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Optimal pain relief in day-case surgery is imperative to patient comfort and timely discharge from hospital. Short-acting opioids are commonly used for analgesia in modern anaesthesia, allowing rapid recovery after surgery. Plasma concentration fluctuations from repeated dosing of short-acting opioids can cause patients to oscillate between analgesia with potential adverse effects, and inadequate analgesia requiring rescue dosing. Methadone's unique pharmacology may offer effective and sustained analgesia with less opioid consumption, potentially reducing adverse effects. Using a double-blind, randomised controlled trial, we compared post-anaesthesia care unit opioid consumption between day-case gynaecological laparoscopy patients who received either intravenous methadone (10 mg), or short-acting opioids intraoperatively. The primary outcome was post-anaesthesia care unit opioid consumption in oral morphine equivalents. Secondary outcomes included total opioid consumption, discharge opioid consumption, pain scores (0–10) until discharge, adverse effects (respiratory depression, postoperative nausea and vomiting, excess sedation), and rate of admission. Seventy patients were randomly assigned. Patients who received methadone consumed on average 9.44 mg fewer oral morphine equivalents in the post-anaesthesia care unit than the short-acting group (18.02 mg vs 27.46 mg, respectively, 95% confidence interval 0.003 to 18.88, P = 0.050) and experienced lower postoperative pain scores at every time point, although absolute differences were small. There was no evidence of lower hospital or discharge opioid consumption. No significant differences between the methadone and short-acting groups in other outcomes were identified: respiratory depression 41.2% versus 31.4%, P adjusted >0.99; postoperative nausea and vomiting 29.4% versus 42.9%, P adjusted >0.99; overnight admission 17.7% versus 11.4%, P adjusted >0.99; excess sedation 8.82% versus 8.57%, P adjusted >0.99. This study provides evidence that, although modestly, methadone can reduce post-anaesthesia care unit opioid consumption and postoperative pain scores after day-case gynaecological laparoscopy. There were no significant differences in any secondary outcomes. [ABSTRACT FROM AUTHOR]

Key content: Hyperthermic intraperitoneal chemotherapy (HIPEC) at the time of cytoreductive surgery is a proposed additional treatment in the management of advanced tubo‐ovarian cancer.Additional organisational approvals, costs, changes to theatre infrastructure and pre‐, intra‐, and post‐operative management considerations are required to implement HIPEC in a clinical setting.Current meta‐analysis data suggest that in the setting of interval cytoreductive surgery, HIPEC prolongs overall survival and progression‐free survival. There is currently no evidence of benefit in the setting of primary surgery or recurrent disease, but results of ongoing clinical trials are pending. Learning objectives: To understand the mechanism of action, safety and efficacy of HIPEC as an adjuvant treatment in tubo‐ovarian cancer. Ethical issues: Because of variation in treatment protocols and heterogeneity of reported outcomes, HIPEC has not yet been adopted into standard practice. Further studies assessing its benefit, mainly in the setting of primary cytoreduction, are ongoing. [ABSTRACT FROM AUTHOR]

Background: Several strategies have been implemented to better identify the course of the ureters intra-operatively due of the morbidity associated with ureteric injuries especially during gynaecological surgery. We described our experience with pre-operative ureteric catherisation in women who underwent major endoscopic gynaecological surgery. Methods: A case-controlled study of 862 women who underwent major endoscopic gynaecological surgery sourced from two health institutions were conducted. Two groups were compared: those who had pre-operative prophylactic ureteric catherisation (study group) and those who had routine cystoscopy performed immediately post surgery (control group). Results: There were no intra-operative ureteric injuries or associated complications noted in the study group. When compared to the control group, length of hospital stay (2 days vs 5 days; p < 0.05) and overall mean time for cystoscopy (11 min vs 35 min; p < 0.05) was significantly shorter in the study group. There was no long-term morbidity recorded in the study group. Conclusion: Our experiences with prophylactic pre-operative bilateral ureteric catheterisation for major endoscopic gynaecological surgeries were favourable and are associated with low complication rates. Routine or adjunct use before major gynaecological and pelvic surgery combined with meticulous surgical technique can help reduce iatrogenic and unintentional ureteric injuries. [ABSTRACT FROM AUTHOR]

Abstract Background Intraoperative iatrogenic ureteral injuries represent rare technical surgical complications with the potential for adverse patient outcomes, particularly when the diagnosis is delayed. Ideally, these technical complications are recognized and repaired intraoperatively. This study was designed to investigate the root causes and outcomes of missed intraoperative ureteral injuries at a tertiary urology referral centre in Tunisia. Methods This is a retrospective cohort study in a tertiary urology referral centre in Tunis from January 1st, 2015, to December 31st, 2020, including all patients with iatrogenic ureteral injury, not diagnosed intraoperatively. The factors associated with the success of endoscopic treatment and those associated with the unfavourable evolution were investigated. Results A total of 40 iatrogenic ureteral injuries were included. Gynaecological surgery was responsible for 85% of ureteral injuries, mainly during hysterectomies (55%). The symptoms were dominated by low back pain (37.5%) and pyelonephritis (25%). Endoscopic treatment was attempted in 22 cases, it was sufficient in 12 cases. Ureteral injury required surgical treatment in 24 cases, and ureteroneocystostomy was performed in 16 cases. Nephrectomy was performed in eight cases, representing 20% of injuries, including three cases as the first treatment for late-diagnosed cases with a destroyed kidney. In the analytical study, endoscopic treatment was sufficient in 50% in case of ureteral fistula versus 27% in case of ureteral stenosis (p = 0.04). Nephrectomy was performed in 10% of cases when ureteral injury was diagnosed within the first month postoperatively compared to 60% of cases when this delay exceeded one month (p = 0.004). Conclusion Iatrogenic ureteral injuries discovered postoperatively are mostly secondary to gynaecologic surgery. Although endoscopic treatment is usually performed as a first treatment, a more aggressive surgical is often necessary, with a nephrectomy rate of 20%.

