Search

Hysterectomy (i.e., surgical removal of the uterus) requires severing the main blood supply to the uterus (i.e., the uterine arteries) while preserving the nearby, often overlapping, ureters. In this paper, we investigate dual-wavelength and audiovisual photoacoustic imaging-based approaches to visualize and differentiate the ureter from the uterine artery and to provide the real-time information needed to avoid accidental ureteral injuries during hysterectomies. Dual-wavelength 690/750 nm photoacoustic imaging was implemented during laparoscopic and open hysterectomies performed on human cadavers, with a custom display approach designed to visualize the ureter and uterine artery. The proximity of the surgical tool to the ureter was calculated and conveyed by tracking the surgical tool in photoacoustic images and mapping distance to auditory signals. The dual-wavelength display showed up to 10 dB contrast differences between the ureter and uterine artery at three separation distances (i.e., 4 mm, 5 mm, and 6 mm) during the open hysterectomy. During the laparoscopic hysterectomy, the ureter and uterine artery were visualized in the dual-wavelength image with up to 24 dB contrast differences. Distances between the ureter and the surgical tool ranged from 2.47 to 7.31 mm. These results are promising for the introduction of dual-wavelength photoacoustic imaging to differentiate the ureter from the uterine artery, estimate the position of the ureter relative to a surgical tool tip, map photoacoustic-based distance measurements to auditory signals, and ultimately guide hysterectomy procedures to reduce the risk of accidental ureteral injuries.

This study examined stability and transitions of school-aged children's self-determination theory-based need satisfaction profiles in physical education (PE) over three years. Participants were 1121 (girls 573, boys 548) Finnish school children. The self-report data were assessed using identical procedures from 2017 to 2020. Three latent need satisfaction profiles were identified: Low, Mid, and High need satisfactions. Transitions mainly occurred between grade 5 and 6 in elementary school, after which the profile memberships remained relatively stable. The profile memberships were not school- or PE group dependent over time. These results indicate that school-based actions to achieve a positive impact on need satisfaction development could already be commenced in the early school years, as it may be more challenging to induce positive changes in student behaviours after children have transitioned to middle school. peerReviewed

Similar to the parking-assist sensors on modern automobiles, which alert drivers of impending impact to an object, we are developing an auditory photoacoustic-based guidance system to assist with avoidance of impending injuries to ureters during hysterectomy procedures. The contribution described in this paper considers international standards for medical alarms. The system was demonstrated during both open and laparoscopic hysterectomy procedures on two human cadavers. Using methylene blue to enhance ureter contrast, the proximity of a surgical tool tip to the ureter was measured using the visual information provided in photoacoustic images. Distance measurements were then successfully mapped to auditory signals, which increased in auditory frequency as the tool-to-ureter distance decreased to convey surgical tool proximity to the ureter. Fundamental frequencies increased from 150 Hz to 866 Hz for tool-to-ureter distances of 2.47 mm to 5 mm. These results are promising to assist with the avoidance of accidental ureteral injuries during hysterectomy and other procedures that suffer from similar challenges with regard to iatrogenic ureteral injuries.

Study Objective The impact of myomectomy on subsequent pregnancies, whether performed open or minimally invasively, is not fully understood. We aim to characterize pregnancy outcomes and complications following myomectomy. Design We performed a retrospective review of all patients who underwent myomectomy from 2010-2018 (n=881) and identified all patients who had a subsequent delivery greater than 24 weeks (n=147). Operative reports and discharge summaries were reviewed to identify surgical factors, including the use of adhesion barriers, and complications at the time of myomectomy, as well as pregnancy complications including rates and severity of adhesions at the time of C-section. Setting A large academic hospital. Patients or Participants Women who underwent myomectomy followed by delivery. Interventions N/A. Measurements and Main Results 85 patients underwent MIS myomectomy and 61 underwent open myomectomy. During pregnancy, there were no statistically significant differences in the rates of placenta accreta (P=0.578, overall rate 0.6%), placenta previa (P=0.546, overall rate 3.4%), EBL during C-section (P=0.546), or rates of complications such as fetal growth restriction (P=0.463, overall rate 1.4%), fetal demise (0.916, overall rate 1.4%), or PPROM (P=0.225, overall rate 1.4%). Adhesions noted at the time of C-section were higher in in the open group compared to the minimally invasive group (P=0.011) and rates of severe adhesions (resulting in bladder or bowel injury or requiring classical C-section) were also higher in the open group as compared to the MIS group (P=0.006). The use of intercede significantly reduced rates of clinically significant adhesions (P= 0.019) whereas the use of Seprafilm or Tisseal did not (P=0.528, 0.323 respectively). Conclusion The use of MIS techniques, as well as the use of the adhesion barrier intercede, reduce the rates of clinically significant adhesions at the time of C-section. Other pregnancy outcomes are not impacted by the use of minimally invasive techniques in our sample.

