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Postoperative shoulder pain remains a significant problem after laparoscopy. Pneumoperitoneum with insufflation of carbon dioxide (CO2) is thought to be the most important cause. Reduction of pneumoperitoneum pressure may, however, compromise surgical visualisation. Recent studies indicate that the use of deep neuromuscular blockade (NMB) improves surgical conditions during a low-pressure pneumoperitoneum (8 mmHg).The aim of this study was to investigate whether low-pressure pneumoperitoneum (8 mmHg) and deep NMB (posttetanic count 0 to 1) compared with standard-pressure pneumoperitoneum (12 mmHg) and moderate NMB (single bolus of rocuronium 0.3 mg kg with spontaneous recovery) would reduce the incidence of shoulder pain and improve recovery after laparoscopic hysterectomy.A randomised, controlled, double-blinded study.Private hospital in Denmark.Ninety-nine patients.Randomisation to either deep NMB and 8 mmHg pneumoperitoneum (Group 8-Deep) or moderate NMB and 12 mmHg pneumoperitoneum (Group 12-Mod). Pain was assessed on a visual analogue scale (VAS) for 14 postoperative days.The primary endpoint was the incidence of shoulder pain during 14 postoperative days. Secondary endpoints included area under curve VAS scores for shoulder, abdominal, incisional and overall pain during 4 and 14 postoperative days; opioid consumption; incidence of nausea and vomiting; antiemetic consumption; time to recovery of activities of daily living; length of hospital stay; and duration of surgery.Shoulder pain occurred in 14 of 49 patients (28.6%) in Group 8-Deep compared with 30 of 50 (60%) patients in Group 12-Mod. Absolute risk reduction was 0.31 (95% confidence interval 0.12 to 0.48; P = 0.002). There were no differences in any secondary endpoints including area under the curve for VAS scores.Deep NMB and low-pressure pneumoperitoneum (8 mmHg) reduced the incidence of shoulder pain after laparoscopic hysterectomy in comparison to moderate NMB and standard-pressure pneumoperitoneum (12 mmHg).Clinicaltrials.gov identifier: NCT01722097.

Background Insufflation of the abdomen during laparoscopy improves surgical space, but may cause post-operative shoulder pain. The incidence of shoulder pain is reduced using a lower insufflation pressure, but this may, however, compromise the surgical space. We aimed at investigating whether deep neuromuscular blockade (NMB) would enlarge surgical space, measured as the distance from the sacral promontory to the trocar in patients undergoing gynaecologic laparoscopy. Methods Fourteen patients were randomised in an assessor-blinded crossover design. The distance from the sacral promontory to the trocar was measured during deep NMB and without NMB at pneumoperitoneum 8 and 12 mmHg both. Additionally, we assessed surgical conditions while suturing the abdominal fascia using a 4-point subjective rating scale. Deep NMB was established with rocuronium and reversed with sugammadex. Results At 12 mmHg pneumoperitoneum, deep NMB improved surgical space with a mean of 0.33 cm (95% confidence interval 0.07–0.59) (P = 0.01, paired t-test) compared with no NMB. At 8 mmHg pneumoperitoneum deep NMB improved surgical space with a mean of 0.3 cm (95% confidence interval, 0.06–0.54) (P = 0.005) compared with no NMB. Deep NMB resulted in significantly better ratings of surgical conditions during suturing of the fascia (P = 0.03, Mann–Whitney U-test). Conclusion Deep NMB enlarged surgical space measured as the distance from the sacral promontory to the trocar. The enlargement, however, was minor and the clinical significance is unknown. Moreover, deep NMB improved surgical conditions when suturing the abdominal fascia.

Key Clinical Message It is important to be aware of the risk of abnormally invasive placenta in patients with a history of Asherman syndrome and uterine scarring. A prenatal diagnosis by ultrasonography is useful when planning of mode of delivery.

