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Drug-induced hypersensitivity and adverse symptoms related to the high mortality remain as a major problem for veterinary practitioners. Although application of Rifamycin SV without intradermal susceptibility tests have been commonly used in wound management in veterinary medicine, there is no literature about this subject. In cases presented here, neoplastic masses on the mammary glands of queens (n=3) and bitches (n=4) were removed by mastectomy. Subcutaneous Rifamycin SV was performed intra- and post-operatively. After the multiple subcutaneous usage of Rifamycin SV, acute symptoms including hypersensitivity reactions such as facial and sublingual swelling, hypersalivation, respiratory distress, tachycardia, acute vomiting, erythema and itchiness around the face, seizures and ataxia developed. In conclusion, although Rifamycin SV provides better healing effects on incision line, veterinary practitioners should consider the serious side effects of subcutaneous Rifamycin SV usage after gynaecological surgeries in companion animals. © 2016 Ataturk Universitesi. All rights reserved.

Acute urinary retention is a common consequence of gynaecological surgery and if unrecognized can lead to irreversible bladder damage. Units must have clear guidelines and staff must be constantly vigilant with the at risk group. Regular post-operative or post-delivery monitoring should prevent acute overdistension. Patients with voiding dysfunction should be referred to specialist Urogynaecology or urology for further investigations and long term management.

Hysterectomy is the most commonly performed gynaecological surgery, which can influence woman's life in sexual, psychological, hormonal and social sphere. The aim of this study was to examine the subjective perceptions of life among women after hysterectomy (positive and negative effects of surgery, sources of social support, satisfaction with support, satisfaction with life and health). 70 women who underwent hysterectomy (mean age was 47.66 ± 9.47 y.; 29–72) were assigned for this study. The Multidimensional scale of perceived social support (MSPSS) and additional questions were used to gain information on social support, positive and negative effects of surgery, satisfaction with support, satisfaction with life and health. The majority (68.6%) of respondents prefer husband or partner as a source of support and were subjectively satisfied with this support (81.4%). 20% sought support outside family and friends network and priest, psychologist and support groups were their preferred supporters. The most cited positive aspects of hysterectomy were the disappearance of symptoms and reduced fear of uterine cancer. Most women did not see any negative consequences of surgery (45.7%) and were subjectively satisfied with their life (90%). Since the social support is one of the important factors affecting women's life, healthcare professionals should also focus on building and strengthening patient's support network when working with these groups of women.

The aim of this descriptive review is to summarise the current knowledge of non-invasive bioelectrical impedance analysis (BIA) used with gynaecological surgical patients in regard to postoperative development of lymphoedema and determination of perioperative fluid balance, and as a prognostic factor in cancer mortality and a predictor of postoperative complications. The databases PubMed, MEDLINE, Scopus Web of Science, the Cochrane Library, and reference lists of selected articles were searched for relevant articles published during the period January 2008-April 2018. Only papers published in English were retrieved. Thirty-seven articles were evaluated. Where gynaecological studies were lacking, studies with a study population from neighbouring clinical fields were used instead. Studies on the clinical use of BIA with gynaecological surgical patients were divided into three categories: the postoperative development of lower limb lymphoedema (n = 7), perioperative hydration measuring (n = 3), and the BIA parameter phase angle as a prognostic factor in cancer survival and as predictive for postoperative complications (n = 6). Of these 16 studies only three used a pure gynaecological study population. Three different methods of BIA were used in these articles: single frequency-BIA, multifrequency-BIA and bioimpedance spectroscopy. BIA was found to detect lymphoedema with a sensitivity of 73% and a specificity of 84%. Studies indicated that BIA was able to detect lower limb lymphoedema at an early stage even before it became clinically detectable. During postoperative hydration measurements, an increase in extracellular fluid volume and extracellular fluid volume in relation to total body fluid volume, as well as a decrease in phase angle, were associated with higher frequencies of postoperative complications. Moreover, low values for the phase angle have been associated with increased mortality in cancer patients. However, the number of studies in this field was limited. From our review, BIA seems to be a useful tool for use in the clinical setting of the gynaecological surgical patient. The theoretical approach of using bioelectrical impedance values to measure the fluid distribution in the body compartments offers wide opportunities in the clinical setting. However, so far, all studies have set up cut-off limits within the study population, and reference values for a general population need to be defined. There are also rather few studies on a gynaecological study population. Hence, there is a need for further studies within gynaecological surgery focusing on early detection of lower limb lymphoedema, perioperative fluid balance, and postoperative complications in order to establish the value of BIA in clinical praxis. (C) 2018 Elsevier B.V. All rights reserved. Funding Agencies|Linkoping University; Region Ostergotland

