Hemihysterectomy in a patient with uterus didelphys, vaginal septum and ipsilateral renal agenesis: A case report and literature review.

Uterus didelphys is a rare Müllerian anomaly, often diagnosed during menarche or in women with a personal history of infertility and/or recurrent pregnancy loss. Its association with other genitourinary anomalies is frequent and may determine the existence of established syndromes. This case report refers to a 13-year-old female patient diagnosed with OHVIRA syndrome (Obstructed Hemivagina with Ipsilateral Renal Agenesis), a condition wherein the presence of a didelphic uterus is associated with hemivagina obstruction and ipsilateral renal agenesis. The patient presented with cyclic pelvic pain, related to the presence of hematocolpos and hematometra, which persisted despite several surgical approaches, including vaginal septum excision and correction of cervical stenosis. The recurrence of the condition indicated exploratory laparotomy, revealing two hemi-uteri and two uterine cervixes, with hematometra on the right. A subtotal hemihysterectomy was performed on the right. Post-procedure, the patient developed with regular menstrual cycles and improvement of pelvic pain complaints. Given the limited prevalence and low index of suspicion, the potential requirement for surgical intervention and its potential impact on reproductive future, diagnosing and treating OHVIRA syndrome and other Müllerian anomalies poses notable challenges in clinical practice. Hence, sharing different therapeutic approaches of a rare diagnosis with the scientific community is of paramount importance to aid in early diagnosis and effective management of similar clinical cases.

Anti-adhesive effect of naturally obtained dicalcium phosphate dihydrate nanoparticles in the rat uterine wound model.

OBJECTIVE: In this study, we aimed to compare the anti-adhesive effects of contractubex and dicalcium phosphate dihydrate (DCPD) particles in rats treated with the uterine horn adhesion model. MATERIALS AND METHODS: Newly adult, 60 Wistar albino rats were used as experimental animals. The modified rat uterine horn adhesion model was used to induce intra-abdominal adhesion. Tumor necrosis factor (TNF)-α, interleukin (IL)-1, vascular endothelial growth factor (VEGF) and transforming growth factor (TGF)-ß1 were studied for biochemical and immunohistochemical examination. RESULTS: TNF-α decreased in each group, while it decreased more in G2 and G3 than in G1. IL-1ß decreased in each group, while it decreased the most in G3. TGF-ß1 and VEGF localization was less in the G2 compared to G1, the least TGF-ß1 and VEGF immunolocalization was detected in the G3 and G4. For both antibodies, the least localization among all groups belonged to G3. From day 7 to day 21, the highest TGF-ß1 immunolocalization was observed in G1, lesser localization in G2 and lowest in G3. CONCLUSION: DCPD nanoparticles show promise as a clinical antiadhesive agent and should be further evaluated in experimental animal models and human trials.

OBJETIVO: En este estudio, nuestro objetivo fue comparar los efectos antiadhesivos de las partículas de contractubex (CTX) y fosfato dicálcico dihidratado (DCPD) en ratas tratadas con el modelo de adhesión del cuerno uterino. MATERIALES Y MÉTODOS: Como animales de experimentación se utilizaron 60 ratas Wistar albinas, recién adultas. Se usó el modelo de adhesión del cuerno uterino de rata modificado para inducir la adhesión intraabdominal. Se estudiaron TNF-α, IL-1, VEGF y TGF-ß1 para examen bioquímico e inmunohistoquímico. RESULTADOS: el TNF-α disminuyó en cada grupo, mientras que disminuyó más en G2 y G3 que en G1. IL-1ß disminuyó en cada grupo, mientras que disminuyó más en G3. La localización de TGF-ß1 y VEGF fue menor en G2 en comparación con G1, la menor inmunolocalización de TGF-ß1 y VEGF se detectó en G3 y G4. Para ambos anticuerpos, la localización mínima entre todos los grupos pertenecía a G3. Desde el día 7 hasta el día 21, la mayor inmunolocalización de TGF-ß1 se observó en G1, menor localización en G2 y menor en G3. CONCLUSIÓN: las nanopartículas de DCPD se muestran prometedoras como agentes antiadhesivos clínicos y deben evaluarse más en modelos animales experimentales y ensayos en humanos.

Short-term outcomes after an enhanced recovery after surgery protocol in abdominal hysterectomies for leiomyomas in a teaching hospital.

