搜索结果：Facts, views & vision in ObGyn

Technological advances in visual systems have contributed to overcoming the limitations in spatial perception of minimally invasive techniques. To date, there is a lack of literature on the advantages of 3D vision systems over 4K in laparoscopic surgery, although benefits have been observed in the training setting. To compare operating times, perioperative outcomes, and task achievement using 3D and 4K vision systems for vaginal cuff closure performed by residents during total laparoscopic hysterectomy (TLH). All surgeons in training have obtained the Gynaecological Endoscopic Surgical Education and Assessment (GESEA) certificate. This is a prospective randomised trial (NCT04637022). Women undergoing total hysterectomies for benign conditions between January 2021 and November 2023 were enrolled in the study. Vaginal cuff closures were performed by surgeons in training who had obtained the second level of the GESEA programme certificate. Fifty-four patients were enrolled. There were no statistically significant differences in time between 3D and 4K vision for vaginal cuff closure (p=0.918). No statistically significant differences were observed for mean estimated blood loss (EBL) (overall: 62.85 ± 22.73mL; 3D: 65 ± 24.83mL; 4K: 61.11 ± 21.18; p=0.556) and median hospital stay (p=0.234). Three non-severe intraoperative complications in the 3D group (p=0.048) and three postoperative complications in the entire cohort (p=0.685) were reported. The operating time for vaginal cuff closure performed by trainee surgeons is similar when comparing 3D vision during conventional laparoscopy and 4K vision systems. The choice of surgical vision systems may be guided by a cost analysis and surgeon preferences. Substantial evidence is lacking regarding the advantages of incorporating 3D vision into standard laparoscopy for gynaecological surgery. This research seeks to assess whether the 3D visual system can provide benefits as compared to 4K visualisation during laparoscopic vaginal cuff closure performed by surgeons in training within the GESEA 2 certification programme.

In recent years, robotic surgery has gained traction across multiple disciplines, establishing a new minimally invasive paradigm. After the Da Vinci® (Intuitive, Sunnyvale, California) patent expired, several platforms with increasingly digital interfaces entered the market. Robotic surgery may represent a bridge between laparoscopy and digital surgery through interfaces that enable integration with emerging technologies. Among platforms, the Toumai robotic system (Medbot-Microport, Shanghai, China) features a single-arm cart with four arms, a three-dimensional console, and a split-view "picture-in-picture" function enabling communication with image-guided surgical technologies. This functionality is particularly valuable for indocyanine green (ICG)-guided sentinel lymph node (SLN) mapping in gynaecologic oncology. We present for the first time, a step-by-step video demonstration of SLN dissection for endometrial malignancies using the Toumai robotic system. A postmenopausal patient with uterine-confined endometrial carcinoma undergoing total hysterectomy, bilateral salpingo-oophorectomy, and bilateral SLN biopsy. The technique includes: 1) ICG injection; 2) robotic trocar placement; 3) docking; 4) pelvic retroperitoneal access; 5) switch to split-view mode; 6) identification of the SLN critical view of safety by developing pararectal and paravesical spaces; 7) introduction of an ICG-capable camera through an accessory trocar; 8) activation of near-infrared visualisation after switching off the robotic light source; 9) SLN identification and dissection; 10) safe extraction. The digital interface of the Toumai system integrates adjunctive technologies, illustrating how next-generation robotics expand the feasibility of SLN dissection in endometrial cancers. The Toumai platform enables SLN dissection even in the absence of an in-house integrated ICG endoscopic camera.

