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Fallopian tube prolapse following hysterectomy is a rare but recognised complication of gynaecological surgery. The majority of prolapses occur after vaginal hysterectomy Various methods of management have been proposed in the literature. This complication was first described by Pozzi in 1902. Since then, to our knowledge, 109 cases have been reported in the English literature, of which at least 23 occurred following total abdominal hysterectomy (Pubmed search using ‘fallopian tube AND prolapse’ as keywords). We observed 2 cases of Fallopian tube prolapse afker abdominal hysterectomy between April 1996 and June 1998, bringing the total number to 111 and the number following abdominal surgery to at least 25.

Review Objective: To review the recent developments and published literature on laparoendoscopic single-site (LESS) surgery in gynaecology. Recent Findings: Minimally invasive surgery has become a standard of care for the treatment of many benign and malignant gynaecological conditions. Recent advances in conventional laparoscopy and robotic-assisted surgery have favorably impacted the entire spectrum of gynaecological surgery. With the goal of improving morbidity and cosmesis, continued efforts towards refinement of laparoscopic techniques have lead to minimization of size and number of ports required for these procedures. LESS surgery is a recently proposed surgical term used to describe various techniques that aim at performing laparoscopic surgery through a single, small-skin incision concealed within the umbilicus. In the last 5 years, there has been a surge in the developments in surgical technology and techniques for LESS surgery, which have resulted in a significant increase in utilisation of LESS across many surgical subspecialties. Recently published outcomes data demonstrate feasibility, safety and reproducibility for LESS in gynaecology. The contemporary LESS literature, extent of gynaecological procedures utilising these techniques and limitations of current technology will be reviewed in this manuscript. Conclusions: LESS surgery represents the newest frontier in minimally invasive surgery. Comparative data and prospective trials are necessary in order to determine the clinical impact of LESS in treatment of gynaecological conditions.

Genital prolapse is one of the most common indications for gynaecological surgery. Surgery is performed traditionally via abdominal, vaginal and laparoscopic approaches.A MEDLINE computer search was performed to explore the recent evidence behind laparoscopic surgery for female pelvic organ prolapse.Advances in minimal access surgery have led to an increase in adoption of laparoscopic techniques. Current evidence supports the use of laparoscopy for sacrocolpopexy and colposuspension as an alternative to open surgery. However, the introduction of less invasive midurethral sling procedures for stress incontinence has reserved laparoscopic colposuspension for special indications. The scientific evidence regarding uterosacral suspension procedures and paravaginal and vaginal prolapse repairs are sparse.The current evidence supports the outcome of laparoscopic sacrocolpopexy as an alternative to open surgery. Further studies are required on the long-term efficiency in laparoscopic paravaginal repair and vaginal wall prolapse.

The incidence of urinary tract injury is low in most gynaecological operations but, if undiagnosed, is a cause of significant postoperative morbidity for the patient and litigation for the gynaecologist. A Medline search of studies of urinary tract injury at gynaecological surgery show that only one in 10 ureteral injuries and one in three bladder injuries are detected at the time of surgery without intra-operative cystoscopy. As cystoscopy is not routinely performed by the majority of gynaecologists during surgery, even in difficult cases, failure to detect injury to the urinary tract by itself should not be seen as negligence. However, all gynaecologists performing pelvic surgery should be encouraged to become competent in cystourethroscopy and perform this intra-operatively, at least in all high-risk cases of gynaecological surgery.

No Abstract

This study has examined the effect of hydration on immediate recovery from anaesthesia in two groups of 15 patients undergoing therapeutic abortion. A standard anaesthetic technique was administered. Patients in group I received no preoperative fluid; those in group II received, before anaesthesia, 20 ml kg-1 of 4% glucose and 0.18% saline. Recovery was assessed using two tests of psychomotor function: a reaction time test and a letter cancellation task. Subjective symptoms were assessed with a questionnaire. There was a significant decrease in reaction time after operation (both motor and reaction times) in group I (no fluids), but not in group II (fluids). There were no significant between-group differences in objective tests or subjective measures. Thus we could not demonstrate any obvious benefit of i.v. fluid administration. Approximately 500 patients would be required to have an 80% chance of establishing a statistically significant between group difference.