OBJECTIVE: To compare the perioperative outcomes of patients undergoing abdominal hysterectomies for leiomyomas before and after the implementation of an enhanced recovery after surgery (ERAS) protocol in a teaching hospital. METHODS: This prospective cohort study compared a patient group from a historical series (pre-ERAS) with another group after ERAS implementation. Fasting time, length of hospital stay, complications, readmission rates, and procedure-related hospital costs were analyzed. RESULTS: Altogether, 187 patients were included in the analysis: 92 (49.2%) and 95 (50.8%) in the pre-ERAS and ERAS groups, respectively. Both groups had similar clinical characteristics. We observed reductions in surgical outcome findings: fasting time (13.9 to 6.7 h, P < 0.001), bladder catheter usage (21.1 to 10.9 h, P < 0.001), infection rates (20.7% to 5.3%, P = 0.002), length of stay (57.5 to 37.6 h), and 38.4% of the total estimated mean cost per procedure (USD $1570.8 to USD $967.2, P < 0.001) in the pre-ERAS and ERAS groups, respectively. Hospital readmission rates (P > 0.99) did not increase. CONCLUSION: ERAS protocol implementation for hysterectomies involving uterine leiomyomas reduced the length of hospital stay, surgical site infection rates, and hospital costs. A mean savings of USD $603.6 per procedure would allow 62.4% more hysterectomies to be performed.

Pain and Quality of Life after Laparoscopic Excision of Endometriosis.

STUDY OBJECTIVE: To evaluate the long-term impact of laparoscopic excision of endometriosis on quality of life through pain reduction as measured by the Endometriosis Health Profile-30 (EHP-30) in uterine-sparing (preservation of the uterus and at least 1 ovary) and nonuterine-sparing (removal of the uterus) surgery. DESIGN: Cohort study. SETTING: Academic medical center. PATIENTS: Sixty-one women who had undergone laparoscopic excision of endometriosis for pelvic pain were enrolled in a tissue-procurement study. INTERVENTIONS: Patients who had previously completed an EHP-30 preoperatively and at 4 weeks postoperatively were mailed a copy of the EHP-30 2.6 to 6.8 years after their index surgery. MEASUREMENTS AND MAIN RESULTS: The primary outcome was quality of life as measured by changes in the EHP-30 scores before their index surgery and those measured weeks and years later. The secondary outcome was a comparison of the EHP-30 scores between patients who underwent excision of endometriosis alone and those who underwent excision of endometriosis with hysterectomy +/- oophorectomy. From 2011 to 2015, 61 women underwent laparoscopic excision of endometriosis for pelvic pain. Forty-six of the 61 patients completed the EHP-30 for a response rate of 75%. The patients demonstrated significant improvement in all 5 scales of the EHP-30 (pain, control and powerlessness, emotional well-being, social support, and self-image) at 4 weeks postoperatively (p <.001), which persisted for up to 6.8 years in follow-up (p <.001) when compared with their baseline scores. The improvement in EHP-30 scores did not differ by American Society for Reproductive Medicine staging or index surgery. Definitive surgery (total laparoscopic hysterectomy/bilateral salpingo-oophorectomy) was not associated with improved outcomes when compared with uterine-sparing surgery. CONCLUSION: Laparoscopic excision of endometriosis offers improvement in all quality-of-life domains as measured by the EHP-30, including a reduction in pain, an effect that may persist for up to 6.8 years. These findings suggest that laparoscopic excision of endometriosis with uterine preservation can be considered as an option for discussion during counseling for treatment of endometriosis.

Enhanced recovery after surgery outcomes in minimally invasive nonhysterectomy gynecologic procedures.

