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Surgical Technology International XXV contains 41 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.

 

Oct, 2014 - ISSN:1090-3941

 

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Gynecology

 

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Electrosurgery in Gynecology – a Comparison of Available Instruments that Coagulate and Cut Tissue
Bernhard Kraemer, MD, Senior Consultant of Operative Gynecology, Wolfgang Zubke, MD, Senior Consultant of Operative Gynecology, Sara Brucker, MD, Professor of Women’s Health and Gynecology, Diethelm Wallwiener, MD, Clinical Director and Professor of Gynecology, Ralf Rothmund, MD, Senior Consultant of Operative Gynecology, University of Tuebingen, Tuebingen, Germany

PMID: 25433176

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Abstract

In the field of minimally invasive gynecology the use of electrosurgical or energy-based devices has become extremely important for rapid preparation and short reconvalescence. The instruments that are on the market vary regarding their technical characteristics, specifications, and handling. We provide an overview of selected instruments that are appropriate for gynecological laparoscopy and review possible indications and limitations.

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Scar Assessment for Patients Undergoing Minimal Invasive Hysterectomy
Steven D. McCarus, MD, FACOG, Chief, Division of Gynecologic Surgery, Florida Hospital Celebration Health, Celebration, Florida, Assistant Professor of Obstetrics and Gynecology, Department of Medical Education, University of Central Florida College of Medicine, Orlando, Florida, Founder and Director, Mccarus Surgical Specialists for Women,  Orlando, Florida

PMID: 25433344

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Abstract

Surgical innovations have positively impacted the way hysterectomy procedures are performed by surgeons and the results experienced by patients. Patients with benign disease requiring a hysterectomy are no longer subjected to living with a large incisional scar that was common only 20 years ago. With the advent of minimally invasive surgery, surgeons can now provide hysterectomy patients with cosmetically pleasing results. To better understand the impact of surgical scars from hysterectomy incisions, 200 subjects answered a surgical incision questionnaire. Cosmetic issues (i.e., hysterectomy scars) were self-reported as important in 93% of subjects, of which 24% indicated this was extremely important. Of these same subjects, 11% indicated they were extremely bothered about their current scars. Subject interest in surgery without scars was 92% and 45% noted extreme interest. Concern about the surgical incision appearance was cited by 85% of subjects. Familiarity about incisions associated with the different hysterectomy procedures resulted in 26% of subjects who were not at all familiar. Low placed incision locations were considered cosmetically superior by 86% of the subjects. The least desirable incision location was above the belly button (69%) whereas the most desirable incision location was below the bikini line (68%). Discussion about the location, number, and incision size prior to surgery was cited to be important by 93% of subjects. Study subjects show there is value in discussing the number and placement of surgical incisions prior to surgery. Cosmesis of the surgical scars is a concern for many women, but most subjects knew little about the hysterectomy incision options. Based on these findings, surgeons can improve patient satisfaction scores by discussing incisional placement and surgical options prior to the procedure.

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Minilaparoscopic Sacrocolpopexy for Vaginal Prolapse after Hysterectomy
Helder Ferreira, MD, Head of Minimally Invasive Surgery Unit, Department of Obstetrics and Gynecology, Centro Hospitalar do Porto, Porto, Portugal, Carlos Ferreira, MD, Urology Resident, Department of Urology, Unidade Local de Saúde Matosinhos, Porto, Portugal, Antonio Braga, MD, Gynecology Resident, Department of Obstetrics and Gynecology, Centro Hospitalar do Porto, Porto, Portugal, Antonio Tome Pereira, PhD, Professor of Gynecology, Department of Obstetrics and Gynecology, Centro Hospitalar do Porto, University of Porto, Porto, Portugal, Serafim Guimaraes, MD, Full Professor of Gynecology, Chairman, Department of Obstetrics and Gynecology, Centro Hospitalar do Porto, University of Porto, Porto, Portugal

PMID: 25433151

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Abstract

Genital prolapse repair is one of the most common indications for benign gynecologic surgery. The lifetime risk of undergoing a single operation for prolapse in the female population is rising. Many different surgical techniques have been described. We report 4 cases of minilaparoscopic sacrocolpopexy to correct vaginal apical prolapse after previous total hysterectomy. For each patient we collected some socio-demographic data, vaginal apical prolapse grade using the Pelvic Organ Prolapse Quantification (POP-Q), intraoperative details and postoperative outcomes. Operative time was recorded as well as difficulties and complications (Clavien-Dindo Classification) at each step of the procedure. The range of women’s ages was from 57 to 71 years old. The mean BMI was 24.75 ± 3.2 Kg/m2. Three patients had a stage III POP-Q prolapses and there was one case of a symptomatic stage II POP-Q prolapse. The mean surgical time was 119 minutes and there were no intraoperative complications. The postoperative pain assessment revealed very positive recovery in every patient. An ambulatory consult and an anatomic assessment were done 1 and 3 months after surgery. The incision scars were almost invisible after 1 month, and the anatomic cure rate was 100%. We confirmed the feasibility of a minilaparoscopic surgical approach for vaginal vault prolapse after total hysterectomy.

