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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

All surgery involves a delicate balance of risk management, from the benefits and disadvantages of when a surgical option is appropriate, to the immediate post-operative care. Recognizing areas of high risk and understanding how these may be minimized, is central to the practice of safe surgery. All surgeons may encounter complications at some point, but recognizing when these occur and the most appropriate initial management is essential to prevent or minimize immediate and long-term complications. In addition, as some complications will involve areas in which the surgeon has relatively little expertise, it is important to acknowledge that limitation and enlist help from an appropriate specialist at an early stage. This review focuses on general advice on avoiding and managing complications in gynaecological surgery, excluding radical cancer surgery.

Any peritoneal inflammatory process consequent to infections or surgical injuries may induce abdominal adhesion formation. Peritoneal adhesions are connective laciniae that develop among abdomino-pelvic organs that limit physiologic visceral motion. Consequently, fertility may be impaired, and intestinal obstruction and pelvic pain may develop, mainly in subjects that had undergone gynaecological surgery. This review illustrates the pathogenic steps of adhesiogenesis and the therapeutic scenario that evolved over the years to tackle the threat of peritoneal adhesions, both in domestic animals and in women.

Surgical site infections are a common complication of Gynaecological surgeries. Up to 8-10% of Gynaecological patients undergoing an operative procedure will develop a surgical site infection. In surgeries with high rates of post-operative infection, antibiotic prophylaxis can play a major role in improving outcomes. In addition there are many indications where antimicrobial treatment is necessary in day-to-day Gynaecological practice. This review summarizes the available medical literature to assess the indications and appropriate antimicrobials for common circumstances in Gynaecological practice.

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.

Summary We aimed to determine if using the EndoFlex® tracheal tube on the first intubation attempt provided improved placement times and intubation success compared with a standard-type tracheal tube in 50 patients undergoing gynaecological surgery in a prospective, randomised, cross-over trial. We found that using the EndoFlex resulted in shorter intubation times (mean (SD) 14.8 (9.7) vs 30.1 (30.5) s), easier intubation (VAS, median (range) 10 (0–70) vs 20 (0–100)), and an increased rate of successful insertion at the first attempt; all p

A few months ago, the Royal College of Obstetricians and Gynaecologists of the UK published the latest clinical guideline relevant to gynaecological surgery entitled “Preventing entry-related gynaecological laparoscopic injuries”, which is freely available for all to read on the college website. The preparation of this document not only took a long time, requiring a considerable amount of literature research, but also very arduous because we were required to make constant changes to the manuscript as a result of the comments and criticisms from the three lead reviewers of the Guidelines and Audit Committee but mainly from having to satisfy the objections of no less than 20 separate peer reviewers. By and large, the document has been well received by our colleagues, but this article intends to highlight some of the difficulties and problems encountered during production and to answer some of the criticisms we have received since publication.

Randomised controlled trials are applied more readily to medical than surgical interventions. There are even more barriers to randomised trials of surgical interventions than to other randomised trials. These include reluctance among surgeons to undertake trials (owing to concern over expressing equipoise, surgical training and surgical learning curve issues, restrictions of funding and time for research, even financial conflict of interest), reluctance of patients to participate in surgical trials owing to fears over 'experimental surgery', failure of randomised trials to detect rare surgical complications and the almost universal failure of those conducting surgical trials to examine important long-term outcomes. Rapid advances in surgical fields mean that new surgical techniques are rapidly superseded and clinical questions surrounding new techniques may linger only until the next new technique becomes available. Nonetheless randomised controlled trials remain the cornerstone of evaluating the effectiveness of surgical interventions. Genuine progress has been made in this field. However, large multicentre collaborative randomised trials that have been prospectively defined in trial registries will be required in the future to answer the important clinical questions regarding gynaecological surgical interventions.

Although there have been reports that women develop constipation following hysterectomy, previous studies were either retrospective or uncontrolled. The aim of this prospective, controlled study was to assess whether constipation develops after elective hysterectomy. Women undergoing elective gynaecological surgery were compared to matched non-surgery controls at enrolment and 3 and 12 months after surgery. The subset of women who underwent elective hysterectomy was the study group for the present report. Fifty-eight of the 132 elective surgery patients underwent hysterectomy and were compared to 123 controls. There was no difference between the groups at any follow-up point in functional constipation (P = 1.0), frequency of stools (P = 0.92), stool consistency (P = 0.42), straining (P = 0.43), feeling of obstruction (P = 0.6) or need to manually evacuate stool (P = 1.0). Significantly, more hysterectomy patients without baseline pain did develop abdominal pain at 3 or 12 months than non-surgery controls (16.7%vs 3.6%, P = 0.008). We conclude that there was no significant change in bowel habit or stool characteristics in women undergoing hysterectomy even though many developed abdominal pain. This prospective, controlled study challenges existing data regarding the effect of hysterectomy on constipation.

