in obstetrics and gynecology. METHODS: After a 3 week training of the student tutors, the student tutors joined an undergraduate ultrasound educational program to teach practical round students. After being certified, the student tutors organized a pre-test, gave a presentation about ultrasound, and then supervised the hands on ultrasound course under faculty staff supervision for round students. Finally, the practical round students had to answer a post-test with image recognition. The practical round students had to evaluate the course using a Likert scale. RESULTS: 111 students joined this ultrasound course. The objective theoretical and practical multiple-choice questions' (MCQ) test showed a statistically significant improvement (50 vs. 90%, p < 0.05). The practical round students expressed a high acceptance (Likert 1.7) and subjective medical skill learning (Likert 1.8). The students also positively graded the student tutors (Likert 1.3). CONCLUSION: Student tutor-based undergraduate obstetrical and gynecological ultrasound course is a useful method to teach a medical skill and is well accepted by students.

Impact of different intraoperative CO2 pressure levels (8 and 15 mmHg) during laparoscopic hysterectomy performed due to benign uterine pathologies on postoperative pain and arterial pCO2 : a prospective randomised controlled clinical trial.

OBJECTIVE: To compare the effects of two different intraoperative CO2 pressures (8 and 15 mmHg) during laparoscopic hysterectomy for benign uterine pathologies in terms of postoperative abdominal and shoulder pain, laparoscopy-mediated vegetative alterations, pain medication requirement, arterial CO2 pressure (pCO2 ), surgical parameters, and safety. DESIGN: Prospective randomised controlled study. SETTING: German university hospital. POPULATION: Female patients undergoing laparoscopic hysterectomy for benign uterine pathologies. METHODS: Patients were randomised to a standard pressure (SP; 15 mmHg, control) or low-pressure (LP; 8 mmHg, experimental) group. MAIN OUTCOME MEASURES: Primary outcomes were postoperative abdominal and shoulder pain intensities, measured via numeric rating scale (NRS) and vegetative parameters (fatigue, nausea, vomiting, bloating) at 3, 24, and 48 hours postoperatively. Secondary outcomes were pain medication requirement (mg) and arterial pCO2 (mmHg). Surgical parameters and intra- and postoperative complications were also recorded. RESULTS: In total, 178 patients were included. Patients in the LP group (n = 91) showed significantly lower postoperative abdominal and shoulder pain scores, fewer vegetative alterations, lower pain medication requirements, a shorter postoperative hospitalization, and lower intra- and postoperative arterial pCO2 values compared with the SP group (n = 87; P ≤ 0.01). No differences in intra- and postoperative complications were observed between groups. CONCLUSIONS: Low-pressure laparoscopy seems to be an effective and safe technique for the reduction of postoperative pain and laparoscopy-induced metabolic and vegetative alterations following laparoscopic hysterectomy for benign indications. TWEETABLE ABSTRACT: Low-pressure laparoscopy seems to be an effective and safe technique for reduction of pain following laparoscopic hysterectomy.

Pilot study: placental biomarker predictive capability (sFlt-1, PlGF and their ratio) of postpartum maternal outcome.

BACKGROUND: Prenatal measurement of placental biomarkers was able to improve screening and diagnosis of preeclampsia. Little is known about the clinical role of placental biomarkers in the postpartum period. METHODS: This study is a prospective monocentric trial that included a total of 30 women with preeclamptic pregnancies. Serum placental biomarkers including soluble fms-like tyrosine kinase 1 (sFlt-1) and placental growth factor (PlGF) were measured before and 2 h after delivery by Enzyme-Linked Immunosorbent Assay (ELISA) using commercially available kits according to manufacturer's instructions and correlated with the postpartum outcome. RESULTS: Postpartum higher serum PlGF level was associated with postpartum elevation of the systolic blood pressure. Yet, the placental biomarkers were not able to predict general worsening of postpartum preeclampsia or other individual clinical or laboratory parameters. CONCLUSION: Serum concentrations of sFlt-1 and PlGF or their ratio in our study cohort did not completely predict the occurrence of postpartum preeclampsia. Yet, postpartum higher serum PlGF level was associated with postpartum elevation of the systolic blood pressure.

Endoscopic surgery: talent or training?

