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A multimodal approach to promoting recovery from surgery was first described by Henrik Kehlet in 1995. This approach has since been significantly developed and refined, and is now referred to as Enhanced Recovery in Surgery (ERS). The goal of ERS is to enable a patient to regain his/her pre-surgery physical and psychological state after a surgical procedure - notably by reducing the stress and the inflammatory response inevitably triggered by surgery. ERS protocols include anesthesia-related items (such as reducing the use of morphine) and surgical items (such as the use of minimally invasive routes, and limiting the postoperative use of drains and probes). Each step is essential - from patient information, education and adherence during the preoperative phase to involvement of the family circle and the attending physician with a view to early discharge. The term ERS corresponds to a set of principles for optimizing pre-, per- and postoperative care, the aim of which is to improve the post-operative course and the patient's experience by decreasing per- and postoperative complications and accelerating a return to the patient's pre-operative physical and psychological state. The use of ERS protocols is associated with a lower complication rate and a shorter hospital stay, regardless of the patient's age and comorbidities., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Peritoneal adhesions remain a major public health problem despite the development of laparoscopy. The rules of microsurgery must be known and followed during any pelvic surgery, even in patients who no longer have a desire for pregnancy. Anti-adhesion products are numerous. All have interest, confirmed by anatomical studies showing a smaller extent or a lesser severity of adhesions associated with their use. No studies, however, show clinical benefit in terms of improved pain or postoperative fertility. Pneumoperitoneum parameters, humidification, and lower abdominal pressure should be optimized to limit peritoneal trauma. Peri-operative corticosteroids, whose benefit has been has been demonstrated in at least one randomized trial, should be systematically used., (Copyright © 2018. Published by Elsevier Masson SAS.)

Objective: To report and visually demonstrate the feasibility of using indocyanine green (ICG) in endometriosis surgery and to discuss potential benefits., Design: ICG fluorescent imaging has been validated to assess tissue perfusion with clinical use in many medical fields, including gynecology and digestive surgery, but has not described in endometriosis surgery for bowel assessment. To our knowledge, there is no validated, objective, intraoperative method to assess the vascularity of the operated bowel in endometriosis surgery, a potentially good indicator for postoperative fistula formation. Our center is conducting a registered clinical trial examining the use of ICG to evaluate the bowel vascularization after endometriosis rectal shaving surgery, and the potential role in reducing fistula rates (Institutional Review Board no 2016-002773-35)., Setting: Tertiary university hospital., Patient(s): Three patients undergoing laparoscopic surgery for deep infiltrating endometriosis (DIE) with the use of a rectal shaving procedure., Interventions(s): Patients undergoing laparoscopic surgery for DIE with a rectal shaving procedure were injected with ICG intravenously at the end of endometriosis resection., Main Outcome Measures: Visual assessment of the rectal shaving area was assessed as fluoresced or not with the use of a Likert-type scale (0 = no fluorescence; 4 = very good fluorescence)., Result(s): After ICG injection, all three patients have showed very good fluorescence levels at the rectal shaving area with no adverse reactions. Other uses of ICG are demonstrated throughout the video (vaginal cuff, ureter, and ovary assessment)., Conclusion(s): ICG fluorescent imaging is feasible in endometriosis surgery, and there is an ongoing trial to determine if its use reduces postoperative fistula formation., Clinical Trial Registration Number: NCT03080558., (Copyright © 2018 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

National and international guidelines recommend referring patients with severe forms of endometriosis to expert centers. However, there is a lack of clear criteria to define an expert center. We examined the roles of surgeon and hospital procedure volumes as determinants of morbidity in deep infiltrating endometriosis of the rectum and sigmoid colon (DIERS)., Methods: We conducted a French retrospective multicenter study of hospital facilities performing colorectal surgery for DIERS in 2015. The primary end point was to analyze the relation between case volume and the incidence of complications. We estimated the optimal cut-off (OCO) determined by a minimal p-value approach., Results: The study included 56 hospital facilities and collected data of 1135 cases of surgical management of colorectal endometriosis. The mean and median number of procedures per year and per surgeon were 9.17 and 5.58, respectively. The overall rate of grade III-V complication was 7.6% (82/1135). One grade V complication occurred. The rates of rectovaginal fistula, anastomotic leakage, pelvic abscess, and ureteral fistula were: 2.7% (31/1135), 0.79% (9/1135), 3.4% (39/1135), and 0.70% (8/1135), respectively. An OCO of 20 procedures per center and per year (p < 0.001) was defined. The OCO per surgeon and per year varied between seven (p = 0.007) and 13 procedures (p = 0.03). In a multivariate analysis, we found that only the volume of activity was independently correlated to complication outcomes (p = 0.0013)., Conclusion: Our results contribute to providing objective morbidity data to determine criteria for defining expert centers for colorectal surgery for endometriosis.