PURPOSE: The latest development in the field of minimal invasive surgery is NOTES (Natural Orifice Transluminal Endoscopic Surgery), in which an endoscopic access through the gastrointestinal tract or the vagina is used. In contrast to classical laparoscopic surgery, this technique allows surgery to be performed without visible scars. Cholecystectomy and appendectomy procedures have already been successfully performed with this technique, but it has not yet been employed in the field of surgical gynaecology. This study examines whether this new technique can also be used in gynaecological surgery. MATERIAL AND METHODS: A flexible endoscope (Storz) was inserted intraperitoneally using a transvaginal approach. Via the integrated working canals, it was possible to perform both an adnexectomy and a hysterectomy. To date, NOTES has been used in two female patients at the I. Gynaecological Hospital of the LMU Munich. RESULTS: The surgical technique and the postoperative outcomes of the patients are presented. CONCLUSION: The NOTES technique is a new and promising development in minimally invasive surgery, which can reduce invasiveness even further compared to classical laparoscopic surgery. Its use in a bigger collective of patients will demonstrate the value of this method in the field of gynaecological surgery.

Background We evaluated the feasibility, safety and pathological findings of incidental robotic appendectomy in patients undergoing robotic gynaecological surgery. Methods Retrospective analysis of 107 consecutive cases of robotic appendectomy done in conjunction with other robotic gynaecological procedures between May 2004 and January 2007. Results All appendectomies were performed robotically in conjunction with other robotic procedures. Mean time for appendectomy was 3.4 min. No perioperative complications related to appendectomy were encountered. Among 90 patients with no gynaecological malignancy, 57 patients reported chronic pelvic pain preoperatively and 21 (37%) of them had an abnormal appendiceal pathology as compared to only 5 (15%) of the 33 patients with no pelvic pain (OR. 3.2; 95% CI, 1.1–9.7, p = 0.032). Of seven patients with ovarian malignancy, three (42%) had appendicular metastasis. Conclusion Incidental robotic appendectomy can be performed safely without the need for switching to conventional laparoscopy. It should be considered in patients undergoing robotic pelvic surgery for pelvic pain and ovarian malignancy. Copyright © 2008 John Wiley & Sons, Ltd.

With the recent publication of the European Society of Gynaecological Endoscopy consensus position on adhesion reduction, all members of the Royal College of Obstetricians and Gynaecologists were sent a postal survey with the aim to understand and benchmark UK gynaecological surgeons’ attitudes and actions on adhesions. As expected, of the 356 who responded, gynaecological surgeons (72%) were the majority. Over 85% of respondents agreed that adhesions develop after any type of gynaecological surgery, and more than 50% considered adhesions were now the most common complication of abdominal surgery. Approximately four out of five respondents agreed that all gynaecological patients should be informed of the risk of adhesions and 61% noted that they routinely inform patients for all or some procedures. However, written information was only provided by 2.3% of respondents. Importantly, respondents agreed that a routine adhesion reduction strategy with good surgical technique was fundamental. Respondents’ use of specific agents was identified with 78.8% relying on surgical technique as their current strategy. While 78.8% would use an anti-adhesion agent in high-risk surgery—only 6.1% would consider use in all surgery. Most surgeons still rely on surgical technique alone as their anti-adhesion strategy despite increasing evidence of the important potential additional benefits of using anti-adhesion agents.