80 patients (ASA I-III, mean age 40-50 years, mean weight 59-68 kg) recovering from major gynaecological surgery (170-200 min) under balanced anaesthesia were randomly assigned to four groups to self-administer intravenous fentanyl during the early postoperative period. PCA devices were ODAC and Prominject with fentanyl demand doses of 34.5 or 34 micrograms, respectively, and lockout times of 1 or 5 min. Concurrent fentanyl infusion was none (group Prom), fixed-rate with 4 micrograms/h (group ODACf), tail-dose, i.e., a fixed-rate infusion with 17 mg/h for a maximum of 60 minutes following a valid demand (group Prom(t)), or adaptive, starting with 4 micrograms/h and being adapted to individual needs depending on total fentanyl consumption in the latest 60-minute period (group ODACa). Data were collected for fentanyl consumption, venous fentanyl serum concentrations in fixed intervals, actual and retrospective verbal rating pain scores (0-5), haemodynamic variables, respiratory rate, side effects and patients' acceptance. Mean duration of patient-controlled analgesia (PCA) was 15-17 hrs. During this period, an average of 12-18 demands were administered per patient, resulting in an average fentanyl consumption of 36-52 micrograms/h (0.57-0.94 micrograms/kg/h). Analgesic efficacy was good in all groups, mean pain scores ranging from 0.4 to 1.1 (actual) and 1.7 to 2.2 (retrospective). Mean duration of a single fentanyl bolus dose was highly variable, ranging from 58 to 90 min if calculated for the total observation period. Statistically significant differences were found for none of the above mentioned PCA parameters. As a trend, the adaptive-rate infusion strategy was favoured (lowest demand rate, best retrospective pain scores).(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective study was carried out to compare the qualities of spinal block with those of combined spinal-epidural anaesthesia (CSEA). It included 63 patients, ranked ASA 1 or 2, aged between 35 and 75 years, scheduled for gynaecological surgery due to last more than 2 hours, and randomly allocated to two groups. In the first group (n = 34), spinal anaesthesia was carried out with the patients sitting, in the L3-4 interspace, using 15 mg of hyperbaric bupivacaine with 0.4 mg of adrenaline. In the second group (n = 29), a catheter was inserted in the epidural space through the L2-3 interspace, and spinal anaesthesia carried out as in the first group, using bupivacaine without adrenaline. Once the highest level of analgesia had been reached, aliquots of 0.5% plain bupivacaine were injected through the epidural catheter, until anaesthesia of T5 was obtained. In the spinal group, general anaesthesia was required in 3 cases, as anaesthesia only reached the T12 level in 2 cases, and as surgery lasted longer than the spinal in the third one. In the CSEA group, excellent analgesia was obtained in all patients. Sensory blockade lasted 308 +/- 48 min at the T12 level, versus 162 +/- 51 min in the spinal group (p < 0.025), and 361 +/- 51 min at the L2 level, versus 210 < 44 min in the other group (p < 0.025). "Topping up" was possible with the epidural catheter only, thus raising the level of sensory blockade, making it deeper, and increasing its duration. It avoids the use of general anaesthesia in case of failed spinal blockade.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective To compare the impact of 1000 μg of self-administered vaginal misoprostol versus self-administered vaginal placebo on preoperative cervical ripening after 2 weeks of pretreatment with estradiol vaginal tablets in postmenopausal women prior to day-care operative hysteroscopy. Design Randomised, double-blind, placebo-controlled sequential trial. Setting Norwegian university teaching hospital. Population Sixty-seven postmenopausal women referred for day-care operative hysteroscopy. Methods The women were randomised to receive either 1000 μg of self-administered vaginal misoprostol or self-administered vaginal placebo on the evening before day-care operative hysteroscopy. All women had administered a 25-μg vaginal estradiol tablet daily for 14 days prior to the operation. Main outcome measures Primary outcome: preoperative cervical dilatation at hysteroscopy. Secondary outcomes: difference in dilatation at recruitment and before hysteroscopy, number of women who achieved a preoperative cervical dilatation of 5 mm or more, acceptability, complications and adverse effects. Results The mean cervical dilatation was 5.7 mm (SD, 1.6 mm) in the misoprostol group and 4.7 mm (SD, 1.5 mm) in the placebo group, the mean difference in cervical dilatation being 1.0 mm (95% CI, 0.2–1.7 mm). Self-administered vaginal misoprostol of 1000 μg at home on the evening before day-care hysteroscopy is safe and highly acceptable, although a small proportion of women experienced lower abdominal pain. Conclusions One thousand micrograms of self-administered vaginal misoprostol, 12 hours prior to day-care hysteroscopy, after 14 days of pretreatment with vaginal estradiol, has a significant cervical ripening effect compared with placebo in postmenopausal women.

Post-operative adhesions are a significant complication of all abdominal surgical procedures. The major strategies for adhesion prevention in gynaecological surgery are focused on the optimization of surgical technique and use of anti-adhesive agents, which fall into two main categories: pharmacological agents and barriers. Surgical technique that minimizes peritoneal trauma can reduce, but cannot prevent post-operative adhesion formation. Various local and systemic drugs that can alter the local inflammatory response, inhibit the coagulation cascade and promote fibrinolysis have been evaluated. Limited data support the administration of post-operative corticosteroids in addition to systemic intra-operative corticosteroids for the prevention of adhesions after gynaecological surgery. None of the remaining pharmacological agents have been found effective for the reduction of post-operative adhesions. Barriers are currently considered the most useful adjuncts, which may reduce adhesion formation. They act by separating the traumatized peritoneal surfaces during the healing period. The separation can be achieved by solid barriers or fluids. There is limited evidence from randomized clinical trials that support the beneficial effect of most of these barrier agents in the prevention of intra-peritoneal adhesions after gynaecological surgery. However, the evidence is not adequate for definite conclusions to be drawn and further research in this field is warranted.