Establishment of sufficient muscle relaxation is essential in laparoscopic surgery. During laparoscopy, surgeons can experience abdominal contractions in their patients. Deep neuromuscular block (NMB) has the potential to prevent such episodes. In this study, we explored if deep NMB reduces the incidence of sudden abdominal contractions as compared with standard NMB.This was a pre-planned secondary analysis of a randomized, controlled study. A total of 110 patients scheduled for laparoscopic hysterectomy were randomized to either deep NMB and 8 mmHg pneumoperitoneum (deep NMB group) or single-bolus NMB and 12 mmHg pneumoperitoneum (standard NMB group). NMB was established with rocuronium and reversed with sugammadex. Two gynaecologists registered episodes of sudden abdominal contractions, alarms from the insufflator due to increased intraabdominal pressure and incidences with tightness of the abdominal wall.No sudden abdominal contractions were detected in the deep NMB group as compared with 12 episodes in the standard NMB group (p0.001). The insufflator alarmed in no versus ten procedures (p = 0.001) in the deep and standard NMB group, respectively. The gynaecologists registered increasing abdominal tensions in no versus eight procedures (p = 0.006) in the deep and standard NMB group, respectively.Deep NMB in combination with 8 mmHg pneumoperitoneum prevented sudden abdominal contractions during laparoscopic hysterectomy.This work was funded in part by a research grant from the Investigator Initiated Studies Program of Merck SharpDohme Corp, USA. The opinions expressed in this paper are those of the authors and do not necessarily represent those of Merck SharpDohme Corp.The study was assigned with EudraCT number 2012-003787-51 and registered with clinicaltrials.gov (NCT01722097).

The objective of this guideline is to provide clinicians with evidence-based information about commonly used and available hysteroscopic distending media to guide them in their performance of both diagnostic and operative hysteroscopy. While necessary for the performance of hysteroscopy and hysteroscopically-directed procedures, distending media, if absorbed systemically in sufficient amounts, can have associated adverse events, including life-threatening complications. Consequently, understanding the physical properties and the potential risks associated with the use of the various distending media is critical for the safe performance of hysteroscopic procedures. This report was developed under the direction of the Practice Committee of the AAGL as a service to their members and other practicing clinicians.

Design A 45-year-old woman with a symptomatic uterine myoma suffering from heavy menstrual bleeding, incontinence, and pain pressure received ulipristal acetate (UPA [Esmya; Gideon Richter, Budapest, Hungary]) for 6 months. Setting A Minimal Invasive Gynecology surgery Unit in Chopenhagen Denmark. Intervention Her symptoms were reduced; however, after 3 months on UPA, she was then admitted because of increased pain. A high level of C-reactive protein was found, and necrosis of the myoma was assumed to be the reason. In December 2015, she opted for a laparoscopic hysterectomy because of the increasing symptoms and lack of conviction that the medical therapy would be sufficient. Measurements and Main Results Ultrasound showed a 106 × 73 mm myoma with no abnormal blood flow or lacuna of fluid inside the myoma; there was no suspicion of malignancies. The video and the report have been approved by the local institutional review board. The weight of the contained morcellated uterus was 575 g, and pathology showed a malignant leiomyoma sarcoma. A postoperative positron emission tomographic scan showed 4 metastatic processes in the lungs. Conclusions The Food and Drug Administration has approved the PneumoLiner (Advanced Surgical Concepts, Dublin, Ireland); however, they also stress the point that the device “has not been proven to reduce the risk of spreading cancer.” In this case, the UPA treatment actually led to a delay in the diagnosis, potentially with a larger or even metastatic tumor as a consequence.

LESS, or laparo-endoscopic single site surgery, is a promising new method in minimally invasive surgery. An increasing number of surgical procedures are being performed using this technique; however, its large-scale adoption awaits results of prospective randomized controlled studies confirming potential benefits. Theoretically, cosmetic outcomes, postoperative pain and complication rates could be improved with use of single site surgery. This study describes introduction of the method in a private hospital in Denmark in which 40 women were treated for benign gynecologic conditions. Although the operations described are the first of their kind reported in Denmark, favorable operating times and very low complication rates are seen. It is the authors' opinion that in addition to being feasible for hysterectomy, single port laparoscopy may become the preferred method for many simple gynecological procedures.

Background: Large uterine fibroids and placenta percreta are often associated with a hysterectomy. The case: A 31-year-old nulligravida had a transcervical resection of a large fibroid (158 g) in the anterior wall of the uterus. A subsequent spontaneous pregnancy was complicated by placenta percreta. In late pregnancy, she had an elective cesarean section, the percrete area was resected, and she had an abdominal cerclage for hemostasis and support. Subsequently, she had two term pregnancies with normal placentation. Conclusion: The woman avoided hysterectomy twice, first for gynecological and second for obstetrical reasons – and had three healthy infants. We conclude that the uterus should be preserved whenever possible in young fertile women.