The apprentice–tutor model was useful for training surgeons for many years, but the complexity of surgical technology in the 21st century, especially endoscopic surgery, has exponentially increased the demands for surgical education. Therefore, more and more people now accept that endoscopic surgery, demanding as it requires specific skills, should also be taught outside the operating theatre. Although many systems, including animal models and simulators, have been proposed, an in-house structured and validated method for testing and training laparoscopic skills is missing in gynaecology. We have developed a laparoscopic skills testing and training (LASTT) model and performed two studies evaluating its feasibility and the construct validity of three different exercises (camera navigation, camera navigation and forceps handling, and forceps handling and bi-manual coordination), specifically selected to test and train laparoscopic psychomotor skills (LPS). In the first study, ten experts and 14 novices repeated each exercise between 20 and 30 times. The results demonstrated that the model is useful for testing and training laparoscopic skills. Clear learning curves were observed for both experts and novices, with better scores for the former at the beginning and the end of the study, proving the construct validity of the model. In the second study, 42 experts and 241 novices repeated each exercise three times during skill evaluation workshops organised by the European Academy of Gynaecological Surgery. The results confirmed the construct validity of the model. In conclusion, the LASTT model seems a cost-effective tool for providing an in-house program for continuous training and evaluation of LPS in all surgical disciplines in which laparoscopic procedures are, or might be, performed.

Objective In an effort to improve patients’ understanding and perception of their surgery and communication between doctors and patients we have evaluated the use of a mobile digital video recorder in the case of women undergoing gynaecological surgery. Study design Patients scheduled for endoscopic or open surgery were asked if they would allow their surgery be recorded on a dedicated computer system. Those who agreed were offered the opportunity to have real-time edited highlights of their surgery recorded simultaneously on a miniature digital video recorder. They were shown the edited recording before discharge from hospital, and their reaction was assessed using a structured questionnaire. Results 51/54 (94.4%) women agreed to their surgery being recorded on the computer system, and 37/54 (68.5%) asked to see the edited highlights. The median duration of the computer and portable recordings for the 37 patients was 90 min (range 2–280) and 3.3 min (range 1–13.6) respectively. Thirty-four (91.9%) reported that the edited recording gave them a better understanding of their medical condition and surgery. Thirty (81.1%) would have liked a copy of the recording. Conclusions Portable video recorders are a convenient tool for recording surgical procedures. In our experience, about two-third of patients are interested in reviewing their surgery and find it provides useful information and a perceived better understanding of their condition. As these recording devices are small and fit into a pocket, their use could easily become a routine part of post-operative ward rounds. For the surgeon, such recordings have an educational value and provide the basis for a library of surgery as well as being useful when planning future management or for referral purposes.

Background: Chronic pain is a well-known adverse effect of surgery, but the risk of chronic pain after gynaecological surgery is less established. Method: This review summarizes studies on chronic pain following hysterectomy. The underlying mechanisms and risk factors for the development of chronic post-hysterectomy pain are discussed. Results and conclusion: Chronic pain is reported by 5–32% of women after hysterectomy. A guideline is proposed for future prospective studies.

Although treating cervical weakness after dilation has rescued many pregnancies, there is a trend toward performing cerclage before the cervix has begun dilating, and this requires a diagnostic test to confirm cervical weakness. This observational study measured the cervical resistance index (CRI)-the force required to dilate the cervix to 8 mm-as an aid in choosing which women with a history of spontaneous mid-trimester miscarriage should have cervical cerclage in subsequent pregnancies. The study group included 175 nonpregnant women with a history of one or more spontaneous mid-trimester losses at 12 to 28 weeks' gestation, and the control group comprised 123 nonpregnant women having CRI measurements during routine gynecological surgery. Women whose CRI indicated an incompetent cervix were advised to have cervical cerclage in future pregnancies. A CRI below 5 1b, or 22 Newtons (N), was taken as an indicator of cervical weakness. The study and control women had median CRI values of 17 and 38 N, respectively. Thirty study women were considered to have a competent cervix by CRI while the obstetrical history suggested otherwise. At the same time, 32 study women had a CRI suggesting an incompetent cervix despite a history indicative of cervical competence. Of 486 previous pregnancies in the 175 study women, 27% had a successful outcome. Subsequently, 94 of these women have had 148 pregnancies, 76% of which had a successful outcome. This study showed that nonpregnant women with a history of spontaneous mid-trimester miscarriage have significantly lower cervical resistance indices than parous women without mid-trimester loss, although the CRI was not in accord with the past history in more than one-third of the present patients. Measuring the CRI may help to detect cervical weakness and thereby to decide when prophylactic cervical cerclage is appropriate in subsequent pregnancies.

