Increasing the adoption of ambulatory hysteroscopy in Australia - cost comparisons and patient satisfaction.

We present the findings of a prospective cohort study in a single tertiary hospital to review the patient experience and economic benefit of ambulatory hysteroscopy (AH). Data were collected between May 2017 and February 2020. Patient satisfaction was measured with qualitative survey. Hospital level financial data were obtained over two financial years (2017/18 and 2018/19) to identify seasonal variation. The primary outcome was patient satisfaction and the secondary outcome was cost of AH compared to hysteroscopy under GA. Three hundred and twenty-nine patients underwent AH. Two hundred and ninety-eight responses (91%) were collected. Ninety-five percent of procedures were successful. Median pain score was five out of 10. Despite pain, 94% of patients would undergo AH again and 97% would recommend it. The average hospital cost for AH was $259 compared with $3098 for hysteroscopy under GA. These findings support AH as a safe, well-tolerated and economically viable alternative to hysteroscopy under GA.Impact StatementWhat is already known on this subject? Hysteroscopy is traditionally performed in an operating theatre under general anaesthesia (GA). Technological advancements allow for the procedure to be performed in an outpatient setting. Despite advantages of ambulatory hysteroscopy (AH), GA hysteroscopy is still the predominant intervention in Australia.What the results of this study add? Patient satisfaction in AH was assessed. The median pain score was five out of 10. Despite pain, 94% of patients would undergo AH again and 97% would recommend it.What the implications are of these findings for clinical practice and/or further research? AH is a well-tolerated alternative to hysteroscopy under GA with significant cost benefits to the hospital and high patient satisfaction. Further research should focus on direct comparison of the two procedure approaches using randomised controlled trials.

Laparoscopic Port-Site Hernia: An Underrecognized Iatrogenic Complication of Laparoscopic Surgery.

IMPORTANCE: Port-site hernia is an iatrogenic complication with a documented incidence between 0.65% and 2.8%. However, the true incidence could be higher because of delayed onset, asymptomatic nature, and loss to follow-up. Port-site hernia could be further complicated by incarceration or strangulation leading to small bowel obstruction requiring emergent surgical intervention, thus imposing significant financial and emotional burden to patients. OBJECTIVE: This article aims to provide a summary of the available literature concerning port-site hernia and explore preventive strategies for future clinical practice. EVIDENCE ACQUISITION: This review was formulated through electronic literature searches in Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. The reference lists of the included studies were hand searched to identify other relevant articles to capture all available literature in this narrative review. RESULTS: Following screening for eligibility based on relevance to the topic under consideration, 28 studies were identified. This included 5 original articles, 1 case series, and 22 review articles, including 4 systematic reviews. Included studies were critically appraised in formulating this review. CONCLUSIONS: Port-site hernia is an underrecognized yet preventable complication with careful consideration of predisposing technical and host factors, thorough attention to surgical technique, or use of a fascial closure device. RELEVANCE: With the widespread and increasing use of laparoscopic methods to treat surgical pathologies, knowledge of this complication is imperative to encourage prevention strategies and facilitate early recognition and management should it occur.

Ovarian cysts in pregnancy: a narrative review.

Most adnexal masses are benign, incidental findings of pregnancy which resolve spontaneously. They may present clinically due to haemorrhage, rupture, torsion and mass effect. Aetiological classification includes ovarian benign, ovarian malignant, non-ovarian, gynaecological, non-ovarian non-gynaecological and an additional subset of pathologies unique to pregnancy. Ultrasound is the first-line imaging modality for the evaluation of adnexal masses. This may be supplemented with magnetic resonance imaging. Tumour markers support evaluation of malignant potential, but interpretation of results in pregnancy is challenging. Surgical intervention requires consideration of gestation, lesion characteristics and presence of complications. Laparoscopy is preferred owing to shorter operative time, quicker recovery and resultant lower thrombotic risk. Post-viability, fetal wellbeing and assessment must be considered. Management of the pregnancy may include cardiotocography, steroids, non-teratogenic antibiotics and tocolytics. In rare cases, particularly related to malignancy, termination of pregnancy may be required to enable immediate management where there are concerns for maternal wellbeing.