Background and Objectives: After the U. S. Food and Drug Administration's recommendation against the use of power morcellation for tissue extraction in minimally invasive hysterectomy, the number of procedures completed laparoscopically declined in favor of open surgery laparotomy. We conducted a retrospective cohort study comparing perioperative and long-term outcomes, including complications associated with laparoscopic hysterectomy before and after the FDA recommendation.Methods: We included procedures performed in Danish government hospitals (GHs) and a hospital specializing in minimally invasive gynecological surgery (MIGS). Different types of hysterectomy over the period from January 2011 through May 2016 were examined.Results: Hysterectomies were analyzed from GHs (n = 21,495) and from a hospital specializing in MIGS (n = 749). In the GHs, we found a decrease in open hysterectomy from 40% in 2011 to 20% in 2016. In the MIGS hospital, 4 of 749 (0.05%) open hysterectomies were performed during the 6 years; however, there was a change in operative technique. After the FDA recommendation, there was a shift from laparoscopic subtotal hysterectomy (LSH) to total laparoscopic hysterectomy (TLH) from 32% in 2011 to 82% by May 2016. Containment bags were used in LSH and large-uterus TLH after the 2014 advisory. Significantly more complications occurred in the GHs than in the MIGS hospital: 3224/21,495 (15%) vs 53/749 (7.0%), respectively.Conclusion: The rate of minimally invasive hysterectomies continues to increase. However, after 2014, many of the morcellation techniques have been replaced by a minilaparotomy to extract the uterus at the end of surgery, compared to the use of the contained morcellation in 100% of cases in the MIGS hospital. There was a major difference in complication rates between the hospitals that is partly explainable by the challenge in training residents and the low operative volume of surgeons in GHs.

Objective To compare the impact of 1000 μg of self-administered vaginal misoprostol versus self-administered vaginal placebo on preoperative cervical ripening after 2 weeks of pretreatment with estradiol vaginal tablets in postmenopausal women prior to day-care operative hysteroscopy. Design Randomised, double-blind, placebo-controlled sequential trial. Setting Norwegian university teaching hospital. Population Sixty-seven postmenopausal women referred for day-care operative hysteroscopy. Methods The women were randomised to receive either 1000 μg of self-administered vaginal misoprostol or self-administered vaginal placebo on the evening before day-care operative hysteroscopy. All women had administered a 25-μg vaginal estradiol tablet daily for 14 days prior to the operation. Main outcome measures Primary outcome: preoperative cervical dilatation at hysteroscopy. Secondary outcomes: difference in dilatation at recruitment and before hysteroscopy, number of women who achieved a preoperative cervical dilatation of 5 mm or more, acceptability, complications and adverse effects. Results The mean cervical dilatation was 5.7 mm (SD, 1.6 mm) in the misoprostol group and 4.7 mm (SD, 1.5 mm) in the placebo group, the mean difference in cervical dilatation being 1.0 mm (95% CI, 0.2–1.7 mm). Self-administered vaginal misoprostol of 1000 μg at home on the evening before day-care hysteroscopy is safe and highly acceptable, although a small proportion of women experienced lower abdominal pain. Conclusions One thousand micrograms of self-administered vaginal misoprostol, 12 hours prior to day-care hysteroscopy, after 14 days of pretreatment with vaginal estradiol, has a significant cervical ripening effect compared with placebo in postmenopausal women.

Hypoestrogenism in postmenopausal women results in skin atrophy with a decrease in both elasticity and skin thickness. The fragility of the skin in aging women may be responsible for the reported 50% or more increase in major laparoscopic complications during the initial entry into the female abdomen. Several first-entry techniques in laparos- copy have been investigated to minimize entry-related complications. The Veress needle approach is the standard method used by most gynecologists. A promising new method is the direct optical access (DOA) which uses optically-guided trocars to provide visual guidance during entry. These 2 techniques have not been compared. The aim of this prospective randomized study was to evaluate the efficacy and safety of these 2 methods in postmenopausal women. The study was conducted at multiple European gynecology centers between 2004 and 2008. A total of 186 postmenopausal women scheduled to undergo laparoscopy for simple, persistent postmenopausal ovarian cysts were randomized to 2 groups: group I (n = 89) was assigned to surgical entry using DOA, and group 2 (n = 97) was assigned to entry using the Veress needle method. The 2 procedures were compared for the following parameters: the time needed for achieve adequate abdominal access, the occurrence of major and minor vascular and bowel injuries, and blood loss during laparoscopic access. The time needed to establish adequate abdominal access was significantly reduced in the DOA access group compared to the Veress group (65.7 ± 11.9 vs. 192.8 ± 5.6 minutes; P < 0.0001), but there were no significant differences between the two groups in the occurrence of major vascular and/or bowel injuries (P = NS). Although fewer minor vascular injuries were found with DOA method than the Veress technique (1 versus 3), the difference was not statistically significant. The findings of this small preliminary study suggest that use of the DOA technique may be a safe and less time-consuming approach to abdominal entry in postmenopausal women and may avoid the risks of blind access laparoscopy.