BACKGROUND: Improved patient outcomes and satisfaction associated with enhanced recovery after surgery protocols have increasingly replaced traditional perioperative anesthesia care. Fast-track surgery pathways have been extensively validated in patients undergoing hysterectomies, yet the impact on fertility-sparing laparoscopic gynecologic operations, particularly those addressing chronic pain conditions, has not been examined. OBJECTIVE: The objective of the study was to determine the effects of enhanced recovery after surgery pathway implementation compared with conventional perioperative care in women undergoing laparoscopic minimally invasive nonhysterectomy gynecologic procedures. STUDY DESIGN: We conducted a retrospective cohort study of women undergoing uterine-sparing laparoscopic gynecologic procedures for benign conditions (tubal/adnexal pathology, endometriosis, or leiomyomas) during a 24 month period before and after enhanced recovery after surgery implementation at a tertiary care center. We compared immediate perioperative outcomes and 30 day complications. The primary outcome was same-day discharge rates. Factors influencing unplanned admissions, postoperative pain, sedation, nausea, and vomiting represented secondary analyses. RESULTS: A total of 410 women (enhanced recovery after surgery, n = 196; conventional perioperative care, n = 214) met inclusion criteria. Following enhanced recovery after surgery implementation, same-day discharge rates increased by 9.4% (P = .001). Reductions in postoperative pain and nausea/vomiting represented the primary driving factor behind lower unplanned admissions. Higher preoperative antiemetic medication administration in the enhanced recovery after surgery group resulted in a 57% reduction in postanesthesia care unit antiemetics (P < .001). Total perioperative narcotic medication use was also significantly reduced by 64% (P < .001), and the enhanced recovery after surgery cohort still demonstrated significantly lower postanesthesia unit care pain scores at hours 2 and 3 (P < .001). A 19 minute shorter postanesthesia care unit stay was noted in the enhanced recovery after surgery cohort (P = .036). Increased same-day discharge did not lead to higher postoperative complications or changes in 30 day emergency department visits or readmissions in patients with enhanced recovery after surgery. CONCLUSION: Enhanced recovery after surgery implementation resulted in increased same-day discharge rates and improved perioperative outcomes without affecting 30 day morbidity in women undergoing laparoscopic minimally invasive nonhysterectomy gynecologic procedures.

Herbal medications for anxiety, depression, pain, nausea and vomiting related to preoperative surgical patients: a systematic review and meta-analysis of randomised controlled trials.

OBJECTIVE: To summarise the effects of herbal medications for the prevention of anxiety, depression, pain, and postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic, obstetrical/gynaecological or cardiovascular surgical procedures. METHODS: Searches of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and LILACS up until January 2018 were performed to identify randomised controlled trials (RCTs). We included RCTs or quasi-RCTs evaluating any herbal medication among adults undergoing laparoscopic, obstetrical/gynaecological or cardiovascular surgeries. The primary outcomes were anxiety, depression, pain and PONV. We used the Grading of Recommendations Assessment, Development and Evaluation approach to rate overall certainty of the evidence for each outcome. RESULTS: Eleven trials including 693 patients were eligible. Results from three RCTs suggested a statistically significant reduction in vomiting (relative risk/risk ratio (RR) 0.57; 95% CI 0.38 to 0.86) and nausea (RR 0.69; 95% CI 0.50 to 0.96) with the use of Zingiber officinale (ginger) compared with placebo in both laparoscopic and obstetrical/gynaecological surgeries. Results suggested a non-statistically significantly reduction in the need for rescue medication for pain (RR 0.52; 95% CI 0.13 to 2.13) with Rosa damascena (damask rose) and ginger compared with placebo in laparoscopic and obstetrical/gynaecological surgery. None of the included studies reported on adverse events (AEs). CONCLUSIONS: There is very low-certainty evidence regarding the efficacy of both Zingiber officinale and Rosa damascena in reducing vomiting (200 fewer cases per 1000; 288 fewer to 205 fewer), nausea (207 fewer cases per 1000; 333 fewer to 27 fewer) and the need for rescue medication for pain (666 fewer cases per 1000; 580 fewer to 752 more) in patients undergoing either laparoscopic or obstetrical/gynaecological surgeries. Among our eligible studies, there was no reported evidence on AEs. PROSPERO REGISTRATION NUMBER: CRD42016042838.

Cambios fisiológicos y consideraciones anestésicas en cirugía robótica no cardíaca / Physiological changes and anaesthetic considerations in non-cardiac robotic surgery

Resumen: La cirugía robótica ofrece numerosas ventajas sobre la cirugía laparoscópica convencional y la cirugía abierta. El anestesiólogo debe conocer los cambios que suceden en el paciente al ser sometido a cirugía robótica en el campo de la ginecología, urología, cirugía general, torácica y transoral. Los cambios fisiológicos son múltiples e involucran todos los sistemas: cardiovascular, respiratorio, neurológico, digestivo, renal; por lo que es de suma importancia el conocimiento de éstos para evitar complicaciones durante el período perioperatorio. De igual manera, es importante conocer el protocolo de seguridad para el retiro de los brazos del robot al verse con la necesidad de convertir la cirugía a laparoscópica o abierta. Se resumen las principales consideraciones anestésicas así como los cuidados específicos que el anestesiólogo debe tener durante cirugía robótica no cardíaca.

