Gynecologic Laparoscopy Research Articles

Effects of Intra-Abdominal Pressure on Lung Mechanics during Laparoscopic Gynaecology.

Investigating the relations between surgical actions and physiological reactions of the patient is essential for developing pre-emptive model-based systems. In this study, the effects of insufflating abdominal cavity with CO2 in laparoscopic gynaecology on the respiration system were analysed. Real-time recordings of anaesthesiology and surgical data of five subjects were acquired and processed, and the correlation between lung mechanics and the intra-abdominal pressure was evaluated. Alterations of ventilation settings undertaken by the anaesthesiologist were also considered. Experimental results demonstrated the high correlation with a mean Pearson coefficient of 0.931.Clinical Relevance- This study demonstrates the effects of intra-abdominal pressure during laparoscopy on lung mechanics and enables developing predictive models to promote a greater awareness in operating rooms.

Prevalence of endometriosis in women undergoing laparoscopic surgery for various gynaecological indications at a Jordanian referral centre: gaining insight into the epidemiology of an important women's health problem

BackgroundEndometriosis is a considerable health challenge for women of reproductive age. Information about its prevalence in the Jordanian population is sparse. The objective of this research was to evaluate the presence of endometriosis in gynaecological patients undergoing laparoscopic surgery for various indications and to correlate the finding of endometriosis with variables, including patient demographics, obstetric history, type, and indication of laparoscopic procedure.MethodsA retrospective cohort study involving 460 women who underwent different laparoscopic procedures for a variety of indications was conducted in the Department of Obstetrics and Gynaecology in Jordan University Hospital, a tertiary referral hospital in Jordan, between January 2015 and September 2020.ResultsThe prevalence of endometriosis in this patient group was higher than that of the general population (13.7% vs. 2.5%), and the mean age at diagnosis (31.9 years) was younger than the general population's age of peak incidence (35–45 years). It was significantly higher in women with lower numbers of pregnancies (p = 0.01) and a lower number of Caesarean sections (p = 0.05) and in those where the indication for surgery was related to decreased fertility or pelvic pain (p = 0.02). Women with high parity or where the surgery's indication suggested normal fertility, such as family planning, were less likely to have endometriosis.ConclusionTo our knowledge, this is the first Jordanian study to assess the prevalence of endometriosis in women undergoing gynaecological laparoscopy. This study suggests that the epidemiology of endometriosis in this region follows similar trends to what has been previously documented in international literature, while emphasizing the need for further research into this important women's health issue in this part of the world.

Effect of Adding Midazolam to Dual Prophylaxis for Preventing Postoperative Nausea and Vomiting.

Multimodal prophylaxis for postoperative nausea and vomiting (PONV) has been recommended, even in low-risk patients. Midazolam is known to have antiemetic properties. We researched the effects of adding midazolam to the dual prophylaxis of ondansetron and dexamethasone on PONV after gynecologic laparoscopy. In this prospective, randomized, double-blinded trial, 144 patients undergoing gynecological laparoscopic surgery under sevoflurane anesthesia were randomized to receive either normal saline (control group, n = 72) or midazolam 0.05 mg/kg (midazolam group, n = 72) intravenously at pre-induction. All patients were administered dexamethasone 4 mg at induction and ondansetron 4 mg at the completion of the laparoscopy, intravenously. The primary outcome was the incidence of complete response, which implied the absence of PONV without rescue antiemetic requirement until 24 h post-surgery. The complete response during the 24 h following laparoscopy was similar between the two groups: 41 patients (59%) in the control group and 48 patients (72%) in the midazolam group (p = 0.11). The incidence of nausea, severe nausea, retching/vomiting, and administration of rescue antiemetic was comparable between the two groups. The addition of 0.05 mg/kg midazolam at pre-induction to the dual prophylaxis had no additive preventive effect on PONV after gynecologic laparoscopy.

Laparoscopy in Gynecologic and Abdominal Surgery in Regional (Spinal, Peridural) Anesthesia, the Utility of the Technique during COVID-19 Pandemic.