Leiomyomata uteri remain a common gynecologic problem, associated with a significant clinical and economic burden of illness. Despite a variety of currently available interventions for uterine fibroids, there remains an unmet clinical need for novel therapies. Doppler-guided uterine artery occlusion is a promising investigational procedure for the treatment of symptoms associated with uterine fibroids. This procedure may also have potential uses in the management of adenomyosis, postpartum hemorrhage, ectopic pregnancy, gestational trophoblastic neoplasia and heavy abnormal uterine bleeding in women with bleeding disorders, and as neoadjuvant therapy in conjunction with myomectomy. A teleconference of leading gynecologic surgeons was held to build consensus around potential uses of this new technology. Based on pilot studies and expert opinion, Doppler-guided uterine artery occlusion appears to have promise for the management of fibroid-associated symptoms and may have application in the setting of other ...

Objective To compare three types of equipment during hysteroscopic resection. Design A randomized study. Setting Women's clinic at Ullevaal University Hospital, Oslo, Norway. Patient(s) Two hundred premenopausal women with menorrhagia caused by dysfunctional bleedings, fibroids, or polyps. Intervention(s) Hysteroscopic resection was performed either with monopolar electrodes using glycine 1.5% as irrigant or with two different types of bipolar electrodes (TCRis; Olympus, Hamburg, Germany and Versapoint; Gynecare, Menlo Park, CA) using saline as irrigant. Main Outcome Measure(s) Change in serum sodium as a result of irrigant consumption, operating time, and amount of tissue removed. Result(s) A statistically significant reduction in mean serum sodium from 138.7 mmol/L to 133.8 mmol/L was seen in the monopolar group, compared with the case of the saline groups with no reduction. The amount of resected tissue in the monopolar and TCRis group was approximately 1.00 g/min, compared with 0.65 g/min in the Versapoint group. Loss of fluid during the procedure was significantly higher in the two bipolar groups. Conclusion(s) Bipolar electrodes appear to have a safer profile compared with monopolar electrodes because of the unchanged serum sodium. Irrigant consumption was significantly higher in the two bipolar groups, without any side effects during or after the procedure. Furthermore, the TCRis loop appears to be superior to the Versapoint loop, as regards operating time and amount of tissue removed.

Objectives To evaluate whether assessment of blood flow by transvaginal color Doppler and three-dimensional power Doppler imaging, enhanced by intravenous contrast, may be useful in the differentiation between benign endometrial polyps and endometrial cancer. Methods A prospective study was performed comparing 17 women with benign endometrial polyps and 17 women with endometrial cancer. Transvaginal color Doppler and three-dimensional power Doppler angiography were performed before and after injection of intravenous contrast. The pulsatility index (PI) and the resistance index (RI) of the polyp feeding vessel or central vessel in malignant lesions, as well as the power Doppler endometrial flow indices vascularization index (VI), flow index (FI) and vascularization flow index (VFI), were calculated before and after enhancement by contrast, and compared between the two groups of women. Results PI (mean difference ± SD, 0.68 ± 0.22; 95% CI, 0.23–1.13; P = 0.004) and RI (mean difference ± SD, 0.16 ± 0.08; 95% CI, 0.00–0.32; P = 0.045) were significantly lower in vessels of malignant tumors than in those of benign endometrial polyps after enhancement by intravenous contrast. No significant differences in PI, RI, VI, FI or VFI before enhancement by contrast, or in VI, FI or VFI after enhancement by contrast, were detected between women with endometrial polyps and those with endometrial cancer. Conclusions Transvaginal color Doppler examination enhanced by intravenous contrast may help to discriminate between benign endometrial polyps and cancer. Larger studies are required to confirm these findings. Copyright © 2008 ISUOG. Published by John Wiley & Sons, Ltd.

The objective of this pilot study was to evaluate the feasibility of a transvaginal clamp prototype used for temporary uterine artery occlusion as a treatment for myomas. In particular, we aimed to evaluate technical aspects of successful occlusion with angiography and magnetic resonance imaging (MRI) and to evaluate possible ureter occlusion with pyelography. Ten premenopausal women aged 34 to 37 years with menorrhagia and myomas were treated with a temporary uterine artery occlusion for 6 hours. Five patients did not complete the clamping procedure because of unsuccessful clamping. While the clamp was in position, angiographic examination of the uterine arteries and pyelography were performed in 8 of the patients. The clamps occluded both uterine arteries in 4 patients and 1 side in another 2. Two procedures occluded the ureter unilaterally. MRI with contrast was done before, the day after, and 3 months after the procedure. Three of 5 patients who completed the clamp treatment had reduced or no contrast enhancement at MRI afterward. Clinical effects were obtained in 3 patients. Difficulties with application of the vaginal clamp were related to initial learning and size of the myomas. Our initial experience shows that the treatment is feasible in some patients with symptomatic myomas. However, improvement of the technique and equipment is needed. Care with regard to the ureters is required during further studies aimed at evaluating this approach.