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Laparoscopic Morcellation and Tissue Spillage Containment Using the LI Endofield™ Bag
James Dana Kondrup, MD, FACOG, Assistant Clinical Professor, Department of Obstetrics/Gynecology, Upstate Medical Center, Syracuse, New York – Binghamton Campus, Binghamton, New York, Fran Anderson, PhD, RN, Research Coordinator, Our Lady of Lourdes Hospital, Binghamton, New York, Brenda Sylvester, PA-C, Lourdes Operating Room Physician Assistant, Our Lady of Lourdes Hospital, Binghamton, New York, Michelle Branning, CST, Lourdes Operating Room Surgical Technician, Our Lady of Lourdes Hospital, Binghamton, New York

PMID: 25419952

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Abstract

There are many times during laparoscopic surgery that a surgeon, whether gynecologist or general surgeon, must work in an environment where spillage of tissue or organ contents should be avoided. In gynecologic surgery, this involves management of ovarian cysts as well as containment of tissue fragments during morcellation of uteri or fibroids. Unfortunately, many laparoscopic containment bags on the market today are not large enough to remain open on their own during the entire procedure. The LI Endofield™ and LI Endofield™ TV bag offer a solution and provide an adjustable and suturable “field bag.” Surgeons can work in an adjustable “field,” are able to see through the bag, and can remove it at the end of the procedure. With the recent FDA cautions on power morcellation, our team only morcellates fibroids and uteri using one of these bags.

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Total Laparoscopic Hysterectomy in Obese Patients
Stuart Hart, MD, MS, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Director, Tampa Bay Research and Innovation Center (TBRIC), Director, USF Center for the Advancement of Minimally-Invasive Pelvic Surgery (CAMPS), USF Health Center for Advanced Medical Learning and Simulation (CAMLS), University of South Florida Morsani College of Medicine, Tampa, Florida, Emad Mikhail, MD, Fellow of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, University of South Florida/, Morsani College of Medicine, Tampa, Florida, Lauren Scott, MD, Fellow of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of South Florida/, Morsani College of Medicine, Tampa, Florida, Anthony N. Imudia, MD, Director, USF Center for Fibroid and Endometriosis Research and Treatment, Assistant Professor, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of South Florida/Morsani College of Medicine, Tampa, Florida

PMID: 25419953

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Abstract

Obesity is a challenging health problem that affects surgical decision-making. Obesity has also been associated with an increase in the perioperative complication rate in open abdominal hysterectomy and can increase the level of difficulty in performing a vaginal hysterectomy. Total laparoscopic hysterectomy (TLH) is a route that can offer advantages in obese patients including smaller incisions that are less likely to become infected as well as less post-operative pain and good visualization. With appropriate perioperative planning and techniques, excellent outcomes can be achieved.

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A New Approach for the Management of Bladder Injury in Retropubic Slings: One Side Transobturator/One Side Retropubic Sling
Orhan Seyfi Aksakal, MD, Director of Urogynecology, Department of Gynecology, Ankara Dr Zekai Tahir Burak Women’s Health Research and Education Hospital, Ankara, Turkey, Sabri Cavkaytar, MD, Gynecologist, Department of Gynecology, Ankara Dr Zekai Tahir Burak Women’s Health Research and Education Hospital, Ankara, Turkey, Mahmut Kuntay Kokanalı, MD, Gynecologist, Department of Gynecology, Ankara Dr Zekai Tahir Burak Women’s Health Research and Education Hospital, Ankara, Turkey, Umit Tasdemir, MD, Gynecologist, Department of Gynecology, Ankara Dr Zekai Tahir Burak Women’s Health Research and Education Hospital, Ankara, Turkey, Hasan Onur Topcu, MD, Gynecologist, Department of Gynecology, Ankara Dr Zekai Tahir Burak Women’s Health Research and Education Hospital, Ankara, Turkey, Melike Doganay, MD, Associate Professor/Chief of Gynecology, Department of Gynecology, Ankara Dr Zekai Tahir Burak Women’s Health Research and Education Hospital, Ankara, Turkey

PMID: 25433345

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Abstract

The aim of this study was to establish a new management modality for bladder perforation during retropubic slings. In 2013, among 102 retropubic slings, there were five bladder injuries. All procedures were performed by one of the fourth year residents under direct supervision of experienced surgeons. Bladder perforation was detected in cystoscopic examination. In the bladder perforated side, tape was retracted and placed by transobturator approach and the Foley catheter remained in place for seven days. Demographic features, preoperative urodynamic examination, and preoperative and postoperative life quality questionnaires (IIQ-7 and UDI-6) were recorded. The mean age of the patients was 44 ± 2.5 years and body mass index was 29.4 ± 1.7 kg/ m2. Mean parity was 2.8 ± 1.8 and all the patients delivered with vaginal route. None of the patients were in menopause. Of the five bladder perforations, 40%(2) occurred on the right side, 60%(3) on the left side. All the surgeons were right handed. All patients underwent other vaginal reconstructive procedures like anterior colporraphy and posterior colporraphy. None of the patients had previous anti-incontinence surgery. Mean follow-up was 10.2 ± 2.4 months. All patients had negative stress tests and improvement in IIQ-7 and UDI-6 at postoperative sixth month. There was no postoperative voiding dysfunction in any of the patients. If bladder perforation occurs in patients who undergo retropubic sling, the tape can be placed by transobturator approach in the bladder perforated side.

