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Abnormal uterine bleeding (AUB) is a substantial cause of ill health in women worldwide. In this study, our aim was to evaluate the effectiveness of endometrial ablation using a modified urologic resectoscope along with tranexamic acid in AUB. Sixty patients were enrolled in this study. All patients underwent resectoscopic surgery. Patients were randomly divided into two groups. Group 1 (n = 30) received 500 mg of tranexamic acid. Group 2 (n = 30) served as the control group and underwent surgery without the administration of tranexamic acid. Total pictorial blood loss assessment chart (PBAC) scores were significantly lower postoperatively (152.14 ± 9.65 versus 6.6 ± 0.90; P < 0.001). When stratified by the administration of tranexamic acid, the number of patients with a postoperative day 1 PBAC score ≤15 was higher in the tranexamic group (19 versus 13), whereas the number of patients with a post operative day 1 PBAC score >15 was lower in the tranexamic group (11 versus 17), but the differences were not statistically significant (P > 0.05). AUB is a complex disease that may need repeated treatments. In expert hands, the treatment rate of resectoscopic surgery seems acceptable. However, some patients may require additional interventions, like repeated surgery, hysterectomy, or a drug therapy in the long run. Introduction of tranexamic acid as a potential adjunct to rollerball endometrial ablation may present an interesting option that requires additional well-designed studies before firm conclusions can be made.

Background Enhanced recovery has been shown to improve patients’ experience after surgery. There are no previous studies comparing patients’ experience between those undergoing laparoscopic and open gynaecological surgery. Therefore, the aim of this prospective study is to compare patients’ functional recovery based on milestones set by the enhanced recovery programme and patients’ satisfaction between the two groups. Methods All eligible patients undergoing gynaecological surgery within an enhanced recovery after surgery (ERAS) programme from March to August 2014 were involved in this study. All patients received the questionnaires on admission which were then collected prior to discharge. They were followed up by telephone within 7 days. Results Two hundred sixty-three patients were involved. One hundred forty-four questionnaires were returned (54% response rate). Fifty-one percent (n = 74) were from the laparoscopic group and 49% (n = 70) were from the laparotomy group. In terms of achieving milestones, more patients in the laparotomy group performed the deep breathing exercises (laparoscopic versus open; 66.2% versus 87.1% (p = 0.003). The laparoscopic group were more able to eat on day 0, but by day 1, there was no difference between the groups. Both groups were similar in their ability to drink (p = 0.98), mobilise (p = 0.123) and sit out in a chair (p = 0.511). In the laparoscopic group, the patients’ experience was better for pain control (p

Background: Gynaecological surgeries refer to surgery on the female reproductive system. Woman may undergo a Gynaecological surgery for different reasons, including; Uterine prolapse, Cancer of the uterus, cervix, or ovaries, Endometriosis, Bleeding, Adenomyosis etc.Gynaecological surgeries includes procedures such as hysterectomy, oopherectomy, salphingectomy, myomectomy, ovarin cystectomy, etc. The Physiotherapy referral is essential in such cases but most of time the patients are not referred for Physiotherapy. Hence the current study was undertaken. Thus the objective is to find out the Effectiveness of Physiotherapy management over quality of life in post-operative Gynaecological patients. Methods: 32 females who underwent Gynecological surgery were taken into the study and divided conveniently into Group A and Group B consisting of 16 females each. Physiotherapy intervention given to Group A includes- Breathing exercises, Coughing techniques, Circulatory exercises, Knee rolling, log rolling, patient made to sit, Abdominal exercises, Pelvic tilting, Getting in and out of the bed, Pelvic floor exercises and mobilization inside the ward, outside the ward and stair climbing where as conventional treatment which includes Breathing exercises and Back care were given to Group B for a period of 5 days. Outcome measures used were VAS (Visual Analog Scale) and ASIS (Abdominal Surgery Impact Scale). Results: There was a significant difference in post test score of VAS (p=0.0001) and ASIS (p=0.0001) in Group A as compared to Group B. Conclusion: This study revealed that physiotherapy intervention performed immediately after Gynecological surgery improves quality of life of the patients and a scheduled exercise program benefits the patient more than conventional Physiotherapy management and it should be emphasized to all the post Gynecological surgery Patients.