Background: laparoscopic surgery is mainly performed in general anesthesia. Symptomatic patients infected with COVID-19 needing surgery are however at higher risk for COVID-19 complications in general anesthesia than in regional anesthesia. Even so, Covid transfection is a hazard to medical personnel during the intubation procedure and treatment drugs may be in shortage during a pandemic. Recovery and hospital stay are also shorter after laparoscopy. Laparoscopy performed in regional anesthesia may have several advantages in limiting Covid. Methods: international literature on the risk of COVID-19 complications development was searched. 3 topics concerning laparoscopic surgery were reviewed: (1) Achievements in laparoscopy; (2) Advantages of regional anesthesia compared to general anesthesia; (3) Feasibility to perform laparoscopy in regional anesthesia in COVID-19 pandemic. The authors reviewed abstracts and full-text articles concerning laparoscopic surgery, gynecology, anesthesia and COVID-19. Studies published in PubMed, Embase, Cochrane Library and found in Google Scholar before 1st FEB, 2021 were retrieved and analyzed. Results: a total of 83 studies were found, all of them written in English. 17 studies could be found in gynecology and in general surgery about laparoscopy with regional anesthesia. In Covid time only one study compared laparoscopic surgery in general anesthesia to laparotomy and another study laparotomy in general anesthesia to regional anesthesia. Laparoscopy showed no disadvantage compared to laparotomy in Covid pandemic and in another study laparotomy in general anesthesia was associated with higher mortality and more pulmonary complications. Trendelenburg position can be a threat if used by inexperienced personnel and can induce unintended anesthesia of breathing organs. On the other hand Trendelenburg position has advantages for cardiovascular and pulmonary functions. Pneumoperitoneum of low CO2 pressure is well tolerated by patients. Conclusions: elective surgery should be postponed in symptomatic Covid patients. In inevitable emergency surgery intubation anesthesia in COVID-19 pandemic is as far as possible to be avoided. In COVID-19 pandemic, regional anesthesia is the preferred choice. The optimum may be the combination of laparoscopic surgery with regional anesthesia. Reducing the pneumoperitoneum is a good compromise for the comfort of patients and surgeons. A special case is gynecology, which needs to be performed in Trendelenburg position to free pelvic organs.

Surgical Principles for Management of Major Vessel Injury during Laparoscopic Gynecologic Surgery

<h3>Study Objective</h3> Vascular injury of the major pelvic vessels is one of the most dreaded complications in gynecologic laparoscopy. Risk factors include distorted anatomy, fibrosis secondary to pathology or previous surgery, and procedures involving retroperitoneal dissection. We aim to outline fundamental principles for management of major vessel injury during gynecologic laparoscopy. <h3>Design</h3> Case report. <h3>Setting</h3> Tertiary academic medical center. <h3>Patients or Participants</h3> We present the case of 32-year-old patient who sustained an injury to the left external iliac artery during surgical excision of deeply infiltrating endometriosis. <h3>Interventions</h3> Critical steps demonstrated in this video include rapid identification, application of direct pressure, and communication with the operating room team regarding the need for additional resources. Once bleeding has slowed, mobilization of surrounding structures including the ureter and bowel can be performed to improve visualization and minimize risk of secondary injury. Atraumatic self-retaining vascular clamps such as laparoscopic Satinsky clamps can be used to occlude without traumatizing vessel walls. If bleeding is unable to be controlled with laparoscopic pressure or additional visualization is required for primary repair, laparotomy must be performed expeditiously. <h3>Measurements and Main Results</h3> This patient received definitive primary repair of a 5mm external iliac artery defect with Vascular Surgery and was discharged home in stable condition on postoperative day two. <h3>Conclusion</h3> This case demonstrates fundamental principles for initial management of acute major vessel injury during gynecologic laparoscopy, including application of direct pressure, communication, identification and mobilization of surrounding anatomy, and application of vascular clamps to temporize bleeding when definitive repair is not possible through a minimally invasive approach.