The role of reproductive surgery is declining due to the widespread availability of assisted reproductive technology, but an evidence-based fundament for this decline is lacking. We therefore performed a systematic review of the literature. We searched MEDLINE, EMBASE and the Cochrane Library for randomised trials evaluating laparoscopic or hysteroscopic interventions in subfertile women, studying pregnancy or live birth rates. We present an overview of the results and quality of the detected studies. The methodological quality of the 63 detected studies was mediocre. The laparoscopic treatment of minimal/ mild endometriosis might increase the pregnancy rate but the two major studies report conflicting results. Excision of the endometriotic cyst wall increases the spontaneous conception rate (RR 2.8, 95% CI 1.4-5.5). Laparoscopic ovarian drilling results at least in equal pregnancy rates as gonadotropin treatment (RR 1.0, 95% CI 0.83-1.2) but decreases the multiple pregnancy rate (RR 0.16, 95% CI 0.04-0.58). Laparoscopic tubal surgery for hydrosalpinx prior to IVF increases the pregnancy rate (RR 1.9, 95% CI 1.4-2.7). Removal of polyps prior to IUI increases the pregnancy rate (RR 2.2, 95% CI 1.6-3.1). Myomectomy for submucosal fibroids results in higher pregnancy rates (RR 2.2, 95% CI 1.6-2.9). The removal of intramural/ subserosal fibroids shows a beneficial trend, albeit not statistically significant (RR 1.2, 95% CI 0.75-1.9). Hysteroscopy in patients with recurrent IVF failure increases the pregnancy rates even in the absence of pathology (RR 1.6, 95% CI 1.3-1.9). Although the limited evidence indicates a positive role for some surgical reproductive interventions, we should be very cautious in providing guidelines for clinical practice in reproductive surgery since more research is needed.

For women who undergo fertility-sparing treatment for early cervical cancer, transabdominal cerclage (TAC) may be considered to prevent adverse obstetric outcomes due to cervical insufficiency. Laparoscopic-TAC (LPS-TAC) is now preferred over conventional transabdominal approaches because of decreased pain and bleeding, shorter hospitalisation and quicker recovery. However, a systematic, precise approach to performing LPS-TAC during pregnancy is necessary to overcome the lack of uterine manipulation and minimise complications such as bleeding and pregnancy loss. To demonstrate the surgical technique of post-conceptional LPS-TAC. A 33-year-old woman with a history of FIGO stage IA1 squamous cervical cancer treated with fertility-sparing surgery. She had suffered a foetal loss after an emergency Caesarean section at 28 weeks because of uterine rupture. In her next pregnancy she presented at 10 weeks gestation with an ultrasound diagnosis of cervical shortening (14 mm). The patient underwent LPS-TAC at a tertiary referral center. The operating time was 51 minutes, and blood loss was minimal. Intraoperative transvaginal ultrasound was used to guide the cerclage placement. No perioperative complications occurred; the hospital stay was two days. Elective C-section was performed at 34+6 weeks with hysterotomy above the tape, which was left in situ. LPS-TAC during pregnancy represents a feasible minimally invasive option for selected patients with cervical insufficiency, particularly those with a history of prior cervical surgery. Intraoperative ultrasound may assist in identifying the internal cervical os, facilitating safe tape placement and minimising the risk of membrane injury during pregnancy. Intraoperative ultrasound guidance may support safe identification of the internal cervical os and optimal tape placement when performing LPS-TAC during pregnancy in patients with previous fertility-sparing treatment for cervical cancer.

Minimally invasive, uterus-sparing radiofrequency (RF) and microwave (MW) ablation have been introduced under ultrasound or laparoscopic guidance to treat uterine fibroids. These technologies enable targeted coagulative necrosis, potentially minimising surgical time and trauma while shortening recovery. They can also be used under hysteroscopic guidance, although feasibility data is lacking. To assess the feasibility and short-term outcomes of hysteroscopic RF and MW ablation for FIGO-type 2 and type 3 fibroids. Four patients were included: two with FIGO-type 2 fibroids and two with FIGO-type 3 fibroids, all presenting with heavy menstrual bleeding (HMB) and no desire for pregnancy. Procedures were performed at a tertiary care university hospital under sedation. As no evidence-based guidelines define selection criteria between MW and RF, both modalities were employed in fibroids with similar presentation. Under direct hysteroscopic visualisation, the needles were inserted through the operative channel into the myoma, maintaining a 10-mm safety margin. Tissue necrosis was confirmed by hyperechogenicity of the treated area. Each procedure lasted approximately 4 minutes. All patients were discharged the same day without complications. Hysteroscopic ablation was technically feasible and safe in this limited case series. The procedure induced necrosis, reduced fibroid vascularisation, and resolved HMB without complications, scarring, or adhesions. Future studies are needed to evaluate long-term outcomes and determine whether it may serve as a standalone option. Hysteroscopic myolysis may expand the therapeutic armamentarium for selected patients seeking uterine preservation. By using the natural intracavitary pathway, the technique allows precise ablation while preserving uterine integrity and minimising procedural invasiveness.