Study Objective The true incidence of adenomyosis is unknown, but the prevalence has been reported ranging from 5-70% in hysterectomy samples. We sought to explore the sensitivity of preoperative imaging by determining the rate of unexpected adenomyosis found on histopathologic review of hysterectomy specimens. Design Retrospective cohort analysis Setting Five hospital healthcare system Patients or Participants Women undergoing hysterectomy for benign indications from 2013-2019 (n=1628), with full pathology report available Interventions We obtained demographics, preoperative imaging, surgical indication, operative approach, and histopathology to determine rates of anticipated as well as unexpected adenomyosis at time of hysterectomy. Patients were retrospectively separated into two cohorts based on the diagnosis of adenomyosis on final pathology: 521 patients with adenomyosis and 1,107 without adenomyosis. Descriptive statistics and multivariate logistic regression were performed using Stata and statistical significance was set at p Measurements and Main Results Of 1628 patients who underwent hysterectomy for benign indications, 521 patients (32%) had adenomyosis diagnosed on pathology. Of these, 402 patients had preoperative ultrasound where 314 (78%) had no imaging characteristics suggestive of adenomyosis and 157 patients had preoperative MRI where 79 (50.3%) had no imaging characteristics suggestive of adenomyosis (unexpected). Pathology-confirmed adenomyosis was significantly less likely in larger uteri (13-18cm, p=0. 013; or >18cm, p=0.046) compared to those measuring 7-10cm. When stratified by surgical indication, unexpected adenomyosis was found on pathology in 93 of 146 patients with abnormal uterine bleeding (63.7%), 44 of 83 patients with endometriosis (53.0%), and 221 of 280 with fibroids (78.9%). Conclusion In our sample, the sensitivity of preoperative imaging for adenomyosis is 22% for ultrasound and 49.7% for MRI. Unexpected adenomyosis was most commonly identified in patients undergoing hysterectomy for fibroids whereas patients with endometriosis were more commonly suspected of having adenomyosis preoperatively.

Gynecologic surgery requires the clamping, cauterization, and transection of arteries that lie within mil- limeters of the ureter, posing significant potential risk for ureteral injury. By leveraging the optical absorption properties of hemoglobin and methylene blue (an FDA-approved contrast agent), we propose intraoperative pho- toacoustic imaging during hysterectomies to simultaneously visualize the uterine arteries and ureter, respectively. Three experiments were performed to test the feasibility of a spectroscopic system aimed at intraoperative visual- ization. At 690 nm, the contrast from blood and urine mixed with 200 uM methylene blue was 13.83 dB and 11.06 dB, respectively, representing a 2.77 dB contrast difference. Conversely, at 750 nm, the contrast from blood was similar (14.61 dB), and the contrast from urine mixed with 200 uM methylene blue decreased to 1.74 dB, which produced a greater contrast difference of 12.87 dB. When tissue was added, similar contrast differences were observed at these wavelengths. Finally, a laparoscopic tool was additionally visualized in real time in proximity to the ureter and uterine arteries, which supports the feasibility of a spectroscopic photoacoustic approach to differentiating the ureter from the uterine arteries in relationship to a laparoscopic tool during hysterectomies.

Study Objective To identify determinants of operative room (OR) time for benign, minimally invasive (MIS) hysterectomy and quantify the relative influence of pre-operative patient and surgical factors. Design Cross-sectional. Setting Five-hospital healthcare system. Patients or Participants Women undergoing MIS (laparoscopic or robotic) hysterectomy from July 2014 to February 2019 for benign indications (excluding prolapse). Interventions N/A Measurements and Main Results Assessed factors to predict OR time included patient (age, BMI, co-morbidities, race, insurance, uterine size on pre-operative imaging, indication for surgery), and surgical (route of surgery, surgeon specialty, surgeon volume, academic vs. community hospital, resident participation and concomitant procedures). Total OR time was measured as wheels in-wheels out time. Multivariate linear regression was used to develop a predictive model. A total of 1,549 hysterectomies performed during the study period with an average OR time of 200 minutes. Patient characteristics associated with a significantly increased OR time included: high BMI (+8-27min by category), 3 or more medical co-morbidities (+10-41min), non-White race (+7-10min), uterine size >10cm on pre-operative ultrasound (+25-141min). There was no relationship between OR time and indication for surgery (fibroids, endometriosis, adenomyosis, and abnormal uterine bleeding). Compared with a laparoscopic approach, OR time was increased with a robotic approach (+33mins). Compared to general gynecologists, gynecologic oncologists had longer operative times (+39min). When surgeon volume was included, for every hysterectomy performed per month on average, operative time decreased by 10 min. Resident participation resulted in a 10 min increased in OR time. Within the five-hospital system, OR time was decreased at private and community hospitals (-16-49min). Concomitant adnexal procedures did not add statistically significant OR time. Conclusion Preoperative factors are associated with differences in total operative time and can be used to streamline OR schedules and productivity.

