Consideration for safe and effective gynaecological laparoscopy in the obese patient.

BACKGROUND: The number of obese and morbidly obese patients within the developed world is dramatically increasing within the last 20 years. Apart from demographical changes, obese patients are especially prone to have oestrogen-dependent morbidities and neoplasias, of which laparoscopic treatment should be the standard of care. The increasing number of patients with BMI >40 is concerning, making it necessary to summarise considerations for safe and effective Gynaecological Laparoscopic Surgery. CONSIDERATIONS: The sequel to successful laparoscopic surgery in obese patients comprises an interdisciplinary appreciation of laparoscopy. Preoperatively, anaesthetics and medical review are suggested to optimise treatment of comorbidities (i.e. infections and blood sugar levels). Positioning of the patient should consider anti-slip options and pannus fixation to ease laparoscopic access and decrease pressure to the chest. There is no standard port placement in obese patients and landmarks have to be the bony structures of the pelvis and ribs. Retraction of the bowel is essential and mobilisation of the sigmoid with fan retractors or endoloops can accomplish adequate vision. 30° scopes can be considered for vision "around the obstacle". An experienced assistant with anticipation of surgical steps is favourable for successful surgery completion. Intra-operatively, good surgical techniques are essential. Vessel sealing systems reduce the need for instrument changes and may be helpful in following visualised tissue planes. A transvaginal vault closure may be advantageous compared to laparoscopic closure and Endostiches may be preferred to close the fascia of large trocar sites under vision.

[Natural orifice transluminal endoscopic surgery in urology: feasability of a transrectal, flexible retroperitoneoscopy in a porcine model]. / "Natural orifice transluminal endoscopic surgery" in der Urologie : Machbarkeit einer transrektalen, flexiblen Retroperitoneoskopie im Schweinemodell.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) in urology is becoming more and more interesting due to technical innovations. One of those innovations is the HybridKnife®, a multifunctional sonde that combines high-frequency electrosurgery and water jet surgery. The aim of this study was to establish a transrectal, flexible endoscopic retroperitoneoscopy in a porcine model by means of the HybridKnife® for further development of a transrectal retroperitoneal NOTES lymphadenectomy (NOTES-RLA). MATERIAL AND METHODS: Five female pigs (25-30 kg body mass) were anesthetized and placed in a supine position. The rectal mucosa was opened 3-5 cm cranially of the linea dentata. After submucosal tunneling, the retrorectal space was opened. We performed a flexible endoscopic retroperitoneoscopy by means of a double-channel gastroscope 13.806 PKS (Karl Storz-Endoskope, Tuttlingen, Germany) and the HybridKnife® I-type (ERBE Elektromedizin, Tübingen, Germany). RESULTS: Transrectal access was safe and feasible without any difficulties. Using the HybridKnife® water jet technology, the retroperitoneal space could be distended which enabled safe access to the iliacal vessels, the bifurcation of the aorta/vena cava, and the pre- and paraaortal/-caval space up to the renal vessels. The water jet did not lacerate or injure blood vessels, nerves, or lymph vessels in any of the surgical procedures. CONCLUSIONS: By means of the HybridKnife®, transrectal access into the retrorectal space is safe and easily feasible. The water jet technology combined with electrosurgery prevented injuries of blood vessels, nerves, and lymph vessels and enabled transrectal flexible endoscopic retroperitoneoscopy as a precondition for further establishment of a transrectal NOTES-RLA.

Second-line treatment of postpartum haemorrhage (PPH).

INTRODUCTION: Postpartum haemorrhage (PPH) remains to be the most common cause of maternal mortality and is responsible for 25 % of the maternal deaths worldwide. Although the absolute risk of maternal death is much lower, a recent increase of PPH and related maternal adverse outcomes has been noted in high-income countries as well. Generally, PPH requires early recognition of its cause, immediate control of the bleeding source by medical, mechanical, invasive-non-surgical and surgical procedures, rapid stabilization of the mother's condition, and a multidisciplinary approach. Second-line treatment of PPH remains challenging, since there is a lack of univocal recommendations from current guidelines and sufficient data from randomized controlled trials. MATERIALS: For this review, electronic searches were performed in PubMed, Embase, and the Cochrane Central Register of Controlled Trials using the keywords "postpartum haemorrhage" in combination with 'uterine tamponade' and, especially with 'arterial embolisation', 'uterine compression sutures', and 'post(peri)partum hysterectomy' (from January 2000 to November 2011). Reference lists of identified articles were searched and article references to the keywords selected. RESULTS: Treatment options such as uterine compression sutures, embolisation, arterial ligation and hysterectomy were evaluated with regard to their prerequisites, benefits, drawbacks and respective success rate. In addition, a treatment algorithm for the second-line treatment of PPH is presented.