Robotic-assisted surgery has improved the precision and accuracy of surgical movements with subsequent improved outcomes. However, it requires steep Trendelenburg positioning combined with pneumoperitoneum that negatively affects respiratory mechanics and increases the risk of postoperative respiratory complications. This narrative review summarises the state of the art in ventilatory management of these patients in terms of levels of positive end-expiratory pressure (PEEP), tidal volume, recruitment manoeuvres, and ventilation modes during both urological and gynaecological robotic-assisted surgery. A review of the literature was conducted using PubMed/MEDLINE; after completing abstract and full-text review, 31 articles were included. Although different levels of PEEP were often evaluated within a protective ventilation strategy, including higher levels of PEEP, lower tidal volume, and recruitment manoeuvres vs a conventional ventilation strategy, we conclude that the best PEEP in terms of lung mechanics, gas exchange, and ventilation distribution has not been defined, but moderate PEEP levels (4–8 cm H 2 O) could be associated with better outcomes than lower or highest levels. Recruitment manoeuvres improved intraoperative arterial oxygenation, end-expiratory lung volume and the distribution of ventilation to dependent (dorsal) lung regions. Pressure-controlled compared with volume-controlled ventilation showed lower peak airway pressures with both higher compliance and higher carbon dioxide clearance. We propose directions to optimise ventilatory management during robotic surgery in light of the current evidence. [ABSTRACT FROM AUTHOR]

We aimed at determining whether a 2-h session of high-flow nasal oxygen (HFNO) immediately after extubation improves oxygen exchange after major gynaecological surgery in the Trendelenburg position in adult female patients. In this single-centre, open-label, randomised trial, patients who underwent major gynaecological surgery were randomised to HFNO or conventional oxygen treatment with a Venturi mask. The primary outcome was the P ao 2 /FiO 2 ratio after 2 h of treatment. Secondary outcomes included lung ultrasound score, diaphragm thickening fraction, dyspnoea, ventilatory frequency, P aco 2 , the percentage of patients with impaired gas exchange (P ao 2 /FiO 2 ≤40 kPa) after 2 h of treatment, and postoperative pulmonary complications at 30 days. A total of 83 patients were included (42 in the HFNO group and 41 in the conventional treatment group). After 2 h of treatment, median (inter-quartile range) P ao 2 /FiO 2 was 52.9 (47.9–65.2) kPa in the HFNO group and 45.7 (36.4 -55.9) kPa in the conventional treatment group (mean difference 8.7 kPa [95% CI: 3.4 to 13.9], P =0.003). The lung ultrasound score was lower in the HFNO group than in the conventional treatment group (9 [6–10] vs 12 [10–14], P <0.001), mostly because of the difference of the score in dorsal areas (7 [6–8] vs 10 [9–10], P <0.001). The percentage of patients with impaired gas exchange was lower in the HFNO group than in the conventional treatment group (5% vs 37%, P <0.001). All other secondary outcomes were not different between groups. In patients who underwent major gynaecological surgery, a pre-emptive 2-h session of HFNO after extubation improved postoperative oxygen exchange and reduced atelectasis compared with a conventional oxygen treatment strategy. NCT04566419. [ABSTRACT FROM AUTHOR]

Hysterectomy may impact young women's perceptions of their gender identity and fertility status, with implications for quality of life. However, research into this important area is limited, particularly among women with benign disease. To investigate gender identity and fertility in this population, semi-structured interviews were conducted with 18 women who underwent hysterectomy for benign disease at age 39 or younger. Women were asked to describe their experience of hysterectomy and how it affected their perceptions of their gender identity, fertility status and overall quality of life. Thematic analysis was used to analyse and code responses. Three themes were identified; Implications of Infertility, I am a Woman and Womanhood Compromised. Within these themes, 3 sub-themes were identified. Implications of Infertility comprised three sub-themes describing women's varied relationships with their post-hysterectomy infertility: Plans Fulfilled, Acceptable Compromise and Persistent Grief. A novel finding was that women engaged in a "trade-off", whereby relief of gynaecological symptoms outweighed their desire for a child/further child/ren. The study also found that women with an extensive history of infertility may have more trouble adjusting to the outcomes of their hysterectomy than women who were satisfied with their fertility history. Counselling around identity and how this can be influenced by fertility status may be needed. Further research into the psychological processes involved in the "trade-off" is also needed. [ABSTRACT FROM AUTHOR]

Uterine leiomyomas, or fibroids, are the most common benign tumours of the female genital tract. Although uterine fibroids are commonly associated with menorrhagia, dysmenorrhea, symptomatic anaemia, urinary or bowel symptoms and infertility, intra-abdominal haemorrhage is an exceedingly rare complication. Often, the diagnosis is poorly recognizable based on the patient's clinical presentation and alternative diagnoses such as ruptured ectopic pregnancy, ruptured ovarian cyst or perforated viscus are frequently considered.Herein, we describe a case of a 50-year-old perimenopausal woman who presented with acute, lower abdominal pain, evolving anaemia, hypovolaemic shock and haemoperitoneum with no discernable source. Emergency exploratory laparotomy confirmed the source of massive haemoperitoneum arising from a ruptured blood vessel supplying a large subserosal uterine leiomyoma and the patient subsequently underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy.Given the paucity of publications on this clinical entity, the aim of this report is to highlight a rare complication of uterine leiomyomas, its pathophysiological spectrum and its relevance to emergency physicians, general surgeons and gynaecologists.

Background: Intraoperative iatrogenic ureteral injuries represent rare technical surgical complications with the potential for adverse patient outcomes, particularly when the diagnosis is delayed. Ideally, these technical complications are recognized and repaired intraoperatively. This study was designed to investigate the root causes and outcomes of missed intraoperative ureteral injuries at a tertiary urology referral centre in Tunisia. Methods: This is a retrospective cohort study in a tertiary urology referral centre in Tunis from January 1st, 2015, to December 31st, 2020, including all patients with iatrogenic ureteral injury, not diagnosed intraoperatively. The factors associated with the success of endoscopic treatment and those associated with the unfavourable evolution were investigated. Results: A total of 40 iatrogenic ureteral injuries were included. Gynaecological surgery was responsible for 85% of ureteral injuries, mainly during hysterectomies (55%). The symptoms were dominated by low back pain (37.5%) and pyelonephritis (25%). Endoscopic treatment was attempted in 22 cases, it was sufficient in 12 cases. Ureteral injury required surgical treatment in 24 cases, and ureteroneocystostomy was performed in 16 cases. Nephrectomy was performed in eight cases, representing 20% of injuries, including three cases as the first treatment for late-diagnosed cases with a destroyed kidney. In the analytical study, endoscopic treatment was sufficient in 50% in case of ureteral fistula versus 27% in case of ureteral stenosis (p = 0.04). Nephrectomy was performed in 10% of cases when ureteral injury was diagnosed within the first month postoperatively compared to 60% of cases when this delay exceeded one month (p = 0.004). Conclusion: Iatrogenic ureteral injuries discovered postoperatively are mostly secondary to gynaecologic surgery. Although endoscopic treatment is usually performed as a first treatment, a more aggressive surgical is often necessary, with a nephrectomy rate of 20%. [ABSTRACT FROM AUTHOR]