Study Objective To evaluate postoperative opioid use and the impact of a patient educational intervention regarding the opioid epidemic and proper opioid use/disposal after benign MIGS procedures. Design Prospective Cohort Study Setting Academic hospital center Patients or Participants Adult patients undergoing benign MIGS procedures were enrolled 1/1/2019-1/1/2020. Exclusion criteria: conversion to laparotomy, preoperative opioid use, incapable of written informed consent, non-English speaking. Interventions Educational pamphlets were provided preoperatively. Patients underwent hysterectomy(HYS), myomectomy(MYO), or other laparoscopic(LSC) procedures. Opioid prescriptions were standardized with 25 tablets oxycodone 5mg for HYS/MYO, 10 tablets oxycodone 5mg for LSC (oral morphine equivalents [OME] were maintained for alternative options). Pill diaries were reviewed and patient surveys completed during postoperative visits. Measurements and Main Results Of 106 consented patients, 65(61%) completed their pill diaries (36 HYS, 17 MYO, 12 LSC). Median opioid use was 35 OME for HYS (∼5 oxycodone tablets; IQR 11.25-102.5), 30 OME for MYO (∼4 tablets; IQR 15-75), and 18.75 OME for LSC (∼3 tablets; IQR 7.5-48.75). Median last post-operative day(d) of use was 3d for HYS (IQR 2, 8), 4d for MYO (IQR 1, 7), and 2d for LSC (IQR 0.5-3.5). One patient (MYO) required a refill of 5mg oxycodone (10 tablets). No difference was found between total opioid use and presence of pelvic pain, chronic pain disorders, or psychiatric co-morbidities. Overall satisfaction with pain control (≥4 on a 5-point Likert scale) was 91% for HYS, 100% for MYO, 83% for LSC. Of the 33 patients who read the pamphlet, 32(97%) felt it increased their awareness/knowledge. Conclusion The vast majority of patients required

Study Objective To compare symptom persistence in women with adenomyosis based on retention or removal of the cervix at the time of hysterectomy. Design Retrospective cohort study and follow-up survey (Canadian Task Force classification xx). Setting Tertiary care academic hospital in Boston, Massachusetts. Patients Women (n = 1580) who underwent laparoscopic hysterectomy for benign indications between 2008 and 2012 at Brigham and Women's Faulkner Hospital and Brigham and Women's Hospital. Intervention Retrospective chart review and follow-up survey. Measurements and Main Results Among the 1580 women contacted, 762 (48%) responded to the postoperative symptom resolution survey. Of these 762 women, 623 agreed to participate in the study. Menopausal women or those who had undergone bilateral salpingo-oophorectomy were excluded. Adenomyosis was identified on histopathologic evaluation of the uterus in 171 of the remaining 443 women (39%). Compared with women without adenomyosis, those with adenomyosis were older on average (mean age, 46.6 ± 6.8 years vs 45.0 ± 5.5 years; p = .009) and more likely to report that abnormal bleeding and pain led to their hysterectomy (87.7% vs 79.8%; p = .03 and 64.9% vs 51.4%; p = .009, respectively). The rates of total and supracervical hysterectomies were similar in the 2 groups. Following surgery, women with adenomyosis were less likely than those without adenomyosis to report persistent pain (adjusted odds ratio [aOR], 0.43; 95% confidence interval [CI], 0.20–0.93; p = .03). Persistent bleeding was similar in the 2 groups (aOR, 0.97; 95% CI, 0.49–1.93; p = .94). Among women with adenomyosis, multivariable logistic regression showed no difference in persistence of symptoms with cervical removal or retention at the time of hysterectomy. Conclusion Compared with women without adenomyosis, those with histopathologically proven adenomyosis were less likely to report persistent pain following hysterectomy. Retention of the cervix does not appear to increase the risk of symptom persistence or postprocedure patient satisfaction.

