Analysis of the operative factors related to anal exhaust time after laparoscopic surgery for benign gynecological diseases.

PURPOSE: The study seeks to determine surgical factors related to anal exhaust in patients treated with laparoscopic surgery for benign gynecological diseases and to explore measures that effectively promote the rapid recovery of intestinal function in these patients. METHODS: From June 2017 to August 2018, 155 patients with benign gynecological diseases who underwent laparoscopic surgery in our hospital were selected as study subjects. Patients were divided into two groups based on anal exhaust time: the ≤ 24-hour group and > 24-hour group. Factors related to the operation were statistically analyzed for all patients. Chi-squared tests and logistic regression were used for univariate and multivariable analyses. RESULTS: Of 155 gynecological patients, 57 (36.8%) underwent laparoscopic ovarian cyst stripping, 48 (30.9%) underwent laparoscopic salpingectomy with/without oophorectomy, and 50 (32.3%) underwent laparoscopic myomectomy. Among all patients, 62 (40.0%) and 93 (60.0%) had anal exhaust within and after 24 h, respectively. Univariate analysis results revealed differences in the operation method (P = 0.040), intraoperative blood loss (P = 0.037), operation duration (P = 0.007), whether an abdominal drainage tube was placed (P = 0.012) and whether warm saline was used (37 °C) for abdominal washing (P = 0.013) between groups. Logistic regression analysis showed that the duration of the operation (P = 0.027) and whether warm saline was used for abdominal washing (P = 0.040) were the main factors affecting anal exhaust time. CONCLUSION: During laparoscopy for patients with benign gynecological diseases, abdominal washing with warm water is an important factor that promotes early postoperative anal exhaust and is worthy of use in clinical practice.

Role of tubal surgery in the era of assisted reproductive technology: a committee opinion.

This document reviews surgical options for reparative tubal surgery and the factors that must be considered when deciding between surgical repair and in vitro fertilization. This document replaces the document of the same name, last published in 2012 (Fertil Steril 2015;103:e37-43). This document reviews surgical options for reparative tubal surgery and the factors that must be considered when deciding between surgical repair and in vitro fertilization.

Peritoneal reimplantation of trophoblastic tissue following laparoscopic treatment of ectopic pregnancy: A case report and review of literature.

Reimplantation of trophoblastic tissue in the abdomen after treatment of an ectopic pregnancy is rarely reported but is very likely an underestimated complication to laparoscopy. We present a case report and review of the literature. A total of 25 cases of reimplantation of trophoblastic tissue following laparoscopic removal of ectopic pregnancy (EP) have been reported in the period January 1989 to January 2018 including our case. No cases have been reported before 1989. The use of salpingostomy vs. salpingectomy as the primary treatment of EP prior to the complication is comparable. In approximately half of the cases the reimplanted trophoblastic tissue was placed in the peritoneum and the rest in the omentum, on the bowel, in the uterosacral ligament and on the uterine body. During surgery it is important to remove all pathologic tissue and the Trendelenburg position should be considered avoided. Treatment using a single-dose Methotrexate should be performed when there is a potential risk of retaining tissue or if the serum human chorionic gonadotropin (S-hCG) is insufficiently decreasing after surgery. All patients treated for an ectopic pregnancy should be considered monitored until S-hCG is undetectable.

Preoperative Practice Paired With Instructor Feedback May Not Improve Obstetrics-Gynecology Residents' Operative Performance.

BACKGROUND: There is evidence that preoperative practice prior to surgery can improve trainee performance, but the optimal approach has not been studied. OBJECTIVE: We sought to determine if preoperative practice by surgical trainees paired with instructor feedback improved surgical technique, compared to preoperative practice or feedback alone. METHODS: We conducted a randomized controlled trial of obstetrics-gynecology trainees, stratified on a simulator-assessed surgical skill. Participants were randomized to preoperative practice on a simulator with instructor feedback (PPF), preoperative practice alone (PP), or feedback alone (F). Trainees then completed a laparoscopic salpingectomy, and the operative performance was evaluated using an assessment tool. RESULTS: A total of 18 residents were randomized and completed the study, 6 in each arm. The mean baseline score on the simulator was comparable in each group (67% for PPF, 68% for PP, and 70% for F). While the median score on the assessment tool for laparoscopic salpingectomy in the PPF group was the highest, there was no statistically significant difference in assessment scores for the PPF group (32.75; range, 15-36) compared to the PP group (14.5; range, 10-34) and the F group (21.25; range, 10.5-32). The interrater correlation between the video reviewers was 0.87 (95% confidence interval 0.70-0.95) using the intraclass correlation coefficient. CONCLUSIONS: This study suggests that a surgical preoperative practice with instructor feedback may not improve operative technique compared to either preoperative practice or feedback alone.