Robotic-assisted hysterectomy is increasingly performed using modular platforms such as the Hugo™ roboticassisted surgery (RAS) system, but optimal or personalised docking strategies remain undefined. To establish expert consensus on port placement and docking configurations for hysterectomy with the Hugo™ RAS system and to identify patient anthropometric factors requiring modification of standard setups. A modified Delphi consensus was conducted involving two iterative rounds of anonymous, structured questionnaires distributed to an international panel of gynaecological robotic surgeons experienced with the Hugo™ RAS system. Survey items addressed preferred docking configurations, the influence of patient anthropometry on docking strategy, and specific technical adjustments in non-standard scenarios. Consensus was predefined as ≥66.7% agreement. Expert agreement on docking setups, port placement modifications, and anthropometric variables influencing technical adjustments. Seventeen experts completed round one and 16 completed round two. No single docking configuration reached consensus as universally optimal for standard hysterectomy. Ranking exercises identified the "standard" hysterectomy setup as the most preferred configuration, followed by the "alternate" and the "three-arm" setups. All experts agreed that patient anthropometry requires modification of port placement. Elevated body mass index (BMI), large uterine size and small pelvis were identified as key variables: increasing inter-port distance was recommended for BMI >30, cranial port displacement for large uteri, while no consensus emerged for patients with a small pelvis. A modified bridge configuration was proposed, and achieved strong expert agreement. No single docking configuration is deemed to be universally optimal for Hugo™ RAS hysterectomy. Expert practice combines a limited number of preferred setups with patient-tailored adjustments. This study provides the first Delphi-based expert consensus on Hugo™ RAS docking strategies, emphasizing patient-specific adjustments and flexible preoperative planning.

Total laparoscopic hysterectomy (TLH) is associated with reduced post-operative pain and enhanced recovery, allowing same-day discharge (SDD). However, adoption of SDD TLH is not established, and practice varies. To conduct a national survey of UK gynaecologists with an interest in laparoscopic surgery to obtain their views, opinions and experience of SDD TLH. Members of the British Society for Gynaecological Endoscopy were invited to complete an online questionnaire between January 2023 and January 2024. The questionnaire consisted of 16 questions about SDD TLH covering three domains: (i) service provision, (ii) prognostic variables and (iii) information giving and education. One hundred and forty-eight clinicians from 148/215 NHS hospitals (69%) responded. One hundred and thirty one (89%) respondents thought that SDD following TLH was beneficial, and 48 (32%) hospitals had an established service. Adequate pain control was considered the most important factor to achieve SDD TLH, followed by control of nausea and vomiting. Seventy-eight (53%) respondents removed the urinary catheter at the end of the procedure. All respondents believed that managing patients' expectations was important to achieve compliance with SDD and 123 (83%) thought that developing an online preadmission patient information resource was needed. One third of UK NHS hospitals have a SDD TLH service but there is variation in availability and protocols (pre-, peri- and post-operative management). These data can help develop health service strategy to promote SDD after TLH and standardise protocols. The survey quantifies and demonstrates hospital-level variation in uptake and practice of SDD provision after TLH.

The core business of reproductive health care in developing countries is HIV/AIDS, contraception and maternal care and not one single reproductive health care program is dealing with couples unable to reproduce. How strange to have on the one hand the reproductive medicine clinics in the resource rich countries focusing mainly on infertility care and on the other hand reproductive health care programs in resource poor countries not giving one single penny to infertility care. In this paper I am exploring the reasons for this unbalanced situation. It is clear from the facts and figures that infertility affects - often with devastating consequences - the lives of roughly one tenth of couples in developing countries. I argue that the neglect of infertility in the public health debate is caused by a mixture of ignorance (mainly by the international aid community) and tunnel vision, opportunism and a non--enlightened attitude of contempt for individual human rights. The prohibitive cost of IVF is contributing to this neglect as well. At present promising low cost IVF techniques are being developed and could potentially make IVF available at a cost accessible for a much larger part of the world population. With the latter becoming available, there should be no impediment for infertility care to become integrated into mainstream reproductive health care in developing nations. Reproductive rights advocates can no longer justify the systematic exclusion of one tenth of couples from the right to decide freely if, when and how to reproduce. Reproductive health, reproductive rights, infertility care, developing countries, public health, simplified IVF.

