Mesh Surgery for Anterior Vaginal Wall Prolapse: A Meta-analysis / Cirurgia com tela para correção de prolapso de parede anterior: metanálise

Abstract Purpose Pelvic organ prolapse (POP) is a major health issue worldwide, affecting 6- 8% of women. The most affected site is the anterior vaginal wall. Multiple procedures and surgical techniques have been used,with or without the use of vaginalmeshes, due to common treatment failure, reoperations, and complication rates in some studies. Methods Systematic review of the literature and meta-analysis regarding the use of vaginal mesh in anterior vaginal wall prolapse was performed. A total of 115 papers were retrieved after using the medical subject headings (MESH) terms: 'anterior pelvic organ prolapse OR cystocele AND surgery AND (mesh or colporrhaphy)' in the PubMed database. Exclusion criteria were: follow-up shorter than 1 year, use of biological or absorbable meshes, and inclusion of other vaginal wall prolapses. Studies were put in a data chart by two independent editors; results found in at least two studies were grouped for analysis. Results After the review of the titles by two independent editors, 70 studies were discarded, and after abstract assessment, 18 trials were eligible for full text screening. For final screening and meta-analysis, after applying the Jadad score (> 2), 12 studies were included. Objective cure was greater in the mesh surgery group (odds ratio [OR] = 1,28 [1,07-1,53]), which also had greater blood loss (mean deviation [MD] = 45,98 [9,72-82,25]), longer surgery time (MD = 15,08 [0,48-29,67]), but less prolapse recurrence (OR = 0,22 [01,3-0,38]). Dyspareunia, symptom resolution and reoperation rates were not statistically different between groups. Quality of life (QOL) assessment through the pelvic organ prolapse/urinary incontinence sexual questionnaire (PISQ-12), the pelvic floor distress inventory (PFDI-20), the pelvic floor impact questionnaire (PFIQ-7), and the perceived quality of life scale (PQOL) was not significantly different. Conclusions Anterior vaginal prolapse mesh surgery has greater anatomic cure rates and less recurrence, although there were no differences regarding subjective cure, reoperation rates and quality of life. Furthermore, mesh surgery was associated with longer surgical time and greater blood loss. Mesh use should be individualized, considering prior history and risk factors for recurrence.

Resumo Introdução Prolapso de órgãos pélvicos é problema de saúde públicas, sendo o mais comumo anterior. Para tratamento são utilizadas cirurgias, comou semtelas. O uso de telas é para diminuir recidivas, mas não h á consenso. Métodos Foi realizada revisão da literatura e metanálise, sobre uso de telas na correção do prolapso anterior. Base de dados foi PUBMED , com termos (MESH): "Anterior Pelvic Organ OR Cystocele AND Surgery AND (Mesh or Colporrhaphy)". Critérios de exclusão foram: seguimento menor que 1 ano, telas biológicas ou absorvíveis. Resultados: foram avaliados 115 artigos. Após revisão dos títulos, 70 estudos foram descartados e 18 após leitura de resumos. Após critérios de Jadad (>2), 12 estudos foram incluídos. Análise estatística foi razão de risco ou diferença entre médias dos grupos, e as análises com grande heterogeneidade foram avaliadas através de análise de efeito aleatório. Resultados Cura objetiva foi superior no grupo com tela - OR 1,28 (1,07-1,53, p 1 0,00001), maior perda sanguínea - diferença média (MD) 45,98 (9,72-82,25, p = 0,01), tempo cirúrgico mais longo - MD 15,08 (0,48-29,67, p = 0,04), porém menor recorrência - OR 0,22 (0,13-0,38, p = 0,00001), não apresentando maior resolução dos sintomas - OR 1,93 (0,83-4,51, p = 0,15). Dispareunia e taxa de reoperação também não foram diferentes entre grupos. Qualidade de vida não apresentou diferença. Conclusões Cirurgia com tela para prolapso vaginal anterior apresenta melhor taxa de cura anatômica e menor recorrência, sem diferenças cura subjetiva, reoperação e qualidade de vida. Há maior tempo cirúrgico e perda sanguínea. Uso de telas deve ser individualizado.