Abstract: Robotic surgery offers numerous advantages over conventional laparoscopic or open surgery. The anesthesiologist must have full knowledge of the physiological changes that happen when the patient undergoes robotic surgery; it being gynecological, urological, general surgery, thoracic or trans-oral surgery. There are multiple changes during robotic surgery involving the cardiovascular, respiratory, neurologic, digestive and renal systems. It is of utter importance the full knowledge of these changes in order to avoid complications during and after surgery. Also, it is important to fully know the emergency protocol for undocking if need be, to convert to laparoscopic or open surgery. We have summarized the main anesthetic considerations as well as the key points of care anesthesiologists must have during non-cardiac robotic surgery.

Carbon Dioxide with a New Pulse Profile and Shape: A Perfect Tool to Perform Labiaplasty for Functional and Cosmetic Purpose.

OBJECTIVE: To describe the benefits and safety of using Carbon Dioxide Laser in multi-pulse modalities when performing labiaplasty and anatomical variants approach for functional and cosmetic indications. DESIGN: This is a prospective, descriptive case series study. SETTING: Private Practice Quirofano Calculaser Megacentro Pinares Pereira Colombia. POPULATION: One Hundred and twelve women seeking labia minora labiaplasty for functional and cosmetic reasons were enrolled in the study protocol from June 2013 to June 2016. Labia minora labioplasty and anatomical variants approach were performed with Carbon Dioxide laser Multi-pulse modalities DEKA M.EL.A Florence Italy. MAIN OUTCOME MEASURES: Good Cosmetic results, functional and sexuality improvement. RESULTS: Dramatic changes in the VAS and VSQ were detected after the surgical procedure. All the participants reported a high degree of satisfaction, felt more confident with their partners during sexual encounters, and the procedure was well tolerated. CONCLUSION: Laser Carbon Dioxide Laser with a new pulse profile and shape seems to be a safe and precise surgical tool to perform this type of procedures, optimal biophysical and bio stimulative laser-tissue interactions allow delicate vulvar tissues to shorten downtime.

Herbal medications for surgical patients: a systematic review protocol.

INTRODUCTION: Postoperative nausea and vomiting (PONV) affect approximately 80% of surgical patients and is associated with increased length of hospital stay and systemic costs. Preoperative and postoperative pain, anxiety and depression are also commonly reported. Recent evidence regarding their safety and effectiveness has not been synthesised. The aim of this systematic review is to evaluate the efficacy and safety of herbal medications for the treatment and prevention of anxiety, depression, pain and PONV in patients undergoing laparoscopic, obstetrical/gynaecological and cardiovascular surgical procedures. METHODS AND ANALYSIS: The following electronic databases will be searched up to 1 October 2016 without language or publication status restrictions: CENTRAL, MEDLINE, EMBASE, CINAHL, Web of Science and LILACS. Randomised clinical trials enrolling adult surgical patients undergoing laparoscopic, obstetrical/gynaecological and cardiovascular surgeries and managed with herbal medication versus a control group (placebo, no intervention or active control) prophylactically or therapeutically will be considered eligible. Outcomes of interest will include the following: anxiety, depression, pain, nausea and vomiting. A team of reviewers will complete title and abstract screening and full-text screening for identified hits independently and in duplicate. Data extraction, risk of bias assessments and evaluation of the overall quality of evidence for each relevant outcome reported will be conducted independently and in duplicate using the Grading of Recommendations Assessment Development and Evaluation classification system. Dichotomous data will be summarised as risk ratios; continuous data will be summarised as standard average differences with 95% CIs. ETHICS AND DISSEMINATION: This is one of the first efforts to systematically summarise existing evidence evaluating the use of herbal medications in laparoscopic, obstetrical/gynaecological and cardiovascular surgical patients. The findings of this review will be disseminated through peer-reviewed publications and conference presentations. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016042838.

