Recommendations for a standardised educational program in robot assisted gynaecological surgery: consensus from the Society of European Robotic Gynaecological Surgery (SERGS)

Background: the Society of European Robotic Gynaecological Surgery (SERGS) aims at developing a European consensus on core components of a curriculum for training and assessment in robot assisted gynaecological surgery. Methods: a Delphi process was initiated among a panel of 12 experts in robot assisted surgery invited through the SERGS. An online questionnaire survey was based on a literature search for standards in education in gynaecological robot assisted surgery. The survey was performed in three consecutive rounds to reach optimal consensus. The results of this survey were discussed by the panel and led to consensus recommendations on 39 issues, adhering to general principles of medical education. Results: on review there appeared to be no accredited training programs in Europe, and few in the USA. Recommendations for requirements of training centres, educational tools and assessment of proficiency varied widely. Stepwise and structured training together with validated assessment based on competencies rather than on volume emerged as prerequisites for adequate and safe learning. An appropriate educational environment and tools for training were defined. Although certification should be competence based, the panel recommended additional volume based criteria for both accreditation of training centres and certification of individual surgeons. Conclusions: consensus was reached on minimum criteria for training in robot assisted gynaecological surgery. To transfer results into clinical practice, experts recommended a curriculum and guidelines that have now been endorsed by SERGS to be used to establish training programmes for robot assisted surgery

Can Prevention of Mesothelial Damage during Endoscopic Surgery Decrease Adhesion Formation and Tumor Implantation ?

Laparoscopic surgery advanced over the last years as it holds the promise of reduced invasiveness and thus of reduced adhesion formation. Results on reduced adhesion formation were however not as good as expected and new approaches to prevent the deleterious complications such as bowel obstruction, infertility and chronic pelvic pain were investigated.Over the last years we developed a laparoscopic mouse model on which preventive measurements concerning gas (temperature, humidification, oxygen) and other means (i.e. dexamethasone, barriers) were tested and the most promising were selected. These favorable actions needed to be brought into clinical practice to reduce adhesion formation and to bring laparoscopic surgery to a new standard.Tumor implantation reduced with the addition of 3% of oxygen to the CO2 pneumoperitoneum in our laparoscopic mouse model. There was however no clinical correlation with reduced port site metastases by adding 4% of oxygen to the CO2 pneumoperitoneum in women undergoing laparoscopy for ovarian malignancies.Intraperitoneal injection of cultured mesothelial cells did decrease adhesion formation in a dose-response dependable way. To bring this approach to clinical practice will need the development of other means to safely remove, culture and inject mesothelial cells in humans in the peri-operative phase.The direct beneficial effect on the peritoneum of the addition of oxygen to the CO2 pneumoperitoneum was demonstrated in mice with scanning electron microscopy, but these experiments were not reproducible in humans. Indirect ways to measure the influence of the addition of oxygen to the CO2 pneumoperitoneum were investigated.Absorption of CO2 was investigated by the study of end tidal CO2 (ET CO2) where we noticed a significant decrease when 4% oxygen was added to the CO2 pneumoperitoneum. Perhaps related to this, was the significant decrease in post-operative pain and inflammation in women who received the oxygenated gas.From ongoing mice experiments we learned that full conditioning of the peritoneal cavity with humidification of the gas at 32°C and with addition 4% of oxygen and 10% of nitrous oxide further reduced adhesion formation.Clinical experiments with full conditioning of the peritoneal cavity studying ET CO2, pain, inflammation and fluid resorption as we carried out with the addition of 4% of oxygen all showed a beneficial effect, with even some more pronounced results on pain and inflammation.To preserve the integrity of the mesothelial layer, injection of cultured mesothelial cells or altering the insufflation gas did provide evidence, but also extensive lavage of the peritoneal cavity did improve inflammatory parameters, suggesting a depletion of inflammatory cells able to degrade the surgical lesion.The peritoneum is a delicate organ which is influenced by its environment in a direct way. Homeostasis of the environment is essential to decrease adhesion formation, post-operative pain and to minimize anesthesiologic problems.Preserving is better than restoring and with this new way of looking at, and entering the peritoneal cavity, laparoscopic surgery may step into a new era.nrpages: 131status: publishe

Incidence of vaginal intraepithelial neoplasia after hysterectomy for cervical intraepithelial neoplasia: a retrospective study