Cervical Cerclage: A Review and Rethinking of Current Practice.

IMPORTANCE: Cervical insufficiency (CI) is a serious complication of pregnancy, which can cause preterm birth. Identifying how to most effectively treat CI has the potential to maximize neonatal survival in this population of women. OBJECTIVE: To determine whether transabdominal cervical cerclage should be offered as a first-line treatment option in high-risk women. EVIDENCE ACQUISITION: An electronic literature search for relevant studies was conducted using keywords (CI, cervical cerclage) on the MEDLINE database. RESULTS: Although transabdominal cerclage (TAC) is reserved as a second-line treatment option over transvaginal cerclage (TVC), it has some advantages over TVC: a higher placement of the suture at the level of the cervicoisthmic junction; avoidance of placement of foreign material in the vagina, in turn, reducing risk of infection and inflammation, which can propagate preterm labor; and the option to leave the suture in place for future pregnancies. Systematic review evidence offers TAC as a more effective procedure to TVC in reducing preterm birth and maximizing neonatal survival. Although TAC is a slightly more complex procedure compared with TVC, advances in minimally invasive surgery now allow gynecologists to perform this more effective procedure laparoscopically and therefore without the added morbidity of open surgery but with the same if not better outcomes. CONCLUSIONS: Laparoscopic TAC can provide a more effective treatment option for CI without the added burdens of open abdominal surgery. RELEVANCE: Our article highlights future directions for study in the area of cervical cerclage and refinement of existing practices.

Correlation between ultrasound findings and laparoscopy in prediction of deep infiltrating endometriosis (DIE).

BACKGROUND: Detailed pre-operative description of endometriotic lesions by non-invasive methods is an important tool for accurate diagnosis and effective treatment of the disease. Transvaginal ultrasound (TVUS) is a sensitive method for diagnosis of deep infiltrating endometriosis (DIE); however, it is highly operator-dependent and consistent results require adequately trained and experienced clinicians. AIMS: The aim of the study is to assess the accuracy of TVUS in predicting DIE by comparing it with laparoscopic findings. We also compared US done in the community by general radiologists with examinations done by specialist gynaecologists. MATERIALS AND METHODS: A retrospective cohort study of patients who underwent laparoscopy for excision of possible endometriosis between July 2014 to February 2019 who had a TVUS prior to laparoscopy. RESULTS: A total of 119 patients were included. TVUS was shown to be useful in detecting all but bladder DIE. Community TVUS was no better than chance at identifying most DIE (area under the curve (AUC) of 0.48-0.60) except in the detection of ovarian endometriomas and adhesions (AUC = 0.84). Specialist TVUS correctly identified most DIE with greatest utility for DIE in rectosigmoid (AUC = 0.85, P < 0.000), followed by pouch of Douglas/pouch of Douglas adhesions (AUC = 0.82, P < 0.000), ovarian endometriomas/ovarian adhesions (AUC = 0.79, P < 0.000), uterosacral ligaments (AUC = 0.75, P < 0.000) and rectovaginal septum (AUC = 0.69, P < 0.05). CONCLUSION: Specialist TVUS is informative in examining the presence of DIE particularly in posterior compartments which may increase surgical complexity. Community TVUS is significantly less beneficial; however, it is more accessible to the general public. This adds to the argument that increasing access to DIE-TVUS appears favourable.

Isolated uterine metastasis from a lung adenocarcinoma.