Creation of a Neovagina by Laparoscopic Modified Vecchietti Technique: Anatomic and Functional Results / Criação de neovagina pela técnica de Vecchietti laparoscópica modificada: resultados anatómicos e funcionais

Abstract Purpose To evaluate the anatomic and functional results of a laparoscopic modified Vecchietti technique for the creation of a neovagina in patients with congenital vaginal aplasia. Methods Retrospective study of nine patients with congenital vaginal aplasia submitted to the laparoscopic Vecchietti procedure, in our department, between 2006 and 2013. The anatomical results were evaluated by assessing the length, width and epithelialization of the neovagina at the postoperative visits. The functional outcome was evaluated using the Rosen Female Sexual Function Index (FSFI) questionnaire and comparing the patients' results to those of a control group of 20 healthy women. The statistical analysis was performed using SPSS Statistics version 19.0 (IBM, Armonk, NY, USA), Student t-test, Mann-Whitney U test and Fisher exact test. Results The condition underlying the vaginal aplasia was Mayer-Rokitansky-KüsterHauser syndrome in eight cases, and androgen insensitivity syndrome in one case. The average preoperative vaginal length was 2.9 cm. At surgery, the mean age of the patients was 22.2 years. The surgery was performed successfully in all patients and no intra or postoperative complications were recorded. At the first postoperative visit (6 to 8 weeks after surgery), the mean vaginal length was 8.1 cm. In all cases, the neovagina was epithelialized and had an appropriate width. The mean FSFI total and single domain scores did not differ significantly from those of the control group: 27.5 vs. 30.6 ( total); 4.0 vs. 4.2 (desire); 4.4 vs. 5.2 (arousal); 5.2 vs. 5.3 (lubrication); 4.2 vs. 5.0 ( orgasm); 5.3 vs. 5.5 (satisfaction) and 4.4 vs. 5.4 ( comfort ). Conclusions This modified laparoscopic Vecchietti technique is a simple, safe and effective procedure, which allows patients with congenital vaginal aplasia to have a satisfactory sexual activity, comparable to that of normal controls.

Resumo Objetivo Avaliar os resultados anatômicos e funcionais da técnica laparoscópica modificada de Vecchietti para a criação de uma neovagina em pacientes com aplasia vaginal congênita. Métodos Estudo retrospectivo de nove pacientes com aplasia vaginal congênita submetidas à técnica laparoscópica modificada de Vecchietti, no nosso departamento, entre 2006 e 2013. Os resultados anatômicos foram aferidos através da avaliação do comprimento, largura e reepitelização da neovagina nas consultas pós-operatórias. Os resultados funcionais foram avaliados com recurso à versão em português do questionário Female Sexual Function Index de Rosen, comparando os resultados das pacientes aos de um grupo de controle de 20 mulheres saudáveis. A análise estatística foi realizada utilizando o programa SPSS Statistics versão 19.0), o teste t de Student, teste U de Mann-Whitney e teste exato de Fisher. Resultados A etiologia subjacente à aplasia vaginal foi a síndrome de Mayer-Roki-tansky-Küster-Hauser em oito casos, e a síndrome de insensibilidade aos andrógenos em um caso. O comprimento vaginal médio pré-operatório era de 2,9 cm. À data da cirurgia, a média de idade das pacientes era de 22,2 anos. A cirurgia foi realizada com sucesso em todos os casos, sem registo de complicações intra ou pós-operatórias. Na primeira avaliação pós-operatória (6 a 8 semanas após a cirurgia), o comprimento vaginal médio foi de 8,1 cm. Em todos os casos, a neovagina estava reepitelizada e com amplitude adequada. As pontuações médias, total e de cada domínio, obtidas no questionário de avaliação da função sexual não diferiram significativamente das do grupo controle: 27,5 vs 30,6 (total); 4.0 vs 4.2 (desejo); 4,4 vs 5,2 (excitação); 5,2 vs 5 , 3 (lubrificação); 4,2 vs 5,0 (orgasmo); 5,3 vs 5,5 (satisfação) e 4,4 vs 5,4 ( conforto ). Conclusões A técnica laparoscópica modificada de Vecchietti é um procedimento simples, seguro e eficaz, permitindo às pacientes com aplasia vaginal congênita uma atividade sexual satisfatória, comparável à dos controles normais.

An update on the management of uterine fibroids.