Study objective To estimate the occurrence of malignancy and atypical hyperplasia in endometrial polyps in patients with and without symptoms. Design Retrospective registration of all patients who underwent hysteroscopic resection of endometrial polyps. Age, menopausal status, presence or absence of symptoms, any use of hormonal medication, as well as histologic diagnosis, complications, and eventual repeated surgery were documented (Canadian Task Force classification II-3). Setting Ullevaal University Hospital, Department of Gynecology. Patients All patients who underwent hysteroscopic resection of an endometrial polyp in our department from January 1, 2001 through March 1, 2005. Interventions Hysteroscopic resection of endometrial polyps. Measurements and main results Four hundred eleven patients were included. One hundred twenty-nine patients (31.4%) had no symptoms. The prevalence of malignancy or atypical hyperplasia was 3.2% in women with symptoms and 3.9% in those without symptoms. Conclusion The prevalence of malignancy and atypical hyperplasia was found to be relatively high, indicating that symptomatic, as well as asymptomatic, endometrial polyps should be removed.

The risk of intraperitoneal fragment dissemination of uterine tissue, especially the dissemination of unexpected leiomyosarcoma during electromechanical morcellation, has been increasingly debated during the last year. An improved technique for contained morcellation of uterine tissue inside an insufflated plastic bag during laparoscopy is presented. Twenty-one consecutive contained morcellations were carried out during the summer of 2014, at one institution. Five laparoscopic myomectomies and 16 hysterectomies were performed. Standard laparoscopic equipment was used and a transparent plastic bag was introduced into the abdominal cavity through the umbilical incision mounted on two curved blunt metal probes, which facilitated the placement of the uterine tissue into the bag. Morcellation was carried out inside the plastic bag through the opening in the umbilicus. All 21 morcellations during the study period were successfully performed. The median operative time was 105 min (range 45–180 min) and applying plastic bag and trocar median 10 min (range 4–30 min). Median specimen weight was 560 g (range 80–1265 g). No complications occurred, and no unintended bag perforation was identified. The presented improved contained morcellation technique is feasible in laparoscopic hysterectomy and myomectomy. Larger studies will however be required before the general introduction of the method.Level of evidence: II-3

Study objective To elucidate the safety and patient satisfaction with laparoscopic supracervical hysterectomy (LSH) performed in an outpatient setting. Design Prospective case study (Canadian Task Force classification II-2). Setting Public hospital. Patients Forty-three women. Intervention Outpatient LSH performed by lap-loop. Measurements and main results The procedure was recommened by 41 out of 43 patients. Three patients (7%) were admitted to the hospital due to complications after the surgery. One patient was admitted because of a vasovagal reaction after anesthesia; she recovered quickly and was discharged after a few hours of observation. One patient was admitted because of postoperative pain and discharged the next day; she had a prolonged postoperative recovery with pain and subfebrile temperature. One patient underwent laparotomy due to major intraabdominal bleeding. Postoperative complications occurred in another five patients (12%) without need for hospitalization (infected intra-abdominal hematoma, urine retention, cystitis, cystitis combined with wound infection, and pneumonia). Conclusion Laparoscopic supracervical hysterectomy as an outpatient procedure is a safe and highly acceptable treatment.

OBJECTIVE: The purpose of this study was to compare the long-term efficacy of the levonorgestrel intrauterine system and transcervical resection of the endometrium in the treatment of menorrhagia. METHODS: This study was an open, randomized 3-year trial. Patients with menorrhagia were assigned randomly to either the levonorgestrel intrauterine system (n = 30) or endometrial resection (n = 29). Pictorial blood loss assessment charts were used to measure menstrual blood loss. A pictorial blood-loss assessment chart score exceeding 75 (representing menstrual blood loss >/=60 mL) was used to diagnosis the patient as having menorrhagia. Discontinuations and cases requiring repeat operations were evaluated. RESULTS: Pictorial blood loss scores decreased from a baseline median of 261.5 (range, 60-1503) to 7 (range, 0-101; P < .001) for the levonorgestrel intrauterine system and from 311 (range, 81-2506) to 4 (range, 0-182; P < .001) for transcervical resection of the endometrium. Nineteen women of 30 using the levonorgestrel intrauterine system completed the 3-year follow-up compared with 22 of 29 for transcervical resection of the endometrium. CONCLUSION: Both treatments efficiently reduced menstrual bleeding. The high continuation rate suggests that the levonorgestrel intrauterine system is comparable with transcervical resection of the endometrium.