Samuel Pozzi was a major figure in the early development of modern gynaecological surgery. His textbook, A Treatise on Gynaecology, published in French in 1890 and rapidly translated into five other languages, was the first internationally acclaimed text integrating modern principles of anaesthesia, antisepsis, diagnosis, surgical technique and postoperative care, and in later editions remained a standard reference up to the 1930s. He was the author of more than 400 papers on gynaecological and general abdominal surgery and his technical expertise drew surgeons from all over the world to his theatre in the Hospital Broca, in one of the poorer parts of Paris. He was equally successful in several professional fields apart from medicine. However, his name is now little known in the English-speaking world. This short biography aims to re-introduce Pozzi to readers of English.

The proximity of the urinary tract to the reproductive organs puts it at risk of injury and incontinence as a consequence of gynaecological surgery. Incontinence to urine after gynaecological surgery is distressing to both the patient and the surgeon; in particular, formation of a urinary fistula after surgery is seen as a disaster by both. It also has long-term medicolegal implications. In this review. the main emphasis is on the prevention, evaluation, diagnosis and management of urinary tract injury. Other causes of postoperative incontinence are addressed briefly.

This consensus position represents the collective views of 35 gynaecologists with a recognised interest in adhesions. The first part of the position was presented in the previous issue of Gynecological Surgery and reviewed the published literature on the extent of the problem of adhesions. In this part, the opportunities to reduce their incidence are considered. Collective proposals on the actions that European gynaecologists should take to avoid causing adhesions are provided. Importantly, in this part, the need to now inform patients of the risks associated with adhesion-related complications during the consent process is discussed. With evidence increasing to support the efficacy of adhesion-reduction agents to complement good surgical practice, all surgeons should act now to reduce adhesions and fulfil their duty of care to patients.

Background: New suture materials may provide patients with a better cosmetic outcome at similar pain and wound complication rate. Methods: To assess pain and cosmetic outcome among patients randomized to receive wound closure after laparotomy for gynaecological surgery using staples, polyglecaprone 25 orpolyglecaprone 6211 subcuticular sutures. Results: Overall, 90 patients (87.4% consent rate) were randomized. There was no difference in wound complications and pain between the three groups. Patients randomized to polyglecaprone 6211 subcuticular sutures rated the cosmetic result at 1 and 6 weeks after surgery somewhat lower than patients randomized to the two alternative groups; however, at 3 months after surgery, all three groups rated the cosmetic result as similar. Conclusions: This study suggests that the three wound closure methods have similar short-term pain and cosmetic outcomes, as well as a similar rate of wound complications, leaving the decision of the most appropriate closure method to individual surgeons.

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The principles related to gynaecological surgery are detailed in this article. 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.

Objective Frailty is the loss of physical or mental reserve that impairs function, often in the absence of a defined comorbidity. Our aim was to determine whether a modified frailty index (mFI) correlates with morbidity and mortality in patients undergoing hysterectomy. Design Retrospective cohort study. Setting Hospitals across the USA participating in the National Surgical Quality Improvement Program (NSQIP). Sample Patients who underwent hysterectomy from 2008 to 2012. Methods An mFI was calculated using 11 variables in NSQIP. The associations between mFI and morbidity and mortality were assessed. Model fit statistics (c-statistics) were utilised to evaluate the ability of mFI to distinguish outcomes. Main outcome measure Wound infection, severe complications and mortality. Results A total of 66 105 patients were identified. Wound complications increased from 2.4% in patients with an mFI of zero to 4.8% in those with mFI ≥ 0.5 (P

Commentary on : Foxman B, Cronenwett AE, Spino C, et al. Cranberry juice capsules and urinary tract infection after surgery: results of a randomised trial. Am J Obstet Gynecol Published Online First: 13 Apr 2015. doi: 10.1016/j.ajog.2015.04.003 Urinary tract infections (UTI) are a common bacterial infection and postoperative UTIs cause significant morbidity and healthcare burden.1 Studies examining postoperative antibiotic prophylaxis to prevent postoperative UTI have yielded inconsistent results and antibiotics carry a risk of side effects and bacterial resistance.2 Cranberry is well tolerated and widely used to prevent recurrent UTIs. This study investigates the use of cranberry capsules to prevent postoperative UTI following benign gynaecological surgery. This randomised double-blind, placebo-controlled trial investigates whether cranberry (2 capsules two times per day, equivalent to two 8 oz servings of cranberry juice) taken for approximately 6 weeks after gynaecological surgery reduces postoperative UTI. Participants were non-pregnant women …