Background Electroacupuncture (EA) is believed to modulate the pain pathway via the release of endogenous opioid substances and stimulation of descending pain inhibitory pathways. In this study, the use of intraoperative 2 Hertz EA stimulation is investigated to determine any opioid-sparing effect and reduction of postoperative nausea and vomiting (PONV) in patients undergoing gynaecological surgery. Patient and methods This was a prospective, double blinded randomized study conducted in a tertiary hospital in Malaysia. Patients (n = 64) were randomly allocated to receive 2 Hertz EA and compared to a control group. EA was started intraoperatively till the end of the surgery (mean duration of surgery was 149.06 ± 42.64 minutes) under general anaesthesia. Postoperative numerical rating scale (NRS), the incidence of nausea, vomiting and usage of rescue antiemetics were recorded at 30 minutes, 2, 4, and 24 hours, respectively. The total morphine demand and usage from the patient-controlled analgesia Morphine (PCAM) were also recorded in the first 24 hours postoperatively. Results The mean NRS was 2.75 (SD = 2.34) at 30 minutes and 2.25 (SD = 1.80) at 2 hours postoperatively in the EA group that was significantly lower than the mean NRS in the control group as 4.50 (SD = 2.37) at 30 minutes and 3.88 (SD = 2.21) at 2 hours. The mean PCA morphine demand was 27.28 (SD = 21.61) times pressed in the EA group and 55.25 (SD = 46.85) times pressed in the control group within 24 hours postoperatively, which showed a significant reduction in the EA group than the control group. Similarly, total morphine requirement was significantly lower in the EA group with the value of 21.38 (SD = 14.38) mg compared to the control group with the value of 33.94 (SD = 20.24) mg within 24 hours postoperatively. Incidence of postoperative nausea also significantly reduced in the EA group at 30 minutes (15.6%) compared to the control group (46.9%). Conclusions It can be concluded that subjects receiving EA intraoperatively experienced less pain and PONV. Hence, it is plausible that EA has an opioid-sparing effect and can reduce PONV.

OBJECTIVE Vesicovaginal fistula (VVF) causes detrimental psychosomatic effects on a woman. It is repaired using open abdominal as well as laparoscopic approach. Here we compare a series of open versus laparoscopic VVF repairs done at a single centre. METHODS Retrospectively data of patients undergoing VVF repair in our department between January 2011 to December 2014 was analyzed. Patients who had a single, primary, simple VVF following a gynaecological surgery were included in the study. 26 patients met all the criteria. Out of these, thirteen patients had undergone a laparoscopic VVF repair (group 1) while thirteen had undergone an open transabdominal VVF repair (group 2). RESULTS Mean fistula size was 2.14±0.23 cm in group 1 and 2.18±0.30 cm in group 2, which was comparable. Mean blood loss was 58.69±6.48 mL in group 1 and 147.30±19.24 mL in group 2, which is statistically significant (P

Background. Pain is commonly experienced following surgical procedures. Suboptimal management is multifactorial.Objectives. The primary objective was to assess whether patients used a device (Navimed) to self-report pain over and above a normal baseline of observations. Secondary outcome measures included comparison of pain scores and patient use of and feedback on the device.Methods. In a prospective randomized controlled trial, elective gynaecological surgery patients received standard postoperative pain care or standard care plus the Navimed, which allowed them to self-report pain and offered interactive self-help options.Results. 52 female patients, 26 in each of device and standard groups, did not differ in the frequency of nurse-documented pain scores or mean pain scores provided to nurses. The device group additionally reported pain on the device (means 18.50 versus 11.90 pain ratings per day,t(32)=2.75,p<0.001) that was significantly worse than reported to nurses but retrospectively rated significantly less anxiety. 80% of patients found the device useful.Discussion and Conclusion. This study demonstrates that patients used the Navimed to report pain and to help manage it. Further work is required to investigate the difference in pain scores reported and to develop more sophisticated software.

The objective of this article is to examine the options, the effectiveness and the safety of the energies used in gynaecological minimal invasive surgery (MIGS), laparoscopic surgery developed in the end of 20th century. The rapid development of the MIGS in the last 3 decades is partly due to the advances and innovations achieved in the field of electro, sono and laser energy modalities. In general the energy modalities that are used in MIGS today are laser, ultrasound, bipolar – monopolar electrosurgery, high radio frequency and sealing electrosurgery techniques. The various sealing techniques provide an excellent haemostasis option avoiding tissue carbonization and necrosis. The monopolar and simple bipolar diathermies and laser thermal and haemostasis effect, depend solely on the surgeon’s arbitrary estimation of the duration and intensity of the energy that has to be applied on the tissue in order to achieve haemostasis. However, once the advanced bipolar and ultrasonic energies are used vascular sealing is achieved automatically since the device calculates the electrical resistance of the tissue thickness and the duration needed for optimum haemostasis results. Hence, in this article we review the various energies used, technical aspects, safety and efficacy in haemostasis during MIGS.