The aim of this study is to evaluate the impact of the 1999 national recommendations for ovarian cancer surgery in England to be performed by specialist surgeons in specialist centres.A retrospective analysis of English cancer registry records, Hospital Episode Statistics (HES) data for all English NHS providers and General Medical Council (GMC) sub-specialty accreditation, to consider changes to the annual proportion of ovarian cancer (ICD10 C56-C57) patients undergoing major gynaecological surgery in gynaecological cancer centres (GCCs) or by specialist gynaecological oncologists (GOs).From 2000 to 2009, 2428 consultants were responsible for surgery on 30,753 patients. There were significant increases in the proportions of patients undergoing surgery at GCCs (43% to 76%, P0.001), by GMC accredited GOs (5% to 36%, P0.001), and by high ovarian cancer caseload (≥18 cases) surgeons (22% to 56%, P0.001).There have been increased centralisation and specialisation of surgery for ovarian cancer patients since the NHS Cancer Plan (2000) and there has also been improved survival. However, by 2009, many ovarian cancer patients were still not receiving specialist surgery; the majority of patients were not operated on by GMC accredited gynaecological oncologists and there was considerable regional variation. Systems of accreditation should be reviewed and trusts should ensure that HES data accurately records clinical activity.

Postoperative nausea and vomiting (PONV) and fentanyl-induced cough (FIC) are two common anaesthesia-related events, which seem to have common risk factors. In this prospective cohort study, we investigate whether patients who have FIC during induction of anaesthesia have an increased incidence of PONV.We studied adult non-smoking gynaecological surgical patients enrolled between July 1, 2011 and July 30, 2012. The presence of FIC during induction and the occurrence of PONV were recorded. Fentanyl-induced cough and other perioperative variables were subjected to multivariate analysis to determine the association between FIC and PONV.All 502 patients enrolled in this study had at least two risk factors for PONV, and 154 (31%) developed FIC. The incidence of PONV in the FIC group was higher than in the non-FIC group (56.5 vs 38.2%; P0.0001). Multivariate logistic regression analysis found FIC to be a predictive risk factor for the development of PONV (adjusted odds ratio 2.08, 95% confidence interval 1.41-3.07).Non-smoking women undergoing gynaecological surgery who develop FIC during induction of anaesthesia have a higher incidence of PONV.

Background To assess the learning curve associated with tele-assisted surgery. Methods We performed a training box-based study, describing speed and accuracy in volunteers performing basic and complex laparoscopic tasks, to assess performance and in the skill acquisition of inexperienced users, using the Telelap Alf X system. Ten surgeons in gynaecology who had never received formal instruction on this new surgical device, completed four modules during a consecutive 3 day training programme. Results All the participants completed the training programme with a good learning curve. Conclusions Use of the TELELAP Alf X advanced surgical robotic system is associated with a rapid learning curve among experienced surgeons. Copyright © 2015 John Wiley & Sons, Ltd.

Small bowel perforation is a unique, serious complication during endometrial biopsy. The authors report a case of a double uterine-ileal perforation totally managed by primary laparoscopic repair. A 63-year-old female was admitted with acute abdomen 2 days after an endometrial curettage. Abdominal X-ray shows signs of pneumoperitoneum. Emergency diagnostic laparoscopy was performed and a uterine-ileal perforation was identified. Repair was accomplished by a totally laparoscopic intracorporeally suturing of the 2 breaches. Postoperative course showed only a delayed ileus and the patient was discharged after 5 days with no complications. When acute abdomen arises following uterine biopsy, a potential iatrogenic intestinal laceration always has to be ruled out. Laparoscopic approach is a quick and safe technique in these cases. Totally laparoscopic primary closure of the iatrogenic ileal laceration may be accomplished with low morbidity.

The authors report a case in which an intravenous injection of Patent Blue V dye instead of Indigo Carmine was given during routine gynaecological surgery. The patient presented with temporary arterial (spurious) desaturation and skin discoloration over a 48-hour period. Pharmacological differences between these dyes are described. Root cause analysis based on the ALARM (Association of Litigation and Risk Management) model is presented. The authors emphasise that use of this model should not be limited solely to describing and correcting well known systems errors such as working conditions or teamwork and communication. Furthermore, they conclude that insufficient knowledge must also be recognised as a systems error and as such should be sought out and corrected using similar strategies to those used to discover other contributory factors, without allocation of blame to any individual.

Key content Over 20% of women attending gynaecology clinics have psychosexual dysfunction and yet training for medical students, trainees, and consultants is inadequate and in some regions non-existent. Common problems include sexual pain disorders, protracted pelvic or vulval pain, hypoactive sexual desire disorder and repeated requests for gynaecological surgery where no pathology has been found. National provision of specialist psychosexual clinics is patchy and yet the Tomorrow's Specialist report from the RCOG includes psychosexual services as a service expected by patients. Learning objectives This article outlines the management of psychosexual dysfunction in the gynaecology outpatient department (GOPD). After reading we would expect clinicians to have a basic understanding allowing the majority of such cases to be managed in the GOPD. The principles of psychosexual medicine are that the patient is the expert but clinicians can allow them to see their problems more clearly through enhanced consultation skills. Ethical issues There are very few trained doctors and specialists in psychosexual medicine despite it being a commonly requested service.

