A prospective observational study comparing proficiency of obstetrics & gynaecology trainees with general surgical trainees using simulated laparoscopic tasks in Health Education England, North-West

BACKGROUND: Training programmes for obstetrics and gynaecology (O&G) and general surgery (GS) vary significantly, but both require proficiency in laparoscopic skills. We sought to determine performance in each specialty. DESIGN: Prospective, Observational study. SETTING: Health Education England North-West, UK. PARTICIPANTS: 47 surgical trainees (24 O&G and 23 GS) were sub-divided into four groups: 11 junior O&G, 13 senior O&G, 11 junior GS, and 12 senior GS trainees. OBJECTIVES: Trainees were tested on four simulated laparoscopic tasks; laparoscopic camera navigation (LCN), hand eye co-ordination (HEC), bimanual co-ordination (BMC) and suturing with intracorporeal knot tying (suturing). RESULTS: O&G trainees completed LCN (P <0.001), HEC (P <0.001) and BMC (P <0.001) significantly slower than GS trainees. Furthermore, O&G found fewer number of targets in LCN (P =0.001) and dropped a greater number of pins than the GS trainees in BMC (P =0.04). In all three tasks, there were significant differences between O&G and GS trainees but no difference between the juniors and senior groups within each specialty. Performance in suturing also varied by specialty; senior O&G trainees scored significantly lower than senior GS trainees; O&G 11.4 ± 4.4 vs GS 16.8 ± 2.1, P = 0.03. Whilst suturing scores improved with seniority among O&G trainees, there was no difference between the junior and senior GS trainees; senior O&G 11.4 ± 4.4 vs junior O&G 3.6 ± 2.1, P = 0.004. DISCUSSION: GS trainees performed better than O&G trainees in core laparoscopic skills and the structure of obstetrics and gynaecology training may require modification

Obesity in laparoscopic surgery

Since the 1980s, minimally invasive techniques have been applied to an increasing number and variety of surgical procedures with a gradual increase in the complexity of procedures being successfully performed laparoscopically. In the past, obesity was considered a contraindication to laparoscopy due to the higher risk of co-morbid conditions such as diabetes, hypertension, coronary artery disease and venous thromboembolism. Performing laparoscopic gynaecological procedures in morbidly obese patients is no longer a rare phenomenon; however, it does necessitate changes in clinical practice patterns. Understanding of the physiological changes induced by laparoscopy, particularly in obese patients, is important so that these may be counteracted and adverse outcomes avoided. Laparoscopy in obese patients confers certain advantages such as shorter hospital stay, less post-operative pain and fewer wound infections. In addition to these benefits, minimal-access surgery has been demonstrated as safe and effective in obese patients; however, specific surgical strategies and operative techniques may need to be adopted

Pudendal Neurolysis: 6-Step Laparoscopic Approach

Objective: To demonstrate the safety and feasibility of the laparoscopic approach to perform pudendal neurolysis in a case of pudendal nerve entrapment syndrome [1–3]. Design: A video tutorial that highlights the laparoscopic steps to performing pudendal neurolysis, with a focus on the main anatomic landmarks [4,5]. Setting: A tertiary care regional hospital. Interventions: This video shows a 6-step approach to laparoscopic pudendal neurolysis for the treatment of pudendal nerve entrapment between the sacrospinous and sacrotuberous ligaments [2,6–8]. Step 1: Identification of the umbilical artery. Step 2: Dissection and development of the lateral paravesical space until the pelvic floor. Step 3: Identification of the arcus tendineus of the endopelvic fascia. Step 4: Identification of the ischial spine and the sacrospinous ligament covered by the coccygeus muscle. Step 5: Coagulation and section of the coccygeus muscle and the sacrospinous ligament. Step 6: Medialization of the pudendal nerve until its entrance into the Alcock canal. Conclusion: This video demonstrates the safety, feasibility, and reproducibility of laparoscopic pudendal neurolysis in 6 steps. A minimally invasive approach is adequate to treat the pudendal compression until the Alcock canal [2]