OBJECTIVE Structure and mechanical properties of red blood cells are markedly influenced by pathophysiology of many diseases which in turn potentially impair microcirculatory blood flow. The physiological association between blood rheological parameters and red blood cell indices was investigated in otherwise healthy unselected mid-age women prior to elective gynaecological surgery. METHODS Red Blood Cell-deformability (RBC 1.2, 3.0; 6.0, 12.0; 30.0, 60.0) during exposure to low (RBC 1.2, 3.0), moderate (RBC 16.0, 12.0) and high shear forces (RBC 30.0, 60.0; Rheodyn; Myrenne), -aggregation (MA1; Myrenne) during low shear (E1; 4-1 S) and in stasis (E0) and plasma viscosity (Pv; KSV 1; Fresenius) were correlated with red blood cell indices (RBC-I: MCV, MCH and MCHC) and subjects' characteristics in 286 healthy women the day before undergoing gynaecologic standard surgery. Women with known pregnancy, malign-, infective-, chronic-disease or extreme BMI ( 40 Kg/m2) were excluded from this trial. RESULTS From June 2014 to December 2014 a total of 286 healthy women (age: 46.5±17.6 y; BMI: 25.5±5.2 kg/m2) were eligible for inclusion into this prospective evaluation. Pv (mean±SD: 1.17±0.12 mPa s) and RBC aggregation (E0:12.6±6.3; E1:17.9±7.3) were not significantly correlated with RBC-I but with age and BMI. In contrast, RBC-deformability correlated significantly with MCV and MCH but significantly inversely correlated with MCHC. Deformability significantly increased with age but was unaffected by BMI of women. The correlation between RBC-I and RBC deformability was most remarkable during moderate shear force exposure. Neither haemoglobin nor haematocrit were correlated with RBC deformability or RBC-I. CONCLUSIONS Cell volume and haemoglobin content had a strong impact on deformability in apparently healthy mid age women, whereas low MCHC and large MCV were associated with an increase in deformability while high MCHC and small MCV correlated with increased rigidity of RBC. BMI had no impact on deformability while age was associated with an increase in all determinants of blood viscosity. RBC aggregability was not affected by MCV, MCHC or MCH in mid-age women.

Introduction. Manikin studies’ data cannot accurately be extrapolated to real-life scenarios and inherent differences in design and materials of newer products may affect their clinical performance.Methods. Hence, we compared the AMBU® Aura-i™ and LMA Supreme™ in this randomized trial involving 100 ASA 1-2 unparalysed anaesthetised patients undergoing minor gynaecological surgery. Investigators had Results. 43 (86%) AMBU Aura-i and 44 (88%) LMA Supremes were successfully inserted on first attempt (p=0.59), with similar ease (p=0.79), and comparable times to first capnogram, mean (SD) 18.2 (6.0) versus 17.3 (6.4) sec,p=0.9. The Aura-i needed significantly less volume of air to inflate its cuff to 60 cmH2O on the manometer, 17.7 (3.5) versus 23.1 (4.4) mL,p<0.001. Both devices exhibited similar OLP, Aura-i versus LMA Supreme, mean (SD) 28.8 (7.1) versus 27.3 (5.3) cmH2O,p=0.24. There was no difference in ease of insertion or adjustment manoeuvres to aid ventilation. 90% of patients had good positioning of Aura-i on fibreoptic check, yielding a view of the vocal cords and epiglottis. In 5 patients (10%), the vocal cords were not seen, but ventilatory function was unaffected.Conclusions. The Aura-i handled well in novices hands, with comparable times to insert and establish ventilation, similar leak pressures, and successful first attempt insertion rates compared to the LMA Supreme.

The aim of this study was to identify, quantify and evaluate the use of robotic materials and operating theatre times in Telelap ALF-X robotic hysterectomy.Cost analysis was performed on 81 patients who underwent a Telelap ALF-X robotic hysterectomy. Data were collected during a phase II study trial conducted at the University Hospital A. Gemelli, Catholic University, Rome. According to micro-costing technique, surgical team costs, materials and operating theatre usage were recorded during each surgical intervention. Cost data were provided by the hospital's accounting office. Probabilistic sensitivity analysis was carried out in order to test the robustness of the results by assuming an Inv-norm random variable.The base case analysis showed a cost/patient of €3391.82. The new robotic device requires a low consumption of robotic materials. Sensitivity analysis showed that the most sensitive cost driver was use of the operating theatre.This study shows that Telelap ALF-X robotic hysterectomy is feasible and safe and could offer specific advantages in terms of cost. Copyright © 2016 John WileySons, Ltd.