Summary Background Women experience more sore throats than men after endotracheal intubation. Aim The aim of this study was to investigate the incidence of self-rated sore throat immediately, and 2–4 hours postoperatively, in women after elective gynaecological surgery under general anaesthesia using an endotracheal tube (ETT) size 6.5 or 7.0 mm in inner diameter. Method Eighty-two female participants who had undergone elective gynaecological surgery participated, 44 and 38 were intubated with size 6.5 mm ETT and 7.0 mm ETT respectively. They estimated the occurrence of sore throat preoperatively and postoperatively, according to a 4-point Likert scale. Statistical data were analysed using the Package for Social Science (SPSS) 19. Results Sore throat was present in 29.5% of participants who were intubated with size 6.5 mm ETT immediately postoperatively and in 39.5% of those who were intubated with size 7.0 mm ETT. Conclusion Nurses specialising in the supervision of daily care specific to the intubated patient should note and alleviate sore throat as part of their nursing care.

The objective of this article is to provide background on preventing, recognizing and treating complications of benign (non-endoscopic) gynaecological surgery. The prevention of vaginal vault haematoma, wound infection and uterine perforation will be discussed in more detail. The importance of understating the design of surgical instruments in highlighted. When instruments are used in their intended way, iatrogenic complications can be prevented. Exposure to the surgical field is essential, and correct positioning of the patient will allow saver surgery. Ergonomics are important for the surgeon and will also help in the prevention of complications.

Regardless the etiology, the development of genitourinary fistula has the most profound and devastating consequences for patient’s physical and social life and remains a challenge to surgeons. Although the advancement has been made in the management but still the controversies are exist on the ideal time and approach. The spontaneous closure of vesicovaginal fistulae after continuous bladder drainage alone for varying periods has been reported in literature. This review was undertaken to look in to the literature regarding recent advancement in the conservative management of genitourinary fistula.

The role of general anaesthesia is to produce a reversible and safe loss of consciousness, to maintain the patient’s physiological parameters within a normal range while blunting the sympathetic response to noxious stimuli and to facilitate optimum surgical conditions for the operation.

The technological advances in surgery, especially the introduction of robotic instruments, require thorough technical as well as logistic education in a safe and effective way. In parallel, medical training itself has undergone changes towards competency based training, which uniquely prepares for the inclusion of new technologies. Unfortunately, at the introduction of robot-assisted surgery, professionals did not yet have the tools to train properly and safely in this new type of surgery. Hence, the first training and ‘certification’ criteria were established and introduced by the manufacturer.

Gynaecologists and anaesthesiologists are both at the patient’s service when performing gynaecological procedures.This chapter emphasizes on anaesthesiological difficulties of vaginal procedures, laparotomy, laparoscopy and robotic assisted gynaecological surgery and is addressed to operating gynaecologists.

Background Surgery for pelvic organ prolapse, urinary incontinence, and hysterectomy are the most common gynaecological surgeries that can affect the function of the bladder and bowel as well as one’s sexual life. There is evidence that adequate patient information given preoperatively regarding expected outcomes of surgery is important because well-informed patients are more satisfied with the results of surgery and recover faster. However, there is little known about the amount and quality of information given to women before surgery. This study investigates whether women received information before gynaecological surgery on the effect of surgery with respect to the functioning of the bladder (micturition, ability to stay continent) and the bowel (empty bowel) as well as the surgery’s effect on sexual functioning. Methods A prospective, cross-sectional study was conducted. Women undergoing hysterectomy, surgery for vaginal prolapse, or surgery for urinary incontinence (n = 972) and included in the Swedish National Register for Gynaecological Surgery participated in the study. A questionnaire was developed and distributed to the women along with the preoperative questionnaire from the register. Results About 50% of the women undergoing prolapse surgery were supplied with information regarding the effect of the surgery with respect to remaining continent, to emptying bowels, micturitaion, and sexual life. One out of four women undergoing hysterectomy received information about the effect of the surgery on the sexual life and bladder function. In the incontinence group, the given information about the surgery’s effect on bladder function and sexual function was 80 and 30%, respectively. Conclusion Surgery in the vagina and the genital organs may affect function of the organs close to the surgical area (i.e., bladder and bowel) and may affect sexual function. According to this study, women are inadequately informed before surgery. Access to information via oral and written counselling needs to be improved. Electronic supplementary material The online version of this article (10.1186/s12905-017-0426-7) contains supplementary material, which is available to authorized users.