Study Objective: To describe a technique for the safe placement of retropubic midurethral slings in patients undergoing concomitant laparoscopic surgery in order to avoid major complications associated with this procedure such as bladder perforation and retropubic hematomas., Design: Step-by-step video demonstration of the technique., Setting: A university tertiary care hospital., Patients: Patients with an indication for retropubic midurethral sling placement because of recurrent stress urinary incontinence, intrinsic sphincter deficiency, or severe pelvic organ prolapse in whom a concomitant laparoscopic surgery has to be performed for other medical conditions., Intervention: Laparoscopic opening and dissection of the Retzius space and insertion of the sling under a laparoscopic view of this space., Measurements and Main Results: This technique has been mainly used in patients undergoing laparoscopic pelvic organ prolapse repair. No complications have been identified so far, even in high-risk patients such as those with previous Burch colposuspension., Conclusion: This is a simple and reproducible technique for preventing major complications associated with retropubic sling placement in patients undergoing laparoscopic surgery for other reasons. It also permits the immediate detection and even resolution of complications in case any arise. Even high-risk patients may be safely approached., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To assess the outcomes and complications of laparoscopic ureteroneocystotomy in gynecologic surgery., Design: We retrospectively reviewed all medical records of patients who underwent ureteroneocystostomy between April 2008 and May 2012., Design Classification: Retrospective case series study., Setting: A university tertiary care hospital., Patients: Nine patients underwent ureteroneocystostomy: 3 patients had ureteral endometriosis stenoses; and 6 patients had iatrogenic ureter injuries., Interventions: All procedures were performed laparoscopically. The ureterovesical re-implantation was unilateral in 8 cases and bilateral for 1 patient., Measurements and Main Results: The mean operating time was 226.7 min (range, 120-480). Average blood loss was 114.4 mL (range, 30-400). The mean duration of the in-dwelling catheter was 10.4 days (range, 7-21); the average hospital stay was 12.6 days (range, 6-26). The mean duration of the ureteral double J stent was 7.8 weeks (range, 6-16). One patient was re-operated for vaginal and laparoscopic drainage of a pelvic abscess on the sixth postoperative day. The median follow-up time was 20.8 months (range, 9-36), No patient had stenosis or breakdown of a suture line., Conclusions: Our series confirms the feasibility and the effectiveness of laparoscopic ureteroneocystostomy. This minimally invasive approach, which avoids laparotomy, requires a multidisciplinary team., (Copyright © 2015 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: Mesh erosion through the vagina is the most common complication of synthetic mesh used for pelvic organ prolapse repair. However, conventional transvaginal mesh excision has many technical limitations. We aimed at creating and describing a new surgical technique for transvaginal removal of exposed mesh that would enable better exposition and access, thus facilitating optimal treatment., Design: A step-by-step video showing the technique., Setting: A university tertiary care hospital., Patients: Five patients previously submitted to pelvic organ prolapse repair using synthetic mesh, presenting mesh erosion through the vagina., Interventions: Mesh excision using a laparoscopy-like operative vaginoscopy in which standard laparoscopic instruments are used through a single-incision laparoscopic surgery port device placed in the vagina., Measurements and Main Results: In all cases, a very good exposure of the mesh was achieved, a minimal tissue traction was required, and the procedures were performed in a very ergonomic way. All the patients were discharged on the same day of the surgery and had a painless postoperative course. So far, there have been no cases of relapse., Conclusion: This seems to be a simple, cheap, and valuable minimally invasive technique with many advantages in comparison with the conventional approach. More cases and time are necessary to access its long-term efficacy. It may possibly be used for the management of other conditions., (Copyright © 2015 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: to evaluate the complications after surgery for deep endometriosis., Design: retrospective study., Setting: data from the CHU Estaing database and patients' charts between January 1987 and December 2007., Sample: all women given surgical treatment for deep endometriosis., Methods: women who underwent surgery for deep endometriosis were reviewed for intra- and postoperative complications., Main Outcome Measures: primary outcomes were rates of intra- and postoperative complications. Complications were compared according to the procedure performed., Results: a total of 568 women were included in the study, with a mean age of 32.4 years. The mean estimated diameter of the nodule felt by vaginal examination was 1.8 cm (ranging from 0.5 to 7 cm). Laparoscopic surgery was performed in 560 women (98.6%), and conversion was required in 2.3%. The mean operative time was 155 minutes. Intraoperative complications occurred in 12 women (2.1%), including six minor (1.05%) and six major (1.05%) complications. Postoperative complications developed in 79 women (13.9%), including 54 minor (9.5%) and 26 major (4.6%) complications (one woman had both minor and major postoperative complications). The overall major postoperative complication rate for women who underwent any type of rectal surgery (shaving, excision and suture, or segmental resection) was 9.3% (21 out of 226), compared with only 1.5% for the other women (five out of 342) (P <  .01). Shaving presented less major postoperative complications compared with segmental resection (24 versus 6.7%; P = 0.004)., Conclusions: surgery for deep endometriosis is feasible, but it is associated with major complications, especially when any type of rectal surgery must be performed.

In this retrospective study of 314 patients undergoing surgery for ovarian dermoid cysts, conducted over a 20-year period, we evaluated the impact of the routine use of laparoscopic surgery without recourse to laparotomy to retrieve the specimen, using an endoscopic retrieval bag placed under the cyst to prevent intraperitoneal spillage of cyst contents, and subsequent postoperative granulomatous peritonitis. Accidental cyst rupture was more frequent when a total laparoscopic approach was used (26/174 or 15% versus 39/140 or 28%; P = 0.005), but there were no cases of intraperitoneal spillage when an endoscopic bag was used. Two cases of granulomatous peritonitis developed out of 26 women with intraperitoneal spillage of cyst contents (8%). We conclude that the risk of granulomatous peritonitis can be minimised by undertaking laparoscopic removal of dermoid cysts with the routine intraoperative use of an endoscopic retrieval bag to prevent intraperitoneal spillage of cyst contents.