Complicated Vesicovaginal Fistulae (VVF) is prevalent in developing countries following obstetric injury. We report a rare case of a large dumbbell shaped vesicovaginal calculus measuring 7x 4.6cm in a patient with recurrent, complicated VVF managed successfully in two stages 6 weeks apart. Holmium laser (30 Watt) cystolithotripsy was used to break the vesical portion of the stone at the waist of the dumbbell, followed by delivery of vaginal part of the stone. Trans-abdominal VVF repair (O’Connor method) with omental interposition flap with right side ureteric reimplant was done after six weeks. Our case was unique because of occurrence of a larger sized fistula after a gynaecological surgery. She had developed larger stone (weight more than190gm- vaginal component) into the fistula tract. Also she had undergone multiple failed VVF repair attempts before. Use of holmium laser energy to break the stone was unique which minimized the morbidity of the first procedure leading to early recovery followed by staged repair of fistula after six weeks.

Whereas the evidence base for surgical thromboprophylaxis has centred on elective orthopaedic surgery and subsequently been adopted in cancer surgery there is a good evidence base for the prevention of thromboembolic disease in other surgical specialities. This chapter will present the evidence base for four surgical specialities — neurological, urological, cardiovascular and gynaecological surgery. A common theme is the difference in elective versus emergency thromboprophylaxis.

To determine patients' understanding and recall of consent information and risks associated with their procedure following gynaecological surgery.Patients planned for routine gynaecological surgery were invited to participate in the study by completing a self-administered questionnaire 4-6 h after day-surgery and 24 h after in-patient surgery. Collated data were analysed using standard statistical methods.544 women participated in the study. 321 (57.9 %) were day-cases and 233 (42.1 %) were in-patients. 33 % and 30.8 % of in-patients and day-cases, respectively did not recall any risk associated with their procedure. Among in-patients, women who did not recall any risk were less likely to have post primary education (84.2 vs. 96.2 %, P = 0.008), understood an information leaflet (79.5 vs. 95.1 %, P = 0.002), understood the consent counselling (85.5 vs. 98 %, P = 0.001), or remember the explanation of procedure and risks (85.5 vs. 98 %, P = 0.001). Among women who did not recall any risk, the day-case women were less likely to have read the information leaflet (86.4 vs. 96.2 %, P = 0.002), understood the information leaflet (79.5 vs. 98.9 %, P = 0.007), or understood the consent counselling (85.5 vs. 98.9 %, P0.001) when compared to in-patients.A third of women who had planned gynaecology procedure do not recall any risk associated with the procedure. Provision of information leaflet did not make any consistent difference.

The aim of this retrospective study was to review what kinds of surgical procedures are most frequently complicated by urovaginal fistulae, to find out how they were diagnosed and managed, and to study the outcome after surgical reconstruction.Nineteen women who underwent fistula repair at Sahlgrenska University Hospital between 2003 and 2009 were retrospectively studied by reviewing the medical records.For 17 of the 19 patients hysterectomy was the causative procedure. Fourteen patients developed vesicovaginal and five developed ureterovaginal fistula. Urethrocystoscopy was sufficient for the diagnosis in nearly 50% of the patients and when combined with methylene blue instillation 90% of all fistulae were found. Several patients sought medical advice due to vaginal leakage following gynaecological surgery without the doctor suspecting a fistula, and for these patients the diagnosis was delayed. Eighteen patients were operated on with an abdominal approach and one with a vaginal approach, in all cases a minimum of 3 months after primary surgery. The reconstruction technique included the interposition of vascularized tissue. None of the patients reported leakage or relapse at follow-up after fistula repair.Hysterectomy was the most common cause behind the formation of urovaginal fistulae. Misinterpretation of symptoms after gynaecological surgery was common even in cases where the symptoms were indicative of a urovaginal fistula. Delayed fistula repair after a minimum of 3 months, via the abdominal route and with the interposition of vascularized tissue, yielded an excellent final outcome.