A 65-year-old woman was referred with an incidental finding of a flurodeoxyglucose-avid uterine lesion, following excision of a local lung adenocarcinoma. MRI had features concerning for an atypical fibroid or smooth muscle tumour of uncertain malignant potential. She underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Histopathology demonstrated a leiomyoma infiltrated with adenocarcinoma consistent with a secondary lesion from the lung cancer. Among the small number of cases of uterine metastases of extra-pelvic primary cancers reported in the literature, those from lung cancers are very rare. Concerning features for an atypical fibroid included the patient's age and postmenopausal status, as well as positron emission tomography and MRI findings. A metastatic secondary cancer was not suspected. Diagnosis was only made after histopathological examination. This case represents a very unusual cause of a uterine mass. It demonstrates the importance of thorough preoperative work-up and accurate histopathological assessment.

Laparoscopic Transabdominal Cerclage and Subsequent Pregnancy Outcomes When Left In Situ.

OBJECTIVE: To evaluate obstetric outcomes of subsequent pregnancies in women who had a laparoscopic transabdominal cerclage. METHODS: A prospective observational study of consecutive women who became pregnant a second or third time after a laparoscopic transabdominal cerclage. Eligible women were considered not suitable for a transvaginal cerclage or had previously failed a transvaginal cerclage. The primary outcome was neonatal survival and the secondary outcome was delivery at 34 weeks of gestation or more. RESULTS: During the study period (2007-2018), 22 women who had undergone a laparoscopic transabdominal cerclage and completed one pregnancy with the cerclage in situ became pregnant a second or third time. In the first pregnancies with the cerclage in situ, the neonatal survival rate was 100% (22/22) and 86% (19/22) of women delivered after 34 weeks of gestation. In the second pregnancies, the neonatal survival rate was 95% (21/22) and 86% (19/22) of women delivered after 34 weeks of gestation. In the third pregnancies, the neonatal survival rate was 100% (3/3) and 100% (3/3) of women delivered after 34 weeks of gestation. CONCLUSION: When left in situ for subsequent pregnancies, laparoscopic transabdominal cerclage is associated with a high rate of neonatal survival.

Laparoscopic transabdominal cerclage in pregnancy: A single centre experience.

BACKGROUND: Transabdominal cerclage can reduce the risk of preterm birth in women with cervical insufficiency. AIMS: This study evaluated outcomes following insertion of a laparoscopic transabdominal cerclage in pregnant women. MATERIALS AND METHODS: A retrospective observational study. PATIENTS: pregnant women who underwent laparoscopic transabdominal cerclage from 2011 to 2017. Eligible women had cervical insufficiency and were not suitable for a transvaginal cerclage. INTERVENTION: the insertion of a laparoscopic transabdominal cerclage in the pregnancy. MEASUREMENTS: neonatal survival, delivery of an infant at ≥34 weeks gestation and surgical morbidity were evaluated. RESULTS: Of 19 women who underwent laparoscopic transabdominal cerclage in pregnancy, at 6-11 weeks gestation, the perinatal survival rate was 100%. There were no complications. The average gestational age at delivery was 37.1 weeks. Sixteen women delivered after 34 weeks. CONCLUSIONS: Laparoscopic transabdominal cerclage is a safe and effective procedure in women with poor obstetric histories. It requires the correct skill, expertise and patient selection.

PREOPERATIVE MAGNETIC RESONANCE IMAGING DIAGNOSTIC FEATURES OF UTERINE LEIOMYOSARCOMAS: A SYSTEMATIC REVIEW.