A 43-year-old woman with menorrhagia, dysmenorrhea, and pelvic pain of several years' duration had a uterus enlarged by myomas to the size of a 16-week pregnancy. Her uterine arteries were noninvasively transvaginally identified and occluded for 6 hours with a clamp that was guided by audible Doppler ultrasound. Following removal of the clamp, blood flow in the uterine arteries returned immediately. Menorrhagia symptoms diminished. Three months following treatment, uterine volume decreased by 48.9%, and dominant myoma volume decreased by 77.2%.

Objective Our purpose was to evaluate the effects of laparoscopic occlusion of uterine vessels in treating symptomatic fibroids and compare with embolization of the uterine arteries. Study design We studied 46 premenopausal women, aged 43 (34-51) years with symptomatic uterine fibroids, undergoing radiologic embolization (n = 24) and laparoscopy closure of the uterine arteries (n = 22). Results The laparascopic technique reduced picture blood assessment score after 6 months by 50% from an initial value of 345 (±288). Uterus volume was reduced by 37% (±18%), and the dominant fibroid was reduced by 36% (±31%). Postoperative pain and use of pain relief differed significantly, requiring more pain medication after embolization: ketobemidon 38 mg compared with 16 mg in the laparoscopic group (P = .008). Specific complications to the laparascopic technique were temporary damage to the obturator nerve in three patients. Conclusion Laparoscopic occlusion of uterine vessels is a promising new method for treating fibroid-related symptoms, with less postoperative pain than embolization and comparable effects on symptoms.

Acta Obstet Gynecol Scand 2003; 82: 65-68. © Acta Obstet Gynecol Scand 2003 Objective. A prospective, single-arm, multicenter, controlled, observational pilot study to assess the safety and efficacy of the NovaSure™ Global Endometrial Ablation (NovaSure™ GEA) system in women with severe menorrhagia secondary to dysfunctional uterine bleeding (DUB). Setting. University tertiary referring center and central hospital. Patients. Forty-six premenopausal women aged 41.3 years with menorrhagia secondary to DUB unresponsive to medical therapy, who had completed childbearing, with non-distorted uterine cavities were included in the study. Methods. Bleeding score was recorded before, 6 and 12 months after treatment. All patients received the treatment under intravenous sedation with para-cervical block and were treated with Nova Sure endometrial ablation for mean 94 s at the day surgery unit. Results. No serious intraoperative complications were observed. Treatment time averaged 94 s. Forty-six patients have comple...

Uterine anomalies result from a defect in the development or fusion of the paired Mullerian ducts during embryogenesis and are the most common types of malformations of the female reproductive system. The septate uterus is the most common structural uterine anomaly and results from failure of the partition between the two fused Mullerian ducts to resorb (Taylor and Gomel 2008). Congenital malformations may be associated with recurrent pregnancy loss, preterm labor, abnormal fetal presentation, and infertility (Heinonen et al. 1982). The overall frequency of uterine malformations was 4.0 % (Raga et al. 1997). Infertile patients (6.3 %) had a significantly (P < .05) higher incidence of Mullerian anomalies, in comparison with fertile patients (3.8 %). Septate (33.6 %) and arcuate (32.8 %) uteri were the most common malformations observed (Raga et al. 1997). The septate uterus is associated with the highest incidence of reproductive failure among the Mullerian anomalies (Fedele et al. 1993). Thirty-eight percent to 79 % of pregnancies in women with septate uteri ended in miscarriage (Raga et al. 1997; Homer et al. 2000). Such outcomes are thought to be a result of poor blood supply, rendering the septum inhospitable to the implanting embryo (Fedele et al. 1996). Diagnosis is established with hysterosalpingography, magnetic resonance imaging, and ultrasound. The diagnostic accuracy of hysterosalpingography in patients with septate uteri has been reported to be between 20 and 60 % (Braun et al. 2005; Pellerito et al. 1992). Transvaginal ultrasonography is more accurate, with a sensitivity of 100 % and a specificity of 80 % in the diagnosis of the septate uterus (Pellerito et al. 1992). Three-dimensional sonography (3DULS) is associated with an even higher diagnostic accuracy of 92 % (Wu et al. 1997) and hysterosonography, with a 100 % diagnostic accuracy in the largest series published to date (Alborzi et al. 2002). The benefit of 3DULS is the view of the uterus in the coronal plane, which allows the operator to distinguish between arcuate, septate, and bicornuate uteri, thereby eliminating the need for simultaneous laparoscopy (Figs. 3.1 and 3.2). In this review we describe the diversity of clinical presentations, management strategies, and report the obstetric outcomes observed in our series of 114 women with uterine septa.