Bowel endometriosis: Current perspectives on diagnosis and treatment

Endometriosis is a chronic condition primarily affecting young women of reproductive age. Although some women with bowel endometriosis may be asymptomatic patients typically report a myriad of symptoms such as alteration in bowel habits (constipation/diarrhoea) dyschezia, dysmenorrhoea and dyspareunia in addition to infertility. To date, there are no clear guidelines on the evaluation of patients with suspected bowel endometriosis. Several techniques have been proposed including transvaginal and/or transrectal ultrasonography, magnetic resonance imaging, and double-contrast barium enema. These different imaging modalities provide greater information regarding presence, location and extent of endometriosis ensuring patients are adequately informed whilst also optimizing preoperative planning. In cases where surgical management is indicated, surgery should be performed by experienced surgeons, in centres with access to multidisciplinary care. Treatment should be tailored according to patient symptoms and wishes with a view to excising as much disease as possible, whilst at the same time preserving organ function. In this review article current perspectives on diagnosis and management of bowel endometriosis are discussed

Sacrohysteropexy: a way to spare the uterus

Study Objective: To show the safety and feasibility of laparoscopic sacrohysteropexy for treating uterine prolapse. Design: An educational video to explain the laparoscopic steps of this procedure by focusing on the main anatomic landmarks and on tips and tricks to avoid complications. Setting: A tertiary care university hospital. Interventions: Laparoscopic sacropexy with uterus preservation for grade 3 apical defect. Conclusion: This video shows a stepwise approach to laparoscopic sacrohysteropexy demonstrating its feasibility and safety. There is a wide choice of surgical procedures and approaches focused on pelvic organ prolapse repair. Since many years, uterine prolapse has been an indication for hysterectomy, regardless of the occurrence of uterine disease and patients’ desires. With the introduction of minimally invasive surgery, the uterine-sparing procedures are being increasingly taken into account, especially in young women [1]. Sacrohysteropexy is a uterus-sparing procedure that allows for a reduction in operating time, intraoperative blood loss, mesh-related complications, and surgical costs [2]. Furthermore, this technique has a high success rate with an objective cure rate of 100% for the apical compartment and 80% for all compartments and does not seem to increase the pelvic organ prolapse recurrence rate [3]. Sacropexy is not a life-threatening procedure, but its main objective is to restore functional anatomy with the primary goal of improvement in patient's quality of life. Moreove, no difference has been found with or without uterus preservation in term of postoperative recurrence rate or ent's quality of life [4]. However, high patient satisfaction has been recently reported; therefore, uterine preservation should be considered during patient's counseling

Pathophysiologic mechanisms by which adenomyosis predisposes to postpartum haemorrhage and other obstetric complications

9sireservedAdenomyosis is characterized by the presence of ectopic endometrium within the myometrium. This features lead to structural changes in the surrounding myometrium and endometrium resulting also in functional changes. Alterations in the myometrium are suspected to lead to defective remodeling of spiral arteries during the early stages of decidualization resulting in altered vascular resistance and defective placentation. These alterations could play a common part in the association between adenomyosis and major obstetric complications. Latest epidemiological studies show that adenomyosis is associated with preterm birth, preeclampsia, IUGR and increased caesarean section rates, but very little is known of any underlying mechanism linking postpartum hemorrhage and adenomyosis. It is our opinion that adenomyosis may increase the risk of postpartum hemorrhage through several mechanisms that will be further clarified. Women with adenomyosis may require specific management during pregnancy and may benefit from wider understanding of the pathological mechanisms associated with this disease process.mixedMartone S.; Centini G.; Exacoustos C.; Zupi E.; Afors K.; Zullo F.; Maneschi F.; Habib N.; Lazzeri L.Martone, S.; Centini, G.; Exacoustos, C.; Zupi, E.; Afors, K.; Zullo, F.; Maneschi, F.; Habib, N.; Lazzeri, L

Obesity in laparoscopic surgery

Since the 1980s, minimally invasive techniques have been applied to an increasing number and variety of surgical procedures with a gradual increase in the complexity of procedures being successfully performed laparoscopically. In the past, obesity was considered a contraindication to laparoscopy due to the higher risk of co-morbid conditions such as diabetes, hypertension, coronary artery disease and venous thromboembolism. Performing laparoscopic gynaecological procedures in morbidly obese patients is no longer a rare phenomenon; however, it does necessitate changes in clinical practice patterns. Understanding of the physiological changes induced by laparoscopy, particularly in obese patients, is important so that these may be counteracted and adverse outcomes avoided. Laparoscopy in obese patients confers certain advantages such as shorter hospital stay, less post-operative pain and fewer wound infections. In addition to these benefits, minimal-access surgery has been demonstrated as safe and effective in obese patients; however, specific surgical strategies and operative techniques may need to be adopted