Study Objective Uterine artery embolization (UAE) can be used as a preoperative adjunct for the surgical management of fibroids. Few, small studies have reported that preoperative UAE may reduce blood loss or facilitate a laparoscopic approach for myomectomies. We assessed outcomes at our institution with preoperative UAE prior to surgical management of fibroids from 7/1/2013 through 8/1/2018. Design Case series Setting Academic medical center Patients or Participants Patients who underwent preoperative UAE prior to surgical management of fibroids Interventions Preoperative UAE followed by myomectomy/hysterectomy Measurements and Main Results Eight patients underwent planned UAE immediately prior to surgery: 2 myomectomies and 6 hysterectomies. One myomectomy was laparoscopic; 22 week size uterus, 3 fibroids removed (largest 11 cm), specimen weight 903g, estimated blood loss (EBL) 300cc with intraop vasopressin use. The other myomectomy was abdominal; 22 week size uterus, 23 fibroids removed (largest 11 cm), specimen weight 1723g, EBL 500cc, with intraoperative vasopressin and misoprostol used. Of the hysterectomy cases, 3 were abdominal and 3 were laparoscopic. A notable open case was a supracervical hysterectomy of a 32 week size uterus; EBL 200cc, specimen weight 5150g. Among the laparoscopic hysterectomy cases, the mean uterine size was 19 weeks (range 17-21 weeks; mean specimen weight 1328g), average EBL 350cc (range minimal-500cc). There were no complications from the UAE and no perioperative surgical complications (conversion to laparotomy, blood transfusions, fever/infection, bleeding, reoperations). All minimally invasive cases were discharged on postoperative day 0. Conclusion Preoperative UAE for surgical management of fibroids appears to be a safe adjunct to myomectomy or hysterectomy with respect to control of EBL, reduced need for transfusions, and maintaining a laparoscopic approach (when applicable). Future larger studies, likely with pooled data from multiple sites, are needed to further evaluate the safety and efficacy of preoperative UAE in this setting.

Study Objective To compare perioperative outcomes, particularly operative time, between uncontained and in-bag power morcellation of uterine tissue at the time of laparoscopic surgery. Design Canadian Task Force classification II-3. Setting Academic tertiary care hospitals. Patients Women undergoing laparoscopic hysterectomy or myomectomy who required morcellation of uterine tissue for specimen extraction. Interventions Outcomes among patients who had in-bag power morcellation were compared with outcomes among patients who had traditional power morcellation. The technique for in-bag morcellation entails placing the specimen into a large containment bag within the abdomen, insufflating the bag within the peritoneal cavity, and then using a power morcellator to remove the specimen from inside the bag. Measurements and Main Results The cohort consisted of 85 consecutive patients who underwent surgery with morcellation of uterine tissue. Prospective data collected from 36 patients who underwent in-bag morcellation were compared with retrospective data collected from the immediately preceding 49 patients who had uncontained power morcellation. Baseline demographics were comparable between the 2 groups although women who underwent in-bag morcellation were on average older than the open morcellation group (mean age in years [standard deviation], 49.19 [1.12] vs 44.06 [8.93]; p = .01). The mean operating room time was longer in the in-bag morcellation group (mean time in minutes [standard deviation], 119.0 [55.91] vs 93.13 [44.90]; p = .02). The estimated blood loss, specimen weight, hospital length of stay, and perioperative complication rate did not vary between the 2 groups. Operative times did not vary significantly by surgeon. There were no cases of malignancy or isolation bag disruption. Conclusions In-bag power morcellation, a tissue extraction technique developed to reduce the risk of tissue dissemination, results in perioperative outcomes comparable with the traditional laparoscopic approach. In this cohort, the mean operative time was prolonged by 26 minutes with in-bag morcellation but may potentially be reduced with further refinement of the technique.

Introduction Operative morbidity of laparoscopic myomectomy largely relates to the potential for intraoperative blood loss. We sought to determine whether blood loss varies according to the menstrual cycle. Material and methods A retrospective study of 268 women who underwent a laparoscopic myomectomy from 2007 to 2012. Patients were categorized into five menstrual groups: follicular phase, luteal phase, oligomenorrheic or amenorrheic on hormonal therapy, postmenopausal or other. Patient and procedure characteristics were compared for the follicular phase group, luteal phase group, and hormonal therapy group. The estimated blood loss was compared across the five groups using a regression model. Results A total of 268 women underwent a laparoscopic myomectomy: 108 (40.3%) were in the follicular phase, 92 (34.3%) were in the luteal phase, 44 (16.4%) were on hormonal therapy, nine (3.4%) were postmenopausal, and 15 (5.6%) could not be classified. Baseline patient characteristics were similar between the groups with the exception of endometriosis. Geometric mean estimated blood loss was 91.9 mL in the follicular phase group, 108.7 mL in the luteal phase group, 114.1 mL in the hormonal therapy group, and 39.8 mL in the postmenopausal group. There was no significant difference in the geometric mean estimated blood loss when comparing the follilcuar phase, luteal phase, and hormonal phase groups (p = 0.41). Upon adjusted multivariable analysis of all five menstrual groups, there was also no difference in estimated blood loss. Conclusions Intraoperative blood loss during laparoscopic myomectomy does not vary significantly with the phase of the menstrual cycle.