PIP: In Jamaica, uterine fibroids are the most common reason for major surgery in hospital gynecology wards. No treatment is needed in asymptomatic women with small fibroids (less than 12-week size). When fibroids are symptomatic, however, they need to be treated. Medical therapy alone (e.g., gonadotropin-releasing hormone agonists) has produced disappointing results. Myomectomy by laparotomy is the method of choice in most women. Adhesion formation can be reduced by careful operative technique, limited number of incisions, and use of an Interceed barrier to prevent contact between damaged tissue. However, a recurrence rate of 27% has been reported after 10 years, necessitating reoperation. Hysterectomy is recommended in women who have completed childbearing. Depo-Provera has been used to reduce the menorrhagia associated with uterine fibroids, but its effect is temporary and there is no impact on the size and growth of the fibroids.^ieng

Transcervical tubal cannulation, past, present, and future.

OBJECTIVE: To evaluate publications that introduced novel diagnostic and therapeutic transcervical procedures on the fallopian tubes. DESIGN: Major studies that conceptually changed the therapeutic approach to the fallopian tubes were reviewed. Minor publications were also included if they introduced a new concept or contributed to the topic. Clinical publications were selected if they involved transcervical diagnosis and treatment of fallopian tubes. RESULTS: Transcervical tubal catheterization procedures for diagnosis of tubal disease, tubal obliteration, tubal recanalization, and tubal medication are minimally invasive procedures that can improve our understanding and diagnostic accuracy of tubal disease. These procedures allow transcervical treatment of proximal tubal occlusion. Further improvements in equipment and methodology are promising. Transcervical tubal occlusion, gamete and embryo deposition, and treatment of ectopic pregnancy may all be performed using the transcervical approach. CONCLUSION: Transcervical tubal catheterization can replace microsurgery and IVF in selected patients with proximal tubal occlusion, improve the diagnostic accuracy of tubal disease, and deliver medications to the fallopian tubes. Cumulative knowledge suggests that transcervical tubal catheterization should become a universally accepted, taught, and practiced approach in the diagnosis and treatment of the fallopian tubes.

Abdominoplasty combined with other intraabdominal procedures.

One hundred three patients underwent abdominoplasty combined with other intraabdominal procedures including 67 tubal ligations, 34 total abdominal hysterectomies and 2 cholecystectomies, from January 1983 to July 1991. The patients were divided into two groups, those undergoing the standard or total abdominoplasty and those undergoing limited abdominoplasty with or without liposuction in delimited areas. In this series of 103 patients, we found only two minor complications and only three patients were transfused with autologous units of blood. When performed by well-schooled surgical teams, abdominoplasty may be combined with intraabdominal procedures with gratifying results.

PIP: Between January 1983 and July 1991, well trained surgical teams performed either standard abdominoplasty or miniabdominoplasty on 103 patients who also underwent tubal ligation, total abdominal hysterectomy, or cholecystectomy to determine whether surgeons can effectively combine abdominoplasty with other intraabdominal procedures. Prescribed preoperative procedures included respiratory exercises. Physicians advised patients to stop smoking 2 weeks before surgery. Physicians also instructed them not to take any aspirin or other drugs with anticoagulant effects 2 weeks before surgery. Tubal ligation patients who also underwent standard abdominoplasty were in the operating room for 3 hours and for 2 hours if they underwent miniabdominoplasty. Total abdominal hysterectomy patients were in the operating room for either 3-4 hours (standard abdominoplasty) or 2.5-3 hours (miniabdominoplasty). Surgeons performed cholecystectomy in those patients who only underwent standard abdominoplasty. They were in the operating room for 4-5 hours. The combination of intraabdominal procedure and standard abdominoplasty increased the time in the operating room by 40-90 minutes. Number of days in the hospital for standard abdominoplasty patients included 2-3 for tubal ligation, 5 for total abdominal hysterectomy, an 5-7 for cholecystectomy. Miniabdominoplasty patients were in the hospital 1-2 days for tubal ligation and 5 days for total abdominal hysterectomy. Only 2 minor complications occurred: a seroma and a minor skin slough. 3 patients required transfusion of autologous units of blood and non of them lost more than 500 ml of blood. The physicians encouraged all patients to become ambulatory soon after the operation and to wear elastic stockings to prevent thromboembolic events. As a result, none of the patients suffered a pulmonary embolism. In conclusion, good surgical teams can safely and effectively combine abdominoplasty with intraabdominal procedures.

[Transvaginal tubal ligation]. / Laqueadura tubaria pela via transvaginal.