Surgical Steps of Total Laparoscopic Hysterectomy and Distinct Types of Energy

Study Objective Show different types of energy that can be used to perform laparoscopic hysterectomy and their particularities. Design Sequential demonstration of hysterectomy steps, using different types of energy (monopolar, bipolar, advanced bipolar and ultrasonic technology) through narrated footage. Setting The use of new generation energy sources in gynecological laparoscopy is steadily increasing. In addition to conventional monopolar and bipolar electrosurgery, many surgeons use advanced bipolar or devices that use ultrasonic technology to seal vessels and tissues. The choice of instrumentation may vary according to the complexity of the surgery, in addition to previous training or experience, in addition to the availability and cost of instrumentation, as well as the appeal of the pharmaceutical industry. Patients or Participants three different cases. Interventions The first surgery focus on the use of bipolar energy with cold scissors, we show how bipolar energy allows greater security in sealing the vessels, despite greater energy dispersion with moderate area of carbonized tissue. in sequence, the use of advanced bipolar energy, where there is less energy dispersion and carbonization of the tissue, either by reading the tissue's bioimpedance and subsequently cutting through the blade of the instrument itself. Finally on the last video we can see sealing and simultaneous cutting we the use of ultrasonic energy, with gain in agility but a reduction in the sealing depth. During colpotomy the use of monopolar energy coupled to the Hulk, presents a great dispersion of energy in the dome section, but guarantees agility and good cutting power. Measurements and Main Results With the technological expansion, new types of energy appeared to improve the surgical technique. Conclusion There is still difficulty in establishing a comparative plan between the new technologies. New clinical trials with adequate power with direct comparison of the various energy sources are needed to guide surgeons in choosing the most appropriate energy source for laparoscopic hysterectomy. Show different types of energy that can be used to perform laparoscopic hysterectomy and their particularities. Sequential demonstration of hysterectomy steps, using different types of energy (monopolar, bipolar, advanced bipolar and ultrasonic technology) through narrated footage. The use of new generation energy sources in gynecological laparoscopy is steadily increasing. In addition to conventional monopolar and bipolar electrosurgery, many surgeons use advanced bipolar or devices that use ultrasonic technology to seal vessels and tissues. The choice of instrumentation may vary according to the complexity of the surgery, in addition to previous training or experience, in addition to the availability and cost of instrumentation, as well as the appeal of the pharmaceutical industry. three different cases. The first surgery focus on the use of bipolar energy with cold scissors, we show how bipolar energy allows greater security in sealing the vessels, despite greater energy dispersion with moderate area of carbonized tissue. in sequence, the use of advanced bipolar energy, where there is less energy dispersion and carbonization of the tissue, either by reading the tissue's bioimpedance and subsequently cutting through the blade of the instrument itself. Finally on the last video we can see sealing and simultaneous cutting we the use of ultrasonic energy, with gain in agility but a reduction in the sealing depth. During colpotomy the use of monopolar energy coupled to the Hulk, presents a great dispersion of energy in the dome section, but guarantees agility and good cutting power. With the technological expansion, new types of energy appeared to improve the surgical technique. There is still difficulty in establishing a comparative plan between the new technologies. New clinical trials with adequate power with direct comparison of the various energy sources are needed to guide surgeons in choosing the most appropriate energy source for laparoscopic hysterectomy.

Effect of Gabapentin on Sedation and Same Day Discharge in Gynecologic Laparoscopy

Study Objective To compare sedation scores, pain scores, and hospital length of stay among patients undergoing outpatient minimally invasive gynecologic procedures based on preoperative gabapentin administration. Design Retrospective cohort study. Setting Academic teaching hospital. Patients or Participants The first thirty patients meeting inclusion and exclusion criteria for each group were selected in a retrospective manner. The sample size was calculated to detect a 1-point difference in the Aldrete sedation score. Patients undergoing outpatient gynecologic laparoscopic surgery with a single surgeon between May 2020 and March 2021 were eligible for inclusion. Interventions Dosages of routine preoperative gabapentin were sequentially decreased from 600 mg to 300 mg to none. Outcomes included sedation based on the Aldrete score and Pasero Opioid-Induced Sedation Scale (POSS) and pain based on the numerical rating scale during the initial recovery period. Rates of same day discharge and hospital length of stay were also tracked. Measurements and Main Results A total of 91 unique persons were included in the analysis. There was no difference between groups for age, race, ASA score, operating time, administered morphine equivalents, or benzodiazepine administration. Comparison between the three groups did not detect significant differences in either sedation scores or pain scores. Same day discharge did differ between groups with 89% of patients receiving 0 mg discharged on the day of surgery compared to 81% and 59% of patients in the 300 mg and 600 mg groups, respectively (p-value=0.019). Hospital length of stay did not reach a statistical difference. Conclusion No differences were identified in sedation or pain scores based on preoperative administration of gabapentin. The percentage of same day discharges was inversely related to dose of preoperative gabapentin, with 0 mg having the highest rate of same day discharge. These results support current recommendations to discontinue routine administration of gabapentin in outpatient gynecologic surgery. To compare sedation scores, pain scores, and hospital length of stay among patients undergoing outpatient minimally invasive gynecologic procedures based on preoperative gabapentin administration. Retrospective cohort study. Academic teaching hospital. The first thirty patients meeting inclusion and exclusion criteria for each group were selected in a retrospective manner. The sample size was calculated to detect a 1-point difference in the Aldrete sedation score. Patients undergoing outpatient gynecologic laparoscopic surgery with a single surgeon between May 2020 and March 2021 were eligible for inclusion. Dosages of routine preoperative gabapentin were sequentially decreased from 600 mg to 300 mg to none. Outcomes included sedation based on the Aldrete score and Pasero Opioid-Induced Sedation Scale (POSS) and pain based on the numerical rating scale during the initial recovery period. Rates of same day discharge and hospital length of stay were also tracked. A total of 91 unique persons were included in the analysis. There was no difference between groups for age, race, ASA score, operating time, administered morphine equivalents, or benzodiazepine administration. Comparison between the three groups did not detect significant differences in either sedation scores or pain scores. Same day discharge did differ between groups with 89% of patients receiving 0 mg discharged on the day of surgery compared to 81% and 59% of patients in the 300 mg and 600 mg groups, respectively (p-value=0.019). Hospital length of stay did not reach a statistical difference. No differences were identified in sedation or pain scores based on preoperative administration of gabapentin. The percentage of same day discharges was inversely related to dose of preoperative gabapentin, with 0 mg having the highest rate of same day discharge. These results support current recommendations to discontinue routine administration of gabapentin in outpatient gynecologic surgery.

