Abstract


The gynecologist’s office was, historically speaking, the original setting for surgical practice. In 1809, Ephraim McDowell performed the first ovariotomy and removed a 22.5-pound tumor from Jane Crawford in his Danville, Kentucky office—decades before the development of anesthesia or the aseptic technique. Three developments—introduction of surgical anesthesia, improved operative techniques, and the evolution of the medical-economic environment—shaped surgical practice for over two centuries. The latter part of the 20th century also brought two dramatic changes that affected gynecologic practice. The first included social changes which created a demand for legalized abortion and elective sterilization. The second was a cascade of technological growth and innovations that created the field of minimally invasive gynecologic surgery (MIGS), allowing many procedures to be transferred from the hospital to the outpatient setting and then to the office. With the increasing demand for patient-centered care, effective operating room utilization, and the efficient use of physicians’ time, many gynecologic procedures are now being performed in an office-based setting. But, at least three important obstacles remain: the need for widespread accreditation, the availability of teaching in an office-based environment, and meeting the ethical obligation for adequate analgesia and sedation in an office environment.

Abstract


The prevalence of obesity has increased, achieving an epidemic status. Obesity has surgical and medical implications on the health of a woman. A minimally invasive surgical approach has several advantages and is considered the preferred approach for various procedures in obese women. The spectrum of gynaecologic surgical care spans over three main domains: benign gynaecologic surgery, reconstructive pelvic surgery, and gynaecologic cancer surgery. In this viewpoint, we chose a signature procedure for each main domain to compare minimally invasive surgery (MIS) trends for obese patients across all domains. Discrepancy was found in minimally invasive surgical trends for obese patients across different gynaecologic surgical domains. Fellowship training or maintaining high surgical volume might help to bridge this gap in the domain of benign gynaecologic surgery and improve quality care offered to obese patients.

Abstract


The present review aims to analyze the current information available on the pathophysiology, clinical presentation and treatment of vesico-vaginal fistulas (VVF), with particular focus on the safety and efficacy of minimally invasive surgical (MIS) techniques. Through the use of the PubMed and Google Scholar databases, we conducted a literature review of all available studies related to MIS treatment of VVF, focusing on laparoscopic techniques. After abstracts were read to identify pertinent studies, full manuscripts were reviewed by two authors according to the aim of the review. Vesico-vaginal fistula is defined as an abnormal passage that connects the bladder to the vagina and affects over 3 million women worldwide. It can be classified according to its complexity (simple or complex) and mechanism (obstetric-related or iatrogenic). Laparoscopic treatment of VVF started in 1994 and is currently the gold-standard approach for this pathology. No differences in terms of efficacy or safety have been reported between MIS (laparoscopy, robotic-assisted laparoscopy and laparoscopic single-site) using extra-vesical and trans-vesical approaches, with success rates of 80% to 100%, and low rates of conversion (1.9%), recurrence (less than 1%) and intra- or post-operative complications (3%). Surgical principles for fistula repair, described independently by Angioli and Couvelaire, must always be followed. A bladder fill and integrity test with at least 300 mL should be performed before ending surgery, since this increases the success rate by about 6%. Other interventions such as flap interposition, number of layers in closure and expectant management (spontaneous closure with a Foley catheter alone) remain controversial. To date, no differences have been seen among the laparoscopic surgical techniques. The lack of prospective evaluations has hindered a better understanding of the natural history of the disease and the development of evidence-based recommendations regarding diagnosis, management and follow-up. Since no differences were found compared to a trans-vesical approach, extra-vesical repair is recommended to avoid bladder bi-valving.

Abstract


When Jacques and Pierre Curie first researched ultrasonic energy and piezoelectric effects in the 1880s, they likely had no idea of the profound impact it would eventually have on surgical patients. Today in operating rooms around the world, ultrasonic energy is used for tissue manipulation, dissection, cutting, and coagulation. Surgeons including but not limited to the specialties of gynecology, general surgery, colorectal, thoracic, breast, and bariatric have activated ultrasonic energy in thousands of patients. As a mainstay surgical energy device, patients have benefited from the ultrasonic versatility of its cutting and coagulating effects. The ability of ultrasonic energy to be used near vital organs with precision by adjusting for tissue tension, power settings, and activation time has accounted for its safety and clinical outcomes. This overview of the mechanics of ultrasonic energy and the evolution of the HARMONIC® (UltraCision, Providence, Rhode Island, now owned by Ethicon Endo-Surgery, Inc., Cincinnati, Ohio) surgical tools since 1988 provides readers an understanding of this energy platform and its distinct advantages. Clinical implications of key research and clinical studies are explored and discussed with a focus on patient and surgical outcomes. Research in a variety of fields and tissues is presented with a special emphasis on the gynecological patient.