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Simulation is widely used to teach and assess fundamental laparoscopic skills; however, program directors have reported that current simulation programs do not meet the needs for trainees and surgeons learning advanced laparoscopic procedures (ALP). The purpose of our study was to identify the key skills required to perform ALP, to serve as the basis to establish an advanced laparoscopic skills training program. Semi-structured interviews were conducted with attending surgeons, fellows, and senior residents in general surgery, gynaecology, and urology. The questions were developed through an iterative process using relevant literature, expert opinions, and in consultation with a qualitative researcher. Interviews were conducted in person, over the phone, or by videoconference, and inductive thematic analysis was performed. 25 interviews were conducted with 16 attending surgeons and 9 fellows/residents from 9 institutions in Canada and USA. Twenty-one skills were identified to be important when performing ALP. The skills most commonly described by faculty were the following : (a) suturing, (b) dissection, (c) procedural expertise, (d) retraction and exposure, and (e) familiarity with relevant anatomy as viewed through the laparoscope. The skills most commonly described by trainees were the following: (a) suturing, (b) dissection, (c) procedural expertise, (d) trocar positioning, and (e) patient factors. There was a large difference between the importance the faculty attributed to the ‘Retraction and Exposure’ skill compared to the trainees. This study identified key skills that are important when performing ALP. In order to address the current needs of trainees/surgeons learning ALP, this work provides the building blocks for the development of an advanced laparoscopic surgery simulation program.

Study Objective: To investigate the short-term outcomes of laparoscopic ureteroneocystostomy in patients with ureteral endometriosis (UE).Design: Retrospective cohort study of consecutive patients who underwent surgery for the ureter endometriosis with hydronephrosis.Setting: A private hospital that provide primary, secondary and tertiary care.Patients: 30 consecutive patients with UE who underwent laparoscopic ureteroneocystostomy at our institution between May 2008 and April 2020. Interventions: Laparoscopic ureteroneocystostomy, if necessary, hysterectomy, salpingo-oophorectomy, cystectomy, partial bladder resection, or partial bowel resection were performed.Measurements and Main Results: The most common chief complaint was pelvic pain (40%). Endometriosis affected only the left ureter in 56.7% of patients, only the right ureter in 33.3%, and both ureters in 6.7%. Involvement of the ipsilateral ovary was confirmed in 64.3%. The most frequent location of UE was 1 to 3 cm above the UVJ (46.7%). A psoas hitch was performed in 7 patients (23.3%), and the Boari flap was used in 9 patients (30%). Hysterectomy was performed in 12 patients (40%), and 6 of them had a concomitant bilateral salpingo-oophorectomy (20%). In addition, 3 patients (10%) underwent partial bowel resection, and 2 patients (6.7%) underwent partial bladder resection. After surgery, 24 of 27 patients (80.0%) were free of sever hydronephrosis after surgery. Hydronephrosis recurred in a single patient (3.3%), but the grade of hydronephrosis improved significantly after surgery (P

Laparoscopic suturing (LS) has become a common technique used in a variety of advanced laparoscopic procedures. However, LS is a challenging skill to master, and many trainees may not be competent in performing LS at the end of their training. The purpose of this review is to identify simulation platforms available for assessment of LS skills, and determine the characteristics of the platforms and the LS skills that are targeted. A scoping review was conducted between January 1997 and October 2018 for full-text articles. The search was done in various databases. Only articles written in English or French were included. Additional studies were identified through reference lists. The search terms included “laparoscopic suturing” and “clinical competence.” Sixty-two studies were selected. The majority of the simulation platforms were box trainers with inanimate tissue, and targeted basic suturing and intracorporeal knot-tying techniques. Most of the validation came from internal structure (rater reliability) and relationship to other variables (compare training levels/case experience, and various metrics). Consequences were not addressed in any of the studies. We identified many types of simulation platforms that were used for assessing LS skills, with most being for assessment of basic skills. Platforms assessing the competence of trainees for advanced LS skills were limited. Therefore, future research should focus on development of LS tasks that better reflect the needs of the trainees.