The main objective is to promote autologous blood transfusion (ABT) in sub-saharian region. It is a prospective study from 2000, september the 1st to october 31st, at the saint Jean de Dieu Hospital of Afagnan (Togo). As results, all the 75 patients who received indication of ABT accepted the protocol; 70 of them, from which 62.9% were female benefited an ABT. The age of the patients varies between 13 and 80 years (average 33.2). Initial rate of the haemoglobin was on average of 11.7 g/dl; 15.3% of these patients had a heamoglobin diseases. The most frequent intervention were hysterectomies (21.4%), bone surgery (15.7%), prostatectomies (11.4%). Only one blood unit was taken out from 63 patients and two units from the 7 others. Giddinesses (5) and headhache (1) were noted during the taking away. During intra and postoperative periods, 41 patients were transfused of 45 units of blood (use rate: 58%). The percentage of patient who received transfusion was 48% in gynaecological surgery, 75% in orthopaedic and 88% in urology. Only one patient received an additional homologous unit of blood. The rate of haemoglobin was on an average 10.2 on the day after the surgery. No incident in connection with the ABT was recorded. In conclusion, the ABT is a feasible, effective and secure method in the context of a small african hospital. It may be a solution to the problems of shortage of blood products and transfusion safety. Training and motivation are necessary for its successful implementation.

Laparoscopy has become a common tool in modern gynaecological surgery. Almost 30 years have passed since the first laparoscopic appendectomy was performed by Semm in 1983. Basic standards are missing though laparoscopic interventions are performed worldwide. The objective of this paper was to report on our experience in laparoscopic surgery and education of young trainees. During 16 years of laparoscopic surgery, we have performed about 15,000 interventions. Inspired by the possibility of videotaping operative sequences, we built up an internal school of laparoscopy. As a function of the result of steady work and education in laparoscopic surgery, we have worked out a common security standard which is to be considered at any intervention performed at our centre. We call this standard ‘The 12 golden rules’. We now report for the first time on our security aspects the 12 golden rules publicly.

The management of a patient with pre-existing deep venous thrombosis (DVT) who was subsequently found to have a malignancy planned for urgent laparotomy is reported. A 30-year-old woman presented to the emergency room and was diagnosed to have a DVT. During work-up, she was found to have a malignanacy and was scheduled for urgent laparotomy. The patient was put on enoxaprin (injection) and warfarin (tablets). The patient was started on heparin (injection) 1000 IU/h at 72 h prior to operation, stopped 6 h prior to surgery. Anaesthesia and surgery were uneventful. A number of issues related to pre-existing DVTs prior to gynaecological surgery require further clarification; the optimal duration of pharmacological treatment, and the optimal duration/modality of prophylaxis to prevent thromboembolism in high-risk patients with cancer. Patients presenting for DVT must be evaluated for its causative factor(s), and malignancy in particular, based on clinical findings and investigations. Before planning surgical procedures, adequate anticoagulation must be achieved to prevent further complications of DVT, thromboembolism and pulmonary embolism in particular.

Intra-abdominal adhesions are common and challenge patients, surgeons and other healthcare providers. They are potentially preventable and several agents that act as barriers between adjacent peritoneal surfaces have been evaluated for prophylaxis. Efficacy, judged by systematic reviews, has only been undertaken in gynaecological surgery.To determine efficacy and safety of peritoneal adhesion prophylaxis on incidence, distribution and adhesion-related intestinal obstruction after non-gynaecological surgery.The Cochrane Central Register of Controlled Trials, the Cochrane Colorectal Cancer Group specialised register, MEDLINE (1966-2008), and EMBASE (1971-2008) were searched.Blinded and non-blinded, randomised and quasi-randomised clinical trials were considered.Two authors individually conducted the searches and assessed the quality of studies for inclusion which were analysed using the Revman Analyses software 5.0.0 provided by the Cochrane collaboration. Meta-analysis used a random effects model.Seven randomised trials were eligible; six compared hyaluronic acid/carboxymethyl membrane (HA/CMC) and one 0.5% ferric hyaluronate gel against controls.HA/CMC reduced the incidence of adhesions (OR 0.15 (95% CI: 0.05, 0.43); p=0.0005) with reduced extent (WMD -25.9% (95% CI: -40.56, -11.26); p=0.0005) and severity. There was no reduction of intestinal obstruction needing surgical intervention (odds ratio: 0.84 (95% CI: 0.24, 2.7) with comparable overall morbidity and mortality.The study of 0.5% ferric hyaluronate gel was prematurely terminated and no valid conclusions could be made but there was a higher incidence of overall morbidity (OR 5.04; 95% CI: 1.1, 22.9) and ileus (OR: 9.29; 95% CI: 1.57, 54.77; p=0.01).There is evidence that the use of HA/CMC membrane reduces incidence, extent and severity of adhesions which may, theoretically, have implications in re-operative abdominal surgery. There is no evidence that the incidence of intestinal obstruction or need for operative intervention is reduced. HA/CMC appears to be safe but there may be a risk of leak when wrapped around an anastomoses. HA/CMC may be considered for intra-abdominal, adhesion prophylaxis at a surgeon's discretion and clinical context.Further research is needed to explore the effectiveness of other agents in abdominal surgery in general. Synergism, using agents which target different aspects of adhesiogenesis, with exploration effectiveness in a wide range of emergency and elective surgery should be considered. Longer term outcomes of recurrent intestinal obstruction and chronic pain, identification of high risk groups of patients with evaluation of cost-effectiveness are required.