Background: Memory of chronic, acute and experimental pain may be inaccurate, but the research findings are inconsistent. The main aim of the study was to compare the memory of three types of pain and their associated affect. Methods: A total of 140 women, who gave birth by vaginal delivery or Caesarean section, or underwent gynaecological surgery, participated in the study. Before childbirth or surgery, the women rated their anxiety about the pain they would experience. Between 24 and 48 h after childbirth or surgery, they rated the intensity and unpleasantness of the pain, and their positive and negative affect. Either 3 or 6 months later, the participants recalled the pain and affect they had felt. Results: The study found that the type of pain had an effect on memory of pain and affect. Surgery led to an overestimation of all but one of the recalled variables. Participants who gave birth by Caesarean section were the most accurate at recalling pain and affect. Memories of pain and affect were most variable in participants who gave birth by vaginal delivery. The three groups of participants differed in terms of the predictors of recalled pain intensity and unpleasantness, and the proportion of variance predicted by the same independent variables. Conclusions: The results of the current study suggest that memory of pain and affect is influenced by the meaning and affective value of the pain experience. This may help us to understand why the previous research on the memory of pain were so diverse.

The subject of this thesisis community care for the women recovering from a gynaecological surgery. Community care is, by definition, a policy that provides help and support to people at the right time, at the appropriate level, and in the suitable form to enable people to achieve the highest possible level of independence, self-sufficiency and control over their lives. It is a set of health, social and other services provided to the sick as well as healthy persons, their families, or groups of a specific community.The objective is to provide as much as care at home as possible, even in the event of disablement, reliance on others, or chronic disease. With the growth of the nursing care, it is exactly the individual work and qualifications of the nurses and midwives caring for healthconsolidation, protection and recovery that is one of the basic characteristic features of an advanced health system. Generally, the time spans of institutional care are getting shorter and this trend can be seen in gynaecologyas well. The primary care is gaining more and more importance. The ongoing health reforms are based on the principles of primary health care which strives to encourage individuals as well as the society to accept responsibility for their health and their healthy lifestyles. Care in the community focuses on the support of health and, in the primary care, is to provide protection of health and prevention of the disease formation.It is more directed at groups of persons and entire communities and draws on their specific needs. The theoretical part of this Bachelor Thesis provides explanations of terms such as "community nursing care", "community", "community care history", and on the practice of thedomiciliary care system in the Czech Republic. The next part focuses on the work of midwives in the primary gynaecological care. Because gynaecology belongs largely to a field of surgery, the thesis also provides categorization of surgical approaches in the gynaecological surgery. The research part of this Bachelor Thesis is concerned with the post-operative period from the perspective of the women. Two main aims were set down. The first aim was to findout whether women undergone genealogical surgeries are interested in community care provided by midwives.The second aim was to find out what is the woman expectation from community care and midwives. Two questions come out from research aims. What is the need of woman undone genealogical surgery after coming home? And how would woman perceive care of midwife? The collection of data was worked out as half structured individual interview. To ensure privacy for all the participants, the interviews were held at a quiet, prearranged setting from February to April 2015. All the respondents provided only oral consent. The information thus obtained was subsequently analysed, sorted into several categories and subcategories and, in order to be clearly understood, represented in well-arranged charts. Direct quotations were used in this thesis. It is written in italics. The research group was made of nine women who went through serious gynaecological surgery. They were able to evaluate their post operative period. In the text they are marked as R1-R9. The results of the research show that the majority of the interviewed women have no idea how community care works. However, they all - with but one exception- showed great interest in the service that would enable them, after they had time to think things over, to call the midwife in order to discuss their problems with a professional person in the quiet of their homes. And indeed, the research discovered that the women are in bad need of such service. For most of the respondents, their first visit at their local gynaecologistfor removal of stiches was a most stressful experience. They all complained about having to wait too long in the doctor's office and about their physicians and nurses being too busy to answer all their questions.