Study Objective To demonstrate how the bipolar method allows for pinpoint dissection with minimal thermal spread in a variety of challenging operative scenarios in gynecology. Design Case presentations. Setting Urban general hospital in Japan. Patients or Participants From December 2018 to April 2021, we performed 485 robotic surgeries using the double bipolar method in a variety of procedures such as hysterectomy for benign pathology, robotic sacro-colpopexy and para-aortic and pelvic lymphadenectomy for cervical and endometrial cancer. Interventions Pinpoint dissection in the case of severe Douglas Pouch adhesion or bladder adhesion, transperitoneal lymphadenectomy and extraperitoneal para-aortic and pelvic lymphadenectomy and nerve-sparing radical trachelectomy is a great advantage. These challenging procedures require the elucidation of fine structures and well as accurate separation of adhered organs. The double bipolar method is accurate, powerful and efficient with minimal thermal spread. Measurements and Main Results Only one patient who had extensive adhesion due to previous surgery required surgery from postoperative peritonitis. All other patients recovered quickly and without complications. Conclusion Monopolar scissors are a standard robotic equipment, used by the majority of surgeons. Although monopolar scissors allow for good quality dissection, thermal spread is always a concern. The thermal spread is known to be source of intraoperative complications and reducing this problem is an important concern. As a result, we implemented the double bipolar method. Not only because of its pinpoint accuracy, but also because the cutting mechanism has minimal thermal spread which is desirable especially when dissection ultra-fine structures.

Aim We aimed to evaluate regional disparities in the proportion of the three main laparoscopic surgeries for benign gynecological diseases among 47 prefectures in Japan and their correlation with the number of laparoscopy-qualified gynecologists per population. Methods In this retrospective ecological study, we collected the data of patients from 47 prefectures in 2017 using "The National Database of Health Insurance Claims and Specific Health Checkups of Japan" Open Data from the Ministry of Health, Labor and Welfare in Japan. The primary outcome of the study was the proportion of laparoscopic surgeries conducted for benign gynecologic diseases (hysterectomy, myomectomy and surgery for the benign ovarian diseases). The main exposure was the number of laparoscopy-qualified gynecologists per 100 000 females. Results The average proportion of laparoscopic hysterectomies, myomectomies and surgeries for the benign ovarian disease were 38% (standard deviation (SD) 16, range 12-74), 48% (SD 18, range 9-81) and 60% (SD 11, range 36-79), respectively. Multiple regression analysis showed a significant correlation between the number of laparoscopy-qualified gynecologists per 100 000 females and the proportion of the three main laparoscopic surgeries. Conclusion There are obvious regional disparities in the proportion of the three main laparoscopic procedures for benign gynecological diseases among 47 prefectures. The number of laparoscopy-qualified gynecologists correlated significantly with these regional disparities. The academic society should monitor these regional disparities and make an effort to reduce these regional disparities by increasing laparoscopy-qualified gynecologists in areas where the widespread use of laparoscopic techniques is lagging.

Study Objective To examine procedures of bowel repair after accidental bowel injury during gynecologic surgery and consider the role of colostomy. Demonstrate the appropriate management of accidental bowel injuries. Design Retrospective cohort study. Setting Urban general hospital in Japan. Patients or Participants From January 2010 to December 2020, 7,154 underwent laparoscopic or robotic hysterectomy for benign pathology. From these cases, the videos of surgeries where bowel injury was experienced were viewed. Interventions 21 cases suffered an intraoperative bowel injury that may normally be recommended for colostomy. These cases were managed by same-session intraoperative repair. In one case where multiple bowel injuries occurred during vaginal retrieval, a colostomy was performed. In the other 20 cases, intraoperative repair was safely completed, and no patients experienced pan-peritonitis after the original surgery. It is important to suture the bowel in two layers. Needle driving needs to be precise with the driving and pull-through perpendicular to the bowel wall. Tissue involvement needs to be both precise and consistent across all sutures. The seromuscular suture is placed to push the mucosa into the lumen. In very severe cases we use LAR (one case). After trimming of the damaged cut end of the rectum, a double stapling technique is very effective for event free anastomosis. Measurements and Main Results One case experienced leakage from the repair site and this was resolved with drainage and no colostomy was required. All other patients had an event-free recovery. Conclusion Bowel injuries have been routinely managed by colostomy. In our series, we have examined the effectiveness of our methods of repair without using colostomy and have found that when repair is sound, colostomy is not required. Colostomy-free surgery is more patient friendly and should be practiced in scenarios where repair training is adequate and suture repair can be performed safely.