OBJECTIVES: There are no current established pathognomonic diagnostic features for uterine leiomyosarcomas in the pre- or perioperative setting. Recent inadvertent upstaging of this rare malignancy during laparoscopic morcellation of a presumed fibroid has prompted widespread debate among clinicians regarding the safety of current surgical techniques for management of fibroids. This study aims to conduct a systematic review investigating significant diagnostic features in magnetic resonance imaging (MRI) of uterine leiomyosarcomas. METHODS: A comprehensive database search was conducted guided by PRISMA recommendations for peer-reviewed publications to November 2017. Parameters available in MRI were compared for reliability and accuracy of diagnosis of leiomyosarcomas. A decision tree algorithm classifier model was constructed to investigate whether T1 and T2 MRI signal intensities are useful indicators. RESULTS: Nine eligible studies were identified for analysis. There appears to be a significant relationship between histopathological type and T1 and T2 intensity signals (p < .05). A decision tree model analyzing T1 and T2 signal intensity readings supports this trend, with a diagnostic specificity of 77.78 percent for uterine leiomyosarcomas. The apparent diffusion coefficient (ADC) values were not observed to have a significant relationship with tumor pathology (p = .18). CONCLUSIONS: Various studies have investigated pre- and perioperative techniques in differentiating uterine leiomyosarcoma from benign fibroids. Given the rarity of the malignancy and lack of pathognomonic diagnostic parameters, there is difficulty in establishing definitive criteria. A decision tree model is proposed to aid diagnosis based on MRI signal intensities.

Laparoscopic transabdominal cerclage: Outcomes of 121 pregnancies.

BACKGROUND: Cervical insufficiency is a significant cause of morbidity and mortality. Cervical cerclage is one option in the management of cervical insufficiency. AIM: To evaluate obstetric outcomes following insertion of a pre-pregnancy laparoscopic transabdominal cerclage in women at high risk for pre-term labour and/or mid-trimester pregnancy loss. METHODS: A prospective observational study of consecutive women who underwent laparoscopic transabdominal cerclage from 2007 to 2017. Eligible women had a diagnosis of cervical insufficiency based on previous obstetric history and/or a short or absent cervix and were considered not suitable for a transvaginal cerclage. The primary outcome was neonatal survival and the secondary outcome was delivery of an infant at ≥34 weeks gestation. Surgical morbidity and complications were also evaluated. RESULTS: During the study period, 225 women underwent laparoscopic transabdominal cerclage. We present the outcomes of 121 pregnancies resulting in 125 babies. The perinatal survival rate of viable pregnancies was 98.5% with a mean gestational age at delivery of 35.2 weeks; 79.7% of babies were delivered at ≥34.0 weeks gestation. CONCLUSION: Laparoscopic transabdominal cerclage is a safe and effective procedure resulting in favourable obstetric outcomes in women with a poor obstetric history. For optimal success the procedure requires the correct surgical expertise, equipment and appropriate patient selection.

Laparoscopic Resection of Cesarean Scar Ectopic Pregnancy.

STUDY OBJECTIVE: To demonstrate a technique for the laparoscopic surgical management of cesarean section scar ectopic pregnancy. DESIGN: Step-by-step presentation of the procedure using video (Canadian Task Force classification III). SETTING: Cesarean section scar ectopic pregnancy is a rare form of ectopic pregnancy with an incidence ranging from 1:1800 to 1:2216. Over the last decade, the incidence seems to be on the rise with increasing rates of cesarean deliveries and early use of Doppler ultrasound. These pregnancies can lead to life-threatening hemorrhage, uterine rupture, and hysterectomy if not managed promptly. Local or systemic methotrexate therapy has been used successfully but can result in prolonged hospitalization, requires long-term follow-up, and in some cases treatment can fail. In the hands of a trained operator, laparoscopic resection can be performed to manage this type of pregnancy. PATIENT: Consent was obtained from the patient, and exemption was granted from the local Internal Review Board (The Womens' Hospital, Parkville). INTERVENTIONS, MEASUREMENTS AND MAIN RESULTS: In this video we describe our technique for laparoscopic management of a cesarean scar ectopic pregnancy. We present the case of a 34-year-old G4P2T1 with the finding of a live 8-week pregnancy embedded in the cesarean section scar. The patient had undergone 2 previous uncomplicated cesarean sections at term. On presentation her ß-human chorionic gonadotropin (ß-hCG) level was 52 405 IU/L. She was initially managed with an intragestational sac injection of potassium chloride and methotrexate, followed by 4 doses of intramuscular methotrexate. Despite these conservative measures, the level of ß-hCG did not adequately fall and an ultrasound showed a persistent 4-cm mass. A decision was made to proceed with surgical treatment in the form of a laparoscopic resection of the ectopic pregnancy. The surgery was uneventful, and the patient was discharged home within 24 hours of her procedure. Her serial ß-hCG levels were followed until complete resolution. CONCLUSION: Laparoscopic excision of cesarean section scar ectopic pregnancy is an effective procedure for the management of this increasingly more common condition. The use of vasopressin intraoperatively and laparoscopic suturing can prevent hemorrhage and allow for the safe removal of the ectopic pregnancy with multilayer repair of the uterine defect.