Is Patient Education About Adhesions a Requirement in Abdominopelvic Surgery?

Background: Over the past decades, our knowledge and understanding of adhesions and adhesion-related complications has increasingly grown and it has become evident that adhesions have significant implications for patients, physicians and the healthcare system. The question arises whether this has resulted in greater awareness of adhesion-related problems among practicing physicians and appropriate patient education on this topic in daily practice. The following article provides a brief overview of the important subject of adhesions, discusses current awareness of adhesions among patients and doctors and addresses the consequences of failure to provide patient education and consent from a medical perspective. Methods: Selective literature searches were conducted in PubMed and the Cochrane Library. A patient information and consent form was developed based on several years' experience and expertise in the field of adhesions. Results: Adhesions are the most common type of complication in abdominopelvic surgery today, with devastating consequences for some patients. Surveys investigating the awareness of adhesions among physicians and patients clearly showed that even well-informed physicians fail to educate their patients adequately. Such failure could potentially lead to successful medical malpractice lawsuits against doctors. Conclusion: Considering their clear clinical impact, adhesions and related consequences should always be discussed with patients preoperatively. A newly developed consent form that specifically addresses adhesion formation may serve to thoroughly educate patients preoperatively and to adequately document the process of doing so.

A new variable-view rigid endoscope evaluated in advanced gynecologic laparoscopy: a pilot study.

BACKGROUND: This pilot study aimed to evaluate the optical performance and clinical handling of a new variable-view rigid endoscope with angulation from 0 º to 120 º in gynecologic laparoscopic surgery. METHODS: The EndoCAMeleon endoscope was assessed by experienced surgeons and assistants during a variety of advanced gynecologic laparoscopic procedures. After each procedure, both the surgeon and the assistant each completed questionnaires designed to assess the endoscope's ease of handling and optical performance. RESULTS: The endoscope was assessed during 21 advanced procedures. Questionnaire responses confirmed surgeon and assistant satisfaction with the mechanical handling and vision provided by the endoscope. In particular, the ability to vary the viewing angles enabled the surgeon to visualize the surgical site without moving the endoscope shaft. CONCLUSIONS: The new endoscope performed well in the hands of experienced surgeons and assistants undertaking advanced procedures. The variable-view rigid endoscope allows the use of visual ports during primary port entry and enhances vision. Further study is required to evaluate its performance in routine practice.

Transvaginal NOTES with semi-rigid and rigid endoscopes that allow adjustable viewing angles.

PURPOSE: To evaluate semi-rigid and rigid endoscopes for transvaginal NOTES surgery. METHODS: One rigid endoscope (EndoCAMeleon, KARL STORZ GmbH & Co. KG, Tuttlingen Germany) and one semi-rigid endoscope (EndoEYE LTF-VH, Olympus Deutschland GmbH, Hamburg, Germany) that allow adjustable viewing angles have been used during four transvaginal gynecological NOTES procedures for chronic pelvic pain and infertility. RESULTS: Feasibility of transvaginal access to enter the abdominal cavity was shown. Posterior peritoneum, ovaries and tubal patency were evaluated. The evaluated endoscopes did not overcome the inability to explore the anterior pelvic structures. CONCLUSIONS: Rigid and semi-rigid endoscopes that allow adjustable viewing angles during transvaginal NOTES approaches cannot explore the whole pelvic anatomical structures.

Establishing transvaginal NOTES for gynecological and surgical indications: benefits, limits, and patient experience.