Objective To evaluate the effect of dienogest (DNG) in preventing the occurrence of pain and endometriomas after laparoscopic resection of uterosacral ligaments (USLs) with deep infiltrating endometriosis (DIE). Study design This retrospective analysis included 126 patients who underwent laparoscopic resection of USLs with DIE followed by postoperative administration of DNG or no medication. Every 6 months postoperatively, patients answered questions and underwent ultrasound examination to identify pain and/or endometrioma. Result There were three (5.0%) cases of endometrioma in 59 patients from the DNG group and 21 (31.3%) cases in 67 patients from the no medication group ( P = 0.0002). Pain returned to preoperative levels in eight (11.9%) cases in the no medication group. No recurrence of pain occurred in the DNG group ( P = 0.0061). Conclusion The administration of DNG after resection of USLs with DIE significantly reduces the occurrence rate of endometriosis-related pain and endometriomas.

Simulation is widely used to teach and assess fundamental laparoscopic skills; however, program directors have reported that current simulation programs do not meet the needs for trainees and surgeons learning advanced laparoscopic procedures (ALP). The purpose of our study was to identify the key skills required to perform ALP, to serve as the basis to establish an advanced laparoscopic skills training program.Semi-structured interviews were conducted with attending surgeons, fellows, and senior residents in general surgery, gynaecology, and urology. The questions were developed through an iterative process using relevant literature, expert opinions, and in consultation with a qualitative researcher. Interviews were conducted in person, over the phone, or by videoconference, and inductive thematic analysis was performed.25 interviews were conducted with 16 attending surgeons and 9 fellows/residents from 9 institutions in Canada and USA. Twenty-one skills were identified to be important when performing ALP. The skills most commonly described by faculty were the following : (a) suturing, (b) dissection, (c) procedural expertise, (d) retraction and exposure, and (e) familiarity with relevant anatomy as viewed through the laparoscope. The skills most commonly described by trainees were the following: (a) suturing, (b) dissection, (c) procedural expertise, (d) trocar positioning, and (e) patient factors. There was a large difference between the importance the faculty attributed to the 'Retraction and Exposure' skill compared to the trainees.This study identified key skills that are important when performing ALP. In order to address the current needs of trainees/surgeons learning ALP, this work provides the building blocks for the development of an advanced laparoscopic surgery simulation program.

Specialist oncology pharmacists are being trained in Japan to assist cancer treatment teams. These specialized pharmacists address patients' physical and mental problems in pharmacist-managed cancer care clinics, actively participate in formulating treatment policies, and are beneficial in offering qualitative improvements to patient services and team medical care. However, the effect of outpatient treatment by oncology pharmacists on therapeutic outcomes and medical costs is still unknown. A retroactive comparative analysis of the treatment details and clinical course was conducted among three groups of patients: patients who underwent adjuvant chemotherapy managed by a gynecologic oncologist only (S arm), patients managed by a non-oncologist (general practice gynecologist) only (NS arm), and patients managed by both a non-oncologist and a specialist oncology pharmacist (NS+Ph arm). The medical cost per course was significantly lower for patients in the NS+Ph arm than for those in the other two arms. Surprisingly, the outpatient treatment rate in the NS+Ph arm was overwhelmingly high. The involvement of an oncology pharmacist did not make a significant difference in therapeutic outcomes such as recurrence rate and survival. The participation of oncology pharmacists in the management of cancer patients undergoing chemotherapy enables safe outpatient treatment and also reduces medical costs.

BackgroundPain-relieving effects of dienogest against endometriosis are comparable to leuprolide acetate for 24 weeks. We assessed whether long-term dienogest administration reduces recurrence after endometrioma excision.MethodsIn this retrospective cohort study, 568 women with MRI-based diagnosis of ovarian endometrioma, who underwent laparoscopic stripping between 2008 and 2013, were studied. Recurrence rates and side effects over 5 years were investigated in 417 without postoperative medication and 151 who received dienogest postoperatively at 2 mg. Transvaginal sonography was performed every 3 months, and when cystic lesions ≥2 cm were observed, diagnostic MRI was conducted. Recurrence was defined as a lesion previously diagnosed as endometrioma by MRI, equal in size or larger 3 months later on ultrasonography. Cumulative recurrence rates were calculated with the Kaplan-Meier method, and group comparison involved log-rank tests. Blood examinations were completed every 3 months, and bone mineral densit...