Single-site laparoscopy in gynecology: preliminary study of a series of 50 cases / Laparoscopia por portal único em ginecologia: estudo preliminar de uma série de 50 casos

Objective: to describe the initial experience of a gynecology team, at a tertiary care center, when performing single-port laparoscopic surgery. Methods: this is a retrospective study reviewing the medical records of 50 patients treated at the outpatient gynecology clinic of our institution between June 2012 and July 2013 who underwent single-port laparoscopic surgery. This study was approved by the institution’s Ethics in Research Committee. Results: the mean age of patients is 37.8 years, ranging from 18 to 70 years, and the most frequent surgical indications were adnexal mass (72%) and chronic pelvic pain (24%). The mean operative time was 94.4 minutes with a mean hospital stay of 25.8 hours. There were no perioperative complications. We recorded two conversions to laparotomy due to technical difficulties during the procedure. All cases of conversion had pelvic adhesions. All operative complications were successfully treated and none were considered severe. Conclusion: this is one of the largest case series in the literature regarding surgical treatment by single-port laparoscopy in gynecology and presents evidence on reduction of surgical morbidity and satisfactory cosmetic results. We conclude that single-port laparoscopy is a viable minimally invasive technique, and that it contributes to the construction of a new scenario in modern gynecological surgery. .

Objetivo: descrever a experiência inicial da equipe de ginecologia, em um centro de referência, na realização de cirurgia laparoscópica por portal único. Métodos: trata-se de estudo retrospectivo, com a revisão dos prontuários de 50 pacientes atendidas no ambulatório de ginecologia do Hospital da Baleia – Fundação Benjamin Guimarães, entre junho de 2012 e julho de 2013, e que foram submetidas a tratamento cirúrgico laparoscópico por portal único. Este trabalho foi aprovado pelo Comitê de Ética em Pesquisa da instituição. Resultados: a idade média das pacientes incluídas no estudo é de 37,8 anos, variando entre 18 e 70 anos, e as indicações cirúrgicas mais frequentes foram massa anexial (72%) e dor pélvica crônica (24%). O tempo médio cirúrgico foi de 94,4 minutos, com tempo de internação médio de 25,8 horas. Em nenhum caso ocorreu qualquer tipo de complicação perioperatória. Registraram-se duas conversões para laparotomia por dificuldade técnica durante o procedimento. Todos os casos de conversão apresentavam aderências pélvicas. Todas as complicações operatórias foram tratadas com sucesso e nenhuma delas foi considerada grave. Conclusão: esta é uma das maiores séries de casos da literatura em relação ao tratamento cirúrgico por laparoscopia de portal único em ginecologia e apresenta resultados que sugerem a redução da morbidade cirúrgica e resultados estéticos satisfatórios. Concluímos que a laparoscopia por portal único é uma técnica minimamente invasiva viável e que traz importante contribuição à construção de um novo cenário na cirurgia ginecológica moderna. .

Avaliação da adesão ao checklist de cirurgia segura da OMS em cirurgias urológicas e ginecológicas, em dois hospitais de ensino de Natal, Rio Grande do Norte, Brasil / Assessment of adherence to the WHO surgical safety checklist in urological and gynecological surgeries at two teaching hospitals in Natal, Rio Grande do Norte State, Brazil / Evaluación de la adherencia al checklist de cirugía segura de la OMS en cirugías urológicas y ginecológicas en dos hospitales universitarios en Natal, Rio Grande do Norte, Brasil