Video Objective To outline the steps and techniques for laparoscopic vaginal cuff closure with a focus on ipsilateral port suturing. Setting Female with abnormal uterine bleeding who desired definitive management with total laparoscopic hysterectomy. Interventions Laparoscopic vaginal cuff closure following hysterectomy. Conclusion Hysterectomies are one of the most common surgeries performed in the United States each year. Minimally invasive surgery has transformed this procedure with improved outcomes, shorter hospital stays, faster recovery, decreased blood loss, and decreased morbidity when compared to abdominal approach. With laparoscopic hysterectomy, there are multiple techniques for vaginal cuff closure including both laparoscopic and vaginal approaches, often determined by surgeon comfort. In general, data suggests both methods are safe with no significant differences. Within laparoscopic cuff closure, there are various approaches. Intracorporeal suturing remains one of the most challenging laparoscopic tasks. However, it is also an essential skill not just for vaginal cuff closure but a variety of gynecologic minimally invasive surgeries including myomectomies and cystectomies. This video focuses on a laparoscopic suturing approach when two ipsilateral ports are used for cuff closure, which is often more ergonomic for the surgeon. The video highlights proper ergonomics, ipsilateral ports placement, techniques for suture insertion and removal and ipsilateral suture techniques with the goal to improve surgeon knowledge and comfort.

Video Objective This objective of this video is to review surgical considerations for the obese patient undergoing minimally invasive surgery. Setting The obese patient is the patient considered. This video addresses risks of laparoscopic surgery, differences in patient counseling, prophylactic measures, patient positioning, laparoscopic entry, management of the panniculus, and prevention of conversion to an open procedure. Interventions Interventions for prophylactic measures include placement of an orogastric/nasogastric tube prior to intubation, increased dose of antibiotic prophylaxis, and optimization of hemoglobin A1c for diabetic patients. Interventions for optimizing patient positioning include allotting extra time for procedures, utilizing bariatric beds and stirrups, anti-skid material and padding during surgery, tucking the patient's arms, and applying a chest strap. Interventions for laparoscopic entry include utilization of bariatric trocars, placing trocars more laterally and cephalad, left upper quadrant or supraumbilical entry, and inserting ports at a 90 degree angle to the abdomen. Interventions for panniculus management and prevention of conversion to an open procedure include limiting the use of steep Trendelenberg, decreasing the insufflation pressure, mechanically retracting the panniculus, and performing a tilt test. Conclusion Gynecologic surgeons will inevitably be operating on more obese patients with coming years given the rising prevalence of obesity. Thus, they should be prepared for preoperative evaluation of the obese patient, surgical preparation, patient counseling, and surgical optimization to prevent conversion to an open procedure, all of which are addressed in this video. Preventing conversion is a balancing act between improving surgical visualization and maintaining stable cardiac and respiratory status of the patient. With increasing volume of cases, gynecologic surgeons can become proficient at minimally invasive surgery for the obese patient, thus, decreasing their operative morbidity and post-surgical quality of life.

The HTMCGC collaboration has been simulating lattice QCD with two light staggered quarks with masses mq = 0.0125 and also mq = 0.00625 on a 163 × 8 lattice. We have been studying the behaviour of the transition from hadronic matter to a quark-gluon plasma and the properties of that plasma. We have been measuring entropy densities, Debye and hadronic screening lengths, the spacial string tension and topological susceptibility in addition to the standard order parameters. The HEMCGC collaboration has simulated lattice QCD with two light staggered quarks, mq = 0.025 and mq = 0.010 on a 163 × 32 lattice. We have measured the glueball spectrum and topological susceptibilities for these runs.

We discuss some aspects of the hadron spectrum with two flavors of Kogut-Susskind dynamical quarks at 6/g2 = 5.6 and amq = 0.01 and 0.025, using both Kogut-Susskind and Wilson valence quarks. Our high statistics simulations allow us to study systematic errors. Among the problematic features of our results are a dip in the pion effective mass which we ascribe to replicating the lattice in the time direction and large finite size effects in the baryon masses. We also compare the full QCD results to a quenched simulation at similar lattice spacing and quark masses to test whether the effects of dynamical fermions can be absorbed into renormalization of the lattice parameters. © 1991.