Uterine fibroids: Investigation and current management trends.

BACKGROUND: Uterine leiomyomas, or fibroids, represent a large proportion of gynaecological presentations in both general and specialist gynaecology practice. The diagnosis is relatively simple with current imaging modalities. The management of fibroids, however, is not always straightforward and can present many challenges. OBJECTIVE: This article reviews current approaches to the management of uterine fibroids, including novel techniques, and highlights important patient counselling points. DISCUSSION: Many fibroids cause debilitating symptoms that greatly affect a woman's quality of life. Traditional surgical treatment options include myomectomy and hysterectomy. Minimally invasive surgical and radiological techniques, as well as symptomatic treatment, including the use of hormonal medication, intrauterine devices, and endometrial ablation, have become increasingly popular treatment choices. While these treatments are associated with reduced perioperative morbidity and shorter hospital stays, patients should be carefully counselled regarding the risks and the benefits. General practitioners may often help to initiate discussions to assist women considering their management options.

Successful laparoscopic transabdominal cerclage in uterus didelphys.

The incidence of uterus didelphys is around 3/10,000 women. It is a class III Müllerian duct anomaly resulting from a complete non-fusion of the paired Müllerian ducts between the 12th and 16th weeks of gestation. Although the prevalence of cervical insufficiency in women with uterus didelphys is unknown, the incidence of cervical insufficiency in women with Müllerian anomalies has been reported as high as 30%. We present a case of successful pregnancy outcome following a laparoscopic transabdominal cerclage in a woman with uterus didelphys and cervical insufficiency. The case demonstrates that laparoscopic transabdominal cerclage can be performed successfully in women with uterus didelphys and a satisfactory obstetric outcome can be achieved.

Transabdominal Cervical Cerclage: Laparoscopy Versus Laparotomy.

STUDY OBJECTIVE: To evaluate the obstetric outcome, surgical morbidity, and pre-abdominal cerclage characteristics of women undergoing transabdominal cerclage (TAC) via laparotomy or laparoscopy. DESIGN: Prospective cohort study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS AND INTERVENTION: Between 2007 and 2014, 51 patients underwent laparoscopic abdominal cervical cerclage to treat cervical incompetence. These women were compared with a historical cohort of 18 patients who underwent the same procedure via laparotomy between 1995 and 2011. All of the women had a diagnosis of cervical incompetence based on previous obstetric history and/or a short or absent cervix. MEASUREMENTS AND MAIN RESULTS: The fetal survival rate postcerclage was 100% in the laparotomy group (n = 30 pregnancies) and 98% in the laparoscopy group (n = 54 pregnancies). There were no perioperative pregnancy losses in either group. The median gestation age was 36.9 weeks (range: 35.0-37.3) in the laparotomy group and 37.0 weeks (range: 34.7-38.0) in the laparoscopy group. Complications were recorded in 4 (22%) cases from the laparotomy group and 1 (2%) of the laparoscopies; however, the types of complications might not be comparable between groups. There were no conversions to laparotomy in the laparoscopy group. Pre-TAC median gestational age in the laparotomy group was 24.0 weeks (range: 20.0-25.1) with 19 (57.6%) previous pregnancies occurring after transvaginal cervical cerclage placement. The corresponding laparoscopy pre-TAC median gestational age was 22.0 weeks (range 19.0-34.0) with 40 (40%) previous pregnancies having a transvaginal cerclage. Before the TAC, women in the laparotomy group had lost 25 babies, and 63 babies were lost in the laparoscopy group. After TAC, these numbers were 0 and 1. CONCLUSIONS: Our findings show that transabdominal cervical cerclage placed laparoscopically appears to be as effective as TAC placed via laparotomy. Neither approach was associated with serious or long-term complications. Because of this finding, the approach depends on the surgical experience and expertise of the unit in conjunction with discussion with the patient.