Women postpone their first delivery and the gynecologist will have to take care of fibroids in a conservative manner. The past decade has witnessed highly sophisticated diagnostic and therapeutic technology development for fibroids. Nonsurgical treatments interfering with the blood supply to the uterus or the fibroids include uterine artery embolization performed by interventional radiologist or laparoscopic uterine artery occlusion/compression by the gynecologist. Uterine arteries were noninvasive transvaginally identified and occluded for 6 h with a clamp that was guided by audible Doppler ultrasound. Another technological advancement is Magnetic Resonance Imaging-Guided Focused Ultrasound, the outcome of MRI-guided focused ultrasound treatment in terms of the nonperfused volume ratio can be enhanced with a high safety profile, Complications: The acute degenerative procedure can be very painful and infection can occur. Hysterectomy may again be required in the case of hemorrhage or severe tissue necrosis. Delivering fibroids or sections of fibroids may be a natural process after uterine artery embolization, therefore it is essential to warn women about the possible risk of infectious symptoms like heavy discharge, fever, consequently close follow-up is essential. A long-term side effect could be premature ovarian failure secondary to interference with the ovarian blood supply. Conclusions: Fibroids present with different symptoms in different patients. In bleeding problems, an important issue is the location of the fibroid, and in cases with submucosal fibroids hysteroscopic resection is the method of choice. In cases with intramural, subserosal, and even multiple fibroids, uterine artery therapy with embolization or laparoscopy seems to achieve good results on both bleeding problems and pressure symptoms. The temporary uterine clamp performed by general gynecologist without incision may in the future replace the more complicated procedures like embolization performed by radiologist and laparoscopic uterine artery closure performed by skilled endoscopist. In infertility patients, the single fibroid should be removed, while when multiple fibroids are present medical or circulation therapy may be the only option for uterus saving therapy.

Udgivelsesdato: 2001-Aug OBJECTIVE: Treatment of menorrhagia with levonorgestrel intrauterine system (LNG IUS) and transcervical resection. DESIGN: An open, therapeutic, randomized study. SETTING: Central county hospital specializing in hysteroscopy. PATIENT(S): Two parallel groups of 30 subjects each. INTERVENTION(S): Thirty patients had a LNG IUS inserted within the first 7 days of menses; 29 patients underwent endometrial resection. MAIN OUTCOME MEASURE(S): A 12-month follow-up of menstrual blood loss and adverse events were evaluated. RESULT(S): LNG IUS group: 13 patients reported one or more pelvic adverse events, bleeding disorders (n = 6), abdominal pain (n = 4), breast tenderness (n = 3), headache, acne (n = 2), and mood changes (n = 1). Six patients discontinued treatment because of irregular bleeding (n = 3), pain (n = 2), and acne (n = 1). In both groups, general feeling of genital health increased with Visual Analogue Scale score. Nine patients reported adverse events. This included pelvic pain indicating inflammation (n = 4), bleeding (n = 3), vaginitis (n = 1), and ulceration (n = 1). Treatment success at 12 months was achieved in 20 (67%) of the 30 patients in the LNG IUS group and in 26 (90%) of the 29 patients in the transcervical resection group. Adverse events were more often reported in the LNG IUS group. CONCLUSION(S): Both treatments effectively reduced the menstrual blood loss. Furthermore, the LNG IUS treatment is reversible and has no operative hazards.

Objective. To evaluate the diagnostic accuracy of transvaginal ultrasonography, sonohysterography and hysteroscopy in patients presenting with abnormal uterine bleeding. Design. Prospective, blind, comparative study. Setting. Outpatient clinic and day surgery unit of a district hospital specializing in operative hysteroscopy. Patients. One hundred consecutive patients referred with abnormal uterine bleeding (AUB). Interventions. Transvaginal ultrasonography and sonohysterography were performed in the outpatient clinic. Within 1 week, all patients underwent operative hysteroscopy. Main outcome measures. All diagnoses established by transvaginal ultrasonography, and sonohysterography were compared to the appearance of the cavity using hysteroscopy as well as the histological diagnosis from removed tissues. Results. In 88 patients information suitable for analysis was obtained by all methods. The detection rate of focal intrauterine pathology using sonohysterography was (94.1%), but was significantly lower w...

