Laparoscopic guided minilaparotomy: a modified technique for management of benign large ovarian cysts.

BACKGROUND: The aim of the study is to evaluate the efficiency and safety of a novel technique to treat large benign ovarian cysts combining benefits of laparoscopic management along with mini-laparotomy without affection of the ovarian reserve. METHODS: The study included 112 women with large benign ovarian cyst candidate for ovarian cystectomy. The technique started with laparoscopy followed by guided cyst aspiration followed by exteriorization of the ovary through minilaprotomy and completion of cystectomy through microsurgical technique. The primary outcome was ipsilateral recurrence of the cyst. Other outcomes included ovarian reserve assessment and postoperative pain. RESULTS: The number of women with recurrence in the ipsilateral ovary after 12, 18 and 24 months were 5 (4.5%),16 (14.3%),20 (17.85%) respectively. Assessment of ovarian reserve revealed a significant decrease in the level of serum AMH (2.82 ± 0.44 vs. 2.50 ± 0.42) and a significant increase in AFC (3.5 ± 1.7 vs. 4.9 ± 1.3) after our novel technique in surgical treatment of ovarian cysts (P value < 0.001). The operative time was 50 ± 7 and 62 ± 7 min in unilateral and bilateral cysts respectively. CONCLUSIONS: Laparoscopic guided minilaparotomy is a safe and effective technique for the management of large benign ovarian cysts with minimal recurrence rate, ovarian reserve affection and adhesions. TRIAL REGISTRATION: clinical trial registry no. NCT03370952. Registered 13 December 2017, https://clinicaltrials.gov/ct2/show/NCT03370952.

A randomized controlled trial of a new technique for laparoscopic management of ovarian endometriosis preventing recurrence and keeping ovarian reserve.

INTRODUCTION: Laparoscopic cystectomy provides more favourable outcomes as regards the recurrence and subsequent clinical pregnancy rates. It is associated with significant reduction in the ovarian reserve due to the inevitable removal of unaffected ovarian tissue. The aim of our study was to evaluate the efficiency of Surgicel in preventing recurrence of endometriomas after their laparoscopic conservative management (cystectomy or drainage). MATERIAL AND METHODS: A randomized controlled trial included two hundred women (candidate for conservative laparoscopic management of ovarian endometriomas). They were randomized into four groups; group D in which patients underwent laparoscopic drainage of the endometrioma, group C in which patients underwent laparoscopic cystectomy of the endometrioma, group DS in which patients underwent laparoscopic drainage followed by insertion of Surgicel inside the cyst cavity & group CS in which patients underwent laparoscopic cystectomy of the endometrioma followed by insertion of Surgicel inside the remaining ovarian tissues. All patients were followed up for 2 years & the primary outcome was the recurrence of endometriomas in the ipsilateral ovary & the postoperative ovarian reserve was reassessed as a secondary outcome. RESULTS: The Surgicel-treated groups had significantly lower hazard of recurrence compared to untreated groups (p = 0.004). Group CS had significantly lower hazard of recurrence compared to Group D & C (p = 0.014, 0.046 respectively). Group DS had significantly lower hazard of recurrence compared to Group D (p = 0.039) but it not significantly different from Group C (p = 0.112). Group DS had the lowest drop of AMH and was significantly lower than the other three groups. CONCLUSION: Surgicel reduces effectively the recurrence risk of endometriomas and its use during laparoscopic drainage is an effective alternative for traditional laparoscopic cystectomy with minimal affection of the patient ovarian reserve. TRIAL REGISTRATION: Name of the registry: clinicaltrials.gov. Trial registration number NCT02947724 . Date of registration October 28, 2016.

The measurement of endometrial volume and sub-endometrial vascularity to replace the traditional endometrial thickness as predictors of in-vitro fertilization success.

To assess the value of endometrial thickness, volume, and sub-endometrial perfusion in women undergoing IVF. In 82 women candidate for ICSI, endometrial thickness and sub-endometrial perfusion were measured with a trans-vaginal 2 D ultrasound and 3 D power Doppler respectively on day of hCG trigger and Embryo transfer (ET). The primary outcome was the clinical pregnancy rate. Endometrial volume showing a statistically significant difference between pregnant and nonpregnant women (4.11 ± 1.19 vs. 3.4 ± 1.1 p = .019) on day of triggering and at ET (4.02 ± 1.15 vs. 3.45 ± 0.90, p = .022). VFI was significantly higher in pregnant group at both days of triggering and ET (0.54 ± 0.48 vs. 0.33 ± 0.31 and 0.47 ± 0.22 vs. 0.34 ± 0.2, p = .02). At cutoff values of 3.265 and 2.95 cm3 (70 & 80% sensitivity, specificity 64.5 & 51.6%, a positive predictive value 38.9 & 34.8%, and negative predictive value 87.0 & 88.9%) to predict pregnancy on the day of hCG trigger & ET respectively. Cutoff value for Endometrial VFI on the day of ET was 0.674 (sensitivity of 70%, specificity of 80.6%, PPV 53.8%, and NPV 89.3%). Higher endometrial volume and VFI were associated with pregnancy.

Laparoscopic transabdominal cerclage: new approach.

OBJECTIVE: To evaluate efficiency and safety of the new approach of laparoscopic cerclage. STUDY DESIGN: Fifteen women were operated with our new technique. Their age ranged from 22 years to 35 years. Inclusion criteria included those with history of two or more second trimesteric abortions or early preterm labor. These women had at least two previous unsuccessful vaginal cerclage or vaginal insertion of cerclage is not possible because of congenitally short cervix, cervical conization or excessive cervical scarring. RESULTS: Twelve of the participants delivered vaginally with the removal of cerclage, two had CS due to breech presentation and the cerclage was left in place and the last one has surgical evacuation. No intraoperative or postoperative complications were encountered namely; excessive bleeding, injury of uterine vessels or postoperative peritonitis. No technical difficulties upon doing the procedure or cerclage removal were met apart from one case where removal of the vaginal stitch was not possible [incision was done in the cervix over the tape and the Mersilene tape was cut followed by repair of the cervical tissue using (00) Vicryl stitches]. CONCLUSION: The new approach for laparoscopic cerclage is a safe, effective and reasonable treatment after failure of vaginal cerclage.

A randomized placebo-controlled trial of preoperative tranexamic acid among women undergoing elective cesarean delivery.

OBJECTIVE: To study the efficacy and safety of preoperative intravenous tranexamic acid to reduce blood loss during and after elective lower-segment cesarean delivery. METHODS: A single-blind, randomized placebo-controlled study was undertaken of women undergoing elective lower-segment cesarean delivery of a full-term singleton pregnancy at a center in Cairo, Egypt, between November 2013 and November 2014. Patients were randomly assigned (1:1) using computer-generated random numbers to receive either 1g tranexamic acid or 5% glucose 15 minutes before surgery. Preoperative and postoperative complete blood count, hematocrit values, and maternal weight were used to calculate the estimated blood loss (EBL) during cesarean, which was the primary outcome. Analyses included women who received their assigned treatment, whose surgery was 90 minutes or less, and who completed follow-up. RESULTS: Analyses included 100 women in each group. Mean EBL was significantly higher in the placebo group (700.3 ± 143.9 mL) than in the tranexamic acid group (459.4 ±7 5.4 mL; P<0.001). Only six women, all in the placebo group, experienced an EBL of more than 1000 mL. There were no reports of thromboembolic events up to 4 weeks postoperatively. CONCLUSION: Preoperative administration of tranexamic acid safely reduces blood loss during elective lower-segment cesarean delivery. Australian New Zealand Clinical Trials Registry:ACTRN12615000312549.