Laparoscopic transabdominal cervical cerclage: a 6-year experience.

BACKGROUND: Cervical cerclage has been used as a treatment for cervical insufficiency for over 60 years. Transabdominal cerclage is indicated for cervical insufficiency not amenable to a transvaginal procedure, or following previous failed vaginal cerclage. A laparoscopic approach to abdominal cerclage offers the potential to reduce the morbidity associated with laparotomy. AIMS: To evaluate the obstetric outcome and surgical morbidity of laparoscopic transabdominal cerclage. METHODS: An observational study of consecutive women undergoing laparoscopic transabdominal cerclage from 2007 to 2013 by a single surgeon (AA). Eligible women had a diagnosis of cervical insufficiency based on previous obstetric history and/or a short or absent cervix. The primary outcome was neonatal survival. Secondary outcomes were delivery of an infant at ≥34 weeks gestation. Surgical morbidity and complications were also evaluated. RESULTS: Sixty-four women underwent laparoscopic transabdominal cerclage during the study period. Three women underwent cerclage insertion during pregnancy; the remaining 61 were not pregnant at the time of surgery. Thirty-five pregnancies have been documented to date. Of those, 24 were evaluated for the study. The remaining cases were either early miscarriages, ectopic pregnancies or are still pregnant. The perinatal survival rate was 95.8% with a mean gestational age at delivery of 35.8 weeks. Eighty-three per cent of women delivered at ≥34 weeks gestation. There was one adverse intra-operative event (1.6%), with no postoperative sequelae. CONCLUSION: Laparoscopic transabdominal cerclage is a safe and effective procedure resulting in favourable obstetric outcomes in women with a poor obstetric history. Success rates compare favourably to the laparotomy approach.

Transabdominal cervical cerclage.

BACKGROUND: Transabdominal cervical cerclage has been performed via laparotomy for over four decades. A laparoscopic approach has recently been developed and offers the potential for lower morbidity. AIMS: The experience of one operator with transabdominal cervical cerclage via laparotomy is reviewed to establish a baseline with which to compare results from the laparoscopic approach. METHODS: Transabdominal cervical cerclage was performed with Mersilene tape. The pregnancy outcome prior to transabdominal cervical cerclage was compared with the outcomes after its insertion. RESULTS: Prior to transabdominal cervical cerclage, there were 58 pregnancies of which 18 ended with a first trimester pregnancy loss. Twenty-eight of the 36 pregnancies delivering between 13- and 26-week gestation resulted in a pregnancy loss. Three of the four children delivered after 26-week gestation survived. Following transabdominal cervical cerclage, there were no first trimester pregnancy losses. Of the 23 pregnancies after transabdominal cerclage, one was terminated at 18-week gestation for spina bifida and the remaining 22 babies were delivered at a mean gestation of 36.2 weeks. Maternal morbidity was limited to a single wound infection. Respiratory distress was the only significant neonatal morbidity with all babies recovering completely. CONCLUSIONS: Transabdominal cervical cerclage via laparotomy is a safe and successful method of treating women who need a cervical cerclage but are unable to have a vaginal suture. A baseline has been established with which to compare the results from laparoscopic transabdominal cervical cerclage in the future.