Angular vs. interstitial pregnancy: A case report highlighting diagnostic nuances with stark management differences

Background: In the literature, the terms “angular”, “interstitial” and “cornual” have often been inappropriately interchanged. The consequence is under-recognition of their differences as well as inaccurate imaging guidelines which do not reliably distinguish them as distinct entities. Angular pregnancies should be considered viable and may be managed to term. Case: A woman at 7w5d was transferred for surgical management of a presumed interstitial ectopic pregnancy. Sonography and MRI confirmed an eccentric fundal pregnancy with a thin myometrial mantle of 2–5 mm; the diagnosis of interstitial pregnancy was favored. Upon laparoscopy, the round ligament was displaced lateral to the pregnancy bulge and the diagnosis of angular pregnancy was thus apparent. The pregnancy was continued to term and delivered via repeat cesarean section without incident. Conclusion: Angular and interstitial pregnancies are different entities which cannot always be reliably distinguished via imaging alone. Diagnostic laparoscopy may be a final step in determining pregnancy location. Angular pregnancies should be considered potentially viable and may be managed to term. Keywords: Angular pregnancy, Cornual pregnancy, Ectopic pregnancy, Interstitial pregnancy, Obstetric ultrasound, Diagnostic laparoscopy, Eccentric pregnanc

Outcomes of Prolonged Minimally Invasive Myomectomy Compared to Open Procedures

Background: Myomectomy is the only fertility sparing surgical approach for the management of fibroids and is increasingly being performed via minimally invasive surgery (MIS). Although MIS has proven clinical benefits over laparotomy, longer operative times in both MIS and laparotomy are associated with adverse outcomes. Little evidence exists to identify patients at risk of excessive operating time. Furthermore, no evidence exists to differentiate an operative time at which risk increases for either approach. Methods: Using the American College of Surgeons National Surgical Quality Improvement Program, laparoscopic and abdominal myomectomies were identified from 2005 to 2013 by CPT code. Procedures were split into laparoscopic and open, and then stratified based on operative time: \u3c 1 hour, 1 to \u3c2 hours, 2 to \u3c3 hours, ≥ 3 hours. Outcomes in open cases were compared to those of laparoscopic cases by time. Results: In all, 2403 laparoscopic and 3436 open procedures were analyzed. In general, open abdominal procedures had worse 30-day outcomes than laparoscopic procedures. Longer surgeries were associated with African American race, higher BMI, lower hematocrit, HTN, age, and large or numerous fibroids. Surgery time was longer for laparoscopic procedures compared with open procedures. Wound complications, clotting, sepsis, UTI, bleeding, return to OR, hospital LOS \u3e 3 days, and a composite complications outcome were significantly associated with surgery time. For most outcomes, there was an increased rate with increased surgery time. After adjusting for confounders, there was no difference in complications between laparoscopic procedures \u3c 1 hour, 1 to \u3c 2 hours, and 2 to \u3c 3 hours long. However, laparoscopic procedures ≥ 3 hours had a higher odds of complications compared with laparoscopic procedures \u3c 1 hour (OR 5.46 [1.31-22.75]; p=.02)). For open procedures, there was no difference in odds of complications for cases \u3c 1 hour and those 1 to \u3c2 hour. However, open procedures of 2 to \u3c3 hours had a higher odds of complications when compared to those \u3c 1 hour long (OR 3.70 [2.20-6.23]; p\u3c.0001). Conclusions: Surgical time was predictive of complications in both laparoscopic and open myomectomy. Laparoscopic myomectomy had a lower complication rate overall. For laparoscopic cases, there was an increase in complications at \u3e 3 hours compared to \u3c 1 hour and for open cases there was an increase in complications at \u3e 2 and \u3c 3 hours compared to \u3c 1 hour. Careful patient counseling and preparation to increase surgical efficiency should be prioritized for either approach

Hysterectomy for the Transgendered Male: a Review of Perioperative Considerations and Surgical Techniques with Description of a Novel 2-Port Laparoscopic Approach.