Abstract Background To assess the hysterectomy probability by calendar period and age, the overall and the age-specific prevalence of hysterectomy in women aged 30–65 years. Methods Baseline data (2005–2007) from the population-based MARZY study conducted in Mainz and Mainz-Bingen, Germany, were analysed. 6429 women aged 30–65 years were asked whether they had undergone a hysterectomy and the date and indication of the procedure. We calculated the 5-year age-specific prevalence of hysterectomy and estimated the probability of undergoing a hysterectomy combining two approaches: 1) Kaplan–Meier and 2) Inverse probability weighting (IPW). We assessed potential changes over calendar periods by simulating survival curves, having hysterectomy as the event, employing a Cox proportional hazard model. Results Data on hysterectomy were available for 4719 women. Of these, 961 (20.4%) had undergone a hysterectomy between 1960 and 2006. The hysterectomy prevalence was highest among the 60–64 year-olds (40.7%). The IPW-corrected probability of having a hysterectomy up to the age of 65 years was 36.4%. The age-specific probability of hysterectomy increased from 0.1% (20–24 years), peaking at 45–49 years (7.8%) and declining thereafter to less than 5% among women aged 50 and older. Over time, women were hysterectomised at an increasingly older age. Most hysterectomies (86.7%) were done due to benign disease. Conclusions A shift to older age at hysterectomy with an advancing calendar period likely reflects changes in clinical practice in Germany. Trial registration Landesärztekammer Rheinland-Pfalz: 837.438.03 (4100).

The aim of this article is to describe an island flap, harvested from the inguinal fold, which can be used for vulvar reconstruction: the inguinal fold island flap (IFI flap). IFI flap is indicated for reconstruction of defects of vaginal vestibule and labia minora and it could be raised bilaterally safeguarding regional symmetry and avoiding vaginal introitus or urethral distortion. This flap has been utilized to reconstruct defects after vulvar melanoma and squamous cell carcinoma resections and in one case to restore vaginal vestibule anatomy in a revision surgery in a transgender woman. IFI flap is an example of an "aesthetic/functional" reconstruction which could be proposed to younger patients too. [ABSTRACT FROM AUTHOR]

Key content: Thromboembolism is a major cause of preventable morbidity and mortality. Hospital acquired thrombosis (HAT) accounts for 50–60% of all thromboembolic events.As well as effects on patient safety, there are considerable cost implications to both prophylaxis and treatment.While guidance exists on thromboprophylaxis for patients in obstetrics and those undergoing general surgery, there is a paucity of guidance relating to gynaecological practice.Increasing prevalence of risk factors and multimorbidity is paralleled by higher risk of thromboembolic events.Gynaecological surgery presents some unique risk factors for thrombosis. Learning objectives: To understand the basic pathophysiology of thrombosis in relation to risk factors particularly relevant to gynaecology and pelvic surgery.To know the current evidence in key areas relevant to gynaecological practice: early pregnancy; day case surgery; minimally invasive gynaecological surgery; open and complex benign gynaecology and gynaecological oncology.To be aware of proposed guidance on risk assessment and prophylaxis in thrombosis as relevant to the gynaecologist based on current evidence. Ethical issues: Problems with thromboprophylaxis in high‐risk patients include noncompliance and refusing animal products/injections.Clinicians may be reluctant to institute thromboprophylaxis, most times because of the possible risks of bleeding. [ABSTRACT FROM AUTHOR]

Enhanced Recovery After Surgery programs have become the gold standard of care in many surgical specialities. This updated systematic review and meta-analysis aims to evaluate how an ERAS program can impact outcomes across both benign and oncological gynaecological surgery to inform standard surgical practice. An electronic search of the SCOPUS, Embase and PubMed Medline databases was performed for relevant studies assessing the use of ERAS in patients undergoing gynaecological surgery compared with those without ERAS. The studies included were all trials using ERAS programs in gynaecological surgery with a clearly outlined protocol which included at least four items from the most recent guidelines and recorded one primary outcome. Meta-analysis was performed on two primary endpoints; post-operative length of stay and readmission rate and one secondary endpoint; rates of ileus. Further subgroup analyses was performed to compare benign and oncological surgeries. Forty studies (7885 patients) were included in the meta-analysis; 15 randomised controlled trials and 25 cohort studies. 21 studies (4333 patients) were included in meta-analyses of length of stay. Patients in the ERAS group (2351 patients) had a shortened length of stay by 1.22 days (95% CI: −1.59 – −0.86, P < 0.00001) compared to those in the control group (1982 patients). Evaluation of 27 studies (6051 patients) in meta-analysis of readmission rate demonstrated a 20% reduction in readmission rate (OR: 0.80, 95% CI: 0.65–0.97). Analysis of our secondary outcome, demonstrated a 47% reduction in rate of ileus compared to the control group. ERAS pathways significantly reduce length of stay without increasing readmission rates or rates of ileus across benign and oncological gynaecological surgery. • The ERAS group had a significantly shortened LOS by 1.22 days. • LOS was 1.92 days shorter after oncological procedures and 0.83 days shorter after benign surgeries. • The ERAS group had a 20% reduction in readmission rate compared to the control group. • Rates of ileus were significantly reduced in the ERAS group. [ABSTRACT FROM AUTHOR]

Women with inherited bleeding disorders (IBDs) may present to healthcare professionals in a variety of ways and commonly will be encountered by either haematology or gynaecology services. Heavy menstrual bleeding is very often the first manifestation of an IBD. There is a wide variation in severity of bleeding for women with IBD and diagnosis and subsequent management of their condition requires multidisciplinary specialised care which is tailored to the individual and includes excellent cross‐specialty communication between gynaecology and haematology teams. This guideline is intended for both haematologists and gynaecologists who are involved in the diagnosis and management of women with bleeding disorders. It sets out recommendations about how to investigate heavy menstrual bleeding (HMB), the commonest presentation for women with IBD to hospital services, to guide physicians about how to diagnose an IBD and covers the management of women with known IBD and HMB. The second section sets out recommendations for patients known to have IBD and covers management of patients with IBD in the setting of gynaecological surgery and management for all other non‐surgical gynaecological situations. [ABSTRACT FROM AUTHOR]