Intraoperative Techniques for Evaluation of Minor Ureteral Injuries

<h3>Study Objective</h3> To demonstrate intraoperative surgical techniques used to evaluate ureteral integrity following gynecologic laparoscopy. <h3>Design</h3> N/A. <h3>Setting</h3> The patients underwent surgery at a tertiary care center. They were placed in dorsal lithotomy position in steep Trendelenburg to aid in performance of pelvic laparoscopy. Insufflation was carried out to 15mmHg. A primary 10mm umbilical trocar was used for the camera and three additional 5mm assist ports were placed. <h3>Patients or Participants</h3> The first patient is a 35-year-old G0 who underwent laparoscopic excision of severe bilateral deep infiltrating endometriosis. The second patient is a 51-year-old G3P2103 who underwent total laparoscopy hysterectomy for pain caused by post-ablation tubal sterilization syndrome. <h3>Interventions</h3> Indocyanine Green dye given intravenously followed by infrared imaging via laparoscopy. Retrograde instillation of methylene blue into the ureter under laparoscopic visualization. <h3>Measurements and Main Results</h3> The first patient had a small area of devascularization along the right ureter and the second patient had a small luminal defect in the distal left ureter. Both were treated with indwelling stents and recovered without complication. <h3>Conclusion</h3> The techniques outlined in this video can aid gynecologic surgeons in identifying minor ureteral injuries intraoperatively, allowing for prompt treatment and avoidance of severe morbidity and long-term sequelae.

The Impact of the Covid-19 Surgical Pause on Operative Timings Elective Benign Gynaecological Surgery

Study ObjectiveTo assess the impact of Covid-19 global pandemic and surgical pause on operative timings in gynaecology.DesignRetrospective cohort study of all laparoscopies and laparotomies undertaken in our gynaecological department (01/01/2019 - 31/12/2020). Cases and timings were identified using computerised theatre records and analysed using Excel.SettingLarge National Health Service (NHS) University hospital in the United KingdomPatients or ParticipantsAll gynaecological laparoscopies and laparotomies over 2-year period.InterventionsThe monthly median timings (anaesthetic, surgical, operative) were compared for 15 months (January 2019 - March 2020) preceding the Covid-19 measures being implemented with the subsequent 9 months (April - December 2020). The gynae-onccology, emergency and elective gynaecology groups were analysed separately to allow secondary assessment of the impact of surgical pause on surgical timings.Measurements and Main Results1565 cases were performed (886 benign elective, 158 emergencies, 522 gynae-oncology) averaging 77 cases/month pre-Covid-19, 27 cases/month in the initial 3 months and 59 cases/month for the subsequent 6 months. The monthly median anaesthetic time increased from 25-31 minutes pre-Covid-19 to 50-53 minutes in the initial 3 months, with a slow return towards baseline over the subsequent 6 months (33-47 minutes). Surgical timings stayed within average monthly fluctuations in gynae-oncology and emergencies, however a clinically significant peak (245 minutes) was observed in benign elective operating times in the first full month of return compared to pre-Covid-19 (46-102 minutes).ConclusionThere was a clinically significant increase in operative times following implementation of Covid-19 measures. The widest clinical impact was near doubling of anaesthetic time over the initial 3 months. The 6-week pause in operating also appeared to impact elective benign gynaecological surgical timings, however continued operating in gynae-oncology and emergencies appeared to have a protective effect on timings. These findings can aid effective surgical list planning to allow sufficient time for the additional measures on the return after the larger second wave.