O checklist de cirurgia segura da Organização Mundial da Saúde é uma ferramenta útil para diminuir eventos adversos em hospitais, porém sua implantação efetiva ainda é um desafio. Este estudo objetiva avaliar a adesão ao checklist em cirurgias urológicas e ginecológicas de dois hospitais de ensino em Natal, Rio Grande do Norte, Brasil. O desenho foi observacional transversal; selecionaram-se cirurgias eletivas, e a coleta se deu por meio de revisão de prontuários. Descreveu-se a adesão mediante a existência e qualidade do preenchimento do checklist, e analisou-se a associação de fatores estruturais e socioprofissionais valendo-se de análise de regressão múltipla. Das 375 cirurgias revisadas, 61% tinham checklist, e 4% estavam totalmente preenchidos. A existência do checklist se associou às cirurgias ginecológicas (maternidade) (OR = 130,18) e à maior duração da cirurgia (OR = 2,13), enquanto a qualidade do preenchimento se relacionou com as cirurgias urológicas (hospital geral) (β = 26,36). A adesão ao checklist precisa ser aprimorada, e as diferenças sugerem a influência das distintas estratégias de implantação utilizadas em cada instituição.

The WHO surgical safety checklist is a useful tool for decreasing the number of adverse events in hospitals, but its implementation is still a challenge. This study aimed to assess adherence to the checklist in urological and gynecological surgeries at two teaching hospitals in Natal, Rio Grande do Norte, Brazil. A cross-sectional observational design was used, elective surgeries were selected, and data were collected from medical charts. Adherence was based on the quality and proper completion of the checklist, and the association of structural and socio-professional factors was analyzed using multiple regression. Of the 375 surgeries reviewed, 61% included a checklist and 4% were correctly filled out. The existence of a checklist was associated with gynecological surgeries (OR = 130.18) and longer operating time (OR = 2.13), while quality of the checklist was related to urological surgeries (β = 26.36). Adherence to the checklist needs to be improved, and the observed differences suggest the influence of distinct implementation strategies at the two institutions.

El checklist de cirugía segura es una herramienta útil para disminuir los eventos adversos en hospitales, pero su implantación efectiva aún es un reto. Este estudo tiene por objetivo evaluar la adherencia al checklist en cirugías urológicas y ginecológicas de dos hospitales universitarios en Natal, Rio Grande do Norte, Brasil. El diseño fue observacional transversal, se seleccionaron cirugías electivas y la recogida de datos fue mediante revisión de historias clínicas. Se describe la adherencia a partir de la existencia y calidad de la cumplimentación del checklist y se analiza la asociación de factores estructurales y socioprofesionales mediante análisis de regresión múltipla. De las 375 cirugías revisadas, el 61% tenía checklist y el 4% estaba totalmente cumplimentado. La existencia del checklist se asoció a las cirugías ginecológicas (maternidad) (OR = 130,18) y a la mayor duración de la cirugía (OR = 2,13), mientras la calidad de la cumplimentación se relacionó con las cirugías urológicas (hospital general) (β = 26,36). La adherencia al checklist es una oportunidad de mejora y las diferencias sugieren la influencia de diferentes estrategias de ejecución utilizados en cada institución.

The outcome of transobturator anterior vaginal wall prolapse repair using porcine dermis graft: intermediate term follow-up

Introduction and Hypothesis We evaluated the anatomical success and complications of Perigee® with porcine dermis Graft in the repair of anterior vaginal wall prolapse (AVWP) Materials and Methods After Institutional Review Board (IRB) approval, the charts of all patients who underwent AVWP repair using the Perigee/InteXen® kit from July 2005 to July 2009 were reviewed. Patients who had less than 6-month follow-up were excluded. Preoperative data including patient age, previous AVWP repairs, hysterectomy status, preoperative dyspareunia and pertinent physical findings were collected and recorded. Postoperative success was defined as anatomical stage 0 or I using the Pelvic Organ Prolapse Quantification (POP-Q) scoring system. Graft related complications were also recorded. Results Out of 89 patients, 69 completed at least 6-month follow-up. Median follow-up was 13 (6-48) months. Seventeen patients (25%) had previous AVWP repair and 32 (46%) had previous hysterectomy. Preoperatively, AVWP stage II was found in 9 (13%), stage III in 27 (39%) and stage IV in 33 (48%) patients. Anatomic success was found in 48 (69%) patients, with 23 (33%) having stage 0 and 25 (36%) stage I AVWP. Intraoperative complications included incidental cystotomy in one patient and bladder perforation in one. Postoperative complications included vaginal exposure and dyspareunia in one case, wound dehiscence in one and tenderness over the graft arm with dyspareunia in one. conclusions The use of porcine dermis in AVWP repair is safe with minimal graft related complications; however, anatomical success is lower than that reported with the use of synthetic grafts. .