Purpose Risk factors for post-surgical adhesions following gynaecological surgery have been identified, but their relative importance has not been precisely determined. No practical tool exists to help gynaecological surgeons evaluate the risk of adhesions in their patients. The purpose of the study was to develop an Adhesion Risk Score to provide a simple tool that will enable gynaecological surgeons to routinely quantify the risk of post-surgical adhesions in individual patients. Methods A group of European gynaecological surgeons searched the literature to identify the risk factors and the surgical operations reported as carrying a risk of post-surgical adhesions. Through consensus process of meetings and communication, a four-point scale was then used by each surgeon to attribute a specific weight to each item and collective agreement reached on identified risk factors and their relative importance to allow construct of a useable risk score. Results Ten preoperative and 10 intraoperative risk factors were identified and weighed, leading to the creation of two sub-scores to identify women at risk prior to and during surgery. The Preoperative Risk Score can range from 0 to 36, and the Intraoperative Risk Score from 3 to 31. Several thresholds between these limits may be used to identify women with low, medium, and high risk of post-surgical adhesions. Conclusions Gynaecological surgeons are encouraged to use this Adhesion Risk Score to identify the risk of adhesions in their patients. This will allow better informed use of available resources to target preventive measures in women at high risk of post-surgical adhesions.

Summary Slow but steady progress in the medical care of mothers and their infants during the 16th–19th centuries received a setback early in the 20th century following a shift of focus from the baby towards gynaecological surgery. The development of paediatrics after 1928 and the formation of a national health service in 1948 led to a renewed interest in the fetus and newborn infant. Special care baby units (SBCUs) were created in the 1960s. At this time, too, obstetric technology arrived in the delivery room and domiciliary birth largely gave way to hospital delivery. Neonatal intensive care arrived in the 1970s. However, a severe lack of resources retarded progress. Many medical reports in the 1970s drew attention to the deplorable situation. In 1980 a House of Commons working party called for the establishment of a sound perinatal service. In 1982 the Government recognized all newborn infants as NHS patients from the moment of birth rather than after their registration. That year too the Royal College of Obstetricians and Gynaecologists (RCOG) acknowledged the need for a subspecialty in maternal and fetal medicine. Meanwhile, a paediatric perinatal pressure group, arising in 1976, became a multidisciplinary association of perinatal medicine in 1981. By 1983 the new discipline of perinatal medicine had become firmly established.

This article aims to show the significance of the consent process. It provides guidance on consent in gynaecological surgery and the areas that must be covered. The content of the preoperative discussion and the means of conveying information, including the risks of complications and unexpected surgical procedures, are considered. The competencies of doctors to provide information are discussed, as well as where to find sources of information. We conclude that the education and training requirements of doctors and medical students need to be addressed in relation to the information needs of women. In particular, doctors and medical students should be aware of consent law, recent case law and the necessity for effective communication skills, as well as having the necessary knowledge and skills with regard to surgical procedures.

Investigation of adverse outcomes in obstetrics and gynaecology requires a systematic and systemically oriented approach. The main objective of these assessments is to decrease their incidence. Lethal complications in obstetrics and gynaecological surgery have become so rare in developed countries that we have to grapple mainly with severe morbidities. A model for such investigation is presented, based on answers to 3 questions: What? How? and Why? These questions correspond to 3 components of quality assurance: Outcome, Process, and Structure, respectively. Aspects of Reason's model of accidents are also included, in the form of "active failures" and "latent conditions." The latter are divided into basic contributory factors, 4 of which are derived from a model of human factors influencing behaviour in anaesthesia or flight-crew environments. To illustrate its basic nature, the model is applied to anonymized cases of surgical complications. Application of the model to the reactive investigation of close calls is discussed, as is application to the proactive interrogation of the care system for the presence and nature of hazards that pose threats to safety.

Patterns and frequency of anxiety in women undergoing gynaecological surgery\ud Aims. Within a gynaecological surgical setting to identify the patterns and frequency\ud of anxiety pre- and postoperatively; to identify any correlation between raised\ud anxiety levels and postoperative pain; to identify events, from the patients’ perspective,\ud that may increase or decrease anxiety in the pre- and postoperative periods.\ud Background. It is well documented that surgery is associated with increased anxiety,\ud which has an adverse impact on patient outcomes. Few studies have been conducted\ud to obtain the patient’s perspective on the experience of anxiety and the events and\ud situations that aggravate and ameliorate it.\ud Method. The study used a mixed method approach. The sample consisted of women\ud undergoing planned gynaecological surgery. Anxiety was assessed using the State\ud Trait Anxiety Inventory. Trait anxiety was measured at the time of recruitment.\ud State anxiety was then assessed at six time points during the pre- and postoperative\ud periods. Postoperative pain was also measured using a 10 cm visual analogue scale.\ud Taped semi-structured telephone interviews were conducted approximately a week\ud after discharge.\ud Results. State anxiety rose steadily from the night before surgery to the point of\ud leaving the ward to go to theatre. Anxiety then increased sharply prior to the\ud anaesthetic decreasing sharply afterwards. Patients with higher levels of trait anxiety\ud were more likely to experience higher levels of anxiety throughout their admission.\ud Elevated levels of pre- and postoperative anxiety were associated with increased\ud levels of postoperative pain. Telephone interviews revealed a range of events/situations\ud that patients recalled distressing them and many were related to inadequate\ud information.\ud Conclusion. This study found higher rates of anxiety than previously reported and\ud anxiety levels appeared raised before admission to hospital. This has important\ud clinical and research implications.Relevance to clinical practice. Patients with high levels of anxiety may be identified\ud preoperatively and interventions designed to reduce anxiety could be targeted to this\ud vulnerable group. Patient experiences can inform the delivery of services to meet\ud their health needs better.