PURPOSE: There are two groups of undergraduate students involved in endoscopic surgery with different degrees of experience: average and more experience. This study proves whether the subjective impression of the laparoscopic trainer is verifiable and which factors influence extreme talent. METHODS: 21 medical students of the eighth term of the University of Witten-Herdecke participated in the study. On their first course day, students got instructed in suturing and knot technique. They were then required to tie a maximum of five knots within 2 h. After a week, students repeated this procedure. Time used for tying knots was stopped. RESULTS: Regarding the time students used for their first knots, great differences were provable (7-8 min, average 23 min). However, an adaption of the knotting time was noticed at the end of the first course day. This was confirmed during the second course day. Neither acquired factors (music, sport, etc.) nor individual factors (visual acuity, handedness, etc.) had any impact on the time used for knotting. Merely, one advantage was seen with the first knots with the factors of playing the guitar and having a more than 10-h surgical previous experience. Knotting times leveled off at 95% to less than 10 min, though. DISCUSSION: Neither normally talented nor extremely talented junior surgeons could be noticed, and so could not the co-factors providing an advantage or disadvantage for surgery, respectively. All prospective surgeons can learn defined tasks (knots) by short interval training, and thus show similarly good results after a few repetitions.

Association between alterations in DNA methylation level of spermatozoa at CpGs dinucleotide and male subfertility problems.

The purpose of this study was to assess the relationship between alterations in sperm DNA methylation levels and sperm count and sperm motility. Five CpG sites underwent deep bisulphite sequencing to validate the observed methylation difference in 78 samples (28 proven fertile males "controls," and 50 subfertile males "cases"). The results showed that variation in methylation levels was found in more than one CpG: the DNA methylation levels in CpG1, CpG2 and CpG3 of the PRRC2A gene-related amplicon showed high significant differences in the case group compared to the control group (p ≤ .0001, p ≤ .003, and p ≤ .0001 respectively). Moreover, three CpGs of the four CpGs tested within the ANXA2 gene-related amplicon (CpG1, CpG3 and CpG4) were significantly different (p ≤ .002, p ≤ .001, and p ≤ .0001, respectively) in the case group compared to the control group. In addition, a significant difference was found in seven CpGs of the twenty-two CpGs tested within the MAPK8Ip3 gene-related amplicon, besides six CpGs of the ten CpGs tested within the GAA gene-related amplicon between case and control groups. In conclusion, this study identifies that CpGs have a significantly different in methylation levels of sperm DNA for subfertile males.

Aberrant DNA methylation patterns of human spermatozoa in current smoker males.

The purpose of this study was to investigate the impact of current cigarette smoking on sperm DNA methylation patterns. A total of 108 males (51 current smokers and 57 never smoked males) were included in the study. Using 450 BeadChip Arrays, the differentially methylated CpGs between current smokers (n=15) and never smoked males (n=15) were identified. Out of significantly 11 CpGs identified, 2 CpGs namely cg07869343 and cg19169023, which are located in the MAPK8IP3 and TKR genes were selected for further analysis. Using deep bisulfite sequencing in an independent cohort of current smokers (n=36) and never smoked males (n=42), 6 and 1 CpGs showed a significant difference in the MAPK8IP (CpG3, CpG5, CpG6, CpG7, CpG8, and CpG21) and in the TKR (CpG4) were identified, respectively (P≤0.05). Our results indicate that cigarette smoking causes biochemical changes in the sperm DNA methylation in many regions and could adversely affect semen parameters.

Spermatozoa from males with reduced fecundity exhibit differential DNA methylation patterns.

Infertility affects 10-15% of couples, and approximately 50% of cases are linked to male factor infertility. The purpose of this study was to evaluate the DNA methylation patterns in spermatozoa from males who are suffering from a reduction in fecundity. Thirty samples were subjected to 450K arrays as a screening study to evaluate the variation in sperm DNA methylation levels between cases and controls groups, and then four CpG sites (cg05799088, cg07227024, cg16338278, and cg08408433) underwent to deep bisulfite sequencing to validate the observed methylation differences in 111 samples (56 proven fertile males as 'controls' and 55 males suffering from a reduction in fecundity as 'cases'). A significant difference in the mean methylation level was found between cases and controls in the CpGs of PRICKLE2 gene-related amplicon (CpG1, p ≤ 0.002, and CpG2, p ≤ 0.004) and CpG of ALS2CR12 gene-related amplicon (CpG1, p ≤ 0.015, and CpG2, p ≤ 0.009). Besides, a significant difference was found at seven from thirteen CpGs tested in the ALDH3B2 gene amplicon CpG2, CpG6, CpG9, CpG10, CpG11, CpG12, and CpG13 (p ≤ 0.005, p ≤ 0.004, p ≤ 0.012, p ≤ 0.028, p ≤ 0.012, p ≤ 0.009, and p ≤ 0.001, respectively). In addition, the results showed that nine CpGs out of the twenty-six within the PTGIR gene-related amplicon (CpG4, CpG6, CpG8, CpG9, CpG11, CpG15, CpG19, CpG23, and CpG26) had a significant difference in their mean methylation level (p ≤ 0.006, p ≤ 0.009, p ≤ 0.003, p ≤ 0.003, p ≤ 0.007, p ≤ 0.002, p ≤ 0.018, p ≤ 0.018, and p ≤ 0.040, respectively) in the case vs. CONTROL GROUP: In conclusion, an alteration in the methylation levels of sperm DNA from males with reduced fecundity was observed. In addition, an association between changes in the methylation level for these CpGs and different semen parameters has been found.