PIP: Vaginal tubal ligation is a simple procedure, offers minor surgical risks, and has few contraindications. The authors consider it the surgical contraceptive of choice in selected cases. From July 1975 to March 1983 the authors performed 155 tubal ligations by the vaginal route after posterior colpotomy. For each patient opinions were sought from at least 3 physicians, who advised regarding the medical or psychological need for sterilization. The median age was 35 years, with ages ranging from 23 to 48. Median parity was 5.3, with 57 patients having 6 or more children. All were from low socioeconomic backgrounds. 140 tubal sterilizations were done by the Pomeroy method, in 14 by the Pomeroy method on 1 side and fimbriectomy on the other, and in 1 patient a bilateral fimbriectomy was performed. In 3 patients the tubal ligation was completed by abdominal route because of difficulty of vision during colpotomy. All patients recovered well postoperatively, with minimal pain. All received antibiotic therapy with penicillin for 5 days following surgery. Average duration of surgery was 42 minutes. There were no occurrences of lesions, hemorrhages, abcesses, or infection of incisions. With an average follow-up of 41.2 months, the incidence of problems was 0.65%. Contraindications against using the vaginal route include a history of pelvic inflammatory disease, anterior gynecological surgery, alterations in the mobility or size of the uterus, and presence of adnexal tumors. Colpotomy presents several advantages: it is well accepted by the patient because there is no abdominal scar, it is an efficient method that does not require special apparatus such as optical or mechanical equipment, it is associated with minimal morbidity, and there are few complications. Additionally, surgery is of short duration, postoperative pain minimal, and it is economical because hospitalization time is short, with rapid convalescence. Disadvantages observed were: it is not applicable to all patients and requires major surgical training to perform; it requires an extended period of postoperative sexual abstinence, usually 4 weeks. This procedure cannot be used during the immediate postpartum period, with a recommended interval of 6 weeks. Tubal sterilization using posterior colpotomy, in view of the advantages and results obtained, is recommended for selected cases.^ieng

[Post-cesarean ovarian transposition as a method of reversible sterilization: initial study]. / Transposición ovárica postcesárea como método de esterilización reversible: estudio inicial.

PIP: A reversible method of sterilization to be performed during cesarean section by moving the ovary through the mesosalpinx to the front of the tube is described. 22 patients at a Mexican Institute of Social Security Hospital who did not wish further pregnancies but did not want definitive sterilizations have undergone the procedure with no pregnancies to date. Most of the procedure is done with the fingers to avoid lesions to the ovary and tube; the steps are briefly described and diagrammed. 1 or 2 silk stitches hold the ovary in place. The surgical technique is simple and rapid, postoperative complications were absent and recovery was the same as that following any cesarean operation. After periods of up to 6 months no pregnancies have been reported. No menstrual or other alterations attributable to the procedure have been identified. It is expected that patients will be followed up for several years to demonstrate the safety and effectiveness of the procedure, as well as its reversibility if some patients desiring restored fertility undergo reversal operations and and achieve pregnancy.^ieng

[Female sterilization. Comparative study of 3 laparoscopic technics]. / Esterilización femenina. Estudio comparativo de tres técnicas laparoscópicas.

PIP: The results of a comparative study of 3 techniques for tubal occlusion are presented. These techniques were silastic ring, staple with spring, and electrofulguration. The incidence of operative complications was greater with electrofulguration, mainly tubal bleeding (18.2%). The use of the staple with rings had a very high incidence of operative difficulties (37.6%) due to the misplacement of the staple. During the postoperative period there was abdominal pain, with greater incidence in the group with the silastic ring and staple with spring (47.8%). Gynecologic problems during the late postoperative period were infrequent and unrelated to the sterilization. (author's modified)^ieng

[Salpingoclasia by minilaparotomy following spontaneous abortion]. / Salpingoclasia por minilaparotomía postaborto espontáneo.

PIP: 200 cases of bilateral tubal occlusion by minilaparotomy after noninfected spontaneous abortion and 1 year follow-up were reviewed. 45% of the patients had a previous abortion. Tubal occlusion was carried out using the same anesthesia for uterine curettage and Pomeroy's technique. Complications may arise in abortions with an IUD in situ, with failure to use a uterine mobilizer in the intrapelvic uterus, obesity, and lack of experience on the part of the surgeon. There was 1 case of pregnancy which occurred, indicating a 0.5% failure rate. Postabortion sterilization should be included in all family planning programs. (author's)^ieng

Access to sterilization in two hospitals in Honduras.