A study was undertaken to evaluate the effectiveness of acupuncture as an anti-emetic in patients undergoing minor gynaecological surgery. 100 patients were studied divided into study group (Group I) and control group (Group II) of 50 patients each. In group I patients, acupuncture needle was inserted at acupuncture point P6, 10 minutes before induction of anesthesia. In group II, no acupuncture was used. Anaesthetic technique was similar in both the groups. Five patients (10%) in group I and twenty (40%) in group II had one or more emetic episodes. These results show that acupuncture can be one of the modalities for the prevention of nausea and vomiting in postoperative period and its use as an anti-emetic should be explored further.

Introduction: It has long been known that gynaecological examination causes a lot of negative emotions for most women. The aim of the study was to learn the views of women on the issue of gynaecological examination. Materials and methods: The study involved 1200 women from the West Pomeranian and Łodź provinces in Poland. Results: The majority of non-pregnant women considered gynaecological examination to be embarrassing. The most embarrassing moment of the visit for the respondents from both groups was lying down on the gynaecological chair, and the most unpleasant stage of examination was palpation through the vagina. The greatest sense of security and mental comfort during the examination was provided by the presence of only the gynaecologist. Most pregnant respondents prefer to be examined by a male gynaecologist. Respondents would most willingly have examinations with a doctor who is nice, talkative, calm, smiling and mature. Most of the pregnant surveyed women claimed that the gynaecological examination is very necessary, while only 49% would appear for it once every 6 months. Conclusions: 1. Gynaecological examination was significantly more embarrassing and stressful for women who were not pregnant. 2. In the opinion of pregnant women, breast examination is the least embarrassing stage of the examination. 3. Pregnant women significantly more often chose a man as their gynaecologist. 4. The frequency of having a gynaecological examination depended significantly on the status of pregnancy. 5. The expectations of the surveyed women to a gynaecologist focused mainly on him/her maintaining a sense of intimacy and security, on informing the women on the procedures taken, as well as on a nice and individual approach.

Background Fresh frozen cadaver training has been proposed as a better model than virtual reality simulators in laparoscopy training. We aimed to explore the relationship between cadaveric surgical training and increased surgical confidence. To determine feasibility, we devised two 1-day cadaveric surgical training days targeted at trainees in obstetrics and gynaecology. Seven defined surgical skills were covered during the course of the day. The relationship between surgical training and surgical confidence was explored using both quantitative (confidence scores) and qualitative tools (questionnaires). Results Participants rated a consistent improvement in their level of confidence after the training. They universally found the experience positive and three overarching themes emerged from the qualitative analysis including self-concept, social persuasion and stability of task. Conclusions It is pragmatically feasible to provide procedure-specific cadaveric surgical training alongside supervised clinical training. This small, non-generalisable study suggests that cadaveric training may contribute to an increase in surgical self-confidence and efficacy. This will form the basis of a larger study and needs to be explored in more depth with a larger population.

Study objective This study aimed to determine the efficacy of ultrasound-guided posterior quadratus lumborum block (QLB) in treating postoperative pain following laparoscopic gynecologic surgery. Design Prospective randomized controlled study. Patients Seventy adult patients scheduled for elective laparoscopic gynaecological surgery under general anesthesia. Intervention This randomized controlled study involved two groups of adult females who were scheduled to undergo laparoscopic gynecologic surgery under general anesthesia. Patients were randomly assigned to either the QLB group or Control group. In the QLB group, patients underwent posterior QLB with 20mL of 0.375% ropivacaine on each side. Patients were blinded to treatment. Measurements At 0, 1, 3, and 24 hours after anesthesia recovery, evaluator recorded the severity of postoperative pain in movement and at rest using a Numeric Rating Scale (NRS). We also evaluated the severity of nausea using NRS and number of additional analgesics. Main results Immediately after recovery from anesthesia, the NRS score for pain in movement did not differ significantly between groups. NRS scores for pain both in movement and at rest were significantly higher in the Control group than in the QLB group at 1, 3, and 24h after recovery from anesthesia. Conclusion Our results suggest that posterior QLB significantly reduces postoperative pain in movement and at rest following laparoscopic gynecologic surgery.

Post-operative adhesions are frequent sequela of abdominal and gynaecological surgery. They are associated with a high level of morbidity. This “field guideline” was written by a panel of European experts (anti-adhesions in gynecology expert group (ANGEL) and the European Society of Gynaecological Endoscopy (ESGE), adhesion research special interest group. It aims to provide surgeons with a quick reference guide to adhesion prevention adapted to the conditions of their daily practice.