Please cite this paper as: Frajzyngier V, Ruminjo J, Asiimwe F, Barry T, Bello A, Danladi D, Ganda S, Idris S, Inoussa M, Lynch M, Mussell F, Podder D, Barone M. Factors influencing choice of surgical route of repair of genitourinary fistula, and the influence of route of repair on surgical outcomes: findings from a prospective cohort study. BJOG 2012;119:1344–1353. Objective The abdominal route of genitourinary fistula repair may be associated with longer term hospitalisation, hospital-associated infection and increased resource requirements. We examined: (1) the factors influencing the route of repair; (2) the influence of the route of repair on fistula closure 3 months following surgery; and (3) whether the influence of the route of repair on repair outcome varied by whether or not women met the published indications for abdominal repair. Design Prospective cohort study. Setting Eleven health facilities in sub-Saharan Africa and Asia. Population The 1274 women with genitourinary fistula presenting for surgical repair services. Methods Risk ratios (RRs) and 95% confidence intervals (95% CIs) were generated using log-binomial and Poisson (log-link) regression. Multivariable regression and propensity score matching were employed to adjust for confounding. Main outcome measures Abdominal route of repair and fistula closure at 3 months following fistula repair surgery. Results Published indications for abdominal route of repair (extensive scarring or tissue loss, genital infibulation, ureteric involvement, trigonal, supratrigonal, vesico-uterine or intracervical location or other abdominal pathology) predicted the abdominal route [adjusted risk ratio (ARR), 15.56; 95% CI, 2.12–114.00]. A vaginal route of repair was associated with increased risk of failed closure (ARR, 1.41; 95% CI, 1.05–1.88); stratified analyses suggested elevated risk among women meeting indications for the abdominal route. Conclusions Additional studies powered to test effect modification hypotheses are warranted to confirm whether the abdominal route of repair is beneficial for certain women.

The principles in relation to gynaecological surgery are detailed. The importance of preoperative management, counselling, consent, surgical approaches, prophylaxis and proactive postoperative management are discussed. Gynaecological conditions are varied and descriptions of the individual surgical procedures are not included.

This was a survey, undertaken in the UK, which was sent to all obstetricians and gynaecologists. The aim was to establish the current advice given for activities during convalescence after commonly performed benign gynaecological surgery. Questionnaires were sent to all the obstetricians and gynaecologists working in 235 NHS hospitals in the UK. The total response rate was 30.51%. There is substantial variability in the advice for activities during convalescence following gynaecological surgery. This has enormous implications - mainly financial. The economic impact of absence from work is enormous. One extra day of sick leave given to patients has a direct cost of approximately £34 million annually. Our survey highlights the need for structured and evidence-based recommendations for convalescence activities following benign gynaecological surgery.

While worldwide, the predominant cause of VVF is obstructed labour due to poor obstetric care, in obstetrically developed countries this is usually an iatrogenic complication of gynaecological surgery, most commonly abdominal hysterectomy, occurring in one in every 1800 hysterectomies [ 2 – 4 ] . Generally, VVF occurs 1 – 6 weeks after gynaecological or obstetric surgery, while recurrent fi stula can develop within the fi rst 3 months after primary repair [ 2 ] .

The study was undertaken to compare the clinical and quality-of-life (QoL) outcomes of the inside-out transobturator vaginal tape (TVT-O)-only procedures and TVT-O procedures with concomitant transvaginal gynaecological surgery for the treatment of stress urinary incontinence (SUI). A review of charts from January 2006 to March 2010 identified 305 patients with urodynamic stress incontinence for whom we performed the TVT-O. Of the initial 305 patients, 272 (89.2%) were re-examined for complications 1 month, 4 months, 1 year and 2-4 years postoperatively (122 TVT-O only; 150 TVT-O + other transvaginal gynaecological surgery). They were also evaluated with the Urogenital Distress Inventory Questionnaire (UDI-6) and the Incontinence Impact Questionnaire (IIQ-7) 1-4 years after the procedure. The median follow-up was 37.3 months. The success rate was 89.3% in the TVT-O-only group vs 93.3% in the TVT-O with concomitant gynaecological surgery group (p =0.729). The QoL score was quite good for 91.8% of the TVT-O-only patients and for 96.7% of the TVT-O with concomitant gynaecologic surgery patients (p =0.405). In conclusion, gynaecological operations performed concomitantly with the TVT-O procedure do not affect the clinical and QoL outcomes of the TVT-O procedure.

We report the case of a patient who presented hypertension paroxysmal with acute pulmonary oedema followed by cardiocirculatory arrest during gynaecological surgery for resection of latero-aortic lymph nodes suspected to be cervical cancer metastases. This intervention, originally oncologic, has discovered ectopic phaeochromocytoma a posteriori. The management of perioperative serious adverse events revealing the undiagnosed phaeochromocytoma is discussed.