PIP: The availability of postpartum sterilizations for women with obstetric deliveries at 2 hospitals in Honduras -- the Hospital Materno-Infantil in Teguicgalpa and the Hospital Leonardo Martinez in San Pedro -- was examined. Data were collected from the hospitals using a maternity record form that provided information regarding patients' sociodemographic backgrounds, obstetric histories, and contraceptive practices. The patients were asked about thier use of contraceptives before pregnancy and about their possible plans for contraception after delivery. If the patient was sterilized before leaving the hospital, this information was also recorded on the form. Analysis of the data reveals that the hospitals do not encourage women to be sterilized, and that they do a poor job of providing services for those women interested in sterilization. Of 18,523 women giving birth from 1977 through 1979, a total of 13,241 (71.5%) indicated that they did not want any more children. Thus, these women constituted a group for which female sterilization could be the contraceptive method of choice. Of these, 13,241 women, 3063 said that they planned to be sterilized. Among women having abortions at these hospitals, about 1/2 do not return for a followup visit 4-6 weeks later. To be eligible for sterilization in Honduras, a woman is supposed to satisfy the "rule of 80" (living children times age must equal 80). Only 6.8% of the women who planned to be but were not sterilized did not satisfy this rule. Among the women who were sterilized, the percentage of those who had cesarean deliveries was 69%. Of the women who said they planned to be sterilized but were not sterilized at delivery, less than 1% had cesarean sections. It seems apparent that women who have abdominal deliveries find it easier to obtain a sterilization at the time of delivery than do women with vaginal deliveries. At both hospitals, the proportion of sterilized women who did not satisfy the "rule of 80" was higher among those with cesarean deliveries than among those with vaginal deliveries. Scarce operating room time appears to be the most important factor affecting sterilization.^ieng

[The microsurgical training of the gynecologist]. / El entrenamiento microquirúrgico del ginecólogo.

PIP: A plan for training gynecologists in microsurgical techniques is described. Candidates for microsurgical training should be obstetrician-gynecologists with a broad background in the field of marital infertility and knowledge of the biology of reproduction and especially of tubal physiopathology. Candidates should also have had a theoretical and practical course in gynecological microsurgery including 2 days of basic practice on experimental animals to become familiar with the basic microsurgical principles. The training program includes a phase of experimental microsurgery undertaken in a microsurgery laboratory and a 2nd phase of observation and participation in reconstructive surgery on infertile women in the operating room. A multidisciplinary microsurgical laboratory helps control costs and encourages communication and sharing of ideas between different specialists. The requirements for such a laboratory are relatively simple; a list of basic materials is suggested. The rat appears to be an adequate animal model for training purposes. The 1st days of training should be continuous and the student should avoid other commitments. Training periods should be 4-8 hours daily but 10 minutes of rest are needed each hour or when the student is fatigued or begins to repeat errors. Lack of sleep and exercise within the 24 hours preceding practice are associated with residual trembling of the hands and should be avoided, but use of alcohol and smoking are less definite problems. The student must also be prepared to overcome considerable initial frustration. Basic procedures should be mastered at the beginning of training, including the correct posture of the operator, placement of the arms and hands, adjustment of the microscope, placement of the microsurgical instruments, and method of picking up the instruments. The 1st 8-12 hours of practice should be done in surgical gloves to learn the handling of microsurgical instruments under the visual field of the microscope at different magnifications, placement of sutures, and practice with simple and double knots. The recommended next steps are anastomosis of the uterine cornu of the rat, anastomosis of surgically removed human fallopian tubes, and microvascular anastomosis of femoral vessels in the rat, including end-to-end arterial and venous anastomosis, end-to-end arterial-venous anastomosis, and venous grafts after arterial segmental excision. A minimum of 60 hours is recommended for this stage of training, but the practice required will vary according to individual abilities. Assistance to an experienced gynecological microsurgeon during 12-15 different reconstructive procedures is recommended for the next phase of training.^ieng

[Tubal occlusion by laparoscopy with unipolar current]. / Oclusión tubaria por laparoscopia con corriente unipolar.

PIP: The results obtained in 285 cases of tubal occlusion by laparoscopic electrofulguration, are presented. Surgical and anesthetic techniques were analyzed, as well as laparoscopic findings, the time used for the procedure, complications, and the time that the patients needed to go back to their usual activities. It is concluded that although there are safer and more harmless methods (and even with recannalization possibilities), the procedure is useful for the purpose. It is especially convenient for large groups of population because of its low cost. (Author's modified)^ieng