We have studied interactions between i.v. propofol and midazolam for induction of anaesthesia in 200 unpremedicated female patients undergoing elective gynaecological surgery. Using end-points of "hypnosis" (loss of response to verbal command) and "anaesthesia" (loss of response to a 5-s transcutaneous tetanic stimulus), we determined dose-response curves for propofol and midazolam alone and in combination. For hypnosis, synergistic interaction was found (P less than 0.01), the combination having 1.44 times the potency of the individual agents. Although midazolam failed to produce anaesthesia in the dose range used, the dose of propofol required to produce anaesthesia was reduced by 52% in the presence of midazolam (P less than 0.01). The reduction in arterial pressure at induction was the same for the combination as for the individual agents. The cause of the synergism was not clear, but may have been interaction at CNS GABAA receptors.

Objective To present a report of the first two years of the Queensland Flying Obstetric and Gynaecology (FOG) Service which commenced operation in July 1988, and to assess the impact of the service on rural Queensland. Design Data were collected retrospectively for the surgical treatment and consultations provided by the FOG Service in its first two years, and for the obstetric and gynaecological surgery performed at Alpha Hospital, a typical rural hospital, before and after the inception of the service. Setting The service provides specialist routine and emergency care for the women of 24 western Queensland towns scattered over approximately three-quarters of the area of the State. Results In the first two years of operation of the service, the team performed 4985 consultations, 1127 colposcopies, 1793 operations, 1143 ultrasound scans, answered 100 emergency calls and flew 318,650 km, equivalent to eight times around the world. In the seven years before the FOG Service began, only 17 gynaecological operations were performed at Alpha Hospital; in the first two years of the service the team performed 47 operations in this town. Conclusions The FOG Service has made a very significant impact on the delivery of specialist services to the women of outback Queensland, and has also provided continuing education opportunities and professional support for remotely placed rural medical and nursing staff. The service has proved its worth in Queensland, and provides a model for the development of similar services in other large States of Australia.

This article describes the indications, methods and complications of bladder drainage following gynaecological surgery. The merits of urethral versus suprapubic catheterisation are discussed. Specific operations and their postoperative bladder management are also discussed.

SUMMARY Objectives To determine reasons for delay during elective operating lists and suggest solutions. Design Prospective observational study. Setting A large under-graduate teaching hospital. Participants Fifty-five consecutivewomen undergoing elective gynaecological surgery under general anaesthesia. Interventions Every time point of individual patient’s passage through the operating theatre (patients sent for, arrival in the anaesthetic room, general anaesthetic commenced, transfer to the operating theatre, surgery started, surgery completed, anaesthetic reversed, patient taken to recovery area) was documented. Main outcome measures Time intervals between the various time points with particular reference to wait by the anaesthetist and surgeon between cases. Results We monitored 55 operations carried out during 22 operating lists. Apart from the surgery itself (median 81min per procedure), the longest interval was the time taken to get patients into the anaesthetic room from the ward (median 20min). Although patients waited a median of 10min before the start of anaesthesia, if the first procedure on the list was excluded, the anaesthetist was waiting for the patient to arrive in the anaesthetic room in 13/30 (43%) cases, wasting a median of 7min per case. The surgeon had to wait a median of 22.5min between operations. Conclusions Considerable operating theatre time is wasted while patients are transferred to and from the operating theatre resulting in both anaesthetists and surgeons having to wait between patients in a high proportion of cases, averaging 1h during a 4h operating list. Surgery could be made more time efficient by ensuring that patients arrive in the operating theatre complex early enough (to reduce time wasted for anaesthetists and surgeons), and by havingtwoanaesthetistsavailableattheendofsurgery,onetoreversetheanaesthetic whilethe other starts the next induction (to reduce time waste for the surgeon), coupled to adequate recovery area capacity. Copyright # 2008 John Wiley & Sons, Ltd.

Background Ureteric injury is usually iatrogenic in origin, in particular as a result of laparoscopic or gynaecological surgery. Of those possible complications of ureteric injury, uretero-uterine fistulae are a rarity. The most common presentation of uretero-uterine fistulae is in women who have had a caesarean section. Case We present the case of a 35 year old woman who presented with continuous vaginal discharge three weeks after undergoing caesarean section. Conclusion Management of ureterouterine fistulae aims to conserve renal function and restore ureteral integrity. The relative rareity of such fistulae however means that there are no clear guidelines on their management. The resolution of this case and general management of uretero-uterine fistulae are discussed.