Minimally Invasive Anesthesia for Minimally Invasive Surgery: A Prospective Cohort Study

<h3>Study Objective</h3> In the minimally invasive era, laparoscopic gynecological surgery is currently performed under general anesthesia (GA), which although considered a safe technique, is accountable for different adverse effects and delayed recovery. Regional anesthesia (RA) from an anesthesiology perspective could be considered the "minimally invasive technique". Aim of this study was to assess the feasibility and the perioperative outcomes of laparoscopic gynecological surgery in regional anesthesia from the point of view of the surgeon, anesthesiologist and patient. <h3>Design</h3> Prospective cohort study. <h3>Setting</h3> Tertiary care University of Naples Federico II. <h3>Patients or Participants</h3> 90 women (class I ASA, BMI <30) who were planned to undergo gynecologic laparoscopy surgery for benign pathology. All women were enrolled from March 2020 to April 2021. <h3>Interventions</h3> All patients underwent surgical laparoscopy under regional (Group A) or general anesthesia (Group B). Postoperative surgical and anesthesiological variables were recorded. Intraoperatively pain score on a Likert scale during all the stages of laparoscopy in RA was assessed. <h3>Measurements and Main Results</h3> Duration of surgery were comparable between the two groups and no conversion to general anesthesia was required. Postoperative pain was significantly lower in Group A up to 6 h (p< 0.005) with no statistically significant differences between the two groups at 24 h. The procedure was very acceptable from the patients. In all steps a maximum of 2 points on the Likert scale was recorded. A faster resumption of bowel motility (p <0.001) and patient's mobilization (<0.001) was observed in the group A as well as a lower incidence of post-operative nausea and vomit. Early discharge and greater patient's satisfaction were recorded in patients who underwent RA. <h3>Conclusion</h3> RA showed to decrease the impact of surgical stress and to guarantee a quicker recovery without compromising surgical results. As well as different surgical approaches can be selected to treat different pathologies, RA technique could be a viable option for patients.

Pelvic Nerves in Laparoscopy: A Review of Anatomy and Approach to Dissection

<h3>Study Objective</h3> Our objective is to review the anatomic course, sensory and motor functions, and approach to dissection of important pelvic nerves encountered during advanced gynecologic laparoscopy. <h3>Design</h3> Using annotated intraoperative footage, we illustrate surgical approaches to safe dissection of the following pelvic nerves: Ilioinguinal, iliohypogastric, lateral femoral cutaneous, femoral, genitofemoral, obturator, sciatic, hypogastric and pudendal nerves, lumbosacral trunk and sacral nerve roots. <h3>Setting</h3> Patients were placed in dorsal lithotomy position with legs in Yellowfin stirrups. The umbilicus was used for camera port placement, and three accessory ports were placed (in the bilateral lower quadrants and a second to the left of the umbilicus). <h3>Patients or Participants</h3> Patients requiring dissection of the aforementioned nerves for surgical treatment of deep infiltrating endometriosis, adhesiolysis, or treatment of pudendal neuralgia were selected. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Surgeons must have a comprehensive understanding of pelvic anatomy and comfort operating in deep pelvic spaces in order to minimize risk of inadvertent nerve injury. A systematic approach to nerve dissection enables adequate exposure of the operative field and safe space for lysis of adhesions, excision of endometriosis, and surgical treatment of pelvic pain syndromes.

Robotic-Assisted Laparoscopic Surgery: Lower Insufflation Pressures Reduced the Risk of Hemodynamic Instability

