Abstract


As innovation continues to evolve in gynecologic surgery, new “cosmetic” techniques are continually being developed. Minimally invasive surgery offers clear benefits over open surgery, such as decreased postoperative pain, infection, length of hospital stay, and time out of work. It is now possible to perform many laparoscopic gynecologic surgeries with minimal to no visible scars. This article reviews the use of 3mm ports and several reduced-port and single-port techniques for use in gynecologic surgery as well as vaginal natural orifice transluminal endoscopic surgery (vNOTES). We also discuss the advantages and challenges that physicians face regarding the adoption of these procedures into general practice. Lastly, we present our novel economic adaption in approach to reduced-port laparoscopic bilateral salpingectomy versus traditional single-site laparoscopic bilateral salpingectomy. In conclusion, minimally invasive approaches to gynecological surgery are considered feasible and safe.

Abstract


Office-based gynecologic surgery (OBGS) has become an integral part of modern practice. The technological achievements of the past few decades have dramatically improved our ability to diagnose and treat a variety of common issues that affect fertility and menstruation. Procedures that once required the complex milieu of a hospital or outpatient setting—diagnostic hysteroscopy, endometrial ablation, hysteroscopic polypectomy, and myomectomy—are now well within the reach of motivated and well-trained practitioners. The recent changes in physician reimbursement and the ongoing need to contain healthcare spending have motivated many gynecologists to offer an array of office-based procedures. But, the transition from a hospital-based technique to one that can safely and comfortably be performed in an office requires thoughtful planning in the acquisition of equipment, the training of physicians, nurses, and support staff, and the management of pain. Finally, some form of accreditation should be considered not only to comply with state and local healthcare laws but as a means to offer public reassurance that the care provided in an office meets a well-recognized standard. In this second of a two-part series, we will review the current state of OBGS technology and offer training guidelines to facilitate the transition from the outpatient to the office setting. Additionally, we will discuss pain management for OBGS and the role of accreditation. The lead author will review his 40-year journey in performing both simple and complex gynecologic procedures in an office-based surgery (OBS) setting and offer recommendations for achieving proficiency, safety, and comfort in the office environment. Finally, the authors will offer their thoughts on what can be expected in the future of gynecologic office-based surgery.

Abstract


Introduction: Fibroids are highly prevalent among reproductive-aged women and have a significant impact on their wellbeing. Myomectomy is a fertility-sparing option for these patients.
Materials and Methods: This paper is a comprehensive, evidence-based and updated review of literature regarding myomectomy techniques.
Results: This paper provides general recommendations for myomectomy techniques, including patient selection and surgical planning. Strategies to overcome intraoperative challenges and prevent blood loss are highlighted. In addition, recommendations are provided for tissue extraction and laparoscopic suturing.
Conclusion: Myomectomy is a safe and feasible alternative to hysterectomy for patients who wish to bear children.

Abstract


Introduction: Clinically, vaginal packing provides the benefit of hemostasis and is designed to prevent the formation of postoperative hematomas. Despite the common use of vaginal packing in pelvic surgery, there is limited data to indicate which material has the ideal characteristics for vaginal packing.
Materials and Methods: Three packing materials were used: DeRoyal® Fluftex™ (DeRoyal Industries, Inc., Powell, Tennessee), NHP Surgi-Pak™ vaginal packing (NHP Industries, Inc., City of Industry, California), and Curad® Plain Packing Strips (Medline Industries, Inc., Northfield, Illinois). A fluid with similar viscosity to human blood, defibrinated sheep’s blood (Remel Laboratories, Nenexa Kansas) was used to saturate the materials. The primary outcome was the amount of fluid absorbance of each product in both the handpacked and unpacked state. The number of drops used to saturate each material were counted and converted to mL/g. Each product was tested three times and the results were measured by counting the number of drops needed to saturate the material in each experiment.
Experiment: Three materials were obtained and conducted into two different experiments to test absorbance. The packed trial consisted of 0.1g of material and was compacted in a 146mm standard Pasteur pipette (Sigma-Aldrich Corp., St. Louis, Missouri). Droplets of sheep’s blood were dispensed until each material had reached its capacity, which was determined by counting the last sequential drop received onto the respective material before the first of the fluid fell from the material into the collecting container. Trials were conducted three times per material and an average of the three trials was calculated. The second experiment tested 1g of each material unpacked and folded into eight layers. Droplets of blood were placed onto the material until each material leaked, which was defined again as the first fluid to fall from the material into the collecting container that it was suspended above. The number of drops needed to produce this effect was recorded. All droplets were counted and converted to mL/g. Standard deviation was calculated for each material in both experiments and an analysis of variance (ANOVA) single factor test was done.
Results: Three trials were conducted per material and there was a difference in absorbance between each packing material (p=0.02 packed, p=0.001 unpacked). Additionally, the plain packing strip absorbed the least amount of blood product in the packed and unpacked state compared to DeRoyal® Fluftex™ and NHP Surgi-Pak™ vaginal packing. The average absorbance of the packed materials was 7.7mL/g for DeRoyal® Fluftex™, 9.8mL/g for NHP Surgi-Pak™ vaginal packing, and 7.5mL/g for the Curad® Plain Packing Strips. There was a standard deviation of 2.08 drops for DeRoyal® Fluftex™, 3.51 drops for NHP Surgi-Pak™ vaginal packing, and 1.73 drops for Curad® Plain Packing Strips. Absorbance for DeRoyal® Fluftex™ unpacked was 8.2mL/g, NHP Surgi-Pak™ vaginal packing unpacked was 7.00mL/g, and Curad® Plain Packing Strips was 4.8mL/g. The standard deviation for the unpacked experiment was 29.02 drops for DeRoyal® Fluftex™, 13.61 drops for NHP Surgi-Pak™ vaginal packing, and 15.59 drops for Curad® Plain Packing Strips. A p-value of less than .05 in a confidence interval of 95% was determined.
Conclusion: Even though there are studies showing the clinical benefits of vaginal packing after a variety of gynecological surgeries, there is less known about the characteristics of the ideal material. Minimal foreign body reaction, decreased adherence to surgical scars, X-ray visualization, low cost, and easy availability are among the ideal characteristics of the presumed ideal material used for vaginal packing. In this study, we compared the absorbance between three commonly used materials and did not find any statistical differences. Further studies are needed to show the clinical benefits and mechanical characteristics of material used for vaginal packing.
Due to the lack of a statistically significant difference in absorbance between the materials, evaluation of mechanical characteristics may be beneficial in determining an ideal vaginal packing product.