O abortamento incompleto (provocado e espontâneo) em pacientes atendidas em maternidade do Sistema Único de Saúde / Incomplete abortion (spontaneous and induced) in patient's admitted to a Sistema Único de Saúde maternity

JUSTIFICATIVA E OBJETIVOS: A interrupção da gestação, no Brasil, é praticada amplamente pelas mulheres, em contexto clandestino. O Ministério da Saúde (MS) defende que é uma questão de saúde pública. O objetivo deste estudo foi conhecer aspectos do abortamento incompleto em 1000 mulheres submetidas à curetagem uterina, atendidas em hospital do Sistema Únicode Saúde (SUS).MÉTODO: Aplicou-se um método descritivo por meio de questionário estruturado.RESULTADOS: Obtiveram-se 36,4% de abortamentos espontâneos e 63,6% provocados; dados obtidos através da classificação da Organização Mundial da Saúde (OMS). Destes, 18,2% são certamente provocados, 2%, provavelmente provocados; 43,4% são possivelmente provocados. Entre os abortamentos certamente provocados, 89% reportaram ao uso do misoprostol.CONCLUSÃO: O perfil das mulheres com risco de provocarem o abortamento é jovem com parceiro estável; são mulatas; não usuárias de anticoncepcional ou preservativo nas relações sexuais;tiveram início precoce da atividade sexual; não planejaram a gestação; secundigestas; primíparas; idade gestacional menor que 10 semanas; raras complicações relacionadas ao abortamento.(AU)

BACKGROUND AND OBJECTIVES: Illegal abortion is a common practice among Brazilian women. Ministry of Health considers it as a matter of public health. The aim of this research is to know the aspects involved in incomplete abortion among 1000 women submitted to uterine curettage attending a public hospital of Sistema Único de Saúde (SUS).METHOD: A descriptive method carried out through interviews by means of a questionnaire was applied and it was duly structured for the data gathering.RESULTS: Through the use of structured questionnaire, 36,4% were spontaneous abortions and 63.3% were induced abortions. Accordingto the classification of World Health Organization (WHO),among the induced abortions, 18.2% were certainly induced, 2% probably induced and 43.4% were possibly induced. Among certainly induced abortions 89% reported the use of misoprostol.CONCLUSION: The profile of women in risk of practicing abortion:young, stable partner, multiethnic, not using a contraceptive method or condom for intercourses, early search, non desired pregnancy, second pregnancy, primipara, gestational age under ten weeks, rare complications related to the abortion.(AU)

Carga microbiana de trocartes reprocessáveis após laparoscopias ginecológicas / Microbial load of reprocessable trocars after gynecological videolaparoscopy