Objective To assess the obstetric outcomes of our total laparoscopic radical trachelectomy (TLRT) cases for early stage cervical cancer. Materials and methods A total of 56 patients who underwent TLRT between December 2001 and August 2012 were reviewed retrospectively using clinicopathological, surgical, and follow-up data from patients' medical records. Results We performed this operation on 56 patients during the study period. The mean age of these 56 patients was 31.9years (range 22–42years). Fifty-three patients' fertility was preserved without requiring post-operative adjuvant treatment. Twenty-five women attempted to conceive, of whom 13 succeeded for a total of 21 pregnancies (52% pregnancy rate). Ten of these 21 pregnancies were the result of assisted reproductive technologies. Of those, 5 resulted in first trimester miscarriages, 2 in second trimester miscarriages, and 13 in live births. Ten pregnancies reached the third trimester. Preterm premature rupture of membranes (8/13, 61.5%) was the most common complication during pregnancy. The rate of preterm delivery was 47.6%. Three patients delivered at 22–28weeks of gestational age. Two of these babies showed permanent damage: one has cerebral palsy; the other has developmental retardation. One pregnancy is ongoing. Conclusion TLRT is a useful technique associated with an excellent pregnancy rate in fertility-preserving surgery to treat early stage cervical cancer.

Aim: The aim of this study was to determine the incidence of perioperative complications and evaluate risk factors for the major complications of total laparoscopic hysterectomy (TLH) using an early ureteral identification technique. We describe the technique we standardized and used for TLH, without exclusion criteria. Material and Methods: A retrospective study was carried out at Kurashiki Medical Center, Japan, based on 1253 TLH procedures performed from January 2005 to March 2009. We reviewed records to identify the major perioperative complications, including bladder, ureteral, and intestinal injuries, and incidences of reoperation. Risk factors for major complications were analyzed using multivariate logistic regression models. Results: A total of 24 patients encountered major complications (1.91%). Complications included 10 intraoperative urologic injuries, five cases of postoperative hydronephrosis, five cases of vaginal dehiscence, one bowel injury, one postoperative hemorrhage, one bowel obstruction, and one ureterovaginal fistula. All 11 cases of intraoperative visceral injury were recognized during the surgery and repaired during the same laparoscopic surgical procedure. Of the risk factors analyzed, a history of abdominal surgery was the only one associated with the occurrence of major complications, with an odds ratio of 2.48 (95% confidence interval 1.23–6.49). Conclusion: While complications are inevitable, even in the hands of the most skilled surgeon, they can be minimized without conversion to laparotomy by a sufficiently developed suturing technique and a precise knowledge of pelvic anatomy. The presented data indicate that our method allows for safe TLH and minimization of ureteral injury, without the use of stringent exclusion criteria.

Introduction: Total laparoscopic hysterectomy has been reported as having a higher incidence of vaginal cuff dehiscence compared with the abdominal and/or vaginal hysterectomy. The cause of vaginal cuff dehiscence after total laparoscopic hysterectomy is not specified, but possible causes may be the use of thermal energy for vaginal incision, reduced suturing width due to magnification, low quality of laparoscopic suturing skills and early resumption of regular activities after surgery. Methods: We performed 677 cases of total laparoscopic hysterectomy for benign diseases, such as fibroids or adenomyosis, from January 2007 to December 2008 in our institute. We experienced four cases (0.6%) of vaginal cuff dehiscence. We checked the operative parameters for these cases, such as whether the retroperitoneum was sutured or not and intrapelvic adhesion, as well as examined operative duration, blood loss, weight of removed organs, and body mass index. Results: Sexual intercourse was the triggering event for three cases (96 days, 103 days and 47 days after total laparoscopic hysterectomy) and the other case occurred during defecation (18 days and no sexual intercourse after total laparoscopic hysterectomy). There were no significant differences in vaginal cuff dehiscence with or without retroperitoneum suture and intrapelvic adhesion. Conclusion: After these four cases of vaginal cuff dehiscence, we recognized the need to review these cases carefully in order to discover the cause and how to prevent this from occurring in other patients. We do not have the answers to prevent this complication at present, but reducing the power-source and attempting different suturing techniques may be important steps.

Surgery and radiotherapy are both regarded as standard treatments for occult cervical cancers. Surgery has several theoretical advantages over radiotherapy; therefore, such cancers, especially in their early stages, are commonly treated with radical parametrectomy. However, postoperative bladder dysfunction is an important potential complication of this type of surgery. This is a case report of total laparoscopic nerve-sparing radical parametrectomy for an occult cervical cancer using our original surgical concept based on detailed anatomical investigation of pelvic nerve networks in a fresh cadaver. We evaluated the validity of our nerve-sparing technique by assessing postoperative bladder function using urodynamic studies.