<h3>Study Objective</h3> The objective is to assess hemodynamic changes with lower abdominal insufflation pressures of pneumoperitoneum during robotic-assisted laparoscopic surgery. <h3>Design</h3> Quality improvement project in robotic surgical patients with an intervention to improve hemodynamic changes during insufflation and positioning. <h3>Setting</h3> All patients were placed in standard dorsal lithotomy, standardized to a Trendelenburg position of 23 degrees after abdominal insufflation. <h3>Patients or Participants</h3> A total of 21 patients undergoing robotic-assisted laparoscopic gynecologic surgery were selected, all of which operated on by the same surgeon. <h3>Interventions</h3> Patients were randomized to two groups: (1) standard insufflation pressure of 15 mmHg and, (2) low insufflation pressure of 12 mmHg. <h3>Measurements and Main Results</h3> Baseline hemodynamics and ventilator readings were noted. Changes in these parameters following insufflation and positioning were then recorded, including any interventions necessary to maintain homeostasis over the subsequent 15 minutes. Data were tabulated and compared amongst the two groups. Independent sample T-tests were used to analyze hemodynamic outcome means between groups. Insufflation groups did not differ based on BMI status (p = 0.72) and had equal quality of visualization as determined by a single surgeon. Patients at higher insufflation pressures on average had significantly more hemodynamic instability events requiring treatments than the lower insufflation pressure group, 2.0 vs 0.33, respectively (p=0.005). Systolic blood pressures (BP), Diastolic BP, and mean arterial pressures showed clear trends of improvements in the low-insufflation group, with mean deltas of +10.0, +19.6, and +16.6, respectively. <h3>Conclusion</h3> This quality improvement project showed that a lower abdominal insufflation pressure decreased hemodynamic instability events during robotic-assisted laparoscopic gynecology surgeries without impacting the surgical visualization.

Comparison of the Effects of Normocapnia and Mild Hypercapnia on the Optic Nerve Sheath Diameter and Regional Cerebral Oxygen Saturation in Patients Undergoing Gynecological Laparoscopy with Total Intravenous Anesthesia.

Cerebral hemodynamics may be altered by hypercapnia during a lung-protective ventilation (LPV), CO2 pneumoperitoneum, and Trendelenburg position during general anesthesia. The purpose of this study was to compare the effects of normocapnia and mild hypercapnia on the optic nerve sheath diameter (ONSD), regional cerebral oxygen saturation (rSO2), and intraoperative respiratory mechanics in patients undergoing gynecological laparoscopy under total intravenous anesthesia (TIVA). Sixty patients (aged between 19 and 65 years) scheduled for laparoscopic gynecological surgery in the Trendelenburg position. Patients under propofol/remifentanil total intravenous anesthesia were randomly assigned to either the normocapnia group (target PaCO2 = 35 mmHg, n = 30) or the hypercapnia group (target PaCO2 = 50 mmHg, n = 30). The ONSD, rSO2, and respiratory and hemodynamic parameters were measured at 5 min after anesthetic induction (Tind) in the supine position, and at 10 min and 40 min after pneumoperitoneum (Tpp10 and Tpp40, respectively) in the Trendelenburg position. There was no significant intergroup difference in change over time in the ONSD (p = 0.318). The ONSD increased significantly at Tpp40 when compared to Tind in both normocapnia and hypercapnia groups (p = 0.02 and 0.002, respectively). There was a significant intergroup difference in changes over time in the rSO2 (p < 0.001). The rSO2 decreased significantly in the normocapnia group (p = 0.01), whereas it increased significantly in the hypercapnia group at Tpp40 compared with Tind (p = 0.002). Alveolar dead space was significantly higher in the normocapnia group than in the hypercapnia group at Tpp40 (p = 0.001). In conclusion, mild hypercapnia during the LPV might not aggravate the increase in the ONSD during CO2 pneumoperitoneum in the Trendelenburg position and could improve rSO2 compared to normocapnia in patients undergoing gynecological laparoscopy with TIVA.

Simulation in surgical education: a review of a multi- tiered gynaecological laparoscopy workshop

Background: While minimally access approach has become the gold standard for many gynaecological procedures, laparoscopic surgery has a steep learning curve and many trainees face challenges acquiring the necessary skills. The aim of our study was to evaluate the effectiveness of a multi-tiered laparoscopy simulation workshop for gynaecology residents. Approach: An observational study was conducted at SingHealth Duke-National University of Singapore (NUS) Institute of Medical Simulation Centre (SIMS) between November 2016 and November 2017. Gynaecology residents were recruited to attend two separate one-day workshops held in November 2016 and November 2017 respectively, involving didactic lectures, dry-lab simulation and animal training. Participants rated various learning domains of the training workshops using a five-point scale Likert in pre- and post-workshop surveys. Findings: The study enrolled 16 residents in total. On a Likert scale from 1 to 5 (1 being poor and 5 being excellent), participants rated significant improvement in domains of general laparoscopy skills acquisition (1.7 + 0.6 to 4.9 + 0.4; p&lt;0.001), dry lab simulation (1.9 + 0.5 to 4.8 + 0.4; p&lt;0.001), confidence in laparoscopy suturing skills (1.1 + 0.3 to 4.8 + 0.4; p&lt;0.001) and laparoscopy knowledge (2.1 + 0.5 to 4.7 + 0.5; p&lt;0.001). Conclusion: A combination of didactic lectures, dry-lab simulation and animal training under expert supervision and guidance dramatically improved surgical skills and confidence in gynaecology residents. Such a multi-tiered format allows for effective learning and acquisition of laparoscopic skills.