Important progress has been made in the field of post-surgical adhesion prevention with the development of consensus statements in gynaecology from the United Kingdom, Germany, the European Society of Gynaecological Endoscopy, Call for Action in Colorectal Surgery and a recent Technical Bulletin from The Practice Committee of the American Society of Reproductive Medicine. These reports suggest that the application of adhesion reduction devices together with the use of microsurgical principles reduces the formation of post-operative adhesions. This commentary provides additional information to assist gynaecologists in making surgical decisions. However, variation in adhesion classifications, mode of device application, lack of uniformity in surgical approaches and variations in interpretation of results make comparative assessment of the efficacy of adhesion reduction devices and surgical techniques difficult. Considering the choice of an adhesion-reduction device, one has to evaluate the cost and its clinical impact carefully. This is particularly important if one were to support routine, prophylactic use of adhesion-reduction devices. Healthcare providers should take into account the needs of individual patients, available resources, and institutional or clinical practice limitations. Good surgical technique and perhaps the use of approved devices for adhesion reduction would give patients the best chance to benefit from reproductive and gynaecological surgery.

Purpose of review: to explore recent developments in the techniques used for the prevention of adhesion formation after gynaecological surgery as well as the current evidence for existing agents and techniques. Recent findings: recent developments are promising new biomaterials such as polyvinyl alcohol gel and hyaluronic acid cross-linked with various agents such as nanoparticles. Other substances that have recently received attention include novel anti-inflammatory agents, Oxiplex (FzioMed, Inc., San Luis Obispo, California, USA), sildenafil, statins and also, there has been some renewed interest in dextran. Furthermore, the combination of barrier and pharmacological agents has led to the introduction of interesting new hybrid systems. Finally, despite the development of many novel antiadhesion agents, good surgical technique remains the mainstay of adhesion prevention. Summary: there is preliminary evidence to support the use of hyaluronic acid, although the best preparation is yet to be determined. The use of icodextrin, Interceed (Ethicon Inc, Somerville, New Jersey, USA) and Oxiplex seem to be justified by the currently available data. The results of interesting new technologies such as the use of hybrid systems and new forms of biomaterials are awaited.

To date there are no data in the literature on the procedure for the indirect measurement of blood loss during cesarean section, based on the post-operative drop in haemoglobin (Hb), which has been due to the lack of biometrically determined parameters for the calculation of blood volume in pregnant women. This study was therefore conducted to determine the applicability of the drop in Hb levels blood loss calculation during cesarean section, based on a model previously validated in non-pregnant women. We compared this procedure in 54 patients who underwent cesarean section and 12 non-pregnant patients subjected to gynaecological surgery. The coefficient of the regression slope for the blood volume collected during surgery and the calculated blood loss in pregnant (y=0.6286x+366) and non-pregnant patients (y=0.7605x+514) did not show any significant difference (t=1.1009, p>0.5, 95% confidence interval:−2.736, +2.473). Our study therefore demonstrated the applicability of the procedure for the indirect measurement of surgical blood loss both in pregnant and non-pregnant women.

John Martin Munro Kerr was born on December 5th, 1868, the son of a Glasgow ship owner. After his education at The Glasgow Academy, he trained in medicine at the University of Glasgow and graduated MB, CM in 1890 at 22 years of age. After junior appointments in Glasgow, he received further training at the Rotunda Hospital, Dublin, before studying in Jena and Berlin, Germany. On his return to Glasgow in 1894 he became assistant to Murdoch Cameron, Regius Professor of Midwifery at the University. From that time on his rise in the profession was rapid. In 1895, at the age of 27, he was elected a fellow of the Royal Faculty of Physicians and Surgeons of Glasgow and the following year he was appointed to the staff of the Royal Maternity Hospital.1–5 In 1908 he was awarded an MD from the University of Glasgow, with high commendation for his thesis, entitled Operative Midwifery . The text of this thesis was published the same year6 and has gone through many editions since, changing its title to Operative Obstetrics 7 in 1937. In 1911 Munro Kerr became the first incumbent of the Muirhead Chair of Obstetrics and Gynaecology in Glasgow. A second important publication, of which he was the main author, appeared in 1923. This work, the Combined textbook of obstetrics and gynaecology for students and medical practitioners ,8 had a powerful influence on bringing together the disciplines of obstetric medicine and gynaecological surgery and also went through many editions up to the present time. In 1927 Munro Kerr succeeded Murdoch Cameron as Regius Professor of Midwifery in the university, a post he held until his retirement in 1934. A third major publication appeared in 1933, with the title Maternal mortality and morbidity: a study of …

Objective To estimate the cost-effectiveness of a treatment strategy for symptomatic uterine fibroids, which starts with Magnetic Resonance-guided Focused Ultrasound Surgery (MRgFUS) as compared with current practice comprising uterine artery embolisation, myomectomy and hysterectomy. Design Cost-utility analysis based on a Markov model. Setting National Health Service (NHS) Trusts in England and Wales. Population Women for whom surgical treatment for uterine fibroids is being considered. Methods The parameters of the Markov model of the treatment of uterine fibroids are drawn from a series of clinical studies of MRgFUS, and from the clinical effectiveness literature. Health-related quality of life is measured using the 6D. Costs are estimated from the perspective of the NHS. The impact of uncertainty is examined using deterministic and probabilistic sensitivity analysis. Main outcome measures Incremental cost-effectiveness measured by cost per quality-adjusted life-year (QALY) gained. Results The base-case results imply a cost saving and a small QALY gain per woman as a result of an MRgFUS treatment strategy. The cost per QALY gained is sensitive to cost of MRgFUS relative to other treatments, the age of the woman and the nonperfused volume relative to the total fibroids volume. Conclusions A treatment strategy for symptomatic uterine fibroids starting with MRgFUS is likely to be cost-effective. Please cite this paper as: Zowall H, Cairns J, Brewer C, Lamping D, Gedroyc W, Regan L. Cost-effectiveness of magnetic resonance-guided focused ultrasound surgery for treatment of uterine fibroids. BJOG 2008;115:653–662.

