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The use of robotic-assisted keyhole surgery in gynaecology has expanded in recent years owing to technical advances. These include 3D viewing leading to improved depth perception, limitation of tremor, potential for greater precision and discrimination of tissues, a shorter learning curve and improved comfort for surgeons compared with conventional keyhole and open abdominal surgery. Robotic-assisted keyhole surgery, compared with conventional keyhole surgery, improves surgical performance without increasing operating time, minimises blood loss and intra- or postoperative complications, while reducing the need to revert to abdominal surgery. Moreover, surgeons using a robot experience fewer skeletomuscular problems of their own in the short and long term than those operating without a robot as an additional tool. This Scientific Impact Paper looks at the use of a robot in different fields of gynaecological surgery. A robot could be considered safe and a more effective surgical tool than conventional keyhole surgery for women who have to undergo complex gynaecology surgery or have associated medical issues such as body-mass index (BMI) at 30 kg/m

Obesity is having an increasingly significant impact on health care services across the developed world. Although initially laparoscopic surgery was thought to be contraindicated in cases of obesity, surgeons, including gynaecologists, are now routinely performing laparoscopic surgery on obese patients. Limited research has been conducted into the effect of obesity on outcomes of major laparoscopic pelvic surgery. Some authors report worsening outcomes in obese women having laparoscopic hysterectomies; others suggest that complication rates do not increase, but operating times are longer. Here, we report our experience from 250 total laparoscopic hysterectomies performed for benign, malignant and pre-malignant conditions, and we compare outcomes among normal, overweight, obese and morbidly obese patients. We used a composite score index calculated on the basis of operating and theatre times, estimated blood loss, length of stay and number and severity of complications for our comparisons. Our conclusions suggest that meticulous, consistent surgical technique may produce similar outcomes in normal and obese patients having total laparoscopic hysterectomy, with longer operating/theatre times noted only at BMI levels >40.

Background and Aims: The evolution of robotic technology has enhanced the scope of laparoscopic surgery. Morbid obesity [body mass index (BMI) >40 kg/m2] due to significant physiological attributes presents a significant surgical and anaesthetic challenge. Robotic surgery in this subset of patients can present with its own problems due to surgical requirements of prolonged pneumoperitoneum and steep Trendelenburg position. Methods: We reviewed the anaesthetic management of 46 morbidly obese patients undergoing robotic-assisted laparoscopic gynaecology surgery. Patient characteristics, anaesthetic management, length of hospital stay (LOS), complications, and readmissions within 30 days were noted. Mean with standard deviation was used for statistical analysis. Results: The mean [standard deviation (SD)] weight and BMI were 121.2 (18.49) kg and 47.83 (7.89) kg/m2, respectively. The mean (SD) anaesthetic and surgical times were 229 (75.9) and 167.7 (62.7) min, respectively. The mean (SD) LOS was 1.57 (1.03) days. About 70% of patients were discharged on the first day after surgery. Six patients needed critical care support. There were two readmissions within 30 days. Conclusion: Good preparation, teamwork, and multidisciplinary input helped us to conduct complex robotic-assisted and long-duration surgery in morbidly obese patients with minimal complications.

The management of women with abnormally invasive placenta remains one of the most challenging aspects of obstetric care. Various surgical and interventional radiological techniques have been developed to limit the risk of massive haemorrhage at caesarean section. Here we describe our experience with three such cases that required caesarean hysterectomy and were managed with prophylactic balloon catheterisation of the common iliac arteries. The details of three cases that received prophylactic balloon catheterisation of the common iliac arteries for the surgical management of placenta accreta/percreta are presented. Observational conclusions from these cases as well as a review of the relevant literature are discussed. Our three cases required caesarean hysterectomy for suspected placenta accreta/percreta. The mean estimated blood loss was 3,333 ml. In one of the cases, we observed notable reduction in blood loss during occlusion of the common iliac arteries, as the balloons were deflated every 5 min to avoid lower limb ischemia. The cases presented here, and also our literature review, suggest that occlusion of the common iliac arteries appears to be more effective than, and as safe as the occlusion of the internal iliac arteries. Clinicians need to be aware of the potential risks and employ measures to prevent them. Further research is required to investigate the optimum length of occlusion and balance between reducing blood loss and risking ischemia of the limbs when occluding the common iliac arteries.

Surgical site infection can result in increased morbidity for the patient, prolonged hospital stay and hospital readmission. Preoperative antibiotics reduce the incidence of such infections, particularly in open surgery. Universal use of antibiotic prophylaxis, however, is not recommended due to the risks of adverse reactions, generation of resistant bacteria and additional cost. Endoscopic procedures carry low risk of wound contamination and infection. Limited data suggest wide variability in antibiotic prophylaxis in gynaecological surgery and potential overuse of antibiotics in gynaecological endoscopic surgery. Bringing together the existing evidence allows for a consensus proposal for the use of preoperative antibiotics in gynaecological endoscopy.

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

Objective. The objective of our study was to compare immunocyte infiltrates in vulval epithelium from low-grade and high-grade vulval intraepithelial neoplasia (VIN) lesions to determine if difference in T-cell presence reflected the grade of VIN. Material and methods. Thirty-six vulval specimens were obtained from 24 patients who had previously undergone vulval biopsies for VIN, 14 high-grade diseases (VIN 3 with or without HPV) and 14 low-grade diseases (VIN 1 and VIN 2 with or without HPV). Eight samples of normal vulval tissue were selected from the excision margins of resected vulval biopsies. The lymphocyte surface markers included CD3 (Pan T-cell marker), CD4 (T helper cells), and CD8 (T cytotoxic cells). Each tissue section was visualized under high power magnification and cells were counted in 10 random areas at the dermo-epidermal junction. Results. A significantly higher number of total mean T lymphocytes were detected in VIN specimens compared to normal vulval tissue ( P = 0.002). In low-grade VIN, there were significantly more CD8 cells than CD4 when compared to high-grade VIN. This difference in CD4/CD8 ratio was significant ( P = 0.001). Conclusions. This study suggests that increased CD8 response in VIN is a feature of low-grade disease and we speculate that this may be a protective mechanism. In high-grade disease, both CD4 cells and CD8 cells are equally present with preservation of normal CD4/CD8 ratio.