Warm and humidified insufflation gas during gynecologic laparoscopic surgery reduces postoperative pain in predisposed patients—a randomized, controlled multi-arm trial

BackgroundPostoperative pain remains a common problem in gynecologic laparoscopy, especially in head zone-related regions, triggered by intra-abdominal pressure during capnoperitoneum. Humidified and prewarmed insufflation gas may ameliorate pain and be beneficial.MethodsThis prospective randomized controlled parallel group multi-arm single-center study investigated the effects of temperature and humidity of insufflation gas on postoperative pain during gynecologic laparoscopy with a duration ≥ 60 min. Female participants (18—70 years) were blinded and randomly assigned—computer generated—to either insufflation with dry cold CO2 with forced air warming blanket (“AIR”), humidified warm gas without forced air warming blanket (“HUMI”), or humidified warm gas with forced air warming blanket (“HUMI +”). We hypothesized that using humidified warm gas resulted in lower pain scores and less analgesic consumption. The primary endpoint postoperative pain was assessed for different pain localizations every 12 h during 7 days after surgery. Secondary endpoints were demand for painkillers and epidural anesthetics, length of stay in recovery room, and hospital stay. (Registration: ClinicalTrials.gov NCT02781194—completed).Results150 participants were randomized. Compared to group “AIR” (n = 48), there was significantly less pain in group “HUMI +” (n = 48) in the recovery room (− 1.068; 95% CI − 2.08 to − 0.061), as well as significantly less ibuprofen use at day two (− 0.5871 g ± 0.258; p-value = 0.0471). Other variables did not change significantly. Stratification for presence of endometriosis or non-previous abdominal surgery in patient history revealed significantly less pain in both groups “HUMI” (n = 50) and “HUMI +” versus group “AIR.” Related side effects were not noted.ConclusionIn the overall population, the use of warm, humidified insufflation gas did not yield clinically relevant effects; however, in predisposed patients with endometriosis and who could otherwise expect high pain levels, warm and humidified gas may be beneficial.

Changes of Physiological parameters of the patient during laparoscopic gynaecology

Abstract Analysing and fusing data from the medical devices of different disciplines (anaesthesiology and surgery) inside the operating rooms may promote awareness during surgical procedures. In this work, the changes of physiological parameters of patients undergoing laparoscopic gynaecology procedures were analysed. The statistical relationship between the intra-abdominal pressure and airway peak pressure was evaluated. Patients ventilated with pressure-controlled ventilation (PCV) and intermittent mandatory ventilation (IMV) were included. The results demonstrated that increasing the intra-abdominal pressure (IAP) resulted in increasing the airway peak pressure and decreasing the lung compliance. The Pearson correlation coefficient between the IAP and the airway peak pressure was 0.910 in PCV-patients and 0.952 in IMV-patients when changes of the ventilation settings were considered. Additionally, major hemodynamic changes included alterations in the mean blood pressure (MBP), where the MBP increased after insufflating the abdomen and decreased after abdomen deflation.

The effects of pre-emptive intravenous ibuprofen on the thiol/disulfide homeostasis and C-reactive protein level as the markers of oxidative stress and inflammation during gynecologic laparoscopy: A randomised clinical trial.