Tips and Tricks for Performing Salpingectomy at the Time of Laparoscopic Hysterectomy.

STUDY OBJECTIVE: To demonstrate various techniques to perform salpingectomy efficiently at the time of laparoscopic hysterectomy. DESIGN: Step-by-step explanation of the techniques by video with narration (educational video) (Canadian Task Force Classification III). INTERVENTION: Salpingectomy at the time of laparoscopic hysterectomy. MEASUREMENTS AND MAIN RESULTS: Ovarian cancer is the deadliest gynecologic malignancy and has no effective screening strategies for average-risk women. After recognizing that the origin site for pelvic serous carcinomas may be the fallopian tube, the Society of Gynecologic Oncology published a practice statement in November 2013 addressing the role of salpingectomy at the time of hysterectomy or other pelvic surgery in average-risk women. (https://www.sgo.org/clinical-practice/guidelines/sgo-clinical-practice-statement-salpingectomy-for-ovarian-cancer-prevention). They now recommend that these women consider opportunistic salpingectomy to reduce their risk of fallopian tube and ovarian cancers. Various techniques allow the surgeon to complete the salpingectomy in a highly efficient manner. CONCLUSION: Salpingectomy at the time of laparoscopic hysterectomy or other pelvic surgery should be considered in women at average risk of ovarian cancer. Salpingectomy can be performed either before or after control of the uterine blood supply. The surgical approach must also consider the coexisting pelvic pathology. Efficient dissection occurs if the surgeon maximizes exposure to the fallopian tube, optimizes presentation of the tissue to the working instrument, and provides gentle yet constant traction with accompanying countertraction. The fallopian tube specimen should be removed immediately to prevent its loss in the pelvis.

Traditional Versus Simulation Resident Surgical Laparoscopic Salpingectomy Training: A Randomized Controlled Trial.

STUDY OBJECTIVES: To evaluate the effectiveness of the porcine training model for obstetrics-gynecology (OB/GYN) residents in laparoscopic salpingectomy. DESIGN: Randomized, controlled single-blinded trial. CLASSIFICATION: Canadian Task Force Classification I. SETTING: A large community-based teaching hospital. PARTICIPANTS: All postgraduate year 1 through year 4 OB/GYN residents were enrolled (n = 22). INTERVENTION: All participants underwent a preintervention objective skills assessment test (OSAT), in which the participant performed live human laparoscopic salpingectomy. Residents were randomly assigned (using a computer-generated randomization table, in blocks of 2, stratified by ranked baseline OSAT scores) to the intervention or control group. The intervention group consisted of 1 educational session with presession assigned reading, a 40-min didactic lecture, viewing of a procedural video, and simulation and practice of laparoscopic salpingectomy on a porcine cadaver. The control group received traditional training per routine residency rotations. MEASUREMENTS AND MAIN RESULTS: Laparoscopic salpingectomy was performed on live patients by study participants pre- and postintervention. These procedures were video recorded, and then scored by a single blinded evaluator of the OSATs. Nine pre- and postintervention OSAT indicators, reflecting provider knowledge and skill, were the primary outcome measures. Secondary outcomes were the changes in 10 subjective measures of comfort, assessed by a pre- and postintervention survey. The outcomes were assessed using 5-point Likert scales (for OSATs 1 = lowest score; for the subjective survey 1 = highest score). The control group OSAT scores did not change (pre: 26.6 ± 10.8, post: 26.2 ± 10.1; p = .65). There were significant improvements in 2-handed surgery (pre: 2.8 ± 1.6, post: 3.5 ± 1.3; p = .004) and use of energy (pre: 2.9 ± 1.3, post: 3.6 ± 1.0; p = .01) in the intervention group, contributing to an overall score change (pre: 26.7 ± 10.6, post: 29.9 ± 9.8; p ≤ .001). The control group had no change in comfort levels. The intervention group experienced both increases (anatomy, steps of surgery, 2-handed surgery, and use of energy) and decreases (reading and learning in operating room) in reported comfort levels. CONCLUSION: This study demonstrates that simulation can improve surgical technique OSATs. However, of 45 possible points, both groups' average scores were <70% of the optimum. Thus, the improvement, although statistically significant, was relatively small and indicates that further supplementation in training is needed to substantially increase the residents' surgical skills.

[Feasibility of opportunistic salpingectomy at the time of vaginal hysterectomy for benign pathology and evaluation of occult tubal lesions prevalence: Preliminary study]. / Faisabilité de la salpingectomie prophylactique lors d'une hystérectomie d'indication bénigne par voie vaginale et évaluation de la prévalence des lésions tubaires occultes : étude préliminaire.