What Are the Advantages of 3D Cameras in Gynaecological Laparoscopy?

Introduction Minimally invasive operative techniques are being used increasingly in gynaecological surgery. The expansion of the laparoscopic operation spectrum is in part the result of improved imaging. This study investigates the practical advantages of using 3D cameras in routine surgical practice. Materials and Methods Two different 3-dimensional camera systems were compared with a 2-dimensional HD system; the operating surgeon's experiences were documented immediately postoperatively using a questionnaire. Results Significant advantages were reported for suturing and cutting of anatomical structures when using the 3D compared to 2D camera systems. There was only a slight advantage for coagulating. The use of 3D cameras significantly improved the general operative visibility and in particular the representation of spacial depth compared to 2-dimensional images. There was not a significant advantage for image width. Depiction of adhesions and retroperitoneal neural structures was significantly improved by the stereoscopic cameras, though this did not apply to blood vessels, ureter, uterus or ovaries. Conclusion 3-dimensional cameras were particularly advantageous for the depiction of fine anatomical structures due to improved spacial depth representation compared to 2D systems. 3D cameras provide the operating surgeon with a monitor image that more closely resembles actual anatomy, thus simplifying laparoscopic procedures.

Safety and perioperative morbidity of laparoscopic sacropexy: a systematic analysis and a comparison with laparoscopic hysterectomy.

PURPOSE: The high prevalence of Pelvic Organ Prolapse (POP) along with the demographic trend of the ageing population raises the value of sacropexy in the treatment of POP. Thus, efforts to decrease risks associated with this procedure have the potential for public health impact. We examined the perioperative morbidity of laparoscopic sacropexy regarding the surgical access and compared it with the morbidity of one of the most common gynecological procedure, the laparoscopic hysterectomy. Our aim was to prove the safety of laparoscopic sacropexy. METHODS: A retrospective evaluation of 80 consecutive laparoscopic sacropexies performed from Sept. 2012 until Oct. 2014 and 126 laparoscopic hysterectomies for a benign indication were undertaken. We assessed the anatomical outcome and the intra- and postoperative complications using the classification system according to Clavien-Dindo (CD). RESULTS: Apical success rate after sacropexy was 100% and global success rate was 95% (POP-Q stage ≤1). The decline in hemoglobin was low in both groups and showed no statistically significant differences. Both operative time (P < 0.001) and the duration of hospitalization (P < 0.001) were longer in case of a sacropexy. Although overall intraoperative complications seemed more frequent during a sacropexy, differences were not statistically significant. Both early and late postoperative complications showed a higher rate of mild complications (CD-I/II) and a lower rate of severe complications (CD-IIIa/IIIb) after a sacropexy. The differences were not statistically significant. CONCLUSION: The laparoscopic sacropexy represents a safe procedure with good anatomical outcome. Despite higher technical severity, it doesn't seem to bare higher risks for perioperative morbidity than the laparoscopic hysterectomy does.

Conversion of intraperitoneal cytology during laparoscopic surgery of uterine cancer.

INTRODUCTION: The laparoscopic surgery of uterine cancer is an oncological safe treatment option in early stage cancer. However, there are no data about whether laparoscopy can lead to intraperitoneal tumor cell dissemination. We aimed in our study to detect a possible cytological conversion during laparoscopic procedures. METHODS: In this prospective study, we included all patients receiving laparoscopic treatment at the early stage endometrial and cervical cancer in the Department of Obstetrics and Gynecology at the University of the Saarland and obtained peritoneal wash for cytological examination at the beginning and at the end of laparoscopic surgery. All patients received stage-adjusted operative and adjuvant therapy. RESULTS: We enrolled 43 patients [endometrial cancer (n = 24) and cervical cancer (n = 19)]. At the beginning of the operation, one patient with endometrial cancer and one patient with cervical cancer showed a positive cytology. One tumor cell conversion from negative to positive cytology during surgery was detected in a patient suffering from endometrial cancer stage FIGO Ia. The median duration of surgery was 191.8 ± 79.3 min. The average time of follow-up was 16.5 ± 10.3 month. At the end of data evaluation at December 2014, two patients (8.6 %) are suffering from recurrent disease, two patients died, none of these patients had a positive cytology. All patients with positive cytology are free of cancer. CONCLUSION: During laparoscopic surgery of early stage endometrial and cervical cancer, only one conversion of cytology was detected, which proves that laparoscopy does not appear to increase the intraoperative tumor cell dissemination or rate of positive cytological results.