Summary Regional anaesthesia has an important role in anaesthesia for day case surgery, either alone or as part of a balanced anaesthetic technique combined with general anaesthesia. The principal advantage is the provision of first-class postoperative analgesia which can be prolonged well into the postoperative period without danger to the patient. Other advantages include reduced perioperative morbidity, particularly postoperative nausea and vomiting, dizziness and sedation, all of which may lead to unexpected hospital admission. These problems are encounted most often with ophthalmic surgery and gynaecological surgery, both of which are frequently suitable for regional anaesthetic techiques. The use of regional anaesthetic techniques does not delay recovery times or discharge from hospital. The disadvantages of regional anaesthetic techniques include a small but significant failure rate, prolonged time to perform, and the fact that certain skills are necessary for its performance. There are a few contraindications to the use of regional anaesthesia but the majority of patients are suitable. These techniques are particularly appropriate for day case surgery in children and are usually used in combination with a light general anaesthetic.

Plasminogen activator inhibitor (PAI-1) antigen and fibrin/ogen degradation products (FbDP, FgDP) were measured before and 8 days after gynaecological surgery in 50 patients randomly submitted to prophylaxis with low molecular weight heparin (Alfa LMW1-OP 2123, Alfa Wassermann, Bologna, Italy; LMWH group) or standard calcium heparin (CH group). All patients were screened for deep venous thrombosis by the 125I Fibrinogen uptake test. In the CH group, but not in LMWH group, postoperative PAI-1 levels were significantly higher (p

The gynaecologist today is likely to encounter elderly patients with severe coronary heart disease requiring major gynaecological surgery. The successful outcome in 2 such patients with compromised coronary circulation and impaired left ventricular function emphasized the importance of combined care with the cardiologist and the anaesthetist. The insertion of a Swan-Ganz catheter for close perioperative monitoring is vital. The intra-and postoperative problems are discussed.

The suitability of triazolam for oral premedication was evaluated in comparison to flunitrazepam. 65 consenting female patients scheduled for gynaecological surgery took part in the trial, were randomly allocated in two groups and were given 0.5 mg triazolam or 2 mg of flunitrazepam as oral premedication 90 min preoperatively

SummaryAmong seventy-five patients having ventrosuspension, dyspareunia and backache were the commonest indications for operation. Fifty-one per cent described their postoperative pain as severe and 29 per cent had some surgical complication in the immediate postoperative period. ‘Cure” rates were disappointing and 29 per cent subsequently had gynaecological surgery. Older and parous women and those who had previously had abdominal or pelvic surgery were more likely to require subsequent surgery.

Recently, the Danish National Register of Medicinal Product Statistics (NRM) was opened for research purposes, and therefore, on an individual basis, can merge with other national registers. The aim of this study was to analyse the use of hormones based on the individual data of the entire Danish female population, with the focus on a detailed evaluation of specific hormone regimens and factors associated with systemic hormone replacement therapy (HRT).All Danish female citizens, aged 15-70 years during the study period 1995-2004, were identified in the Civil Registration System, and their redeemed prescriptions for hormones and medication for diabetes, hypertension, hypercholesterolemia and heart conditions were retrieved from the NRM. Information on habitation, education, employment and gynaecological surgery was obtained from other national registers.After 2002, the use of HRT was reduced by 65%. In 2002, HRT was most prevalent in women aged 55-59 years, when an average of 200 defined daily doses per 1,000 women per day was recorded. In 2002, approximately 39% of women aged 50-57 years were ever exposed to HRT. The mean duration of HRT was 5 years in an 8-year time window. During the study period, there was a significant decline in the use of systemic hormones, initially due to a decrease in cyclic combined therapy, but after 2002 continuous combined therapy decreased rapidly. HRT was positively associated with middle-term education, employment status, and living in urban areas. Women treated for diabetes used hormones less frequently than women without diabetes. Women using antiarrhythmics or antihypertensives used hormones more often than women not using this medication. HRT was positively associated with gynaecological surgery.One in five women, aged 50-59 years, redeemed daily HRT. Use of HRT declined from 1995 to 2002, but more than halved after 2002. HRT is associated to redemption of other medications of significance for health.

It is well known that 40 - 80% of information provided by clinicians is forgotten immediately by patients. Furthermore, 50% of the information remembered is incorrect. Research has shown that receiving written communication meets with high satisfaction from patients. According to the NHS plan to improve healthcare delivery, it has been recommended that patients should receive copies of letters written by doctors and that the policy would be implemented in full by April 2004. A total of 100 consecutive patients undergoing day-case gynaecological surgery under a single consultant were sent a postal questionnaire. Questions included were whether the letter was helpful, informative, reassuring, confusing or alarming. Patients were further asked whether they would prefer a similar communication in the future. A total of 78 patients replied. Of these, 67 patients found the letter helpful and preferred to have similar communication in future. Only two patients found the letter confusing and one of these was alarmed as well. Overall, 62 patients found the letter reassuring. The majority of the patients found the copy of GP discharge letter helpful, informative, non-alarming and reassuring and wanted a similar communication in the future. The extra workload involved was minimal and the extra expense involved only an extra page, envelope and postage.