OBJECTIVE: Hysterectomy with concomitant cervical intraepithelial neoplasia (CIN), is often considered a definitive treatment for CIN, but development of subsequent vaginal intraepithelial neoplasia (VAIN) is known to range from 0.9% to 6.8%. STUDY DESIGN: In a retrospective analysis of 3030 women with CIN2+ without history of VAIN in the University Hospital Gasthuisberg, Leuven, Belgium, from January 1989 until December 2003, we identified 125 women who underwent a hysterectomy within 6 months after diagnosis of CIN2+ and reviewed their postoperative Papanicolaou smears. RESULTS: Thirty-one patients (24.8%) were lost to follow-up. Seven of the 94 women in the follow-up group (7.4%) developed VAIN2+, of which 2 were invasive vaginal cancers. Median interval between hysterectomy and diagnosis of VAIN2+ was 35 months (5-103 months). Women with recurrence were significantly older (P = .003). CONCLUSION: Hysterectomy may not be considered as a definitive therapy for CIN2+ because the incidence rate of subsequent VAIN2+ is as high as 7.4%

Authors' reply re: Towards painless and adhesion-free laparoscopy

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Myomectomy: surgical techniques anno 2018. A systematic review.

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Implementing robotic assisted myomectomy in surgical practice - a retrospective cohort study

© 2019, The Author(s). Background: To compare surgical outcomes of patients with leiomyomas after robotic-assisted laparoscopic myomectomy (RALM), laparoscopic myomectomy (LsM), or laparotomic myomectomy (LtM) and to construct a useful algorithm for the best modus operandi for uterine leiomyomas. Methods: Design: A retrospective chart review. Data included patient (age and BMI) and fibroid characteristics (number, measurements of the primary fibroid, type, and location), operating time, blood loss, hospitalization length, complications during and after surgery, and complications during posttreatment pregnancies. Comparisons were based on chi-square and two-sample t tests. Setting: University teaching hospital. Patients: Between 1 January 2009 and 31 December 2016, 51 RALMs, 84 LsMs, and 52 LtMs were performed at our institution. Interventions: Three different approaches of myomectomy were performed: robotic-assisted laparoscopy (RALM), laparoscopy (LsM), and laparotomy (LtM). Results: There was no significant difference in the distribution of the location and the type of myoma between the three groups. The mean size of the largest myoma removed by LsM, RALM, and LtM was 60.9, 70.8, and 92.6 mm (p < 0.05), respectively. Surgical outcomes between the three modalities were comparable except for increased mean blood loss and postoperative bleeding and longer hospital stay for patients with LtM and for longer operation time when performing RALM. Conclusion: RALM should replace open surgery if feasible and should not replace traditional laparoscopy unless other benefits are proven.status: publishe

Verantwoordt het risico op een bekkeninfectie het plaatsen van intra-uteriene contraceptie bij nullipara?

Het resultaat van een consensusvergadering over het risico van een opstijgende bekkeninfectie („pelvic inflammatory disease” – PID) bij het plaatsen van een intra-uterien spiraaltje („intrauterine contraceptive device” – IUCD) bij nullipara wordt hier samengevat. De kans op een infectie in functie van de bekende risicofactoren van een PID, de zin of de onzin van een screening naar cervicale infecties, alsook van het systematisch toedienen van profylactische antibiotica worden toegelicht. Na het plaatsen van een IUCD is er tijdens de eerste drie weken tijdelijk een verhoogd risico op het ontstaan van een PID. Dit risico ligt hoger bij vrouwen jonger dan 25 jaar en is te wijten aan het subklinische bestaan van cervicitis met onder andere Chlamydia trachomatis (CT) en Neisseria gonorrhoeae (NG). In de aanwezigheid van onbehandelde CT of NG leidt het plaatsen van een IUCD tot een vier keer verhoogd risico op een PID. Vermits er een duidelijk verband bestaat tussen de kans op CT en een jongere leeftijd en aangezien het bij deze (meestal) nullipara cruciaal is om de verminderde vruchtbaarheid ingevolge de PID te beperken, is het noodzakelijk om jongeren te screenen naar het voorkomen van een seksueel overdraagbare aandoening (SOA) (bv. NG, CT en mogelijk ook bacteriële vaginose en aerobe vaginitis) alvorens een IUCD te plaatsen. Bij vrouwen met een lag risico op een SOA is noch een screening, noch voorafgaande antibiotische profylaxe aangeweze