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Vaginal Reconstruction/Rejuvenation: Is There Data to Support Improved Sexual Function? An Update and Review of the Literature

Dr. Robert D. Moore, DO, FACOG, FPMRS, Urogynecologist, International Urogynecology Associates of Atlanta and Beverly Hills, Vaginal Rejuvenation Center of Atlanta, Atlanta Medical Research, Inc., Atlanta, Georgia, John R. Miklos, MD, Urogynecologist, International Urogynecology Associates of Atlanta and Beverly Hills, Vaginal Rejuvenation Center of Atlanta, Atlanta Medical Research, Inc., Atlanta, Georgia, Orawee Chinthakanan, MD, MPH, Urogynecologist, International Urogynecology Associates of Atlanta and Beverly Hills, Vaginal Rejuvenation Center of Atlanta, Atlanta Medical Research, Inc., Atlanta, Georgia

PMID: 25433228

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Abstract

Vaginal rejuvenation” is a term that is commonly utilized to describe surgical repair of the vaginal canal and introitus following childbirth and/or aging to treat sexual dysfunction related to vaginal relaxation. It is well known that vaginal prolapse may lead to sexual dysfunction and in many studies repair of prolapse improves this dysfunction. During the progression of prolapse, sexual dysfunction or decreased vaginal sensation due to vaginal wall laxity may be one of the early symptoms that women suffer prior to the prolapse itself becoming symptomatic. Surgical repair or reconstruction of this type of vaginal defect may be indicated if repair will improve symptoms of sexual dysfunction caused by vaginal wall laxity. In this review, we will examine the existing data and make conclusions regarding vaginal rejuvenation and its impact on female sexual function. Core tip: This is the first review of vaginal rejuvenation that shows improvement of sexual function. In this review, we covered the topic of relaxed vagina and sexual function, prolapse repair and sexual function, vaginal rejuvenation surgical techniques, and data to support vaginal rejuvenation techniques.

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Sexual Function After Hysterectomy and Myomectomy
Luiz Gustavo Oliveira Brito, MD, MsC, PhD, Department of Obstetrics and Gynecology, Minimally Invasive Gynecological Surgery Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, Nieck Sebastiaan Alexander Pouwels, BSc, Department of Obstetrics and Gynecology, Minimally Invasive Gynecological Surgery Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, Jon Ivar Einarsson, MD, MPH, PhD, Department of Obstetrics and Gynecology, Minimally Invasive Gynecological Surgery Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

 

PMID: 25433152

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Abstract

Sexual function after hysterectomy and myomectomy is a controversial topic and influenced by several factors. With regard to hysterectomy, there is not a consensus whether the removal of the cervix will modify sexual function after surgery, and patients who choose to preserve their cervix should be counseled about the possibility of continued vaginal bleeding and the need for continued pap smear surveillance after surgery. In most studies, hysterectomy has been found to improve sexual function because usually patients have symptoms that indicated the surgery, such as abnormal uterine bleeding and pelvic pain, and as these symptoms cease, they report an improvement in their sexual life. In regards to myomectomy, literature is scarce, however few studies have shown an improvement in sexual function due to the same reasons as hysterectomy. For purposes of research, it is important to standardize sexual questionnaires when performing studies about this outcome. It is also important to emphasize that during discussion of your patient, sexual outcomes should be addressed and that the surgeon should consider all patients’ personal, religious, and cultural background during the decision-making process because it will minimize patient’s disappointment if she develops a negative response after surgery.

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Recurrent Twin Pregnancy, with the Second a Heterotopic Pregnancy, Following Clomiphene Citrate Stimulation: An Unusual Case and a Review of the Literature
Labib M. Ghulmiyyah, MD, FACOG, Assistant Professor, Joe Eid, Medical Student, Anwar H. Nassar, MD, Professor, Fadi G. Mirza, MD, FACOG, Assistant Professor, Joseph Nassif, MD, Assistant Professor, Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon

PMID: 25433229

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Abstract

Multiple gestations are on the rise with the advent of artificial reproductive technologies. Even with ovulation induction using clomiphene citrate alone, the twinning rate can reach up to 9 percent. We report a case of recurrent twin gestation after treatment with clomiphene citrate, with the second pregnancy being heterotopic. We also review, using Medline and PubMed, previously reported cases of recurrent twin gestation after treatment with clomiphene citrate published before June 2014. Patients undergoing ovulation induction for oligoovulation, anovulation, or unexplained infertility should always be counseled about the possibility of multiple gestation prior to the treatment including the probability, although low, of a heterotopic pregnancy.

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