Objective To compare the impact of 1000 micrograms of self-administered vaginal misoprostol versus self-administered vaginal placebo at home on preoperative cervical ripening in both premenopausal and postmenopausal women before operative hysteroscopy. Design Two separate but identical parallel, randomised, double-blind, placebo-controlled sequential trials, one in premenopausal women and one in postmenopausal women. The boundaries for the sequential trials were calculated on the primary outcomes of a difference of cervical dilatation ≥1 mm, with the assumption of a type 1 error of 0.05 and a power of 0.95. Setting Norwegian university teaching hospital. Sample Eighty-six women referred to outpatient operative hysteroscopy. Methods The women were randomised to either 1000 micrograms of self-administered vaginal misoprostol or self-administered vaginal placebo the evening before outpatient operative hysteroscopy. Main outcome measures Preoperative cervical dilatation (primary outcome), number of women who achieve a preoperative cervical dilatation ≥5 mm, acceptability, complications and adverse effects (secondary outcomes). Results In premenopausal women, the mean cervical dilatation was 6.4 mm (SD 2.4) in the misoprostol group and 4.8 mm (SD 2.0) in the placebo group, the mean difference in cervical dilatation being 1.6 mm (95% CI 0.5–2.7). Among the premenopausal women receiving misoprostol, 88% achieved a cervical dilatation of ≥5 mm compared with 65% in the placebo group. Twelve percent of the women who received misoprostol were difficult to dilate compared with 32% who received placebo. Dilatation was also quicker in the misoprostol group. Misoprostol had no effect on cervical ripening in postmenopausal women compared with placebo, and 43% of the women were difficult to dilate. The trials were terminated after analysis of 21 postmenopausal women and 65 premenopausal women after reaching a conclusion on the primary outcome with only 28% of the number of women needed in a fixed sample size trial. Three of 45 women who received misoprostol experienced severe lower abdominal pain, and there was an increased occurrence of light preoperative bleeding in the misoprostol group. Most women did not experience misoprostol-related adverse effects. The majority (83% of premenopausal and 76% of postmenopausal women) found self-administered vaginal misoprostol at home to be acceptable. There were two serious complications in the premenopausal misoprostol group: uterine perforation with subsequent peritonitis and heavy postoperative bleeding requiring blood transfusion, but these were not judged to be misoprostol related. Complications were otherwise comparatively minor and distributed equally between the two dosage groups. Conclusions One thousand micrograms of self-administered vaginal misoprostol 12 hours prior to operative hysteroscopy has a significant cervical ripening effect compared with placebo in premenopausal but not in postmenopausal women. Self-administered vaginal misoprostol of 1000 micrograms at home the evening before operative hysteroscopy is safe and highly acceptable, although a small proportion of women experienced severe lower abdominal pain. There is a risk of lower abdominal pain and light preoperative bleeding with this regimen, which is very cheap and easy to use. Please cite this paper as: Oppegaard K, Nesheim B, Istre O, Qvigstad E. Comparison of self-administered vaginal misoprostol versus placebo for cervical ripening prior to operative hysteroscopy using a sequential trial design. BJOG 2008;115:663–e9.

Background - Preoperative autologous blood donation (PABD) is utilized to circumvent the use of allogenic blood for various reasons. Objective - To describe the distribution in terms of demographic characteristic, trends in participation and result of screening test of the PABD programme of the Accra Area Blood Center from 1993-2003. Design and Setting Retrospective descriptive study of PABD in patients scheduled for a variety of elective surgical procedures. Setting- Different levels of institutional health care in Accra, Ghana. Methods Data from existing records of patients who had participated in PABD were collated and analyzed Results Five hundred and forty six (546) females and 89 males participated, with ages ranging between 14-74 years. Majority of the patients (76.7%) underwent gynaecological surgery. A total of 330 (52%) donated one unit only, and 299 (47.1%) donated two units. Majority of the patients (56.4%) had the surgery at the Korle-Bu Teaching Hospital (KBTH). Of the donations, 21 (3.3%), 1 (0.2%), 1 (0.3%) and nil were positive for HBV, HIV I & II, HCV and VDRL respectively. A total of 848 (89.4%) autologous crossmatched units were issued out. There was a steady progressive increase in participation. Conclusion Mainly adult females scheduled for gynaecological surgeries in KBTH participated, while almost equal proportions donated one or two units of blood which meets the blood needs of most elective surgeries. Therefore healthy patients going for elective surgeries in regions with limited blood supply must be encouraged to enter a PABD Programme. Further studies in this field should evaluate motivational factors for participation

To survey the practice and reasons of use of local infiltration in prolapse and continence surgery in UK, an electronic survey of gynaecologists with special interest in urogynaecology, urogynaecologists, urologists and allied professionals who were on the email list of the International Continence Society (ICS), UK was carried out in April-July 2006. Out of the 238 questionnaires that were sent, 112 failed mail delivery and 57 questionnaires were returned, giving a response rate of 50.1%. Of the respondents, 40/46 (86.9%) used local infiltration for vaginal hysterectomy and vaginal repairs, whilst 43/46 (93.4%) used it for TVT. Of the respondents, all of 18 who performed vaginal mesh procedures used local infiltration. While 90% of respondents felt it helped reduce blood loss, only 46% were convinced that it helped reduce visceral injury. The survey reflects that the majority use local infiltration for gynaecological surgery: however, there is wide variation in the type and strengths of agents used.