Objectives To identify factors that influence the decision-making process on the type of hysterectomy (total or supracervical) and the impact of surgery of subsequent sexual function. Study design A cross-sectional survey was undertaken on 212 women who underwent total laparoscopic hysterectomy (TLH) or laparoscopic supracervical hysterectomy (LSH) for benign conditions at the Division of Minimally Invasive Gynecology at Brigham and Women's Hospital in Boston, MA, USA. We analyzed the factors that patients considered in their decision-making process, their sexual function after surgery and their satisfaction with the surgery overall. Demographic and perioperative outcomes were also collected. Results A total of 115 women answered the survey, for a response rate of 54.24%. The patients who underwent LSH ( n =54) and TLH ( n =61) were overall similar in terms of baseline factors and perioperative outcomes. Patients reported that the physician was the main source of information regarding decision to remove or retain the cervix (79.13%). The physicians' recommendation was viewed as very or extremely important (83.68%) to the decision-making process, followed by concerns regarding their future sex life (51.09%). Almost half of the women reported that hysterectomy had no impact on sexual function. No statistically significant differences were seen between groups regarding satisfaction with sexual function ( p =.822), impact on sexual function ( p =.753) or recommendation of this surgery to other women ( p =.505). Conclusion Concerns about sexual health were important to women when considering the type of hysterectomy to undergo. Cervix removal or retention at the time of hysterectomy did not impact women's sexual function after mean follow-up of 15.2 months.

Transcervical sterilization is a minimally invasive option for permanent contraception with high reported rates of patient satisfaction. A small percentage of women subsequently choose to have the tubal inserts removed due to regret or perceived side effects. There is limited information with regard to the improvement in the symptom profile following surgical removal of the tubal inserts. We present a retrospective case series of 11 women who underwent surgical removal of Essure by hysteroscopy, salpingectomy, and/or hysterectomy. The predominant symptom at presentation was pain (n = 10; 90.91%), as well as bleeding (n = 6; 54.54%) and/or dyspareunia (n = 5; 45.45%). After surgical removal, the majority of patients (n = 8; 72.72%) reported an improvement of their symptoms. However, 3 (27.27%) patients continued to have persistent symptoms after surgery. Before surgical removal of Essure, it is important to thoroughly discuss the risk of continuing symptoms with patients.

Background and objectives To evaluate whether the route and surgical technique by which hysterectomy is performed influence the incidence of vaginal cuff dehiscence. Methods We performed a retrospective analysis of total hysterectomy cases performed at Brigham and Woman's Hospital or Faulkner Hospital during 2009 through 2011. Results During the study period, 2382 total hysterectomies were performed; 23 of these (0.96%) were diagnosed with cuff dehiscence, and 4 women had recurrent dehiscence. Both laparoscopic (odds ratio, 23.4; P = .007) and robotic (odds ratio, 73; P = .0006) hysterectomies were associated with increased odds of cuff dehiscence in a multivariate regression analysis. The type of energy used during colpotomy, mode of closure (hand sewn, laparoscopic suturing, or suturing assisted by a device), and suture material did not differ significantly between groups; however, continuous suturing of the cuff was a protective factor (odds ratio, 0.24; P = .03). Women with dehiscence had more extensive procedures, as well as an increased incidence of additional major postoperative complications (17.4% vs 3%, P = .004). Conclusion The rate of cuff dehiscence in our cohort correlates with the current literature. This study suggests that the risk of dehiscence is influenced mainly by the scope and complexity of the surgical procedure. It seems that different colpotomy techniques do not influence the rate of cuff dehiscence; however, continuous suturing of the cuff may be superior to interrupted suturing.

The integration of robotics into the field of gynecologic surgery initially involved a voice-recognition system and robotic control of laparoscopic camera movement (AESOP® Endoscope Positioner (Computer Motion Inc., Goleta, CA)). This technology further evolved with the ZEUS® Surgical System (Computer Motion Inc., Goleta, CA) to include two robotic arms, thereby allowing the surgeon to operate from a console away from the operative table. The da Vinci Surgical System® (Intuitive Surgical, Sunnyvale, CA, USA), which was approved for gynecologic surgery in 2005 by the United States Food and Drug Administration, incorporates three or four robotic arms to allow surgeon control of the visual field and up to three laparoscopic instruments.

OBJECTIVE: To describe a technique for contained power morcellation within an insufflated isolation bag at the time of uterine specimen removal during minimally invasive gynecologic procedures. METHODS: Over the study period of January 2013 to April 2014, 73 patients underwent morcellation of the uterus or myomas within an insufflated isolation bag at the time of minimally invasive hysterectomy or myomectomy. This technique involves placing the specimen into a large plastic bag within the abdomen, exteriorizing the opening of the bag, insufflating the bag within the peritoneal cavity, and then using a power morcellator within the bag to remove the specimen in a contained fashion. Procedures were performed at four institutions and included multiport laparoscopy, single-site laparoscopy, multiport robot-assisted laparoscopy, or single-site robot-assisted laparoscopy. Demographic and perioperative characteristics were collected for the cases. RESULTS: Surgical specimen morcellation within an insufflated isolation bag was successfully used in all cases. The median operative time was 114 minutes (range 32–380 minutes), median estimated blood loss was 50 mL (range 10–500 mL), and the median specimen weight was 257 g (range 53–1,481 g). There were no complications related to the contained morcellation technique nor was there visual evidence of tissue dissemination outside of the isolation bag. CONCLUSION: Morcellation within an insufflated isolation bag is a feasible technique. Methods for morcellating uterine tissue in a contained manner may provide an option to minimize the risks of open power morcellation while preserving the benefits of minimally invasive surgery. LEVEL OF EVIDENCE: II