Rectal endometriosis is a severe form of deep endometriosis affecting up to 12% of patients, causing significant pain and bowel dysfunction. The optimal surgical approach can be individually tailored based on lesion size and localization as assessed by preoperative imaging. To compare the postoperative and long-term clinical results of two alternative surgical approaches to symptomatic rectal endometriosis. A retrospective single-centre study of 115 patients who had surgical resection of rectal endometriosis either by complete nodular resection (CNR) (n=55) or segmental rectal resection (SRR) (n=60). The surgical approach was indicated based on #Enzian related presurgical transvaginal sonography. #Enzian C1-2 lesions were planned for CNR, and #Enzian C3 lesion for SRR. Postoperative pain and satisfaction data were collected. Satisfaction and change in pre-operative and post-operative pain symptoms and overall improvement in symptoms, urinary and bowel dysfunction measured at follow-up and complications following surgery. 68/115 (59%) women provided follow up data. There were significant reductions in dysmenorrhoea, dyspareunia and dyschezia following surgical resection compared to pre-operative levels in both groups (P&#x2264;0.001). Patients treated with CNR had significantly lower postoperative defecation dysfunction compared to SRR (12.1% vs. 42.9%, P=0.007) and lower postoperative C-reactive protein (CRP) levels (P<0.001), but satisfaction and complication rates were comparable between the two surgical approaches. One case of leakage occurred following SRR and no cases of fistulisation or bowel stenosis were observed. CNR and SRR are both safe and effective in treating symptomatic rectal endometriosis. CNR may be associated with lower postoperative defecation dysfunction rates and lower postoperative CRP levels. Complete nodular mucosa-sparing resection of rectal endometriosis seems to be feasible and potentially efficacious in lesions up to 3 cm. Compared to SRR, CNR may be associated with less post-operative defecation dysfunction.

"Buddy operating" is a subtype of dual operating described in the Clark model, where two surgeons of comparable proficiency collaborate during complex procedures. Potential benefits include improved surgical efficacy and safety, shared intraoperative decision making, enhanced skill development, and improved surgeon wellbeing. However, implementation must be justified given resource constraints and potential impacts on surgical training. We propose that buddy operating should be selectively applied to clearly defined complex cases, supported by governance frameworks, structured protocols, and outcome monitoring. Importantly, buddy operating must be distinguished from supervisory training. Future research should evaluate its effects on clinical outcomes, cost-effectiveness, surgeon health, and access to training opportunities.

Urinary tract endometriosis affects fewer than 6% of patients with endometriosis, with ureteral involvement representing the second most common site of disease (9-23%). The condition is often asymptomatic, which may result in silent loss of renal function. Surgical intervention is required in cases of ureteral obstruction. Ureteroneocystostomy is indicated for distal ureteral disease, particularly when ureterolysis is insufficient or vascular compromise is present. The Lich-Gregoir technique is an extravesical approach to ureteral reimplantation into the bladder. To present a step-by-step demonstration of robot-assisted ureteral reimplantation using the Lich-Gregoir technique following excision of a parametrial and vaginal endometriosis nodule. A 47-year-old nulliparous woman presented with dysuria, deep dyspareunia, and dyschezia. Imaging revealed a left parametrial endometriosis nodule extending to the vagina, causing distal ureteral obstruction and grade III hydronephrosis. This narrated video demonstrates the surgical management of severe ureteral endometriosis, including ureterolysis, safe nodule excision, and ureteral reimplantation using the Lich-Gregoir technique. Reimplantation was preferred to segmental resection or ureterolysis due to distal stenosis, proximity to the bladder, and the depth of disease infiltration. The patient remained asymptomatic at follow-up visits at 1 and 6 months. Retrograde cystography performed 3 weeks postoperatively showed no leakage. Robot-assisted Lich-Gregoir ureteral reimplantation represents a feasible and reproducible option for distal ureteral endometriosis. The robotic platform may facilitate precise and complex reconstructive procedures. The case illustrates the role of robotic surgery in complex pelvic endometriosis, demonstrates the feasibility of integrating ureteroneocystostomy with simultaneous excision of parametrial and vaginal endometriosis.

