Laparoscopic Surgery For Benign Conditions Research Articles

Impact of human ovarian tissue manipulation on follicles: evidence of a potential first wave of follicle activation during fertility preservation procedures.

The aim of this study was to investigate the impact of processing human ovarian tissue on follicle activation dynamics. Fresh ovarian tissue was retrieved from 9 women undergoing laparoscopic surgery for benign conditions. Biopsies from each patient were divided into 3 fragments, the first of which was immediately fixed in the operating room (T0) and the second and third just after processing at 25 (T25) and (T90) 90 min. To evaluate follicle activation, markers of the PI3K and Hippo signaling pathways were immunolabeled at each time point, targeting phospho-Akt (p-Akt) by immunohistochemistry and yes-associated protein (YAP) cellular localization in the granulosa cell layer by immunofluorescence. Four hundred forty primordial follicles were evaluated for p-Akt and 420 for YAP. Significantly stronger p-Akt expression was observed at T25 (23.01 ± 13.45%; p=0.04) and T90 (38.99 ± 25.21%; p<0.001) than at T0 (2.72 ± 3.35%). A significant nucleus-to-cytoplasm shift in YAP was detected at T25 (1.21 ± 0.25; p=0.015 compared to T0 (0.95 ± 0.09), while T90 (1.10 ± 0.16) values were similar to T25. Our data prove that ovarian tissue manipulation significantly impacts follicle dynamics by stimulating the PI3K and Hippo signaling pathways involved in primordial follicle activation. Further experimental evidence must nevertheless be gathered to understand and gain control of follicle activation mechanisms in non-physiological conditions (like ovarian tissue manipulation), in order to optimize fertility preservation and restoration strategies.

P-410 First wave of primordial follicle activation during human ovarian tissue manipulation for fertility preservation

Abstract Study question Does ovarian tissue biopsy, transportation and processing for fertility preservation and restoration trigger primordial follicle activation? Summary answer Early manipulation of ovarian tissue is sufficient to trigger follicle activation by stimulating PI3K/Akt and disrupting the Hippo pathway. What is known already Primordial follicle recruitment occurs continuously in physiological conditions by modulation of autocrine and paracrine factors, like the PI3K/Akt and Hippo pathways, to ensure follicle growth over time. During fertility preservation and restoration procedures, follicle activation may be disrupted and follow nonphysiological patterns. The ability to control activation dynamics by up- or downregulation of these pathways may enhance fertility restoration outcomes in a number of ways. Indeed, downregulation of follicle activation shortly after transplantation may protect the ovarian reserve from early depletion. Conversely, ovarian tissue in vitro culture may benefit from upregulation of primordial follicle activation to boost further growth. Study design, size, duration Fresh ovarian tissue was retrieved from nine women undergoing laparoscopic surgery for benign conditions. Three timepoints were investigated. One-third of collected tissue per patient was immediately fixed in the operating room, without any manipulation (time zero, T0). The remaining tissue was transferred to the laboratory and dissected to remove any surplus medulla. It was then cut into small cortical fragments, half of which were fixed after 25 minutes(T25) and the other half after 90 minutes(T90). Participants/materials, setting, methods All cortical fragments were fixed in 4%formaldehyde and embedded in paraffin for histology. In order to explore follicle activation,markers of the PI3K/Akt and Hippo signaling pathways were immunolabeled at each timepoint, targeting: (i) phospho-Akt (p-Akt) in primordial follicles by immunohistochemistry as a marker of early PI3K/Akt pathway activation; and (ii) Yes-associated protein (YAP) cellular localizationin the granulosa cell layer of primordial follicles by immunofluorescence as a marker of Hippo disruption. Main results and the role of chance An upturn in p-Akt expression was observed at T25 (22,34 ± 0.13%; p = 0.0233) and T90 (39,01 ± 0.22%, p = &amp;lt; 0.0001) compared to T0 (2,87 ± 0,03%). In terms of YAP cellular localization, a significant nucleus-to-cytoplasm shift was detected at T25 (1.11 ± 0.09; p = 0.0428) compared to T0 (0.97 ± 0.10), while T90 (1.07± 0.14) values were similar to T25. Our data prove that ovarian tissue manipulation triggers primordial follicle activation very early, involving both the PI3K/Akt and Hippo signaling pathways, which appear to cooperate in primordial-to-primary follicle transition. Our results indicate that the first stages of any fertility preservation or restoration procedure involving ovarian tissue manipulation contribute to dysregulation of the very mechanisms responsible for the ovarian reserve maintenance and follicle growth. Additional strategies are required to gain the control of follicle activation mechanisms in nonphysiological conditions (ex vivo ovarian tissue manipulation), in order to exploit ovarian reserve dynamics to serve the need of patients. Limitations, reasons for caution Analyses in the study were limited to histology and immunolabeling to acquire a descriptive picture of pathway activation kinetics over time. Further investigations using dynamic experimental models are essential to advance our understanding of signaling pathway synergy in vivo. Wider implications of the findings Since dysregulation of follicle activation in nonphysiological conditions appears to be associated with poor oocyte quality, enhancing our ability to control the relevant signaling pathways is crucial to optimizing fertility preservation procedures. Trial registration number not applicable

Laparoscopic surgery for benign adnexal conditions under spinal anaesthesia: Towards a multidisciplinary minimally invasive approach