Objectives: To systematically evaluate the effectiveness and safety of enhanced recovery after surgery (ERAS) in gynaecological surgery and provide a scientific basis for its clinical promotion and application in the Chinese population. Material and methods: Systematic retrieval from CNKI, Wanfang, VIP database and other Chinese literature databases. Studies on ERAS application with a randomised controlled trial in gynaecological surgery were included in the present report. Outcome indicators: hospitalisation time, postoperative ambulation time, postoperative feeding time, postoperative exhaust time, postoperative defecation time, operation time, postoperative blood loss, postoperative morbidity, patient satisfaction, hospitalisation expenses, etc. The meta-analysis was performed using the Revman 5.3 software. Results: A total of 24 studies were included in the analysis. The results showed that, compared with the traditional group, the ERAS group had a lower hospitalisation time (SMD = -1.67, 95% CI = -2.03 ~ -1.30, p < 0.0001), postoperative ambulation time (SMD = -4.16, 95% CI = -5.12 ~ -3.20, p < 0.0001), postoperative feeding time (SMD = -7.36, 95% CI = -9.67 ~ -5.05, p < 0.0001), postoperative exhaust time (SMD = -2.59, 95% CI = -3.15 ~ -2.03, p < 0.0001), postoperative defecation time (SMD = -2.23, 95% CI = -2.88 ~ -1.57, p < 0.0001), postoperative morbidity (OR = 0.22, 95% CI = 0.15 ~ 0.31, p < 0.0001) and hospitalisation expenses (SMD = -0.53, 95% CI = -0.78 ~ -0.28, p < 0.0001). The patient satisfaction was significantly improved (odds ratio = 8.11, 95% CI = 4.96 ~ 13.24, p < 0.0001), and there were no significant differences in intraoperative blood loss and operation time between the two groups. Conclusions: The application of the ERAS protocol in gynaecological surgery significantly improves the effectiveness and safety of the procedure. Thus, it can be promoted and applied in clinical practice in China. [ABSTRACT FROM AUTHOR]

Abstract Objectives To evaluate the effect of intraperitoneal normal saline instillation (INSI) of 15 mL/kg body weight on postoperative pain after a gynaecological laparoscopic procedure. Design Randomised controlled trial. Setting University Hospital in Kuala Lumpur, Malaysia. Participants Patients aged 18–55 years, with American Society of Anaesthesiologists (ASA) classification I–II, scheduled for an elective gynaecological laparoscopic procedure for a benign cause. Intervention The patients were randomly allocated to two groups. In the intervention group, 15 mL/kg body weight of normal saline was instilled intraperitoneally, while the control group received the conventional combination of open laparoscopic trocar valves with gentle abdominal pressure to remove the retained carbon dioxide. Main outcome measures The outcomes measured were the mean pain scores for shoulder and upper abdominal pain at 24 h, 48 h, and 72 h postoperatively. Results A total of 68 women completed the study, including 34 women in each group. There was no difference in the shoulder pain score at 24 h, 48 h, and 72 h postoperatively. However, a significant improvement in the upper abdominal pain score after 48 h (95% confidence interval [CI] 0.34–1.52, p = 0.019) and 72 h (95% CI 0.19–0.26, p = 0.007) postoperatively were observed. Conclusions INSI of 15 mL/kg body weight does not lower postoperative shoulder pain compared to no fluid instillation. A modest pain score improvement was observed in the upper abdominal area at 48 h and 72 h after surgery. An INSI of up to 30 mL/kg body weight may be required to eliminate shoulder pain. Care must be taken before administering a higher amount of INSI, considering the potential risk of peritoneal adhesions. Clinical registration ISRCTN Identifier: 87898051 (Date: 26 June 2019) https://doi.org/10.1186/ISRCTN87898051

Background & objectives: Subarachnoid block is commonly used for lower abdominal and lower limb surgeries. Racemic bupivacaine 0.5% is commonly used in spinal anaesthesia. Various additives are added for various reasons. Buprenorphine is a synthetic opioid analgesic with a mixed agonistantagonist action and is a commonly used one such adjuvant. This study has been designed to evaluate the sensorimotor effects, onset and duration of analgesia, vital parameters and any adverse effects of addition of buprenorphine (60 µg) to 3 ml of 0.5% racemic bupivacaine intrathecally for elective open gynaecological surgeries. Methods: In this randomized, double-blind prospective study, 60 patients (age 18-60years) of ASA I and II were randomized into two groups: group BO and BB (n=30). Group BO received a 3ml of 0.5% racemic bupivacaine (15 mg) only and Group BB received 3ml of 0.5% racemic bupivacaine along with 60mcg buprenorphine. Results: It was found that the onset of sensory block upto T10 and motor block is statistically significantly faster in group BB (109.33 sec and 153.5 sec) over group BO (133 sec and 167.67 sec). The mean time for two segment regression, the mean time to sensory regression to L1, the mean duration of analgesia and the mean duration of motor blockade is significantly prolonged in Group BB (106.67 min, 322 min, 343 min, x 330.5 min) over Group BO (132.67 min, 259.67 min, 290.67 min, 253.34 min) with p<0.001. Conclusion:60µg of Buprenorphine used as an adjuvant in subarachnoid block was found to be a better adjuvant in prolonging the sensory and motor blockade intraoperatively and the duration of postoperative analgesia compared than 0.5% bupivacaine alone, without significant adverse effects making it a good option in prolonged surgeries and for good post-operative analgesia. [ABSTRACT FROM AUTHOR]

Mature Cystic Teratomas (MCT) of the ovary or Dermoid Cysts are common benign tumours found in 10–20% of women. However, 0.2–2% of those cysts underwent malignant transformation. Squamous Cell Carcinoma (SCC) is the most frequent histological type reported in the literature.As 2021, there are limited reports of malignant tumours arising from MCT with no guidelines related to the management of these atypical cases. Herein, we describe two cases of MCT that evolved into SCC with different stages and prognosis and we review the current literature to date highlighting the potential risk of malignant transformation of these considered benign cysts and the need for strong evidence protocols for staging and treatment of this atypical entity. What is already known on this subject? Mature Cystic Teratomas are found in 10-20% of women. However, a malignant behavior is observed in 2% of cases. What do the results of this study add? Our paper will describe two cases of malignant transformation of dermoid cyst in an effort to highlight the possible malignant risk of this entity and the need for specific management guidelines. What are the implications of these findings for clinical practice and/or further research? The prognosis of this converted cyst is very poor. By elaborating a standard management protocol for this tumour and operating every large cyst (>10 cm) in postmenopausal women, we may prevent this event. [ABSTRACT FROM AUTHOR]