Study Objective To evaluate risk of leakage and tissue dissemination associated with various contained tissue extraction (CTE) techniques. Design In vitro study (Canadian Task Force classification: II-1). Setting Academic hospital simulation laboratory. Intervention Beef tongue specimens weighing 400 to 500 g were stained using 5 mL indigo carmine dye and morcellated under laparoscopic guidance within a plastic box trainer. CTE was performed via 3 different techniques: a stitch-sealed rip-stop nylon bag and multi-port approach; a one-piece clear plastic 50 × 50-cm isolation bag and multi-port approach; or a 1-piece clear plastic 50 × 50-cm isolation bag and single-site approach. Four trials of each CTE method were performed and compared with an open morcellation control. All bags were insufflated to within 10 to 25 mmHg pressure with a standard CO 2 insufflator. Visual evidence of spilled tissue or dye was recorded, and fluid washings of the box trainer were sent for cytologic analysis. Measurements and Main Results Blue dye spill was noted in only 1 of 12 CTE trials. Spillage was visualized from a seam in 1 of the 4 stitch–sealed rip-stop nylon bags before morcellation of the specimen. The only trial in which gross tissue chips were visualized in the box trainer after morcellation was the open morcellation control. However, cytologic examination revealed muscle cells in the open morcellation washings and in the washings from the trial with dye spill. Muscle cells were not observed at cytologly in any of the other samples. Conclusion CTE did not result in any leakage or tissue dissemination with use of the single-site or multi-port approach when using a 1-piece clear plastic 50 × 50-cm isolation bag. Further studies are needed to corroborate these findings in an in vivo context and to evaluate use of alternate bag options for specimen containment.

A mixture of cis- and trans-2-(6-m-methoxyphenyl-3-oxohexyl)-2,4-dimethylcyclopenta-1,3-dione (±)-10 was synthesized and incubated with Schizosaccharomyces pombe (NRRL Y-164) to give (+)-11, (+)-12, (−)-13, and (−)-14 in 19, 13, 22, and 16% yields, respectively. Chromic acid oxidation of these microbiologically reduced products gave (−)-10a, (+)-10b, (+)-10a, and (−)-10b, respectively.

We describe experimental ultra-high-speed HBT circuits for lightwave communications applications. High speed circuits such as multiplexer/demultiplexers, variable gain amplifiers, (VGAs), and transimpedance amplifiers operating at high bit rates (>30 Gb/s) are required for the realization of high-performance lightwave systems using TDM or WDM. We have demonstrated 40 Gb/s 4:1 multiplexer, >30 Gb/s 1:4 demultiplexers, DC-26 GHz VGAs, DC-25 GHz transimpedance amplifiers, 30 Gb/s data and clock regenerators, 40 Gb/s differentiate-and-rectify timing recovery circuits, and 40 Gb/s delay-and-multiply timing recovery circuits, for use in such systems using a manufacturable hybrid digital/microwave HBT process.

Technology and performance of electronic crosspoint switches with data rates above 1 Gb/s/channel are reviewed. Switch applications and architectures are described, as well as the principal problems in achieving low output jitter. Recent results for different IC technologies are summarized. As a particular example, a 10 Gb/s crosspoint switch implemented in GaAlAs/GaAs-HBT technology is described, including details of design, packaging, testing methodology, and performance results.