Urinary tract injuries during gynaecological surgery are increasing with the advent of more complex and laparoscopic techniques; ureteric and bladder injuries are the most common. Adequate knowledge of the anatomy will help avoid some problems, but prompt recognition during surgery offers the best chance of treatment without long-term compromise. When the problems are not recognised during surgery, various techniques can be used to effect repair. Surgery for stress incontinence has undergone many changes in technique in recent years. Any procedure needs to combine a low morbidity with high long-term success rates. Colposuspension has been the 'gold standard' for many years, against which other techniques are judged. A laparoscopic approach has reduced hospital stay, although with increased morbidity. The tension-free vaginal tape technique is now widely employed as the first-line procedure. It is a relatively easy technique to learn, with a good success rate and low morbidity; long-term results are still awaited. This chapter deals with two aspects of urogynaecological surgery. The first section reviews urinary tract injuries occurring during gynaecological surgery. In the second section we look at recent developments in surgery for urinary stress incontinence.

Amaç: Çalışmamızda, Pfannenstiel insizyonla yapılan jinekolojik cerrahide ultrason eşliğinde uygulanan rektus kılıf bloğunun etkisini araştırmayı amaçladık. Yöntemler: Etik kurul onayı ve olguların onamı alındıktan sonra, American Society of Anesthesiologists (ASA) I-II grubu, 20-70 yaş arası, Pfannenstiel insizyonla jinekolojik cerrahi yapılması planlanan 75 hasta çalışmaya dahil edildi. Genel anestezi uygulandıktan sonra olgular randomize olarak üç gruba ayrıldı. Grup UR'ye (n=25) 0,2 mL kg-1 %0,25 levobupivakain ile ultrason eşliğinde rektus kılıf bloğu, Grup SR'ye (n=25) 0,2 mL kg-1 %0,25 levobupivakain ile cerrahi rektus kılıf bloğu uygulandı. Grup T'deki olgulara ise (n=25) cerrahi bitiminden 30 dakika önce intravenöz 2 mg kg-1 tramadol yapıldı. Tüm olgulara postoperatif ağrı kontrolü için hasta kontrollü analjezi cihazı kuruldu. Hemodinamik veriler ve inspire edilen sevofluran konsantrasyonu ameliyat boyunca kaydedildi. Postoperatif dönemde ağrı skorları, toplam tramadol tüketimi, ek analjezik ihtiyacı ve yan etkiler değerlendirildi. Bulgular: Demografik özellikler, cerrahi süre ve hemodinamik parametreler gruplar arasında benzer bulundu. Grup UR'de inspire edilen sevofluran konsantrasyonu (%) ve VAS skorları Grup SR ve Grup T'ye göre daha düşük saptandı. Toplam tramadol tüketimi Grup UR ve Grup SR'de Grup T'ye göre belirgin düşük bulundu. Gruplar arasında yan etki profili açısından fark saptanmadı. Sonuç: Bu çalışma, Phannenstiel insizyonla yapılan jinekolojik cerrahide, ultrason eşliğinde uygulanan rektus kılıf bloğunun cerrahi rektus kılıf bloğu ve tramadole kıyasla yan etki sıklığını arttırmadan etkin bir analjezi sağlamaya yardımcı olduğunu göstermiştir. Objective: This study aimed to evaluate the effects of ultrasound-guided rectus sheath block in gynaecological surgery with Pfannenstiel incision. Methods: After the approval of the ethics committee and the patients’ consent, 75 ASA I-II patients who were aged between 20 and 70 years and scheduled for a gynaecological surgery with Pfannenstiel incision were included in this study. After induction of general anaesthesia, patients were randomly divided into three groups. In Group UR patients (n=25), ultrasound-guided rectus sheath block with 0.25% levobupivacaine (0.2 mL kg?1) was performed. In Group SR patients (n=25), surgical rectus sheath block with 0.25% levobupivacaine (0.2 mL kg?1) was applied. In Group T (n=25) patients, tramadol (2 mg kg?1) was intravenously administered 30 min before the end of surgery. Patient-controlled analgesia device was established for postoperative pain relief in all groups. Haemodynamic data and inspired sevoflurane concentration were recorded during the operation. Pain scores, total tramadol consumption, supplemental analgesic requirement and side effects were postoperatively evaluated. Results: Demographic characteristics, duration of surgery and haemodynamic parameters were similar between the groups. Inspired sevoflurane concentration (%) and VAS scores were significantly lower in Group UR than those in Groups SR and T. Total tramadol consumption was significantly lower in Groups UR and SR than that in Group T. There was no significant difference in the incidence of side effects. Conclusion: This study demonstrates that ultrasound-guided rectus sheath block helps to provide the effective analgesia without any side effects compared with surgical rectus sheath block and intravenous tramadol for gynaecological surgery with Pfannenstiel incision.