© 2017 American Association of Gynecologic Laparoscopists Transgendered individuals can suffer a significant amount of psychological distress that can be alleviated through hormonal treatments and/or gender-affirming surgery. The World Professional Association for Transgender Health considers a hysterectomy and bilateral salpingo-oophorectomy medically necessary gender-affirming procedures for the interested transgendered male. Several surgical approaches have been described in the literature, most of which endorse a laparoscopic approach. This review summarizes the available literature on surgical techniques in addition to reporting our institutional outcomes using a novel 2-port laparoscopic approach. Additional preoperative and perioperative considerations are needed when caring for this patient population and are reviewed

Phthalates exposure and uterine fibroid burden among women undergoing surgical treatment for fibroids: a preliminary study.

© 2018 American Society for Reproductive Medicine Objectives: To examine the association between phthalate exposure and two measures of uterine fibroid burden: diameter of largest fibroid and uterine volume. Design: Pilot, cross-sectional study. Setting: Academic medical center. Patient(s): Fifty-seven premenopausal women undergoing either hysterectomy or myomectomy for fibroids. Intervention(s): None. Main Outcome Measure(s): The diameter of the largest fibroid and uterine dimensions were abstracted from medical records. Spot urine samples were analyzed for 14 phthalate biomarkers using mass spectrometry. We estimated associations between fibroid outcomes and individual phthalate metabolites, sum of di(2-ethylhexyl) phthalate metabolites (∑DEHP), and a weighted sum of anti-androgenic phthalate metabolites (∑AA Phthalates) using linear regression, adjusting for age, race/ethnicity, and body mass index. Fibroid outcomes were also examined dichotomously (divided at the median) using logistic regression. Results: Most women were of black ethnicity, overweight or obese, and college educated. In multivariable models, higher levels of mono-hydroxyisobutyl phthalate, monocarboxyoctyl phthalate, monocarboxynonyl phthalate, mono(2-ethylhexyl) phthalate, mono(2-ethyl-5-hydroxyhexyl phthalate) (MEHHP), mono(2-ethyl-5-oxohexyl) phthalate (MEOHP), and mono(2-ethyl-5-carboxypentyl) phthalate (MECPP), ∑DEHP, and ∑AA Phthalates were positively associated with uterine volume. Associations were most pronounced for individual DEHP metabolites (MEHHP, MEOHP, MECPP), ∑DEHP, and ∑AA Phthalates. For example, a doubling in ∑DEHP and ∑AA Phthalates was associated with 33.2% (95% confidence interval 6.6–66.5) and 26.8% (95% confidence interval 2.2–57.4) increase in uterine volume, respectively. There were few associations between phthalate biomarkers and fibroid size. Conclusions: Exposure to some phthalate biomarkers was positively associated with uterine volume, which further supports the hypothesis that phthalate exposures may be associated with fibroid outcomes. Additional studies are needed to confirm these relationships

Ob/Gyn resident self-perceived preparedness for minimally invasive surgery.

© 2020 The Author(s). Background: Very little is known regarding the readiness of senior U.S. Ob/Gyn residents to perform minimally invasive surgery. This study aims to evaluate the self-perceived readiness of senior Ob/Gyn residents to perform complex minimally invasive gynecologic surgery as well as their perceptions of the minimally invasive gynecologic surgery subspecialty. Methods: We performed a national survey study of 3rd and 4th year Ob/Gyn residents. A novel 58-item survey was developed and sent to residency program directors and coordinators with the request to forward the survey link along to their senior residents. Results: We received 158 survey responses with 84 (53.2%) responses coming from 4th year residents and 74 (46.8%) responses from 3rd year residents. Residents who train with graduates of a fellowship in minimally invasive gynecologic surgery felt significantly more prepared to perform minimally invasive surgery compared to residents without this exposure in their training. The majority of senior residents (71.5%) feel their residency training adequately prepared them to be a competent minimally invasive gynecologic surgeon. However, only 50% feel prepared to perform a laparoscopic hysterectomy on a uterus greater than 12 weeks size, 29% feel prepared to offer a vaginal hysterectomy on a uterus 12-week size or greater, 17% feel comfortable performing a laparoscopic myomectomy, and 12% feel prepared to offer a laparoscopic hysterectomy for a uterus above the umbilicus. Conclusions: The majority of senior U.S. Ob/Gyn residents feel prepared to provide minimally invasive surgery for complex gynecologic cases. However, surgical confidence in specific procedures decreases when surgical complexity increases