AIM: To assess the feasibility of prophylactic salpingectomy during vaginal hysterectomy for benign pathology and the prevalence of occult tubal lesions. MATERIALS AND METHODS: In this prospective study from 09/01/2013 to 11/01/2014, patients who underwent vaginal hysterectomy with salpingectomy or salpingo-oophorectomy were included. The prevalence of bilateral salpingectomy with or without ovariectomy and the prevalence of histopathological and immunohistochemical (p53 expression) abnormalities were evaluated. RESULTS: Bilateral salpingectomy was performed in 51/69 patients (73.9%). An elevated BMI was statistically associated with a failure of the salpingectomy (29.4 vs 25.8; P=0.01). There was only one case of postoperative hemorrhage in the salpingectomy group. On the 51fallopian tubes, there were 4 (12.9%) immunohistochemical abnormalities "p53 signature". CONCLUSION: The recent tubal origin of most ovarian cancer cases raised the question of the prophylactic salpingectomy in the population with genetic risk as well as in the general population. Bilateral salpingectomy may be performed during vaginal hysterectomy. However caution is needed because we do not know what is the exact evolution of the p53 signatures.

[Urinary, infectious and digestive adverse events related to benign hysterectomy and the associated surgery on the Fallopian tube: Guidelines]. / Hystérectomies d'indication bénigne: complications viscérales et gestes associés sur les annexes: recommandations.

OBJECTIVES: To provide clinical practice guidelines from the French College of Obstetrics and Gynecology (CNGOF) based on the best evidence available, concerning the urinary, infectious and digestive adverse events related to benign hysterectomy and the associated surgery including opportunistic salpingectomy and adnexectomy. MATERIAL AND METHOD: Review of literature using following keywords: benign hysterectomy; urinary injury; bladder injury; ureteral injury; vesicovaginal fistula; infection; bowel injury; salpingectomy. RESULTS: Urinary catheter should be removed before 24h following uncomplicated hysterectomy (grade B). In case of urinary catheter during hysterectomy, immediate postoperative removal is possible (grade C). No hemostasis technics can be recommended to avoid urinary injury (grade C). There is not any evidence to recommend to perform a window in the broad ligament or an ureterolysis, to put ureteral stent or a uterine manipulator in order to avoid ureteral injury. An antibiotic prophylaxis by a cephalosporin is always recommended (grade B). Mechanical bowel preparation before hysterectomy is not recommended (grade B). If there is no ovarian cyst/disease and no familial or personal history of ovarian/breast cancer, ovarian conservation is recommended in premenopausal women (grade B). In postmenopausal women, informed consent and surgical approach should be taken in account to perform a salpingo-oophorectomy. Since the association salpingectomy and hysterectomy is not assessed in the prevention of ovarian cancer, systematic bilateral salpingectomy is not recommended (expert consensus). CONCLUSIONS: Practical application of these guidelines should decrease the prevalence of visceral complications associated with benign hysterectomy.

Introducing a laparoscopic simulation training and credentialing program in gynaecology: an observational study.

BACKGROUND: Simulation training in laparoscopic surgery has been shown to improve surgical performance. AIMS: To describe the implementation of a laparoscopic simulation training and credentialing program for gynaecology registrars. MATERIALS AND METHODS: A pilot program consisting of protected, supervised laparoscopic simulation time, a tailored curriculum and a credentialing process, was developed and implemented. Quantitative measures assessing simulated surgical performance were measured over the simulation training period. Laparoscopic procedures requiring credentialing were assessed for both the frequency of a registrar being the primary operator and the duration of surgery and compared to a presimulation cohort. Qualitative measures regarding quality of surgical training were assessed pre- and postsimulation. RESULTS: Improvements were seen in simulated surgical performance in efficiency domains. Operative time for procedures requiring credentialing was reduced by 12%. Primary operator status in the operating theatre for registrars was unchanged. Registrar assessment of training quality improved. CONCLUSIONS: The introduction of a laparoscopic simulation training and credentialing program resulted in improvements in simulated performance, reduced operative time and improved registrar assessment of the quality of training.

Role of tubal surgery in the era of assisted reproductive technology: a committee opinion.

This document reviews surgical options for achieving patency in obstructed fallopian tubes and the factors that must be considered when deciding between surgical repair and IVF. This document replaces the document of the same name, last published in 2012 (Fertil Steril 2012;97:539­45).

A structured four-step curriculum in basic laparoscopy: development and validation.