This study investigates the experience and satisfaction with care of fast-tracked gynaecological patients. The Sydney Gynaecological Oncology Group, New South Wales, Australia, has previously shown the benefits of a fast-track surgery programme for gynaecology patients with both complex benign gynaecological pathology and gynaecological malignancy. The question of whether these benefits translate into a positive experience for fast-tracked patients, in the context of their hospital stay and healthcare team care, has not been previously explored in detail. A self-administered satisfaction questionnaire incorporating the European Organisation for Research and Treatment of Cancer (EORTC) cancer in-patient satisfaction with care measure (INPATSAT-32) questionnaire with additional questions was administered to 106 gynaecology participants at Royal Prince Alfred Hospital. Participants reported high levels of satisfaction with patient care and support received from doctors, ward nurses and the hospital as a service and care organisation, within the context of a fast-track surgical programme. Early hospital discharge after gynaecological surgery results in both enhanced recovery after surgery (ERAS) and high levels of patient satisfaction.

Objective To investigate the relationship between two connective tissue pathologies: striae and pelvic organ prolapse (POP). Study design Four hundred and eighty-eight women who had undergone gynaecological surgery were divided into two groups. The study group (n = 244) consisted of symptomatic patients with POP, and the control group (n = 244) consisted of cases who underwent surgery for benign gynaecological conditions without evidence of POP. The groups were compared in terms of the presence, intensity and severity of striae, as well as their general characteristics. Results The presence of striae (p = 0.001), number of striae (p = 0.001) and Davey score (p = 0.00001) were significantly higher in the study group, and the absence of striae was more common in the control group (p = 0.00001). According to multivariate analysis, the presence of striae, an increased number of striae (>15) and a Davey score >2 increased the risk of POP 1.29 fold (p = 0.03, 95% confidence interval [CI] 1.14–1.35), 1.19 fold (p = 0.04, 95% CI 1.14–1.25) and 2.51 fold (p = 0.01, 95% CI 1.66–3.78), respectively. Conclusion Striae may serve as a promising marker for POP. In particular, women who develop striae should be cautious about their risk for developing POP in the future, and should be informed about preventive methods for POP.

Summary We investigated whether laparoscopic vs open surgical approaches affected the duration of neuromuscular blockade following a single bolus dose of rocuronium. Fifty-three female patients underwent either laparoscopic or open gynaecological surgery. Rocuronium 0.6 mg.kg−1 was administered to achieve neuromuscular blockade in all subjects, and adductor pollicis train-of-four responses following ulnar nerve stimulation were monitored with mechanomyography. The mean (SD) time from injection of rocuronium until spontaneous recovery of the first twitch, and to 5% and 25% of baseline, was significantly prolonged in the laparoscopic group (27.2 (8.3) min, 31.3 (9.1) min and 38.1 (10.6) min, respectively) compared with the open surgery group (21.1 (5.8) min, 25.6 (6.3) min and 31.2 (6.7) min, respectively). Changes in liver function both before surgery and at 24 h postoperatively were similar between the two groups (p > 0.05). Our findings suggest that neuromuscular blockade may be prolonged following a single bolus dose of rocuronium given during laparoscopic procedures.

Introduction To determine current hospital practices and the opinions of senior health professionals working in Western Australian (WA) hospitals performing gynaecological procedures regarding pre-operative pregnancy testing. Methods Anonymous questionnaire survey sent to all WA public and private hospitals' senior clinical staff (38 units where gynaecological surgery was performed in WA). Results Sixty-one senior health professionals (heads of department, medical directors, theatre nurse managers), completed the survey (estimated response rate 71%). Thirty-eight (68%) of respondents' units had guidelines for pre-operative pregnancy testing and 55% respondents worked in hospitals which tested all women of reproductive potential. Nineteen (33%) respondents reported cases in which patients had presented for surgery unaware they were pregnant. Forty-one (76%) respondents believed that all women of reproductive potential should have routine pre-operative pregnancy testing. Fifty-four (89%) supported the introduction of national or statewide guidelines. Discussion There are inconsistent processes of pre-operative assessment of pregnancy status in WA hospitals performing gynaecological surgery potentially resulting in adverse incidents. The majority of senior clinical staff surveyed supported routine pre-operative testing and the need for national or statewide guidelines.

Frozen sections are a valuable resource when utilised properly. This review aims to raise awareness of the strengths and limitations of its use in gynaecological surgery.This is a review of literature combined with experience and survey of the practice in the United Kingdom.Frozen sections are a valuable adjunct to diagnosis and management in gynaecological surgery, when requested appropriately, handled by a pathologist who is aware of the clinicopathologic setting and accepted by a surgeon who is acquainted with the limitations of the procedure.