OBJETIVO: identificar a carga microbiana presente em trocartes reprocessáveis usados nas laparoscopias ginecológicas. MÉTODOS: estudo exploratório descritivo. Um total de 57 trocartes, sendo 30 com 10 mm de diâmetro e 27 com 5 mm, foram recolhidos na sala de operação, imediatamente após o ato cirúrgico, e colocados em recipiente esterilizado onde foram adicionados 250 mL de água destilada estéril. Foi feita agitação dos trocartes para desprendimento de partículas e obtenção do lavado a ser analisado. Realizou-se filtração por meio de membrana de celulose 0,22 µm, colocadas, com pinça esterilizada, em placas ágar sangue. Após incubação, foi feita a análise microbiológica para contagem de unidades formadoras de colônias e posterior identificação do micro-organismo, usando-se técnicas laboratoriais padronizadas. RESULTADOS: a carga microbiana foi recuperada em 47,4 por cento dos trocartes analisados. Destes, 45,6 por cento apresentou crescimento de 1 a 100 unidades formadoras de colônias. Foram identificados 14 tipos de micro-organismos, dentre os quais, Staphylococcus coagulase negativo (28 por cento) e Bacillus sp (21 por cento) foram isolados com maior frequência. Identificou-se também Aeromonas hydrophila, Alcaligenes sp, Candida parapsilosis e enterobactérias. CONCLUSÕES: o estudo demonstrou que o desafio microbiano enfrentado pelos operadores responsáveis pela limpeza e esterilização dos trocartes é baixo quando comparado com o desafio imposto pelos indicadores biológicos; no entanto, não se pode inferir que os riscos de complicações infecciosas sejam mínimos para pacientes.

PURPOSE: to identify the microbial charge present in reusable trocars used in gynecological laparoscopies. METHODS: a descriptive exploratory study. An amount of 57 trocars, 30 with 10 mm of diameter and 27 with 5 mm, have been collected from the surgical unit, immediately after the surgery and placed in a sterilized recipient, in which 250 mL of sterile distilled water was added. Then, the trocars were agitated for the drainage of particles and to obtain a wash-out fluid to be analyzed. After being filtered through 0.22 µm cellulose membrane, the residue was placed on blood agar plates with a sterilized forceps. Following incubation, microbiological analysis has been done to count the number of colonies and further identify the microorganisms, using standard laboratorial techniques. RESULTS: microbial charge was recovered from 47.4 percent of the trocars analyzed. Among those, 45.6 percent presented 1 to 100 growing colonies. Fourteen types of microorganisms have been identified, among which the more frequently isolated were coagulase-negative Staphylococcus (28 percent) and Bacillus sp (21 percent), Aeromonas hydrophila, Alcaligenes sp, Candida parapsilosis, and enterobacteries were also identified. CONCLUSIONS: the study has demonstrated that the microbial challenge faced by the technician responsible for the cleaning and sterilization of trocars is low, as compared to the challenge imposed by biological markers. Nevertheless, it may be not inferred that the risks for infectious complications for patients are minimal.

Entrada umbilical con trocar mínimamente invasivo bajo visión directa en laparascopía ginecológica / Umbilical access with minimally invasive trocar under direct vision in gynecological laparoscopy: initial experience

Objetivo: Analizar la experiencia inicial de entrada umbilical con trocar mínimamente invasivo, Endopath Xcel, bajo visión directa en laparoscopia ginecológica. Método: 20 pacientes ingresadas para cirugía laparoscópica, por patología ginecológica benigna. Pacientes con una media de 54 años, IMC de 32. Cinco pacientes tenían antecedente de cirugía pélvica previa. Se utilizó el trocar blindado Xcel, con cámara endoscópica en su interior. Se identificaron los planos de la pared abdominal a la entrada. Se detuvo la entrada al identificar vasos sanguíneos susceptibles de dañar u órganos adheridos a pared abdominal con posibilidad de perforación. Se utilizó una entrada alternativa. Una vez terminada la cirugía se retiró el trocar, sin suturar la aponeurosis, sólo la piel. Resultados: Sólo en un caso (1 de 20, 5 por ciento) fue necesario detener la inserción del trocar, por identificar la adherencia de intestino delgado a la pared abdominal, susceptible de dañar. Se utilizó el cuadrante superior izquierdo como entrada alternativa. Se soltó el intestino y se realizó adherensiolisis con bisturí ultrasónico exitosamente. Conclusión: El método de inserción del trocar umbilical Xcel con cámara endoscópica acoplada, es un método que permite reducir la posibilidad de complicaciones a la entrada, durante laparoscopia ginecológica.