OBJECTIVE: The objective of this study was to develop a four-step curriculum in basic laparoscopy consisting of validated modules integrating a cognitive component, a practical component and a procedural component. DESIGN: A four-step curriculum was developed. The methodology was different for each step. Step 1: A 1-day course in basic laparoscopy developed on the background of a regional needs analysis. Step 2: A multiple-choice test, developed and validated through interviews with experts in laparoscopy and subsequently through a Delphi audit involving regional chief physicians. Step 3: A procedural training task (a salpingectomy) on a validated virtual reality simulator. Step 4: An operation on a patient (a salpingectomy) with following formative assessment based on a validated assessment scale. SETTING: University hospital, Copenhagen, Denmark. POPULATION: Fifty-two first-year residents in obstetrics and gynecology from 2009 to 2011. METHOD: Observational cohort study. MAIN OUTCOME MEASURE: Completion rate. RESULTS: All participants completed step 1 and improved post-course test scores compared with pre-course test scores, p = 0.001. Step 2 was completed by 75% (37/52); all improved test scores after 6 months, p = 0.001. Step 3 was completed by 75%. Participants used 238 min (range 75-599) and 38 repetitions (range 8-99) to reach proficiency level on a virtual reality simulator. Step 4 was completed by 55%. There was no correlation between test scores and simulator training time. Protected training time was correlated with increasing completion rate. CONCLUSION: A four-step curriculum in basic laparoscopy is applicable in residency training. Protected training time correlated with increasing completion rate.

Can both residents and chief physicians assess surgical skills?

BACKGROUND: It is known that structured assessment of an operation can provide trainees with useful knowledge and potentially shorten their learning curve. However, methods for objective assessment have not been widely adopted into the clinical setting. This might be because of a lack of expertise using an assessment tool. The aim of this present study was to investigate if a validated laparoscopic procedure-specific assessment tool could be used by doctors with different levels of experience. METHODS: The study was conducted as an observer-blinded, prospective cohort study. Three video recordings of a right-side laparoscopic salpingectomy were distributed to ten chief physicians, eight residents (fourth year trainees), and two expert assessors (all in gynecology) in order to be assessed using a validated procedure-specific assessment tool. The three salpingectomies were selected because they easily showed the different operational levels: novice, intermediate, and expert. The two expert assessors, i.e., our gold standard, were familiar with the OSA-LS assessment scale, but the chief physicians and the residents were not. All participants were blinded to the fact that surgeons with different experience had performed the salpingectomies. RESULTS: No significant differences between the residents and chief physicians were observed in any of the three assessed operations: novice, p = 0.63; intermediate, p = 0.93; and expert, p = 0.93. The chief physicians and residents matched our gold standard in assessing the intermediate operation (p = 0.177), but not the novice operation (p = 0.005) or the expert operation (p = 0.001). CONCLUSIONS: Residents and chief physicians generated similar performance scores when assessing operations using a laparoscopic procedure-specific assessment scale, and they could distinguish performance levels between the surgeons. They matched the assessment score of our expert on the intermediate operation. We conclude that a procedure-specific assessment scale can be used by both residents and chief physicians when giving formative feedback.

Standardized technique of laparoscopic pelvic and para-aortic lymphadenectomy in gynecologic cancer optimizes the perioperative outcomes.

INTRODUCTION: The main objective of this study is to illustrate the effectiveness and the safety of standardized technique of laparoscopic lymphadenectomy (LNE), newly introduced in a University Hospital, in patients with gynecologic malignancy. MATERIALS AND METHODS: A cohort of 104 patients with gynaecologic malignancies (71 with endometrial and 33 with cervical cancer), who underwent laparoscopic pelvic with or without para-aortic LNE between September 2008 and March 2010, were analyzed. Total laparoscopic hysterectomy with bilateral salpingo-oophorectomy (TLH & BSO) was the standard approach for patients with endometrial cancer (n = 71), while laparoscopic (nerve sparing) radical hysterectomy (n = 29), laparoscopic-assisted radical vaginal hysterectomy (n = 2) and radical trachelectomy was the treatment for patients with cervical cancer. All LNE were performed by a learning team under the supervision of an expert surgeon, familiar with the technique. RESULTS: The median number of pelvic lymph nodes yielded was 22 (range 16-34) and of para-aortic 14 (range 12-24). The mean operative time ± standard deviation for pelvic LNE for each side was 29 ± 17 and 64 ± 29 min for para-aortic LNE. The overall complication rate was 7.6% (n = 8). Two patients were reoperated laparoscopically, one because of postoperative hemorrhage and the other because of lymphocyst formation; laparoconversion was not necessary. DISCUSSION: Laparoscopic lymphadenectomy performed by a learning team with standardized technique is effective with adequate number of harvested nodes, in acceptable operative time and with low rate of perioperative complications.