Gynecologists have been performing transvaginal surgery for over a century and consequently the transvaginal approach was advocated for establishing natural orifice transluminal endoscopic surgery (NOTES) in gynecological and surgical practice. From 2008 the NOTES alternative has been offered to selected patients. Transvaginal cholecystectomies were intended in 13 patients and completed in 12. Various additional procedures were performed. All surgical procedures and postoperative courses were uneventful. The mean operating time for transvaginal cholecystectomy only was 88.4 minutes (standard deviation [SD] 17.3). A questionnaire was posted to the patients after a mean follow-up of 8.5 months. Patients primarily chose transvaginal NOTES because of the lack of scarring. Vaginal sensation was not affected. Patients perceived transgastric, transvesical, and transrectal surgery to be less acceptable approaches. The feasibility of transvaginal NOTES was proven for different indications. Patients' experiences and perceptions concerning transvaginal NOTES were excellent.

[Acute compartment syndrome of the lower leg as an interdisciplinary complication after long duration intervention in the lithotomy position]. / Das lagerungsbedingte Kompartmentsyndrom des Unterschenkels als Komplikation nach Eingriffen in Steinschnitt-Position.

INTRODUCTION: The positioning-related compartment syndrome of the lower leg after long-duration operations in the lithotomy position -represents a rare complication. The aim of this retrospective study was to draft recommendations to avoid this rare complication by reviewing the cases with positioning-related compartment syndromes in our own patient data. PATIENTS / MATERIAL AND METHODS: From January 1996 to February 2009, 3 women and 1 man with an average age of 38 years (24 to 55 years) were treated with a medial and lateral dermatofasciotomy with opening of lower leg loges due to a clinically manifested compartment syndrome of the -lower leg after long-duration operations in the -lithotomy position. RESULTS: In all 4 patients a dermatofasciotomy with opening of the lower leg compartments could -avoid considerable secondary damage of the limb. A long-duration lithotomy position in connection with obesity, a low positioning of the head as well as nicotine abuse are only some of the risk factors contributing to the development of a positioning-related compartment syndrome. An epidural anaesthesia bears the risk of a protracted diagnosis. CONCLUSION: The positioning-related compartment syndrome represents a rare but considerable complication after long-duration operations in the -lithotomy position. It is a clinical complication and the inducing and exponentiation risk factors as well as the clinical symptoms should be known by the treating team. If the operation time is expected to be longer than 3 hours, we recommend written information to the patient concerning this complication. Consequent postoperative controls of risk patients are obligatory. An epidural anaesthesia bears the risk of a protracted diagnosis. In the case of suspected compartment syndrome we recommend early dermatofasciotomy in order to avoid -irreversible damage to the limb.

Awareness and perception of intra-abdominal adhesions and related consequences: survey of gynaecologists in German hospitals.

OBJECTIVE: Intra-abdominal adhesion formation after abdominal surgery is the most common postsurgical complication, and the consequences are a considerable burden for patients, surgeons and health systems. Since a wide variety of factors influence adhesion formation, it is difficult to define clear guidelines on how to reduce adhesion formation in daily practice. Given this dilemma, this study assessed the awareness and perception of adhesion formation among gynaecologists in Germany in order to define a baseline for further research and education. STUDY DESIGN: The Clinical Adhesion Research and Evaluation (CARE) group of the University of Giessen designed a questionnaire that was sent to the heads of all gynaecological departments in Germany. The director or one of the surgical consultants was asked to complete the questionnaire and return it for evaluation. RESULTS: The completed questionnaire was returned by 279 of 833 gynaecological departments. Interviewed surgeons expected adhesions to form in 15% of cases after laparoscopy and 40% after laparotomy. Before surgery, 83.1% of the respondents told their patients about the risk of prior adhesion formation. More than 60% believed that postsurgical adhesion accounts for major morbidity. Infections within the abdomen, previous surgery and extensive tissue trauma were thought to have the most influence on adhesion formation. Risk of adhesion formation was thought to be highest in endometriosis and adhesiolysis surgery. The respondents agreed on performing adhesiolysis in symptomatic but not in all patients. Only 38.4% used adhesion reduction agents regularly. A total of 65.1% of a repertoire of adhesion prevention agents were familiar to the interviewed surgeons. Only 22.0% of them used anti-adhesion products in clinical practice. In general, the respondents were uncertain whether these products play an important role in adhesion reduction, represented by a range of 1.97+/-0.98% on a scale from 0 to 4. CONCLUSIONS: Even though postoperative adhesions are recognized as a major cause for morbidity, and it is widely agreed that infections, extensive tissue trauma and surgery lead to adhesion formation, there is uncertainty about the treatment and prophylactic strategies for dealing with adhesions. This dilemma reflects the awareness and perception of gynaecologists in Germany and is an initial point for further research.