Key content Nerve injuries are a common complication of gynaecological surgery, occurring in 1.1–1.9% of cases. Patient mal-positioning, incorrect placement of self-retaining retractors, haematoma formation and direct nerve entrapment or transection are the primary causative factors in perioperative nerve injury. Nerves most commonly injured during surgery include the femoral, ilioinguinal, pudendal, obturator, lateral cutaneous, iliohypogastric and genitofemoral nerves. The majority of neuropathies resolve with conservative management and physiotherapy. Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants and gamma-aminobutyric acid (GABA) antagonists are of significant benefit in managing painful neuropathies. Learning objectives To gain an overview of the spectrum of different neuropathies that may occur following pelvic surgery. To learn about safe surgical techniques in the prevention of postoperative neuropathies. To review the clinical anatomy of the lumbo-sacral and brachial plexuses. Ethical issues Neuropathies can cause considerable postoperative morbidity. Should neuropathies following gynaecology surgery be discussed routinely during consent taking? Neuropathies following surgery may have considerable medico-legal implications.

Key content Injury of the urinary tract is the most common major complication of gynaecological laparoscopic surgery. Injury to either bladder or ureter results in significant morbidity for the patient and may lead to litigation. Knowledge of pelvic anatomy, training and meticulous technique are of paramount importance in reducing the incidence of urinary tract injury. Ideally an injury should be identified and repaired during the primary operation, but vigilance in the immediate postoperative period may result in early recognition and intervention. Learning objectives To understand the common risk factors of urinary tract injury at laparoscopy. To learn strategies to prevent injury where possible. To learn strategies for intraoperative and postoperative recognition and repair of such injuries. To understand the significance of multi-disciplinary management of such injuries. Ethical issues Limited evidence shows that laparoscopic hysterectomy may carry a higher risk of urinary tract injury compared with abdominal hysterectomy. Should patients be counselled accordingly?

Obesity is a big problem which is growing. Thus clinicians and surgeons are likely to treat obese patients more frequently. Obesity can affect medical practice in a number of ways. In order to protect ourselves from potential litigation, we need to focus on risk management efforts on creating a safe environment for patients of all sizes. The aim of our study was to review the risk management strategies of obese women prior to surgery, perioperatively and following surgery. We then identified the strategies and have brought them forward in our article.

Background Fast-track surgery (FTS), also known as enhanced recovery after surgery, is a multidisciplinary approach to accelerate recovery, reduce complications, minimise hospital stay without increasing readmission rates, and reduce health care costs, all without compromising patient safety. The advantages of FTS in abdominal surgery most likely extend to gynaecological surgery, but this is an assumption, as FTS in elective gynaecological surgery has not been well studied. No consensus guidelines have been developed for gynaecological oncological surgery although surgeons have attempted to introduce slightly modified FTS programmes for patients undergoing such surgery. To our knowledge, there are no published randomised controlled trials; however, some studies have shown that FTS in gynaecological oncological surgery leads to early hospital discharge with high levels of patient satisfaction. The aim of this study is whether FTS reduces the length of stay in hospital compared to traditional management. The secondary aim is whether FTS is associated with any increase in post-surgical complications compared to traditional management (for both open and laparoscopic surgery). Methods/design This trial will prospectively compare FTS and traditional management protocols. The primary endpoint is the length of post-operative hospitalisation (days, mean ± standard deviation), defined as the number of days between the date of discharge and the date of surgery. The secondary endpoints are complications in both groups (FTS versus traditional protocol) occurring during the first 3 months post-operatively including infection (wound infection, lung infection, intraperitoneal infection), post-operative nausea and vomiting, ileus, post-operative haemorrhage, post-operative thrombosis, and the Acute Physiology and Chronic Health Enquiry II score. Discussion The advantages of FTS most likely extend to gynaecology, although, to our knowledge, there are no randomised controlled trials. The aim of this study is to compare the post-operative length of hospitalisation after major gynaecological or gynaecological oncological surgery and to analyse patients’ post-operative complications. This trial may reveal whether FTS leads to early hospital discharge with few complications after gynaecological surgery. Trial registration number NCT02687412. Approval Number: SCCHEC20160001. Date of registration: registered on 23 February 2016.

Objectives A common complication of surgery is peri-operative blood loss, which increases the likelihood of red blood cell (RBC) transfusion and its associated risks. The objective of this study was to identify demographic, medical, and surgical factors that may predict the need for RBC transfusion in patients undergoing benign gynaecological surgery. Methods We performed a retrospective cohort study of patients undergoing benign gynaecological surgery between April 1st 2016 to March 31st 2017 in a tertiary care hospital. Log binomial regression model was used to calculate risk ratios and adjusted risk ratios, while controlling for the effect of preoperative anaemia. Results Among the 988 patients included, 41 patients (4.1%) received an RBC transfusion and 185 (18.7%) had preoperative anemia. In the total cohort, mean haemoglobin was 126.19+/-15.43g/L, while itwas 104.39+/-21.59g/L among those who received RBC transfusion. Patients had an increased risk of requiring RBC transfusion if they had preoperative anemia (RR 8.37[95%CI 4.48-15.64]), abnormal uterine or vaginal bleeding (RR 2.47[95%CI 1.21-5.03]), underwent vaginal/hysteroscopic myomectomy (RR 6.28[95%CI 1.82-21.69]), or had a salpingectomy (RR 2.13[95%CI 1.01-4.48]). Risk of RBC transfusion was lower among patients with vaginal hysterectomy (RR 0.08[95%CI 0.01-0.57]) and prolapse repair (RR 0.06[95%CI 0.01-0.44]). After controlling for preoperative anemia, only vaginal/hysteroscopic myomectomy showed increased risk of requiring RBC transfusion (RR 3.36[95%CI 1.13-10.01]). Conclusions Preoperative anemia and vaginal/hysteroscopic myomectomy are important independent risk factors for predicting the need for increased RBC transfusion in the peri-operative period. Identifying risk factors can facilitate peri-operative management to minimize the need for transfusion.