Objective: To analyze the initial experience of umbilical access with minimally invasive trocar Endopath Xcel, under direct vision in gynecological laparoscopy. Method: 20 patients under laparoscopy surgery for benign gynecological pathology. Media age 54 years old, BMI 32. Five patients had previous surgery. The trocar utilized was Xcel, with endoscopio camera. The planes of the abdominal wall during the entrance were identified. The access was stopped when identifying vessels or organs adhered to the abdominal wall with perforation possibility. An alternative entrance was used. Once finished the surgery the trocar was retired without suturing the muscular fascia, only the skin. Results: Only in one case (1 of 20, 5 percent) it was necessary to stop the trocar insertion, when was identified adhesion of the intestine to the abdominal wall. The left superior quadrant was used like alternative entrance. The adhesions were solved with ultrasonic scalpel. Conclusions: The method of primary access with visual umbilical Xcel trocar connected to the endoscopio camera allows reducing the possibility of complications during the entrance in gynecological laparoscopy procedures.

Robotic Surgery in Gynecologic Field

Operative laparoscopy was initially developed in the field of gynecology earlier on and the advent of laparoscopic surgery led to advances in general surgery as well. In the last few years, a number of articles have been published on the performance of surgical procedures using the robot-assisted laparoscopy. The shortcomings of conventional laparoscopy have led to the development of robotic surgical system and future of telerobotic surgery is not far away, enabling a surgeon to operate at a distance from the operating table. The complete loss of tactile sensation is often quoted as a big disadvantage of working with robotic systems. Although the first generation da Vinci robotic surgical system provides improved imaging and instrumentation, the absence of tactile feedback and the high cost of the technology remain as limitations. New generations of the robotic surgical systems have been developed, allowing visualization of preoperative imaging during the operation. Though the introduction of robotics is very recent, the potential for robotics in several specialties is significant. However, the benefit to patients must be carefully evaluated and proven before this technology can become widely accepted in the gynecologic surgery.

Mallas protésicas con dispositivo en la corrección del prolapso genital / Prosthetic meshes with device in the correction of genital prolapse

OBJETIVO: Evaluar la factibilidad, seguridad y eficacia de la corrección quirúrgica del prolapso genital, con sistema Gynecare Prolift. MÉTODO: Durante junio y agosto del 2006, se realizó corrección de prolapso genital anterior y/o posterior en tres pacientes de la Unidad de Uroginecología y Cirugía Vaginal de Clínica Las Condes. Correspondían a prolapsos grado 2 y 4. RESULTADOS: Se logró una corrección exitosa en los tres casos, no hubo complicaciones intraoperatorias, ni en el postoperatorio inmediato o tardío. El tiempo operatorio fue de 55 y 60 minutos para los dos casos de corrección posterior y de 90 minutos para el de anterior y posterior. La escala visual análoga del dolor a las 12, 24 y 48 horas, fue de puntuación 3. Todas expresaron su entera satisfacción frente a los resultados logrados. CONCLUSIONES: La corrección quirúrgica del prolapso genital con sistema Gynecare Prolift, es factible, seguro y eficaz. Sólo el seguimiento a largo plazo permitirá objetivar la permanencia de estos excelentes resultados.

OBJECTIVE: To evaluate the feasibility, efficacy and safety of the genital prolapse surgery correction with Gynecare Prolift System. METHOD: Between June and August 2006, 3 cases of anterior and/or posterior genital prolapse with this new technique were performed, in patients of Urogynecology and Vaginal Surgery Unit of Las Condes Clinic. The prolapse degree was 2 and 4. RESULTS: The correction was obtained in all cases. Intraoperative, immediate and remote postoperative period not registered any complication. The operating time was 55 and 60 minutes for the posterior correction and 90 minutes for anterior and posterior correction. The pain visual analogue scale at 12, 24 and 48 hours was 3. All patients expressed total satisfaction with the surgical results. CONCLUSIONS: The surgical correction of the genital prolapse with system Gynecare Prolift is feasible, safe and effective. Only the long term following will allow observing the permanence of these excellent results.