No more abdominal hysterectomy for myomata using a new minimally-invasive technique.

To perform hysterectomy in uterus myomatosus, there are several surgical techniques. For a uterine weight of >1000 g, after a caesarean section and in nullipara per vaginam, the most common surgical technique for hysterectomy in patients is hysterectomy per laparotomiam. A new endoscopical technique developed to treat such patients and to avoid laparotomy is described in this case report: the laparoscopic combined hysterectomy (LACH) using the change-over technique. Adhesiolysis, preparation of the ureters and the bladder and morcellation of the uterus of 2480 g were performed minimally-invasive in two steps, from one side of the patient with a change-over of the OP-team to the other side of the patient. The cervix was removed per vaginam.

Uterine surgery in postpartum hemorrhage.

Uterine atony accounts for the majority of primary postpartum hemorrhage. Timely recognition and intervention are fundamental in preventing serious maternal morbidity and mortality. Combinations of conservative manual and medical therapies are adequate and successful treatment options in most cases. However, when the hemorrhagic process continues and when either clotting abnormalities or hemodynamic instability develop, the next step must be an invasive intervention. Depending on the mode of delivery a vaginal approach (i.e. curettage and uterine packing) after spontaneous delivery or an abdominal surgical approach (i.e. compression sutures and systematic devascularization) after a Cesarean delivery can be performed. Uterine compression sutures are especially highly effective and a straightforward and easy emergency procedure which conserves fertility. The ultima ratio in all cases of persistent haemorrhage after conservative and uterus preserving surgical therapy is the emergent hysterectomy. It might be of advantage to perform a subtotal or supracervical hysterectomy compared to a total hysterectomy in an emergency setting.

Uterine compression U-sutures in primary postpartum hemorrhage after Cesarean section: fertility preservation with a simple and effective technique.

BACKGROUND: Transmural uterine compression suturing methods are a fertility-preserving alternative in patients with atonic primary postpartum hemorrhage (PPPH), which does not respond to manual compression or drugs. This study evaluated the effectiveness of a modified U-suturing technique in effecting uterine compression in patients with PPPH after Cesarean section. METHODS: U-suture uterine compression was introduced at our hospital at the beginning of 2005. The medical records of patients with PPPH after Cesarean section who had undergone this treatment, and results of a follow-up and questionnaire were evaluated and our experience with this method was reviewed. RESULTS: Between January 2005 and September 2007, seven patients underwent uterine compression with U-sutures after PPPH. In all cases, treatment was successful, the hemorrhage was controlled and the uterus preserved. Normal menstruation patterns returned in the five patients who returned the questionnaire and no surgery related morbidities were noted at the follow-up examinations of six patients. The technique was simple to perform in an emergency situation. CONCLUSIONS: Uterine compression with U-sutures is a highly effective and straightforward emergency procedure which conserves the uterus in these patients.

Contact allergy to propolis in beekeepers.

BACKGROUND: Some toothpastes, cosmetics and ointments contain propolis, a bee product, and it is increasingly popular as a dietary supplement. Although propolis is known to cause contact allergy, there have been no studies of the prevalence of this. OBJECTIVES: This study aimed to determine the prevalence of contact allergy to propolis in beekeepers and any relationship between propolis allergy and environmental and physical and mental health characteristics in this group. SUBJECTS AND METHODS: A specially developed instrument which included a validated questionnaire on emotional stability was included in the issues of three German beekeeping journals sent to subscribers in a number of regions (potential readership 35,000). A reference group also completed questionnaire. RESULTS: 1051 questionnaires were returned and 37 cases of allergic reactions to propolis were reported (3.6%). Only 10 of the 37 (27%) beekeepers had recognised the allergy before participating in this study. Propolis contact allergy was significantly associated with lung diseases and other allergic reactions. Only some affected beekeepers protected their hands more while working with bees and showed significantly greater emotional instability than those not sensitised to propolis. CONCLUSIONS: Contact allergy to propolis is common among beekeepers, but they do not seem to recognise the problem or protect themselves properly.