In this study, we aimed to investigate the anti-inflammatory and antioxidant effects of intravenous ibuprofen by using the C-reactive protein level and thiol/disulfide homeostasis as the oxidative stress marker. This study was conducted on 70 patients aged between 30 and 65 who were scheduled for elective laparoscopic hysterectomy. The patients were divided into two groups to receive either pre-emptive 800mg of intravenous ibuprofen plus 1000mg of intravenous paracetamol (Group IP) or only 1000mg of intravenous paracetamol as a control group (Group P). The blood samples for thiol/disulfide homeostasis were collected as follows: before induction of anesthesia (T0), before pneumoperitoneum (T1), following postdeflation and discontinuation of anesthesia (T2), and postoperative 24th hour (T3). Simultaneous blood samples for C-reactive protein (CRP) were also collected. The pre- and postoperative urea, creatinine, alanine aminotransferase (ALT), and aspartate aminotransferase (AST) levels were measured. A total of 69 patients were included in the study. The patient's characteristics and intraoperative variables were comparable between groups (P>.05). The number of patients requiring rescue analgesia, the total amount of analgesic used, Visual Analog Scale (VAS) scores, and postoperative side effects were significantly lower in Group IP (P<.001). The decrease in native and total thiol levels at T1, T2, and T3 measurement points was significant in Group IP (P<.001). In both groups, the comparison to baseline values demonstrated no significant changes in terms of disulfide level (P>.05). The simultaneous CRP levels indicated a significant increase at the postoperative 24hour in both groups (P<.001). The difference between groups was insignificant (P>.05). There was a significant increase in urea and creatinine levels in patients of Group IP (P<.05). The pre-emptive administration of ibuprofen provided effective pain control after gynecologic laparoscopy. However, ibuprofen changed the thiol/disulfide homeostasis in favor of oxidation and had no beneficial effect in surgically induced oxidative stress.

Exploring the nature and focus of feedback when using video playback in gynecology laparoscopy training

BackgroundFeedback about intraoperative performance remains a cornerstone of surgical training. Video playback offers one potential method for more effective feedback to surgical residents. More research is needed to better understand this method. This study explores the nature of instructional interactions and feedback in the operating room (OR) and when using video playback during post-operative review in obstetrics and gynecology (OBGYN) training.MethodThis case study occurred between September 2016 and February 2017. Three OBGYN residents and five OBGYN supervising surgeons were involved in six laparoscopic cases. Intraoperative and video playback dialogues were recorded and analysed, the former deductively using codes identified from published literature, and the latter both deductively, using the same codes, and inductively, with codes that emerged from the data during analysis.Results:1090 intraoperative interactions were identified within 376 minutes of dialogue. Most interactions were didactic, instructing the resident how to use an instrument to perform a task. Deductive analysis of postoperative video playback review identified 146 interactions within 155 minutes. While the most common interaction type remained didactic, a teaching component was included more often. It became apparent that deductive analysis using the intraoperative codes did not adequately capture the nature and focus of feedback during video playback. Hermeneutic phenomenological analysis identified more dialogic video playback sessions with more resident-initiated questions and reflection.Conclusions:This study demonstrates that the nature of feedback during video playback is fundamentally different from that in the OR, offering a greater potential for collaborative and improved learning.

Efficacy of Intraperitoneal Dexamethasone Infusion in Reduction of Shoulder Pain and Nausea/Vomiting After Gynecological Laparoscopy

Background: The reduction of shoulder pain and postoperative nausea and vomiting (PONV), causing great discomfort for patients after gynecological laparoscopy, requires preventive or treatment strategies. Objectives: The present study aimed to determine the efficacy of intraperitoneal (IP) dexamethasone in the reduction of shoulder pain and PONV after gynecological laparoscopy. Methods: In this double-blind, randomized clinical trial, 130 consecutive patients undergoing gynecological laparoscopy were randomly assigned to two groups of 65 patients within May 2015 to May 2016. One group received 16 mg IP dexamethasone before the end of the surgery, and the other group received the placebo (i.e., the IP infusion of distilled water). Patients' age and body mass index (BMI), and surgery duration were recorded in this study. The severity of shoulder pain was evaluated by the visual analog scale (VAS) at recovery and 2, 6, 12, and 24 h after the surgery. Moreover, the need for opioid use and PONV were recorded within the first 24 h after the surgery. The study outcomes were compared between the two study groups and among the different intervals using SPSS software (version 21). Results: The groups had similar demographics (i.e., age and BMI) and mean surgery duration (P &gt; 0.05). The mean values of VAS scores of the intervention group were lower than those of the placebo group at five intervals (P = 0.001). The frequency of opioid use was significantly lower in the dexamethasone group (P = 0.010). In addition, 20% and 60% of the patients in the dexamethasone and placebo groups had PONV, respectively (P &lt; 0.001). Conclusions: The IP dexamethasone is effective in the reduction of shoulder pain and nausea/vomiting after gynecological laparoscopy and can significantly reduce opioid requirement within the first 24 h after surgery; however, IP dexamethasone does not increase surgery duration. Therefore, it is recommended to use this technique during gynecological laparoscopy.

WITHDRAWN: Preoperative duloxetine to prevent postoperative shoulder pain after gynecologic laparoscopy: a randomized controlled trial

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