Gynaecology surgery is the commonest cause of iatrogenic injury of the urinary tract. Rapidly evolving surgical techniques and gynaecological training involving less surgical experience compared to previous years means there is a need to proactively minimise this risk. If ureteric injury is unrecognised it can result in prolonged morbidity and potential loss of organ function. Injuries may be avoidable by preoperative assessment, attention to risk factors and meticulous surgical technique. Counselling patients regarding potential injury is important especially if there are pre-existing risk factors. A high index of suspicion and prompt evaluation may improve immediate recognition and thereby improve prognosis. Any delay in postoperative recovery especially with flank pain should raise the suspicion of urinary tract injury and prompt diagnostic evaluation should be undertaken. Surgical repair should be done by specialists with sufficient expertise and woman should be debriefed and followed up to improve patient satisfaction and reduce litigation rates.

Venous thromboembolism (VTE) and pulmonary embolism (PE) are two of the major causes of perioperative mortality and morbidity. In the past, thromboembolism has been considered as a rare disease in ...

Highlights • We encountered a peculiar case of surgical emphysema 3 days after an uneventful laparoscopic left colectomy. • We reviewed the literature to ascertain the presence of similar episodes. • Albeit unable to determine the cause of the event, this is the first case of delayed emphysema after a laparoscopic colorectal procedure., INTRODUCTION Surgical emphysema is a known early complication of laparoscopic surgery, common during upper gastrointestinal and gynaecological surgery; the authors present the first case of delayed subcutaneous emphysema following a laparoscopic left hemicolectomy. PRESENTATION OF CASE A 52-year-old woman underwent a laparoscopic left hemicolectomy for a sigmoid malignancy; on the third post-operative day after an uneventful procedure, she developed a massive surgical emphysema involving her face, neck and chest with associated pneumoperitoneum but without any evidence of pneumothorax. A gastrograffin enema ruled out an anastomotic leak. Apart from a borderline tachycardia, mildly low saturations and an area of erythema in her right flank, she was totally asymptomatic. The emphysema resolved spontaneously around the 6th post-operative day. DISCUSSION Massive subcutaneous surgical emphysema after laparoscopic colorectal surgery is a rare complication and can me managed conservatively with a good outcome. CONCLUSION To our knowledge, this represents the first case of delayed massive surgical emphysema following colorectal surgery, the aetiology of which has still not been clearly explained, after exclusion of the most common causes.

Key content Enhanced recovery pathways improve the quality and experience of care for patients undergoing elective gynaecology surgery. Enhanced recovery pathways enable patients to recover more quickly and leave hospital sooner. Enhanced recovery pathways reduce physical and psychological stress on patients. Enhanced recovery pathways involve patients in their own care, which leads to better outcomes. Learning objectives To understand the principles and benefits of enhanced recovery pathways. To share learning and experience of enhanced recovery pathways. Ethical issues Further research in the form of a randomised controlled trial of enhanced recovery versus ‘old fashioned’ care would be difficult as denying aspects of care would not be ethical.

Intra-operative oesophageal Doppler monitor-guided fluid management has been associated with improved postoperative length of hospital stay and morbidity in gastrointestinal and orthopaedic surgery. We designed a randomised controlled trial to test the hypothesis that this approach to intra-operative fluid management in major elective open gynaecological surgery would shorten the length of postoperative stay, defined as time to readiness for hospital discharge. Postoperative morbidity was evaluated as a secondary outcome. The oesophageal Doppler monitor group underwent intra-operative fluid management using an oesophageal Doppler-guided stroke volume optimisation algorithm. Control group (conventional fluid therapy) intra-operative fluid management was based on conventional haemodynamic indices. In a single centre, 102 patients were randomly assigned: 51 to the oesophageal Doppler monitor group (51 analysed) and 51 to the control group (50 analysed). Evaluators who were blinded to patient assignment collected postoperative outcome data. There was no difference in the length of postoperative hospital stay between the groups: median (IQR [range]) number of days until ready for discharge was 6 (5-8 [4-25]) days in the oesophageal Doppler monitor group compared with 7 (5-9 [4-42]) days in the control group, p = 0.5. There was no difference between the groups in postoperative morbidity survey scores on postoperative days 1, 3 or 5. Seven patients in the oesophageal Doppler monitor group and 11 in the control group experienced postoperative complications (p = 0.41). These findings question whether intra-operative oesophageal Doppler-guided fluid therapy is of benefit in patients undergoing open gynaecological surgery.