The impact of Coronavirus disease 2019 pandemic on Italian Gynaecological Units practice and the compliance and satisfaction with available guidelines/recommendations is unknown. Therefore, a survey was conducted among all Italian Gynaecological Units Directors in April 2020. The response rate was 90% (135/150). 77.8% of centres performed surgery only for oncologic or not deferrable pathologies, and 9.6% was closed. 68.7% of directors were at least moderately satisfied by published guidelines/recommendations, but 94.8% of respondents identified limitations, mainly (83%) the absent definition of benign non-deferrable pathology. Responders considered as non-deferrable severe endometriosis (69.6%), endometriosis with organ failure/dysfunction (74.1%), and unresponsive symptomatic fibroids (89.6%). Despite guidelines/recommendations, respondents treated ovarian (77%) and endometrial (71.6%) cancer as usual. Only a minority of respondents reduced the laparoscopic approach (11.2%) and adopted all recommended surgical precautions (9.6%). Compliance with available guidelines/recommendations appears incomplete. Reconsidering guidelines/recommendations regarding oncological cases and specify non-deferrable benign pathologies would improve guidelines/recommendations compliance. What is already known on this subject? The SARS-CoV-2 pandemic has profoundly influenced medical routine practice worldwide. Surgery units have been forced to reduce or even completely restrict their activity to re-allocate human resources. Many major international gynaecological societies have released statements and guidelines, providing various recommendations to guide practice changes. However, the impact of the SARS-CoV-2 pandemic on Italian Gynaecological Units practice and the compliance and satisfaction with available guidelines/recommendations is unknown. What do the results of this study add? Study results provide evidence showing how the SARS-CoV-2 pandemic has changed surgical activity in the Italian Gynaecological Units. Most centres reduced surgical activity, limiting surgery only for oncologic or not deferrable pathologies. Moreover, our research shows the level of compliance and satisfaction with available guidelines/recommendations and where they need to be improved. Most directors were at least moderately satisfied but identified different limitations. Guidelines/recommendations do not provide enough details, such as the absent definition of benign non-deferrable pathologies. What are the implications of these findings for clinical practice and/or further research? The limited compliance with available guidelines/recommendations and identified limitations suggest reconsidering guidelines/recommendations focussing on identified gaps. Provide more details, such as specifying non-deferrable benign pathologies, would improve guidelines/recommendations compliance. [ABSTRACT FROM AUTHOR]

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Ovarian vein thrombosis (OVT) is a relatively rare, but serious disease more commonly seen in puerperal patients. In the postpartum period, there is an unequal incidence of OVT in women with vaginal delivery (0.18%) and caesarean section (2.0%).OVT is usually associated with other conditions like pelvic inflammatory disease, malignant tumours, sepsis, enteritis, and recent pelvic or abdominal surgery. The incidence of idiopathic OVT is extremely rare and only a few cases have been reported to date in healthy patients with unknown aetiology. Patients with OVT present with abdominal pain, nausea, vomiting, fever or abdominal mass. Complications of OVT include pulmonary embolism, ovarian infarction, sepsis and death. CT scanning of the abdomen provides reliable evidence for the diagnosis of idiopathic OVT. Thrombus in most patients with idiopathic OVT is located in the right ovarian vein. This may be due to the longer length of the right ovarian vein, right shift of the uterus and relative insufficiency of the right ovarian vein valve. Treatment of OVT includes systemic anticoagulation which will achieve resolution of symptoms and prevent life-threatening complications. Our case report documents a non-puerperal patient who underwent hysterectomy a year before presenting to the ED with complaints of diarrhoea and found to have OVT on a CT scan. Our case brings attention to the fact that OVT can occur outside the puerperium and might present as a rare complication of minimally invasive surgeries for endometrial cancer. Furthermore, we posit that OVT in the non-puerperal patient may be a separate clinical entity.

There are multiple classifications in imaging and surgery of endometriosis and in this article, we offer a review of the main evaluation systems. The International Deep Endometriosis Analysis group consensus is the leading document for ultrasound assessment, while magnetic resonance imaging is guided by the European Society for Urogenital Radiology recommendations on technical protocol. In surgery, the revised American Society for Reproductive Medicine classification is the oldest system, ideally combined with newer classifications, such as Enzian or Endometriosis Fertility Index. Recently, The World Endometriosis Research Foundation Endometriosis Phenome and Biobanking Harmonisation Project introduced detailed proforma for clinical and intraoperative findings. There is still no universal consensus, so the initial emphasis should be on the uniform reporting of the disease extent until research clarifies more the correlations between extent, symptoms and progression in order to develop a reliable staging system. What is already known on this subject? There have been several reviews of surgical classifications, comparing their scope and practical use, while in the imaging the attempts for literature review has been scarce. What do the results of this study add? This is the first up to date review offering detailed analysis of the main classification systems across the three main areas involved in endometriosis care - ultrasound, MRI and surgery. The mutual awareness of the radiological classifications for surgeons and vice versa is crucial in an efficient multidisciplinary communication and patient care. On these comparisons we were able to demonstrate the lack of consensus in description of the extent of the disease and even further lack of prognostic features (with the exemption of one surgical system). What are the implications of these findings for clinical practice and/or further research? Future attempts of scientific societies should focus on defining uniform nomenclature for extent description. In the second step the staging classification should encompass prognostic value (risk of disease and symptoms recurrence). [ABSTRACT FROM AUTHOR]