Objective To compare early versus delayed postoperative feeding in women undergoing major gynaecological surgery with regard to clinical outcomes, duration of postoperative stay, and patient satisfaction. Methods We conducted a parallel-randomized controlled trial at a tertiary care centre in Montreal, Quebec, between June 2000 and July 2001. Patients undergoing major gynaecological surgery were randomized following a 1:1 allocation ratio to receive either early postoperative feeding in which oral clear fluids were begun up to six hours after surgery followed by solid foods as tolerated, or delayed postoperative feeding, in which clear fluids were begun on the first postoperative day and solid foods on the second or third day as tolerated. The primary outcomes analyzed were duration of postoperative stay and patient satisfaction. Secondary outcomes included mean time to appetite, passage of flatus, and bowel movement, as well as the presence of symptoms of paralytic ileus. Results A total of 119 patients were randomized; 61 patients were assigned to the early feeding group and 58 to the delayed feeding group. Demographic characteristics, including age, weight, smoking status, and prior surgical history were comparable between both groups. There was no difference in length of postoperative stay between the two groups (86.4±21.0 hours in the early feeding group vs. 85.6±26.2 hours in the delayed feeding group; P >0.05). No significant difference was noted in patient satisfaction ( P >0.05). No difference was found in the frequency of postoperative ileus, mean time to appetite, passage of flatus, or first bowel movement. Conclusion The introduction of early postoperative feeding appears to be safe and well tolerated by patients undergoing major gynaecological surgery. The duration of postoperative stay, patient satisfaction, and gastrointestinal symptoms are comparable between patients undergoing early or delayed postoperative feeding.

We investigated the morbidity in elderly patients undergoing surgery due to pelvic organ prolapse.Perioperative data of 113 patients aged at least 50 years who underwent gynaecological prolapse surgery between 2005 and 2011 were analyzed retrospectively. Forty-eight women were older than 70 years and matched our inclusion criteria. Sixty-five patients aged 50-69 years undergoing similar surgical procedures during the same period of time formed the control group. Operating time, duration of hospital stay, intra- and postoperative complications, comorbidity, and body mass index were evaluated.There were no significant differences between study and control collective regarding operating time, duration of hospital stay, intra- and postoperative complications, and body mass index although a significant difference could be notified between the pre-existing comorbidity.Surgery due to a pelvic organ prolapse in patients aged more than 70 years is a feasible and save treatment to improve quality of life in elderly patients.

Background Adhesions lead to considerable patient morbidity and are a mounting burden on surgeons and the health care system alike. Although adhesion formation is the most frequent complication in abdominal and pelvic surgery, many surgeons are still not aware of the extent of the problem. To provide the best care for their patients, surgeons should consistently inform themselves of anti-adhesion strategies and include these methods in their daily routine. Methods Searches were conducted in PubMed and The Cochrane Library to identify relevant literature. Findings Various complications are associated with adhesion formation, including small bowel obstruction, infertility and chronic pelvic pain. Increasingly, an understanding of adhesion formation as a complex process influenced by many different factors has led to various conceivable anti-adhesion strategies. At present, a number of different anti-adhesion agents are available. Although some agents have proved effective in reducing adhesion formation in randomised controlled trials, none of them can completely prevent adhesion formation. Conclusion To fulfil our duty to provide best possible care for our patients, it is now time to regard adhesions as the most common complication in surgery. Further research is needed to fully understand adhesion formation and to develop new strategies for adhesion prevention. Large clinical efficacy trials of anti-adhesion agents will make it easier for surgeons to decide which agent to use in daily routine.

Objective To generate structured detailed uniform convalescence recommendations after gynaecological surgery by a modified Delphi method amongst experts and a representative group of physicians.

Background Respiratory rate is an important measurement in patient care but frequently poorly assessed. We set out to develop a simple non-invasive device to reliably measure respiratory movements and estimate respiratory rate, in clinical circumstances. Methods Respiratory movement was detected with an encapsulated tri-axial accelerometer (Orient speck) and the data transmitted wirelessly to a computer for analysis. We studied subjects after gynaecological surgery who received opioid analgesia, and compared the derived signal with a signal from nasal cannula using directly matched breaths and within the same 5 min epoch. We analysed the signals for 5 min epochs over a 15 h recording period. Results For matched breath analysis, the instantaneous respiratory rates matched within 2 bpm on 86% of occasions. A similar match was found between epoch averages of the respiratory rate. The mean absolute difference between the respiratory rate measured by nasal cannula and Orient speck was 0.6 bpm. The Orient speck generated reliable measures of respiratory rate every 5 min in 95.4% of epochs. Conclusions The Orient speck provides a reliable measure of respiratory rate at frequent intervals in subjects receiving patient-controlled morphine analgesia after surgery.

