Intra- and post-operative outcomes in benign gynaecologic surgeries before and after the implementation of enhanced recovery after surgery protocols: A comparison.

Objective: To compare intra- and post-operative outcomes in patients undergoing benign gynaecologic surgery before and after the implementation of enhanced recovery after surgery (ERAS) protocols. Introduction: ERAS is a multidisciplinary teamwork with the aim to reduce the body's reaction to surgical stress. The key components of ERAS include pre-operative counselling, avoiding prolonged fasting, standardised analgesic and anaesthetic regimes, early mobilisation and early discharge. Materials and Methods: Women undergoing hysterectomy and myomectomy were included in the study. The pre-ERAS group had 100 cases and the ERAS group had 104. Demographic data of both the groups were compared. Duration of surgery, amount of blood loss, intra-abdominal drain, oral feed, catheter removal, ambulation, passage of flatus and length of stay were compared. Results: The demographic profiles of both the groups were comparable. Time taken to intake of liquids (P < 0.001), solid food (P < 0.001), passage of flatus (P = 0.001), removal of Foley's catheter (P = 0.023), ambulation (P = 0.007), pain score (P = 0.001) and length of stay in hospital (P < 0.001) were statistically significantly shorter in the ERAS group when compared to the pre-ERAS group. A significant difference was seen in the use of intraperitoneal drains in the ERAS group (81% vs. 23.1%), and if used, drains were removed early in the ERAS group (66.66% vs. 28.39%) within 40 h. Both the groups had similar intra- and immediate post-operative complications. Conclusion: ERAS helps in reducing length of stay with early feeding and ambulation, leading to early discharge without increase in intra- and post-operative complications in women undergoing benign gynaecological surgeries.

Pre-operative mapping and structured reporting of pelvic endometriotic lesions on dynamic ultrasound and its correlation on laparoscopy using the #ENZIAN classification.

PURPOSE: The objective of this study was to evaluate and compare the diagnostic performance of ultrasonography (USG) assessment using structured reporting with intraoperative laparoscopic assessment in deep infiltrating endometriosis (DIE) using the recent update of the #ENZIAN classification. METHODS: This was a retrospective study conducted in Tertiary Multi-disciplinary Endometriosis Care Hospital over a period of 8 months which included 50 patients who underwent a planned laparoscopic endometriosis excisional surgery after a dedicated USG assessment using International Deep Endometriosis Analysis (IDEA) protocol and #ENZIAN score (updated ENZIAN classification), between Feb 2021 and Sept 2021 at Apollo Hospitals, Hyderabad. The pre-operative USG findings were reported in a structured reporting format and intraoperative findings were classified using the standard #ENZIAN classification. No prospective interventions were done. A review of pre-operative ultrasound and laparoscopic findings as per the #ENZIAN was done. RESULTS: Sensitivity and the negative predictive value of ultrasound were 86% and 84.2% for peritoneal lesions, 97% and 93.3% for left ovarian lesions, 93% and 91.6% for right ovarian lesions, 91% and 84% for left tubal lesions, 90% and 86.3% for right tubal lesions, 93% and 75% for uterosacral ligaments, 93.3% and 97% for rectal lesions and sensitivity and negative predictive values were 100% for rectovaginal lesions, adenomyosis, and ureteric lesions as confirmed on laparoscopy. CONCLUSION: Dynamic ultrasound assessment with a structured report based on IDEA protocol and #ENZIAN score is accurate for mapping of pelvic endometriosis in all forms, and it correlates with laparoscopic findings, thus helps surgeon for better planning and providing a road map for surgeons. From a clinical perspective, a uniform and shared reporting system across imaging and therapeutic modalities will simplify communication, improving patient management by conservative or surgical treatments, avoiding multiple repeat surgeries, and improving quality of treatment.

Primary Umbilical endometriosis - case series and review of clinical presentation, diagnosis and management.

INTRODUCTION: Umbilical endometriosis is the most common cutaneous form and is seen mostly secondary to surgical scar and rarely occurs as primary umbilical endometriosis. The objective of this retrospective case series evaluation is to report the presentation, diagnosis, and management of patients with primary umbilical endometriosis. PRESENTATION OF CASES: We present a retrospective, observational and descriptive review of cases presenting with primary umbilical endometriosis among Indian women managed in two private tertiary care centres between 2018 and 2020. Patients were assessed at the gynaecological outpatient department. We analysed age, parity, presenting symptoms and duration, associated symptoms, imaging, size of the lesion, associated pelvic endometriosis or any pelvic pathology, management, and histopathological diagnosis for confirmation in all four patients. DISCUSSION: The patients were aged between 25 and 31 years with an average of 28 years with no previous history of any abdominal surgeries. The mean duration of the symptoms presented in these cases was 25.5 months, with a range from 18 to 48 months. The diagnosis was made by clinical examination supported by imaging followed by complete surgical excision and confirmation on histopathology. CONCLUSION: Primary umbilical endometriosis is a rare disease with a limited number of cases reported in the literature and should be included in the differential diagnosis if women present with umbilical lesions with cyclical pain. Diagnosis is clinical but can be aided by high resolution imaging such as Ultrasound (US) and Magnetic Resonance Imaging (MRI). Complete surgical excision is the treatment of choice.

Acute Presentation of Port Site Hernia Following Robot-Assisted Hysterectomy: A Case Report and Review of the Literature.

Port site hernia (PSH) has been reported following both laparoscopic and robotic surgery. Subsequent surgical intervention increases postoperative morbidity. We report the case of a PSH through the 8-mm trocar following robot-assisted hysterectomy in a 49-year-old female patient, along with a review of the literature. The case was performed with the standard protocol; however, increased intraoperative bleeding was encountered from right uterine artery and vein. Discharged at 48 h, she presented in emergency on the fourth postoperative day with acute intestinal obstruction. Computed tomography scan showed herniation of the jejunal loop through the 8-mm left-sided port. She underwent resection and anastomosis of the necrosed jejunal loop. We review the literature for PSH following robotic gynecological surgeries. Although rare, PSH requires surgical intervention, increasing the postoperative morbidity. Need for fascial closure of 8 mm ports should be considered. High index of suspicion and early recognition can avoid resection of the bowel loop.

Secondary vaginal atresia following caesarean section: an unreported entity.

Postpartum genital tract adhesions are infrequent and exact incidence is not reported. Severe dystocia, obstructed labour and frequent pelvic examinations have been proposed as possible causes of vaginal adhesion following vaginal delivery. Atresia/adhesions of vagina following caesarean section is very rare. Here, we report a rare case of 21-year-old P1L1 woman presenting with secondary amenorrhoea associated with cyclical abdominal pain following caesarean section. Per speculum examination showed a blind vagina with no communication with the upper one-third. We created a neovagina after adhesiolysis. We hope to increase the awareness of the obstetricians around the globe about postpartum genital tract adhesion, which may even occur as a rare secondary complication of caesarean section. We also wish to bring to the light of obstetricians that numerous pelvic examinations or difficult vaginal delivery may lead to genital tract trauma, and thus, must be minimised in an attempt to prevent postpartum genital tract adhesions.