Background: In high-income countries, laparoscopic surgery is the preferred approach for many abdominal conditions. Conventional laparoscopy is a complex intervention that is challenging to adopt and implement in low resource settings. This systematic review and meta-analysis evaluate the clinical effectiveness of gasless laparoscopy compared to conventional laparoscopy with CO2 pneumoperitoneum and open surgery for general surgery and gynaecological procedures. Methods: A search of the MEDLINE, EMBASE, Global Health, AJOL databases and Cochrane Library was performed from inception to January 2021. All randomised (RCTs) and comparative cohort (non-RCTs) studies comparing gasless laparoscopy with open surgery or conventional laparoscopy were included. The primary outcomes were mortality, conversion rates and intraoperative complications. Secondary outcomes: operative times and length of stay. The inverse variance random-effects model was used to synthesise data. Results: 63 studies were included: 41 RCTs and 22 non-RCTs (3,620 patients). No procedure-related deaths were reported in the studies. For gasless vs conventional laparoscopy there was no difference in intraoperative complications for general RR 1.04 [CI 0.45–2.40] or gynaecological surgery RR 0.66 [0.14–3.13]. In the gasless laparoscopy group, the conversion rates for gynaecological surgery were high RR 11.72 [CI 2.26–60.87] when compared to conventional laparoscopy. For gasless vs open surgery, the operative times were longer for gasless surgery in general surgery RCT group MD (mean difference) 10 [CI 0.64, 19.36], but significantly shorter in the gynaecology RCT group MD − 18.74 [CI − 29.23, − 8.26]. For gasless laparoscopy vs open surgery non-RCT, the length of stay was shorter for gasless laparoscopy in general surgery MD − 3.94 [CI − 5.93, − 1.95] and gynaecology MD − 1.75 [CI − 2.64, − 0.86]. Overall GRADE assessment for RCTs and Non-RCTs was very low. Conclusion: Gasless laparoscopy has advantages for selective general and gynaecological procedures and may have a vital role to play in low resource settings. [ABSTRACT FROM AUTHOR]

Abstract Background Technology for minimal access surgery is rapidly progressing in all surgical specialities including Gynaecology. As robotic surgery becomes established in increasing numbers of hospitals, there is no set curriculum for training in robotic gynaecological surgery or the assistant role in use in the UK. The purpose of this study was to determine a list of competencies that could be used as the basis of a core robotic gynaecological surgery curriculum, to explore its acceptability and the level of interest in undertaking training in robotics among obstetrics & gynaecology (O&G) trainees. Methods A four-round Delphi study was conducted using members and associates of British & Irish Association of Robotic Gynaecological Surgeons (BIARGS). In Round 1 respondents were asked to propose standards that could be used in the curriculum. In the following three rounds, the respondents were asked to score each of the standards according to their opinion as to the importance of the standard. Items that scored a mean of 80% or above were included in the final proposed curriculum. Following this, a national survey was conducted to explore the interest among O&G trainees in undertaking a formal robotic training for the first assistant and console surgeon roles. Results The items proposed were divided into three separate sections: competencies for a medical first assistant; competencies for a console surgeon; continued professional development for trained console surgeons. From the national survey; 109 responses were received of which 60% were interested in undertaking a formal training for the first assistant role, and 68% are expressing interest in training for the console surgeon role. Conclusion Undertaking a Delphi exercise to determine a core gynaecological robotic training curriculum has enabled consensus to be achieved from the opinions of BIARGS members/associates. There is interest among O&G trainees at all levels of training to gain experience and develop their skills in robotic surgery by undertaking a formal training in robotic surgery at both the first assistant and console surgeon level.

This article discusses two cases of primary peritoneal malignant mesothelioma that presented with symptoms similar to peritonitis carcinomatosis. Peritoneal malignant mesothelioma is a rare and aggressive tumor that originates from the peritoneum. The patients in the cases had undergone hysterectomy and bilateral salpingo-oophorectomy, which led to the initial misdiagnosis of advanced stage ovarian cancer. The article emphasizes the importance of considering mesothelioma in the differential diagnosis of peritoneal carcinomatosis. The diagnosis of mesothelioma can be challenging, and histopathological examination is essential for accurate diagnosis. [Extracted from the article]

Assuming we know the perfect management for endometriosis or pelvic pain is folly, but we should be celebrating our successes, not abandoning everything that we currently know. [ABSTRACT FROM AUTHOR]

Abstract Background Patients undergoing gynaecological surgery are known to experience anxiety. While the use of music selected by patients based on their personal taste has hardly been evaluated, a recent study suggests that musical preferences significantly alter the anxiolytic and relaxing effects of music. Our study aims to determine whether self-selected music decreases patient anxiety prior to gynaecological surgery, as compared with predetermined music from a software programme such as MUSIC CARE®. Methods The study will consist of a clinical trial comparing the effects of self-selected music versus predetermined music on patient anxiety prior to gynaecological surgery. A minimum of 170 patients will be randomised in a 1:1 ratio. Inclusion criteria will be: women aged 18–55 years, awaiting scheduled gynaecological surgery under general/local anaesthesia or under sedation; having created a personal 20-min playlist; and not having received anxiolytic drugs prior to surgery. The primary outcome will be the difference between the preoperative anxiety score taken 15 to 20 min before the music-listening session and the preoperative anxiety score taken shortly after the session, as measured with the STAI for state anxiety. Discussion This study should help to identify more effective non-medical treatments for preoperative anxiety, as well as to adapt music therapy to the cultural context of patients. Trial registration ClinicalTrials.gov, ID: NCT03226834. Registered on 24 July 2017.

Key content: Surgical site infection (SSI) is an important cause of postoperative morbidity and, in severe cases, mortality.The epidemiology of SSIs varies depending on the type of surgery and the country. It is influenced by patient‐related, preoperative, intraoperative and postoperative risk factors.Prevention strategies target these risk factors and include measures taken before, during and after surgery. Learning objectives: To understand how SSIs can be prevented, depending on the type of wound, especially perioperative measures including antibiotic prophylaxis, and when to institute repeat antibiotics or alter dosages.To understand the bases of and approaches to perioperative antibiotics in women with incidental infections (for example, lower genital and urinary tract) and in women with comorbidities, such as those who are immunosuppressed or with mechanical valvar heart diseases.To understand what specific measures to take to reduce the risk of SSIs in special cases in obstetrics and gynaecology, such as in morbidly obese women, those undergoing cancer surgery, or those with cardiac conditions or transplants. Ethical issues: Should perioperative antibiotics be given to every woman undergoing surgery?What is the risk of antibiotic resistance as a result of administration of perioperative antibiotics? [ABSTRACT FROM AUTHOR]

