The prepped vaginal canal may be a sterile conduit for ventral hernia mesh insertion: a prospective comparative study.

BACKGROUND: Although still experimental, natural orifice translumenal endoscopic surgery (NOTES) aims to use the natural orifices for intraabdominal surgery. Pure transvaginal umbilical hernia repair has been reported. However, mesh protection devices were used to minimize mesh contamination during mesh insertion. The authors believe that before widespread implementation of this technique, more foundational research is indicated to establish the sterility of hernia mesh insertion through this route. This prospective study aimed to compare transvaginal ventral hernia mesh insertion sterility with laparoscopic trocar-site insertion sterility to establish baseline data to help promote the safety of NOTES tranvaginal hernia repair. METHODS: This was a prospective descriptive study (Canadian Task Force classification 2A). With institutional review board approval, 10 patients undergoing laparoscopic surgery for benign gynecologic disease were enrolled in the study. Atrium Prolite mesh (polypropylene monofilament) was inserted into the vagina before and after standard surgical preparation with 10 % povidone­iodine. As a control, mesh also was inserted through a prepped laparoscopic port site. The mesh was cultured for bacterial, fungal, and viral contamination. All patients received standard infection prophylaxis that included preoperative intravenous cefazolin and metronidazole. RESULTS: The unprepped vaginal canal was cultured and demonstrated normal multiorganism vaginal flora in all 10 cases. Of the 10 skin incision mesh samples, 3 (30 %) grew bacteria, including Staphylococcus lugdunensis, a potentially pathogenic organism. In contrast, none of the prepped vaginal mesh specimens yielded any growth of microorganisms or potential pathogens. CONCLUSIONS: This study showed that a surgically prepped vaginal canal can be a sterile conduit for insertion of polypropylene mesh for transvaginal ventral hernia repair without the use of additional mesh protection. Surprisingly, the prepped vaginal conduit in our patients was more sterile than a prepped skin incision.

Sling procedures after repair of obstetric vesicovaginal fistula in Niamey, Niger.

INTRODUCTION AND HYPOTHESIS: The purpose of this paper is to evaluate the results of sling procedures for stress incontinence after repair of vesicovaginal fistulae at the National Hospital in Niamey, Niger. METHODS: This study is a retrospective chart review of 701 women surgically treated for vesicovaginal fistulae. One hundred forty women subsequently underwent a sling procedure for stress incontinence after fistula repair. RESULTS: The demographics among the groups were similar. No significant difference was seen in results between the sling types except the risk of erosion was significantly greater in the synthetic sling group. There was a trend towards greater sling success in the fascia lata group. CONCLUSIONS: Correction of incontinence is a common and difficult challenge following repair of obstetric vesicovaginal fistula. Compared to published studies on sling procedures, these patients have higher rates of continued incontinence. This is likely due to the frequent loss of a urethral sphincter as well as high prevalence of detrusor overactivity and decreased bladder capacity.

Obstetric fistula in low and middle income countries.

Vesicovaginal fistula secondary to obstructed labor continues to be an all-too-common occurrence in underdeveloped nations throughout Africa and Asia. Vesicovaginal fistula remains largely an overlooked problem in developing nations as it affects the most marginalized members of society: young, poor, illiterate women who live in remote areas. The formation of obstetric fistula is a result of complex interactions of social, biologic, and economic influences. The key underlying causes of fistula are the combination of a lack of functional emergency obstetric care, poverty, illiteracy, and low status of women. In order to prevent fistula, some strategies include creation of governmental policy aimed toward reducing maternal mortality/morbidity and increasing availability of skilled obstetric care, as well as attempts to increase awareness about its prevention and treatment among policymakers, service providers, and communities. Whereas prevention will require the widespread development of infrastructure within these developing countries, treatment of fistula is an act which can be done "in the now." Treatment and subsequent reintegration of fistula patients requires a team of specialists including surgeons, nurses, midwives, and social workers, which is largely unavailable in developing countries. However, there is increasing support for training of fistula surgeons through standardized programs as well as establishment of rehabilitation centers in many nations. The eradication of fistula is dependent upon building programs that target both prevention and treatment.

Robot-assisted laparoscopic myomectomy is an improvement over laparotomy in women with a limited number of myomas.

STUDY OBJECTIVE: To compare surgical and immediate postoperative results of robot-assisted laparoscopic myomectomy vs myomectomy via laparotomy in patients with 3 myomas or fewer. DESIGN: Case-control (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: Seventy-five women who had undergone robotic-assisted laparoscopic myomectomy were compared with patients who had undergone myomectomy via laparotomy. INTERVENTIONS: Medical records were reviewed for surgical and postoperative variables. Both groups had 3 myomas or fewer confirmed at preoperative magnetic resonance imaging or final pathology report. MEASUREMENTS AND MAIN RESULTS: No significant differences were observed between patients insofar as preoperative demographic data. There was a significant increase in mean duration of surgery for robotic-assisted myomectomy. There was a significant decrease in blood loss, change in hematocrit concentration on postoperative day 1, length of stay, number of days to regular diet, and febrile morbidity in robotic-assisted myomectomies. There were no significant differences in operative or postoperative complications. CONCLUSION: Although robotic-assisted myomectomy took substantially longer, most of the other variables improved in comparison with similar procedures performed via laparotomy.

An evaluation of the resident learning curve in performing laparoscopic supracervical hysterectomies as compared with patient outcome: five-year experience.

STUDY OBJECTIVE: To compare surgical and postoperative results after laparoscopic supracervical hysterectomy between the first 2 cases and last 2 cases performed by each senior resident. DESIGN: Retrospective, case-control study (Canadian Task Force classification II-B). SETTING: University hospital. PATIENTS: Two hundred six women underwent laparoscopic supracervical hysterectomy. INTERVENTIONS: Charts were reviewed to determine length of surgery, operative and postoperative complications, and other surgical values. A comparison was made between the first 2 and last 2 cases of 25 chief residents. MEASUREMENTS AND MAIN RESULTS: There was no statistically significant difference between the first 2 and last 2 patients of each resident in terms of age, indication for surgery, uterine mass, ethnicity, body mass index, or parity. There was a significant decrease in the mean time of the first 2 cases versus the last 2 cases: 201.4 minutes versus 137.2 minutes (p <.001). There was no significant difference in blood loss, change in hematocrit, length of hospital stay, and surgical or postoperative complications. CONCLUSIONS: Laparoscopic supracervical hysterectomy is a technically challenging procedure that nevertheless can be learned quickly with rapid improvement in operative time and without undue risk to the patient. Since initially presenting these data in 2003, the senior residents are now getting twice the amount of exposure to this surgery. In addition, these data now include residents who were exposed to this type of surgery as junior residents. Although residents are beginning to have increased experience in performing laparoscopic supracervical hysterectomy before their chief year, there is still a significant difference in operative time from the initial 2 procedures to the last 2 procedures completed by a chief resident.