The distribution of enterotoxin types and toxic shock syndrome toxin I (TSST-1) strains for 176Staphylococcus aureusstrains obtained from food samples and 62S. aureusstrains isolated from clinical samples were compared. It was found that for both the food and clinical isolates, staphylococcal enterotoxin A (SEA) strains accounted for the major part (75% and 45% of the total enterotoxigenic strains for food and clinical isolates, respectively) followed by SEB or SEAB, SEC and SED strains. For food isolates, none of theS. aureusstrains was TSST-1 strain while for clinical isolates, three strains (1 SEC, 1 SED and 1 SEAB strain) were found to be TSST-1 strains. When susceptibilities for these enterotoxigenicS. aureusstrains to antibiotics, such as penicillin, oxacillin, vancomycin, methicillin, streptomycin, tetracycline, gentamycin and kanamycin were compared, results showed that 51.6% of the food isolates were resistant to penicillin G only but sensitive to the other antibiotics tested. Also, 8 of the 64 enterotoxigenic strains isolated from food samples were all sensitive to antibiotics while none of the enterotoxigenic strains from clinical samples showed this antibiotic susceptibility pattern. No methicillin resistantS. aureus(MRSA) strains could be found among the food isolates. On the other hand, the majority (42.4%) of the enterotoxigenicS. aureusstrains from clinical samples were penicillin and/or other antibiotics resistant MRSA strains. Since MRSA strains often posed the therapeutic problem, the MRSA strains were further confirmed by PCR assay using the primers specific formecA gene. It was found that results obtained from the disc agar diffusion method and the PCR method were the same.

Production and laboratory AlGaAs/GaAs HBT processes were developed, enabling implementation of high-precision and high-speed circuits to meet the ever increasing demands on information bandwidths. Under normal bias conditions, the production HBT process shows transistor f t and f max above 50 GHz, while the laboratory process reveals f t of 60 GHz and f max of 110 GHz. With these two HBT processes, numerous high-speed and high-precision circuits for signal and data processing were implemented. In particular, we have designed and fabricated a 8-bit, 2 GS s −1 ADC and a 6-bit, 4 GS s −1 ADC for instrumentation and digital receiver applications; a 40 GBit s −1 4:1 multiplexer and an 8-channel, 2.5 GBit s −1 laser driver array for optical communication transmitters; a 50 dBΩ, 25 GHz preamplifier, a DC-26 GHz 10–16 dB variable gain amplifer, a 30 GBit s −1 data/clock regeneration circuit, two 40 GBit s −1 nonlinear (differentiate/rectify and delay/multiply) clock regeneration circuits, and a 40 GBit s −1 phase detector circuit for optical communication receivers.

We have extended our earlier simulations of the high-temperature behavior of lattice QCD with two light flavors of staggered quarks on a 16{sup 3}{times}8 lattice to a lower quark mass (m{sub q}=0.00625). The transition from hadronic matter to a quark-gluon plasma is observed at 6/g{sup 2}=5.49(2) corresponding to a temperature of T{sub c}{approx}140 MeV. We present measurements of observables which probe the nature of the quark-gluon plasma and serve to distinguish it from hadronic matter. Although the transition is quite abrupt, we have seen no indications that it is first order. {copyright} {ital 1997} {ital The American Physical Society}

To evaluate the adverse events encountered during robotic gynecologic surgery, as reported to the FDA MAUDE database from January 2006 to December 2012.Database search (Canadian Task Force classification III).A search of the FDA MAUDE database was performed by brand name "da Vinci" and manufacturer "Intuitive Surgical." Reports reflecting gynecologic procedures either by description or procedure name were included. A record of reports was kept to ensure that no duplicates were added. The date and type of event (operator-related error, technical system failure, or surgical injuries attributed to use of the robot) and the clinical outcome were recorded.Twenty-six percent of reported events (n = 73) resulted in injury, and 8.5% (n = 24) resulted in death. Of note, although adnexal procedures were performed in3% of the cohort, they accounted for 20% of the fatalities. Twenty-one percent of injuries were attributed to operator-related error, and 14% to technical system failure; 65% were not directly related to use of the robot. Fifteen deaths were reported during planned hysterectomy. Four of those were due to injury to a major blood vessel (iliac artery in 3, and aorta in 1), although a detailed description of how the injury occurred was absent from the event description.It is important to continue to evaluate the occurrence of injuries during robot-assisted surgery in an effort to identify unique challenges associated with this advanced technology.

Non-compact lattice QED is simulated for various numbers of fermion species $N_f$ ranging from 8 through 40 by the exact Hybrid Monte Carlo algorithm. Over this range of $N_f$, chiral symmetry breaking is found to be strongly correlated with the effective monopoles in the theory. For $N_f$ between 8 and 16 the chiral symmetry breaking and monopole percolation transitions are second order and coincident. Assuming powerlaw critical behavior, the correlation length exponent for the chiral transition is identical to that of monopole percolation. This result supports the conjecture that monopole percolation ``drives" the nontrivial chiral transition. For $N_f$ between 20 and 32, the monopoles experience a first order condensation transition coincident with a first order chiral transition. For $N_f$ as large as 40 both transitions are strongly suppressed. The data at large $N_f (N_f \mathrel {\mathpalette \vereq >} 20)$ is interpreted in terms of a strongly interacting monopole gas-liquid transition., Revtex file, 23 pages, hardcopy figures only.