A prospective quasiexperimental single blind study was conducted to test the hypothesis that the LOTUS (laparoscopic operation by torsional ultrasound) shears have significant advantage over conventional cutting bipolar forceps when used to divide and coagulate pedicles in gynaecological surgery. Ten university teaching hospital patients between 35 and 51 years of age were recruited. They all underwent elective abdominal hysterectomy and bilateral salpingo-oophorectomy for nonmalignant indications such as fibroids and menorrhagia. The round and infundibulopelvic ligaments were divided with the LOTUS shears or the Power Blade cutting bipolar forceps at open hysterectomy, and the time taken to complete the division was recorded. Two hundred histological samples were examined for thermal damage by the blinded histopathologist. The main outcome measures were the degree of thermal damage on histology, the time taken to divide each structure, and the need for additional haemostasis. Thermal damage was present in 99/200 slides. The LOTUS shears caused thermal damage in 47 sections. The cutting bipolar forceps caused thermal damage in 52 sections. The degree of thermal damage was less with the LOTUS shears. The mean times taken by the LOTUS shears to divide the round ligaments and infundibulopelvic ligaments were 9.24 s and 20.02 s, respectively. The corresponding times for the bipolar forceps were 9.69 s and 27.53 s, respectively. The LOTUS shears were associated with shorter bisection times and less thermal damage in this pilot study. These results were not statistically significant.

Adhesions are a common and unfortunate consequence of most abdominal surgical operations, which start to form within three hours of surgery. Some patients form extensive permanent adhesions that can cause abdominal or pelvic pain, infertility and bowel obstruction. Epidemiological studies have highlighted the extent of this problem and the cost to the Health Service, and although there are numerous approaches to prevent adhesion formation by careful laparoscopic or microsurgical techniques or the use of various adhesion barriers, no method so far has proved completely efficacious in randomised controlled trials. This article reviews the pathogenesis of adhesions, the epidemiological data and the various methods used to try to prevent their formation.

Ureteric injury is one of the most serious complications of gynaecological surgery with important medico-legal considerations. This review is aimed at understanding the anatomy of the ureter, sites of ureteric injuries, types and causes of injury, simple preventive measures and management.

Abdominal myomectomy is the commonest conservative surgical procedure offered to patients with symptomatic fibroids and as a fertility enhancing procedure to some women with large intramural fibroids when no other cause for subfertility is evident. Historically myomectomy has been considered to be a complex procedure with high risk of complications. However, there is no evidence to support this assumption and recent studies have shown that the morbidity of myomectomy and hysterectomy is comparable. In recent times, new treatment strategies with a minimally invasive approach have evolved but are available only in selected centres and their efficacy has not been evaluated in the light of well-designed research trials. Therefore, myomectomy remains the mainstay of surgical treatment in women who wish to retain their uterus. This review aims to dispel the misconceptions about morbidity of myomectomy and provides an evidence-based account of the measures that can be taken to minimise it.