Background: In laparoscopy, the digital camera offers surgeons the opportunity to receive support from image-guided surgery systems. Such systems require image understanding, the ability for a computer to understand what the laparoscope sees. Image understanding has recently progressed owing to the emergence of artificial intelligence and especially deep learning techniques. However, the state of the art of deep learning in gynaecology only offers image-based detection, reporting the presence or absence of an anatomical structure, without finding its location. A solution to the localisation problem is given by the concept of semantic segmentation, giving the detection and pixel-level location of a structure in an image. The state-of-the-art results in semantic segmentation are achieved by deep learning, whose usage requires a massive amount of annotated data. We propose the first dataset dedicated to this task and the first evaluation of deep learning-based semantic segmentation in gynaecology.Methods: We used the deep learning method called Mask R-CNN. Our dataset has 461 laparoscopic images manually annotated with three classes: uterus, ovaries and surgical tools. We split our dataset in 361 images to train Mask R-CNN and 100 images to evaluate its performance.Results: The segmentation accuracy is reported in terms of percentage of overlap between the segmented regions from Mask R-CNN and the manually annotated ones. The accuracy is 84.5%, 29.6% and 54.5% for uterus, ovaries and surgical tools, respectively. An automatic detection of these structures was then inferred from the semantic segmentation results which led to state-of-the-art detection performance, except for the ovaries. Specifically, the detection accuracy is 97%, 24% and 86% for uterus, ovaries and surgical tools, respectively.Conclusion: Our preliminary results are very promising, given the relatively small size of our initial dataset. The creation of an international surgical database seems essential. [ABSTRACT FROM AUTHOR]

Objective: The unicornuate uterus is a rare uterine malformation (2.4–13.7% of all uterine malformations (Engmann et al., 2004)) which usually features a rudimentary accessory horn in more than 75% of the cases. Pregnancy in the rudimentary horn is rare, but the complications attached to such pregnancies could be defined as the first clinical manifestation of rudimentary horn. Case Reports: We hereby describe five cases of unicornuate uterus with rudimentary horn (UUWRH), each one with a different clinical presentation and without any correct preoperative diagnosis, and henceforth reflect on the practical aspects learnt about the differential diagnosis and management of this rare malformation. Conclusion: Our experience with UUWRH is that perhaps asymptomatic cases are not as rare as reported in medical literature. We highlight the need for a greater awareness of the differential diagnosis of genital malformations and accurate in the exact subtype and their correct treatment.

Hysterectomy remains mostly performed via the abdominal route in the United Kingdom, despite advances in minimal access techniques and increased training in laparoscopic hysterectomy. The use of uterine manipulators remains a key component of the laparoscopic approach. During abdominal surgery, access to the pelvis can be challenging on occasion, and there may be a higher incidence of intraoperative complications. We describe the use of a laparoscopic uterine manipulator during total abdominal hysterectomy as a novel approach to facilitate the procedure by improving surgical exposure, reducing dissection, while safeguarding vital structures and maintaining vaginal length.Impact StatementWhat is already known on the subject? Hysterectomy remains mostly performed via the abdominal route in the United Kingdom, despite advances in minimal access techniques and increased training in laparoscopic hysterectomy. The use of uterine manipulators remains a key component of the laparoscopic approach.What do the results of this study add? We describe the use of a laparoscopic uterine manipulator during total abdominal hysterectomy as a novel approach to facilitate the procedure by improving surgical exposure, reducing dissection, while safeguarding vital structures and maintaining vaginal length.What are the implications of these findings for clinical practice and/or future research? The proposed technique is safe, easily reproducible and could be widely adopted. This approach may be considered as an option in morbidly obese women or those women with anticipated complex pelvic pathology. [ABSTRACT FROM AUTHOR]

Background: Technology for minimal access surgery is rapidly progressing in all surgical specialities including Gynaecology. As robotic surgery becomes established in increasing numbers of hospitals, there is no set curriculum for training in robotic gynaecological surgery or the assistant role in use in the UK. The purpose of this study was to determine a list of competencies that could be used as the basis of a core robotic gynaecological surgery curriculum, to explore its acceptability and the level of interest in undertaking training in robotics among obstetrics & gynaecology (O&G) trainees. Methods: A four-round Delphi study was conducted using members and associates of British & Irish Association of Robotic Gynaecological Surgeons (BIARGS). In Round 1 respondents were asked to propose standards that could be used in the curriculum. In the following three rounds, the respondents were asked to score each of the standards according to their opinion as to the importance of the standard. Items that scored a mean of 80% or above were included in the final proposed curriculum. Following this, a national survey was conducted to explore the interest among O&G trainees in undertaking a formal robotic training for the first assistant and console surgeon roles. Results: The items proposed were divided into three separate sections: competencies for a medical first assistant; competencies for a console surgeon; continued professional development for trained console surgeons. From the national survey; 109 responses were received of which 60% were interested in undertaking a formal training for the first assistant role, and 68% are expressing interest in training for the console surgeon role. Conclusion: Undertaking a Delphi exercise to determine a core gynaecological robotic training curriculum has enabled consensus to be achieved from the opinions of BIARGS members/associates. There is interest among O&G trainees at all levels of training to gain experience and develop their skills in robotic surgery by undertaking a formal training in robotic surgery at both the first assistant and console surgeon level. [ABSTRACT FROM AUTHOR]

Introduction: Postoperative infections are among the most common complications after many surgical procedures, especially after gynaecological surgeries. Aim of the research: The evaluation of risk factors and the epidemiological pattern of nosocomial infection after gynaecological surgery. Material and methods: In a descriptive epidemiological hospital-based study, all patients who had reported at Imam Khomeini Hospital Infection Control Unit after Gynaecological Surgery from the beginning of April 2011 to the end of March 2016 were included in the study. Then, the demographic information and details about infections were extracted from the patient's records and recorded in the pre-determined checklists and analysed by SPSS version 22 software. Results and conclusions: The average age of the patients was 30.59 ±9.52 years, and 11.6% of patients had diabetes, 7.1% had hypertension, and 81.3% had no underlying disease. The type of surgery performed in 78.8% of patients was caesarean section, 11.1% hysterectomy, 2% laparotomy, 4% episiotomy, and 4% other surgical procedures. 22.2% of the patients underwent the surgery in the elective state and 77.8% in the emergency condition, and Escherichia coli were more frequent than other microorganisms. Patients within the age range 25 to 35 years undergoing caesarean section in the emergency situation in winter and having diabetes were more susceptible to postoperative infections than others, and Escherichia coli was the most common microorganism in these patients. [ABSTRACT FROM AUTHOR]