PURPOSE OF REVIEW To provide an overview of the available evidence on the role of the different methods in laparoscopic training, and to summarize the results obtained with standardized training programmes in advanced laparoscopic gynaecological surgery. RECENT FINDINGS Box trainers as well as virtual reality simulators ensure a benefit in terms of surgical skills development. No data are available showing superiority of one method compared to another. Global Operative Assessment of Laparoscopic Skills (GOALS) remains the most widely used and established scoring system to assess the acquired laparoscopic abilities, also in the field of advanced gynaecological surgery. Standardized training programmes have been recognized as reliable tools able to improve the development of surgical skills, particularly for innovative surgical techniques, such as laparoscopic endoscopic single-site surgery. SUMMARY The traditional approach based on observing and assisting needs to be updated incorporating box trainers and virtual reality simulators. The development of innovative training methods, integrating box trainers and virtual reality simulators, represents the future horizon. All tertiary centres involved in advanced laparoscopic gynaecological surgery should contribute to the development of an integrated network of standardized training programmes, in order to ensure a high-quality laparoscopic training to gynaecologists.

In the past 2 decades, a gradual shift has taken place from the 'person approach' to patient safety (in which the individual clinician at the sharp end is blamed for any accident) to a 'systems approach' (in which causation of accidents is attributed to loopholes in the organisational defences). Increasingly, however, concern has been expressed that the systems approach risks absolving individuals from responsibility for patient safety, and a balance between the systems and person approaches has been sought. In this paper, resolution of the tension between the person and the systems approaches is advocated through the use of a paradigm that places more emphasis on the relationships between the individual at the sharp end and other components of the system. This paradigm, which is adapted from ecosystems, has been labelled the 'bionomic approach'. A bionomic approach to patient safety incorporates principles and concepts of human ecology and applies them to the healthcare system, situating the individual as an intrinsic component of the system rather than an adjunct. It builds on the notion that 'people create safety' and on the recognition that, in some clinical areas, particularly surgery, the individual is the primary defence against patient safety incidents. Skills required for 'error wisdom' are described, and the principles of the bionomic approach are applied to gynaecological surgery, using an illustrative case study.

Objectives This randomized, double-blind study compared the antiemetic efficacy of ramosetron with that of ramosetron combined with midazolam, and investigated whether the timing of midazolam administration affected the incidence of postoperative nausea and vomiting (PONV). Methods Nonsmoking female patients undergoing laparoscopic gynaecological surgery were randomized to three groups: group R received intravenous (i.v.) normal saline at induction of anaesthesia and 30 min before the end of surgery; group RM1 received midazolam i.v. at induction of anaesthesia and normal saline i.v. 30 min before the end of surgery; group RM2 received normal saline i.v. at induction of anaesthesia and midazolam i.v. 30 min before the end of the surgery. All patients received 0.3 mg ramosetron i.v. at the end of surgery. Incidence of PONV and need for rescue antiemetics were assessed during the 48-h postoperative period. Results A total of 126 patients were included in the analyses. There was no significant difference in the incidence of severe nausea, emetic episodes or use of antiemetics among the three groups. The incidence of complete response (no PONV and no rescue antiemetics) was significantly higher in the RM1 (30/41; 73%) and RM2 (30/42; 71%) groups compared with group R (19/43; 44%). Conclusions Midazolam given at induction of anaesthesia or at the end of the surgery, combined with ramosetron, was more effective than ramosetron alone in reducing the incidence of PONV.

The term 'laser' is an acronym for Light Amplification by Stimulated Emission of Radiation. Lasers are commonly described by the emitted wavelength, which determines the colour of the light, as well as the active lasing medium. Currently, over 40 types of lasers have been developed with a wide range of both industrial and medical uses. Gas and solid-state lasers are frequently used in surgical applications, with CO2 and Ar being the most common examples of gas lasers, and the Nd:YAG and KTP:YAG being the most common examples of solid-state lasers. At present, it appears that the CO2, Nd:YAG, and KTP lasers provide alternative methods for achieving similar results, as opposed to superior results, when compared with traditional endoscopic techniques, such as cold-cutting monopolar and bipolar energy. This review focuses on the physics, tissue interaction, safety and applications of commonly used lasers in gynaecological surgery.