Endometriosis has been reported as a major cause of pelvic pain. Most notably, deep infiltrating endometriosis is a very active disease that occurs in 20 % of women with endometriosis. We have been actively dissecting deep infiltrating diseased areas within the sacral ligaments around the uterus in order to improve dysmenorrhea and chronic pelvic pain caused by deep infiltrating endometriosis. Laparoscopic surgery is an ideal option to treat deep infiltrating endometriosis involving complete cul-de-sac obliteration due to its minimal invasiveness and ability to achieve an appropriate depth of surgical field. It is important to prevent pain recurrence by providing systematic surgery and removing the deep infiltrating endometriosis safely and widely. To reduce recurrence, it is ideal to provide postoperative education to maintain the effect of surgery.

The aim of this study was to determine the incidence of perioperative complications and evaluate risk factors for the major complications of total laparoscopic hysterectomy (TLH) using an early ureteral identification technique. We describe the technique we standardized and used for TLH, without exclusion criteria.A retrospective study was carried out at Kurashiki Medical Center, Japan, based on 1253 TLH procedures performed from January 2005 to March 2009. We reviewed records to identify the major perioperative complications, including bladder, ureteral, and intestinal injuries, and incidences of reoperation. Risk factors for major complications were analyzed using multivariate logistic regression models.A total of 24 patients encountered major complications (1.91%). Complications included 10 intraoperative urologic injuries, five cases of postoperative hydronephrosis, five cases of vaginal dehiscence, one bowel injury, one postoperative hemorrhage, one bowel obstruction, and one ureterovaginal fistula. All 11 cases of intraoperative visceral injury were recognized during the surgery and repaired during the same laparoscopic surgical procedure. Of the risk factors analyzed, a history of abdominal surgery was the only one associated with the occurrence of major complications, with an odds ratio of 2.48 (95% confidence interval 1.23-6.49).While complications are inevitable, even in the hands of the most skilled surgeon, they can be minimized without conversion to laparotomy by a sufficiently developed suturing technique and a precise knowledge of pelvic anatomy. The presented data indicate that our method allows for safe TLH and minimization of ureteral injury, without the use of stringent exclusion criteria.

OBJECTIVE: This study was conducted to ascertain the correlation between preserved pelvic nerve networks and bladder function after laparoscopic nerve-sparing radical hysterectomy. METHODS: Between 2009 and 2011, 53 patients underwent total laparoscopic radical hysterectomies. They were categorized into groups A, B, and C based on the status of preserved pelvic nerve networks: complete preservation of the pelvic nerve plexus (group A, 27 cases); partial preservation (group B, 13 cases); and complete sacrifice (group C, 13 cases). To evaluate bladder function, urodynamic studies were conducted preoperatively and postoperatively at 1, 3, 6, and 12 months after surgery. RESULTS: No significant difference in sensory function was found between groups A and B. However, the sensory function of group C was significantly lower than that of the other groups. Group A had significantly better motor function than groups B and C. No significant difference in motor function was found between groups B and C. Results showed that the sensory nerve is distributed predominantly at the dorsal half of the pelvic nerve networks, but the motor nerve is predominantly distributed at the ventral half. CONCLUSION: Various types of total laparoscopic nerve-sparing radical hysterectomies can be tailored to patients with cervical carcinomas.

Preimplantation development is marked by four major events: the transition of maternal transcripts to zygotic transcripts, compaction, the first lineage differentiation into inner cell mass and trophectoderm, and implantation. The scarcity of the materials of preimplantation embryos, both in size (diameter < 100 microm) and in quantity (only a few to tens of oocytes from each ovulation), has hampered molecular analysis of preimplantation embryos. Recent progress in RNA amplification methods and microarray platforms, including genes unique to preimplantation embryos, allow us to apply global gene expression profiling to the study of preimplantation embryos. Our gene expression profiling during preimplantation development revealed the distinctive patterns of maternal RNA degradation and embryonic gene activation, including two major transient waves of de novo transcription. The first wave corresponds to zygotic genome activation (ZGA). The second wave, mid-preimplantation gene activation (MGA), contributes dramatic morphological changes during late preimplantation development. Further expression profiling of embryos treated with inhibitors of transcription or translation revealed that the translation of maternal RNA is required for the initiation of ZGA, suggesting a cascade of gene activation from maternal RNA/protein sets to ZGA gene sets and thence to MGA gene sets. To date, several reports of microarray experiments using mouse and human preimplantation embryos have been published. The identification of a large number of genes and multiple signaling pathways involved at each developmental stage by such global gene expression profiling accelerates understanding of molecular mechanisms underlining totipotency/pluripotency and programs of early mammalian development.