BackgroundLaparoscopic gynaecological surgery is commonly performed under general anaesthesia with endotracheal intubation. In general surgery, locoregional anaesthesia was applied to laparoscopic procedures, increasing minimally invasive surgery advantages. AimsTo assess and compare postoperative pain after laparoscopic adnexal procedures for benign conditions under spinal anaesthesia (SA) versus general anaesthesia (GA). Furthermore, anaesthesiologic, surgical and clinical data were evaluated in both groups. Materials and MethodsThis is a prospective cohort study performed in a tertiary level referral centre for minimally invasive gynaecological surgery (Gynaecology and Human Reproduction Physiopathology, University of Bologna). Women scheduled for adnexal laparoscopic surgery for benign conditions between February and May 2019 were assigned to receive either SA or GA with endotracheal intubation. A sample size of 13 women per group was needed to detect a 2-point difference in pain scores. Main findings13 women were enrolled in the SA arm, 15 in the GA arm. In the SA cohort, the most common intraoperative adverse event was shoulder pain, reported by 3/12 women. At 1, 8, 12, 24 and 48 h after surgery pain was significantly lower in the SA arm (p < .05). Patients submitted to SA experienced no need for opioid drugs administration, unlike those receiving GA. Patients’ mobilization and return of bowel function were noted significantly earlier in the SA group (p < .05). ConclusionsSA is a feasible, safe and effective anaesthesiologic technique for laparoscopic gynaecological procedures for benign conditions, allowing a better control of postoperative pain. Women undergoing SA achieve earlier mobilization and bowel canalization. During the Covid-19 pandemics, SA could be useful in reducing the need for invasive procedures on respiratory tract.

Gynaecological laparoscopic surgery for benign conditions: do women care about incisions?

ObjectiveTo determine the relevance of the number and location of incisions in women undergoing gynaecologic laparoscopy due to benign conditions. Study designThis study included 141 women, who underwent gynaecologic laparoscopic surgery with 4 incisions due to benign conditions between November 2010 and November 2011 at the University Medical Centre Mannheim, Germany. Women with malign histology were excluded. Demographic parameters, type and duration of surgery, perioperative complications and duration of hospital stay were analysed. Women were contacted using a standardized telephone survey with an interval of at least 22 weeks after surgery. Patients were interviewed regarding the number, postoperative pain and their preferences for omission of incisions. ResultsEighty-seven women (61.7%) responded to the standardized questionnaire. 38 (43.7%) remembered the number of incisions correctly. 45 of the women (51.7%) thought they had less, 4 (4.6%) thought, they had more incisions as they actually did have. If one of the incisions had to be discarded 28 (32.2%) patients did not have any preferences with regard to the localisation. Of the other 59 patients, 44 (74.6%) would prefer to eliminate the umbilical one. ConclusionThe majority of the women remembered fewer incisions than actually used. Most of the patients interviewed would, if possible, eliminate the umbilical incision. Therefore from the patient's perspective the skin scars after conventional laparoscopic surgery seem to be of limited importance and the alleged advantage of omission of additional incision using single site surgery remains debatable.

Effect of Presurgical Local Infiltration of Levobupivacaine in the Surgical Field on Postsurgical Wound Pain in Laparoscopic Gynecological Surgery

ients undergoing laparoscopic surgery require close attention to providing adequate pain management. This randomized, double-blind, controlled study was designed to determine whether infiltrating the surgical field preoperatively with levobupivacaine, which is as effective as bupivacaine but causes fewer cardiovascular and central nervous system problems, would reduce the frequency, intensity, and duration of postsurgical wound pain in women treated for benign gynecologic disorders. Thirty-seven women undergoing laparoscopic surgery for benign conditions received an injection of 7 mL of a solution containing 5 mg/mL levobupivacaine 15 minutes before skin incision, whereas 37 others received the same volume of physiological saline. All incisional sites were infiltrated. An open laparoscopy technique with open step-by-step access was used for laparoscopy. Pain intensity was estimated using a 10-point visual analog scale 6, 12, and 24 hours postoperatively. The 2 groups were similar with regard to demographic and intraoperative characteristics. Mean pain intensity was significantly lower in the levobupivacaine group than in control patients 6 and 12 hours after surgery. Actively treated patients required less analgesia postoperatively, and the mean time to ambulation was significantly less than in control subjects. Women treated with levobupivacaine also had a shorter mean postoperative stay, but this difference was not statistically significant. Postoperative pain after laparoscopic gynecologic surgery, performed under general anesthesia, is substantially less—especially in the first 12 hours—if the surgical field is exposed preoperatively to levobupivacaine solution. Patients managed in this way require less postoperative analgesia.

Increased expression of cyclooxygenase-2 in local lesions of endometriosis patients.

Human endometrial glands contain the highest levels of cyclooxygenase (COX), although whether it is COX-1 and/or COX-2 has not been previously determined. Overexpression of COX-2 may result in the pathogenesis of endometriosis. Tissue sections were obtained from 28 premenopausal women undergoing laparotomy or laparoscopic surgery for benign conditions. Endometrium, ectopic endometriosis tissue and peritoneum were obtained at the time of surgery. Informed consents were obtained from all the patients participating in this study. Immunohistochemistry was performed on consecutive sections of paraffin-embedded tissue using anti-COX-2 antibody. Expressions of COX-2 mRNA in endometrium, ectopic endometriosis tissue, and peritoneum were quantitavely determined by competitive reverse transcription-polymerase chain reaction (RT-PCR). In the uterus, COX-2 was localized in the endometrial epithelium. Eutopic endometrial surface epithelium contains more COX-2 than does glandular epithelium. We observed more frequent and denser COX-2 staining in the ectopic endometriosis implants when compared with eutopic endometrium. Level of COX-2 mRNA in endometriosis was increased up to five times that of eutopic endometria. Hyper activation of COX-2 with abnormal prostaglandin generation is considered to contribute to the pathophysiology of endometriosis and disease progression.