The public discussion about health care financing has an enormous relevance for the field of gynaecology and obstetrics. This second part of the paper of the financing commission of the DGGG presents essential financial aspects and problems, influencing our speciality. Among other aspects, the inputs of the DRG system are discussed for our field. The representation of all levels of care and all German states in the InEK calculation system is still a problem. Regarding the inpatient care, the number of cases has decreased by 23 over the last years due to the shift to the outpatient setting. Surgeries in the outpatient setting have increased by 31.5 from the year 2004 to the year 2008 (all specialities). Moreover, a decrease of obstetric cases by 5.7 and cases directly associated with birth by 7.3 has to be mentioned. Altogether, our field has lost 6.8 of all inpatient cases over the last years. The economic pressure is still high and it is difficult to maintain cost recovery. Regarding the personal resources, legal demands are problematic for perinatal centres, e. g. loss of the on-call duty possibility, availability of medical specialist expertise and necessity of permanent standby service of the head of the perinatal centre. Further problems of the inpatient setting concern the field of urogynaecology (lack of young academics, new technical procedures with lack of data, missing representation of complex surgeries and lack of reimbursement in case of surgeries in the outpatient setting) and the benign and malign gynaecological surgery. While standard procedures are almost represented in the DRG system, there is still a high demand for development of appropriate reimbursement for complex and infrequent case constellations, interdisciplinary procedures and simultaneous multiplex surgeries. The collaboration of all colleagues is essential.

Background and objectiveFentanyl is metabolised by cytochrome P450 (CYP) 3A4 and CYP3A5. Our previous work demonstrated that the CYP3A4*1G polymorphism significantly affects the post-operative fentanyl analgesic effect in Chinese women undergoing gynaecological surgery. However, whether CYP3A5*3, a

Recent studies using universal cystoscopy have demonstrated a higher rate of urinary tract injury at major gynaecological procedures than previously thought. These injuries are associated with significant medical and medico-legal implications. The sensitivity of visual inspection is low and cystoscopic screening with intravenous dye improves detection. We review the evidence for intra-operative cystoscopy in gynaecology, with emphasis on rates of urinary tract injury and the use of intravenous contrast dye.

Both sevoflurane and desflurane have shorter emergence times compared to isoflurane based anaesthesia. Because of its pharmacological properties, desflurane appears to yield a rapid early and intermediate recovery compared with sevoflurane. The aim of this study was to assess the maintenance and emergence characteristics after anaesthesia with sevoflurane or desflurane. One hundred female patients scheduled to undergo daycare laparoscopic gynaecological surgery were enrolled for this prospective study. Patients were randomised into two groups to receive either desflurane [group I (D); n = 50] or sevoflurane [group II (S); n = 50] for maintenance of anaesthesia. The demographic data and the duration of procedure were comparable in both the groups. The early recovery time was shorter after maintenance of anaesthesia with desflurane compared with sevoflurane. However, this faster early recovery failed to lead to early readiness for home discharge. The intraoperative haemodynamic characteristics were comparable with both sevoflurane and desflurane. Both sevoflurane and desflurane provide a similar time to home readiness despite a faster early recovery with desflurane. The intraoperative haemodynamics are similar with both the agents.

Iatrogenic injury of the lower urinary tract occurs during benign gynaecological surgery with a frequency of approximately 0.3%. The injuries sustained are often not detected intra-operatively, but on many occasions, the vulnerability of the urinary tract to injury can be anticipated by rigorous pre-operative assessment and the risk of injury reduced by intra-operative vigilance. Primary prevention offers the best outcome for patients, reducing acute and long-term morbidity, and reducing the risk of litigation. A high index of suspicion must be maintained for patients who present with atypical symptoms such as loin pain or per vaginal clear fluid loss following gynaecological surgery and early recourse to imaging and urological review should be sought. The risk of litigation following iatrogenic urinary tract damage can be reduced by appropriate behaviour of clinicians. Iatrogenic urinary tract infection or bladder over-distension injuries can also be reduced by following evidence based guidelines for cystoscopy and catheterization.

We have an improved understanding of the pathophysiology and impact of perioperative pain. Targeted interventions to prevent and manage nociception are effective in improving patient satisfaction and surgical outcome. There are many alternatives, each with its own profile of benefits, risks and side-effects. A logical, stepwise, balanced approach utilising multiple modalities is effective, scales easily to the type of surgery, can adapt to changing requirements and resources, and promotes a seamless transition from theatre care to the ward and patient self-reliance.