The introduction of ultra-high-definition laparoscopic cameras (4K), by providing stronger monocular depth perception, could challenge the existing 3D technology. There are few available studies on this topic, especially in gynaecological setting. Prospective, single institution, randomised clinical trial (NCT04209036). The two laparoscopes utilised were the 0&#xb0;ULTRA Telescopes with 4K technology and the 0&#xb0;3D-HD by Olympus. The surgeons were all trainees and in their last year of residency and who had obtained the certificate of first or second level of the Gynaecological Endoscopic Surgical Education and Assessment program - GESEA program. Twenty-nine patients with benign uterine pathology were enrolled. To compare if the use three-dimensional (3D) versus ultra-high-definition laparoscopic vision system (4K) for total laparoscopic hysterectomy performed by trainees was associated with a shorter operative time. The 3D vision system did not prove to be superior to the 4K vision system. Operators reported significantly more vision-related side effects when using 3D than 4K. Completing the GESEA training program was the only factor with a positive and statistically significant impact on the overall time of the procedure, especially when greater dexterity and tissue handling were required. Neither technology used proved superior to the other, although operators showed a preference for 4K over 3D due to the lower number of visual side effects. Attendance at courses on laparoscopic simulators and training programs allowed trainees to demonstrate excellent surgical skills.

In the last years, laparoscopy has been progressively introduced in the management of advanced- stage ovarian cancer (AOC) not only to evaluate tumour resectability, but also to perform primary or interval minimally invasive debulking surgery in selected patients. During laparoscopic debulking for AOC, the need to change the surgical field to treat disease in the upper abdomen can be a time-consuming procedure. To demonstrate feasibility, safety and effectiveness of laparoscopic approach to remove bulky para- aortic nodes in AOC with a 30-degree 3D-endoscope without repositioning the laparoscopic surgical field. A 51-year-old woman was referred to our centre due to AOC with bulky para-aortic nodes (7 cm polylobate mass at CT-scan). The narrated surgical video article demonstrates the surgical steps for laparoscopic removal of bulky para-aortic nodes with a 30-degree 3D-endoscope, maintaining the vision from the upper abdomen perpendicular to the main axis of the vascular structures for the whole duration of the surgery ("top-bottom" view), without repositioning surgical field. Complete laparoscopic excision of disease was achieved. Post-operative course was uneventful. Patient recovered from surgery and was able to start adjuvant chemotherapy within 30 days from surgery. Repositioning the surgical field to perform para-aortic dissection can be a time-consuming procedure during laparoscopic debulking for ovarian cancer. Laparoscopic removal of bulky para-aortic nodes with a 30-degree 3D-endoscope and "top-bottom view" is feasible, safe and effective.

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We propose the junctional zone- magnetic resonance imaging (JZ-MRI) ReproClass, a four-tiered MRI-based classification for describing JZ morphology, developed from more than a decade of clinical experience in women with recurrent implantation failure or pregnancy loss despite normal embryo quality. The system characterises the spectrum of JZ appearances -from normal architecture to complete loss of differentiation- and is particularly informative when ultrasound and hysteroscopy appear normal. By standardising MRI assessment of the JZ, the ReproClass may help identify morphological patterns associated with impaired reproductive performance and support more individualised diagnostic reasoning. It provides a foundation for future research into the role of JZ architecture in fertility outcomes.

Hysteroscopic uterine evacuation of early pregnancy loss using tissue removal devices seems to be a safe and feasible procedure in selected cases. The hysteroscopic approach allows the precise localisation of the gestational sac inside the uterine cavity. The endoscopic approach allows one to perform hysteroembryoscopy before uterine evacuation and this technique appears to be more accurate than dilatation & curettage for fetal chromosome karyotyping, with lower maternal cell contamination. This "under vision" procedure may reduce retained products of conception rates and risk of intrauterine adhesions formation.

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