Transvaginal bowel evisceration is an under-reported postoperative complication of vaginal or abdominal gynaecological surgery (Yuce et al. 2005). It has a variable timeframe and may occur immediat...

Objectives To develop and describe NEST (network enhanced surgical training), an affordable and easily reproducible telementoring system. Study design We have developed the system around two standard personal computers: a desktop computer for the surgeon in the operating room (OR), equipped with a digital video-capture system; and a laptop computer for a mentor outside the OR. In an attempt to reduce the costs, freeware software has been tested and chosen to allow visual and audio interaction between the two computers. No IT technicians were involved in the process at any stage. Results Following 6 months of hardware and software testing, we have successfully developed NEST (network enhanced surgical training), an affordable telementoring system based on two standard personal computers connected through an Ethernet cable. We tried NEST during the whole range of gynaecologic interventions performed in our unit, including abdominal, vaginal and laparoscopic surgery. We also successfully used NEST to provide visual access to the operative field to medical students and endoscopy workshop delegates. In addition, we also used NEST to simulate telementoring during pelvi-trainer sessions in our endoscopy skills laboratory. Surgeons’ interaction through NEST seems reliable since the mentor's instructions, both vocal and visual (by pointing at landmarks), were always followed on time by the surgeon during our tests. Conclusions We believe that surgical telementoring deserves attention and our NEST system could be an ideal tool for studies on telementoring in safe environments. In its simplest incarnation with the mentor “next-door”, just outside the operating theatre, he/she could intervene at any stage if necessary. Moreover, NEST is affordable and reproducible as it is based solely on two standard personal computers, a video-capture system, an Ethernet cable, and two freeware computer programs.

OBJECTIVE: The aim of this study was to estimate intra- and post-operative risk using the American Society of Anaesthesiologists (ASA) classification which is an important predictor of an intervention and of the entire operating programme. STUDY DESIGN: In this retrospective study, 4435 consecutive patients undergoing elective and emergency surgery at the Gynaecological Clinic of the University Hospital of Zurich were included. The ASA classification for pre-operative risk assessment was determined by an anaesthesiologist after a thorough physical examination. We observed several pre-, intra- and post-operative parameters, such as age, body-mass-index, duration of anaesthesia, duration of surgery, blood loss, duration of post-operative stay, complicated post-operative course, morbidity and mortality. The investigation of different risk factors was achieved by a multiple linear regression model for log-transformed duration of hospitalisation. RESULTS: Age and obesity were responsible for a higher ASA classification. ASA grade correlates with the duration of anaesthesia and the duration of the surgery itself. There was a significant difference in blood loss between ASA grades I (113+/-195 ml) and III (222+/-470 ml) and between classes II (176+/-432 ml) and III. The duration of post-operative hospitalisation could also be correlated with ASA class. ASA class I=1.7+/-3.0 days, ASA class II=3.6+/-4.3 days, ASA class III=6.8+/-8.2 days, and ASA class IV=6.2+/-3.9 days. The mean post-operative in-hospital stay was 2.5+/-4.0 days without complications, and 8.7+/-6.7 days with post-operative complications. Multiple linear regression model showed that not only the ASA classification contained an important information for the duration of hospitalisation. Parameters such as age, class of diagnosis, post-operative complications, etc. also have an influence on the duration of hospitalisation. CONCLUSION: This study shows that the ASA classification can be used as a good and early available predictor for the planning of an intervention in gynaecological surgery. The ASA classification helps the surgeon to assess the peri-operative risk profile of which important information can be derived for the planning of the operation programme.

Endometriosis is the presence of endometrial tissue outside the uterine cavity. It has been previously reported in the abdominal wall secondary to gynaecological surgery. We present the case of a 32-year woman with endometrioma of the abdominal wall masquerading as an intramuscular lipoma with no previous surgical history.

One hundred and eighty-seven patients undergoing gynaecological surgery in two different international centres were reviewed daily by 'blinded' interviewers. They were analysed for the presence of nausea, vomiting, eating, mobilisation, general well-being and use of make-up. On starting to wear make-up their statement of well-being improved significantly but 1 in 3 patients in London complained of nausea, one in four still had a urinary catheter in place, required intramuscular analgesia or intravenous access, one in eight were unable to tolerate food, and one in 10 patients were pyrexial. Although wearing make-up was associated with improved well-being their was no correlation with their clinical condition.

No Abstract. Ghana Medical Journal Vol. 38(4) 2004: 127-130