Introduction: Fast Track Surgery (FTS) programs have been adopted by many specialties with documented improved patient outcomes and reduced length of stay (LOS). Methods: We initiated a FTS program in January 2008 and present our experience up to and including November 2010 on patients whose LOS was 2 days. Results: During the study period 242 patients had a laparotomy performed. Overall 54(22.3%) patients were discharged on day 2. In the first year of initiating our FTS program 10% were discharged on day 2, 25% in year 2 and 31% in year 3. Twenty-two patients (41%) had malignant pathology and of these, 16 (73%) had local or regional spread and 6 (27%) had distant spread. Forty patients (74%) had vertical midline incisions (VMI) performed. Surgery was classified as complex in 40 cases (74%) and 6 (11%) patients underwent staging lymph node dissection. Average patient BMI was 26.1 with 44% of patients considered overweight or obese. There were no intraoperative complications recorded. When compared to 188 patients whose LOS was greater than 2 days, the early discharge cohort were more likely to have benign pathology, more likely to be younger, to have a transverse incision, to have received COX II inhibitors, to have a lower net haemoglobin (Hb) change and to tolerate early oral feeding. Conclusions: Increased clinical experience with FTS enables over 31% patients undergoing laparotomy to be safely discharged on day 2 without an increase in the read-mission rate or morbidity.

Enhanced recovery provides pathways of care consistent with the accepted definition of quality in the NHS – they are clinically effective, safe and are associated with increased patient satisfaction. The Royal College of Obstetricians and Gynaecologists has endorsed this approach for gynaecological surgery, and further work developing pathways for obstetrics is already underway. There are four key principles around surgical procedures: (1) reduction of the physiological and psychological stress associated with surgery; (2) patient preparation including optimizing fitness and providing detailed patient information; (3) patients having an active role and responsibility for enhancing their recovery, and (4) evidence-based proactive management along the pathway from community to hospital and back to the community. Designing pathways of care using these principles offers effective, safe peri-operative care that is associated with earlier post-operative recovery, leading to shorter length of stay and high patient satisfaction.

Paragangliomas are uncommon tumors arising from the neuroendocrine elements (chief cells) of the paraganglia and symmetrically distributed along the aorta in close association with the sympathetic chain. Although functional tumors are easier to diagnose due to the clinical fi ndings caused by excess secretion of catecholamines and an elevation of the urinary catecholamine levels, however the diagnosis of nonfunctioning paraganglioma of the retroperitoneum is diffi cult and only few cases have been made before exploratory laparotomy. Although our patient was initially planned and operated by our gynaecological team, the incidental fi ndings had to involve the general surgeons. She is fortunate that the tumour did not show any features of malignancy nor metastasis, however a long time follow up is needed in case of any possible recurrence. KEYWORDS: Paraganglioma, Non-functioning, Retroperitonium

Between 1979 and 1983, 1,292 cases who underwent major gynaecological operations in the Department of Obstetrics and Gynaecology, Khyber Hospital, Peshawar, were studied. One group (777 cases) had catheterization of bladder whereas the other group (515 cases) emptied their bladders immediately before anaesthesia and were not catheterized. There was no significant difference in the number of cases of retention of urine and bladder injury between the 2 groups except that in cases of laparotomy there were significantly fewer cases of retention in the non-catheterized patients (P = 0.05).

Increasingly, women of all ages are enjoying scuba diving. Therefore gynaecological issues involved diving medicine need to be considered in order be able to give suitable advice. Here we describe the effects of diving on body functions, and comment on the special aspects of decompression sickness in female divers, diving with breast implants, diving when taking oral contraceptives or during pregnancy and lactation, and after gynaecological surgery or tumour disease.

This study was made by a qualitative approach based on symbolic interactionism and grounded theory. The subject was defined as what mutilation means for nurses who take care of women submitted to gynaecological surgery. The aim was to identify the interaction relationship of nurses as female with the phenomenon of mutilation in gynaecological surgeries and how it affects their relationship with female patients in this situation. Data were obtained by interviews with 16 nurses who work in gynaecology units. The findings present two core categories: speaking as a professional and speaking as female. When they spoke as professional nurses they defined mutilation technically. As females they verbalized their conflict and difficulty in working with mutilation and redefined it as being the loss of something very important for themselves. We conclude that female nurses when confronting female surgery distances themselves behind the professional nurse and performs nursing care as a daily routine. It means that these nurses live a personal conflict that influences directly on how they supply care. They care for but do not care about, the ethos of biomedicine leads carers on to a technical path from which it is difficult to get off. This is the pre-reviewed version of the following article:O Vargens and Carina Berterö, Caring with difficulty: Brazilian nurses' experiences of gynaecological surgery care, 2010, International Journal of Nursing Practice, (16), 2, 159-165.which has been published in final form at: http://dx.doi.org/10.1111/j.1440-172X.2010.01824.xCopyright: Blackwell Publishing Ltdhttp://eu.wiley.com/WileyCDA/Brand/id-35.html