Cervical cancer is the fourth most frequent cancer in women worldwide and the ninth cause of death in women between 30 and 49 years of age. Increase in early detection and diagnosis has allowed the implementation of more conservative management strategies. The radical trachelectomy (RT) is considered the treatment of choice for patients with early stage cervical cancer that desire fertility preservation, without compromising oncologic outcomes. The published data regarding reproductive and obstetric outcomes after RT reports decreased fertility, and increased abortion rates, prematurity and obstetric complications. On the other hand, data on oncologic outcomes has not shown higher rates of residual disease compared to radical hysterectomy. Data on obstetric outcomes following RT is scarce, generating controversy. We present the case of a patient diagnosed with stage IB1 cervical cancer managed with a vaginal radical trachelectomy (VRT), who subsequently had two successful gestations that resulted in premature deliveries with associated neonatal morbidity. [ABSTRACT FROM AUTHOR]

This article investigates if severe morbidity associated with ectopic pregnancy (EP) is related to patient characteristics or the quality of patient care after presentation. This is a retrospective study of women who had surgical management of tubal EP between 2008 and 2012. Severe maternal morbidity was defined as a blood loss ≥800 mL. Women of a white ethnicity were statistically more likely to have a blood loss of <800 mL (p = .0228). The patient related risk factors were significantly higher in the women with a blood loss of <800 mL (p = .0139). The incidence of substandard care was low in both groups although a substandard care due to a misdiagnosis of EP was significantly higher in the patients with a blood loss ≥800 mL (p = .0150). We found that a severe morbidity from EP is multifactorial involving patient awareness of risk factors and timely diagnosis by healthcare professionals. IMPACT STATEMENT What is already known on the subject? Ectopic pregnancy (EP) can be associated with severe maternal morbidity with up to a third of women with EP being managed after the pregnancy has ruptured. To try and reduce severe maternal morbidity and improve management for these women it is vital to identify the important risk factors associated with severe maternal morbidity. What do the results of this study add? We found ethnicity to be a predictive factor of severe maternal morbidity, with women of white ethnicity significantly more likely to have reduced severe maternal morbidity compared to other ethnicities. We also found multiple risk factors for an EP were statistically protective of severe maternal morbidity. We found the rate of substandard care to be low in our study but identified that where there was substandard care it was associated with diagnostic and therapeutic delays. Our findings lead us to conclude that a severe maternal morbidity from EP is multifactorial, and an improvement will involve both a patient awareness of risk factors and a timely diagnosis by health care professionals. What are the implications of these findings for clinical practice and/or further research? We believe that this to be an important article as it identifies the importance of the increasing knowledge both of women in the community but also educating health care professionals on the signs and symptoms of EP. These steps are vital to improve severe maternal morbidity associated with EP. [ABSTRACT FROM AUTHOR]

Obesity is a global health epidemic with a rising trend. There are well-established links between obesity and benign gynaecological pathology, premalignant gynaecological conditions and gynaecological malignancy. Obese women may need surgery just as non-obese women do, hence clinicians should be well versed with the impact of obesity on the woman's physiology, the surgical challenges and the effects of obesity on surgical outcomes. Clinicians should be able to counsel women regarding the risks of surgery as well optimizing their perioperative care whilst working within a multidisciplinary team. Current evidence highlights the efficacy and safety of minimally invasive surgery in obese women and it should be offered in preference to laparotomy when possible. All forms of surgery are more challenging in the obese population and routine techniques may need to be modified as described in this review. [ABSTRACT FROM AUTHOR]

Introduction: According to the guidelines of Royal College of Obstetricians and Gynaecologists gynaecological treatment (including the treatment with a speculum and bimanual treatment and test nipple) is one of the most intimate medical procedures that in many women can cause a feeling of shame and embarrassment. At the same time, in some patients, the study calls so considerable discomfort, anger and embarrassment and even if they don’t tell, they may experience prolonged stress resulting from the unpleasant and traumatic experience. Aim of the research: To investigate the opinions of women about the stress associated with their visit to the gynaecologist’s. Material and methods: The study included 331 anonymous, non-pregnant, randomly selected women. The respondents were divided into three age groups: the first group were women aged 29 years and below, the second group aged 30–39, and the third group aged 40 years and above. The study was conducted in the author’s private gynaecological office and in the Faculty of Health Sciences at the University of Jan Kochanowski in Kielce. The measurement tool was a survey of his own authorship. Results and conclusions: The greatest stress associated with gynaecological examination accompanied the woman aged 29 years and below, and the smallest at the age of 40 years and over (respectively, 46% and 35%). For most women, the gender of the gynaecologist does not matter when choosing a doctor. The opinion of the studied woman states that the most embarrassing moment of a visits at the gynaecologist is sitting down on the specialist chair and the gynaecological treatment, whereas the highest stress is evoked by the palpation through the anus and vagina. The frequency of reporting for a gynaecological examination decreases with the women’s age. Most women during the gynaecological treatment visit feel safe when alone with the doctor. Women expect the gynaecologist to be nice, talkative, and calm. When choosing a gynaecologist, patients usually guide themselves by the opinion of other women.

Background and Aims: Combined spinal–epidural (CSE) anaesthesia is being increasingly used for effective post-operative analgesia. This study was designed to evaluate the effect of epidural clonidine on characteristics of spinal anaesthesia for gynaecological surgeries. Methods: This was a prospective randomised, double-blind, controlled study involving sixty patients belonging to American Society of Anesthesiologists Physical Status I and II who underwent gynaecological surgeries were randomly divided into clonidine (C) group and saline (S) group of thirty each. All patients received CSE anaesthesia. Ten minutes before subarachnoid block (SAB), Group C received clonidine 150 μg diluted to 5 ml in normal saline (NS) and Group S received NS epidurally. Hyperbaric bupivacaine (15 mg) was administered intrathecally for both groups after epidural injection. Sensory and motor block characteristics, analgesia, sedation and haemodynamics were observed. Statistical analysis was performed using appropriate tests. Results: Epidural clonidine produced faster onset (37.83 ± 8.58 s in Group C compared to 50.33 ± 8.80 s in Group S, P = 0.001) and prolonged duration of sensory block (241.17±18.65 minutes in group C compared to 150.33±19.16 minutes in group S, P = 0.001). Time for two segment regression of sensory block was193.67 ± 19.82 min in Group C and 109.33 ± 18.56 min Group S (P < 0.001). The duration of analgesia was 299.00 ± 43.38 min in Group C and 152.50 ± 21.04 min in Group S (P < 0.001). Haemodynamics and sedation scores were comparable between two groups. Conclusion: Administration of clonidine epidurally, 10 min before SAB, caused early onset and prolonged duration of motor blockade and analgesia, without any significant post-operative complication.