Intoxicação hídrica durante histeroscopia: relato de caso / Water intoxication during hysteroscopy: case report

JUSTIFICATIVA E OBJETIVOS: Intoxicação hídrica e distúrbios eletrolíticos produzindo toxicidade sistêmica podem ocorrer durante ressecção prostática transuretral e cirurgia histeroscópica, sendo em geral causados pelo volume de líquido e pela duração do procedimento. RELATO DO CASO: Apresenta-se um caso incomum de intoxicação hídrica em uma paciente de 42 anos submetida à ressecção endoscópica de mioma uterino submucoso, com descrição do diagnóstico e do tratamento. CONCLUSÕES: A intoxicação hídrica pode ser resultado de sobrecarga líquida, sendo importante o controle cuidadoso dos líquidos empregados e monitorização clínica.

Anestesia para endoscopia ginecologica / Anesthesia for ginecologic endoscopy

En este artículo se analiza en forma puntual el estado clínico de las pacientes previa laparoscopia, la fisiopatología general por invasión abdominal de gases extraños, los efectos del neumoperitoneo en aspectos ardía respiratorios, sistemas renal, neurológico, gastrointestinal, así como los diversos cambios hemodinámicos por la posición y la técnica de laparoscopia. Hacemos un análisis de los métodos anestésicos recientes y se hace énfasis en las complicaciones de leve y grave intensidad, para lo cual se requiere una vigilancia y monitoria especializada constantes

Miomectomía por laparoscopía: experiencia de 3 años / Laparoscopic myomectomy: esperience of 3 years

Se presenta la experiencia clínica en el abordaje quirúrgica por vía laparoscópica de 40 mujeres portadoras de miomas intramurales y subserosos. Se describe la preparación preoperatoria, técnica quirúrgica, sutura intracorpóreas, extracción del mioma por morcelación, evolución postoperatoria y complicaciones

Songkla uterine manipulator.

The Songkla Uterine Manipulator (SUM) was developed for laparoscopic procedures. Its shaft consists of two stainless steel rods, which pivot a head and locking system. The obturator has a plate and is connected to the pivot head with a screw. The obturator has a diameter of 4.7 mm with three standard lengths of 6, 8, and 10 cm and there is a spring hook to retain it with the tenaculum. The SUM allows antevertion of the uterus up to 95 degrees and lateral motion of about 45 degrees bilaterally. From December 1996 to December 1999, the SUM was used successfully in 150 laparoscopic procedures, including 51 tubal sterilizations, 42 cases of adnexal surgery, 12 total laparoscopic hysterectomies and 45 laparoscopic assisted vaginal hysterectomies. The visualization of pelvic organs including both adnexae was good in all cases without trauma to the vagina, cervix or uterus. Conclusion: The simplified low cost uterine manipulator was developed. Early results were good but more modifications are needed, such as mechanism to retain it to the cervix without the tenaculum and sealing of gas leakage from the vagina during laparoscopic hysterectomy.

The use and maintenance of instruments for large loop excision of transformation zone at Ramathibodi Hospital.

The average use of LLETZ in Ramathibodi Hospital from 1993 to 1998 was 73.3 cases per year (range 26-116 cases). The endocervical box (F2) loop electrode was the most frequently damaged at the rate of 4 pieces per 100 procedures. The damage rate of the 25 mm loop electrode was 3 pieces per 100 procedures and 20 mm loop electrode was 2 pieces per 100 procedures. The life of the instrument can be prolonged through proper care and continuous maintenance as well as by experienced operators and the assisting team.