Contact allergy to propolis in beekeepers / Alergia de contacto al propolis en apicultores

Background: Some toothpastes, cosmetics and ointments contain propolis, a bee product, and it is increasingly popular as a dietary supplement. Although propolis is known to cause contact allergy, there have been no studies of the prevalence of this. Objectives: This study aimed to determine the prevalence of contact allergy to propolis in beekeepers and any relationship between propolis allergy and environmental and physical and mental health characteristics in this group. Subjects and methods: A specially developed instrument which included a validated questionnaire on emotional stability was included in the issues of three German beekeeping journals sent to subscribers in a number of regions (potential readership 35,000). A reference group also completed questionnaire. Results: 1051 questionnaires were returned and 37 cases of allergic reactions to propolis were reported (3.6 %). Only 10 of the 37 (27 %) beekeepers had recognised the allergy before participating in this study. Propolis contact allergy was significantly associated with lung diseases and other allergic reactions. Only some affected beekeepers protected their hands more while working with bees and showed significantly greater emotional instability than those not sensitised to propolis. Conclusions: Contact allergy to propolis is common among beekeepers, but they do not seem to recognise the problem or protect themselves properly

Antecedentes. Algunas pastas de dientes, cosméticos y pomadas contienen propolis, un producto de las abejas, que esta teniendo un popular incremento como suplemento alimenticio. Aunque el propolis es conocido como causante de alergia de contacto, no hay estudios sobre la prevalencia de esto. Objetivos. Este estudio está dirigido para determinar la prevalencia de la alergia de contacto al propolis en apicultores y la relación entre alergia al propolis y ambiente, y las características físicas y mentales de este grupo. Controles y métodos. Un instrumento especialmente desarrollado que incluía un cuestionario validado sobre estabilidad emocional, se incluyó en la edición de tres revistas Alemanas de apicultores, enviado a los suscriptores de un número de regiones (35.000 potenciales lectores). El cuestionario también lo completó un grupo de referencia. Resultados. Retornaron 1.050 cuestionarios que reportaron 37 casos de reacciones alérgicas a propolis (3,6%). Sólo 10 de los 37 (27%) apicultores habían reconocido la alergia antes de participar en este estudio. La alergia de contacto al propolis estuvo asociada significativamente con enfermedad pulmonar y otras reacciones alérgicas. Solamente algunos apicultores protegían sus manos cuando trabajaban con las abejas y mostraron una mayor significativa inestabilidad emocional que los no sensibilizados al propolis. Conclusiones. La alergia por contacto al propolis es común entre apicultores, pero ellos no parece que reconozcan el problema y se protejan adecuadamente

Evaluation of target scores and benchmarks for the traversal task scenario of the Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) laparoscopy simulator.

BACKGROUND: The Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) simulator is validated for laparoscopy training, but benchmarks and target scores for assessing single tasks are needed. METHODS: Control data for the MIST-VR traversal task scenario were collected from 61 novices who performed the task 10 times over 3 days (1 h daily). Data were collected on the time taken, error score, economy of movement, and total score. Test differences were analyzed through percentage scores and t-tests for paired samples. RESULTS: Improvement was greatest over tests 1 to 5 (improvement: test(1.2), 38.07%; p = 0.000; test(4.5), 10.66%; p = 0.010): between tests 5 and 10, improvement slowed and scores stabilized. Variation in participants' performance fell steadily over the 10 tests. CONCLUSION: Trainees should perform at least 10 tests of the traversal task-five to get used to the equipment and task (automation phase; target total score, 95.16) and five to stabilize and consolidate performance (test 10 target total score, 74.11).