Objective To identify the effect of the levonorgestrel coil (Mirena; LNG IUS) vs. transcervical resection of the endometrium (TCRE) for treatment of menorrhagia. Design A randomized study of 60 patients performed at a gynaecological clinic specializing in operative hysteroscopy. Results 24 patients in the LNG IUS group and 29 patients in the TCRE group completed 20 months of follow up. In the TCRE group one patient refused to continue after the result of randomization. Reasons for discontinuation in the LNG IUS group included abdominal pain (2), acne (1) and bleeding or continuous spotting (3). The bleeding intensity was assessed using the PBAC score and was reduced in both groups, from 418 to 42 in the LNG IUS group, and from 378 to 6.6 in the TCRE group. Conclusion Both methods have a dramatic effect on bleeding intensity and furthermore the LNG IUS is reversible and has no operative hazards or side-effects.

In our department, laparoscopic supracervical hysterectomy has gradually replaced hysterectomy by laparotomy in patients with a benign condition and no history of cervical dysplasia. During the last year, we experienced serious complications in two patients because of inadequate removal of the tissue in the morcellator procedure. These cases are presented and discussed in this case report.

Shoulder pain is a commonly reported symptom following laparoscopic procedures such as myomectomy or hysterectomy, and recent studies have shown that lowering the insufflation pressure during surgery may reduce the risk of post-operative pain. In this pilot study, a method is presented for measuring the intra-abdominal space available to the surgeon during laproscopy, in order to examine whether the relaxation produced by deep neuromuscular blockade can increase the working surgical space sufficiently to permit a reduction in the CO2 insufflation pressure. Using the laproscopic grasper, the distance from the promontory to the skin is measured at two different insufflation pressures: 8 mm Hg and 12 mm Hg. After the initial measurements, a neuromuscular blocking agent (rocuronium) is administered to the patient and the intra-abdominal volume is measured again. Pilot data collected from 15 patients shows that the intra-abdominal space at 8 mm Hg with blockade is comparable to the intra-abdominal space measured at 12 mm Hg without blockade. The impact of neuromuscular blockade was not correlated with patient height, weight, BMI, and age. Thus, using neuromuscular blockade to maintain a steady volume while reducing insufflation pressure may produce improved patient outcomes.

The objective of this study was to identify whether the endometrial thickness, or the anteroposterior diameter of the uterus as assessed by transvaginal ultrasonography (TVS), could be used to predict the clinical outcome following transcervical resection of the endometrium (TCRE). An open observational trial was carried out, involving 195 consecutive patients undergoing TCRE, 188 of whom completed follow-up. The patients were examined by TVS preoperatively, and then 6 weeks, 6 months and 1 year following TCRE. In all examinations, endometrial thickness, the anteroposterior diameter and residual endometrium, uterine morphology and the clinical outcome as measured by pain reduction, bleeding index and amenorrhea were assessed. Patients with a preoperative endometrial thickness of 8 mm or less had a higher rate of amenorrhea after 1 year than patients with an endometrial thickness exceeding 8 mm. Outcome did not relate to the histological phase of the endometrium obtained during resection. Neither the uterine anteroposterior diameter, or the presence of submucous fibroids, had any influence on the clinical outcome. Cavity fluid was observed in some cases but was not always associated with symptoms. Residual endometrium could be detected by TVS in 38% of the women after 1 year, but the vast majority of these patients reported a satisfactory outcome from the procedure. We conclude that the size of the anteroposterior diameter does not affect the clinical outcome of TCRE, whilst the preoperative endometrial thickness does have a significant impact on the likelihood of achieving amenorrhea after 1 year. The data suggest that TCRE should preferably be performed when the endometrium is at its thinnest and that there may be a useful role for agents that produce endometrial atrophy prior to surgery. Copyright © 1996 International Society of Ultrasound in Obstetrics and Gynecology

Objective To determine if women who have undergone transcervical resection of the endometrium can be treated safely with estrogens alone. Methods Sixty-two postmenopausal women who had undergone endometrial resection were recruited into a double-blind, randomized study. Twenty-one had menopausal symptoms at the primary operation and were recruited at the time of the surgery, and 38 were recruited an average of 20 months (range 8–42) after the primary endometrial resection and underwent a second resection to remove any residual endometrium before entering the study. Three patients were excluded from the study. Subjects were allocated randomly to one of two hormone replacement therapy (HRT) regimens: 17-β-estradiol 2 mg alone or combined with norethisterone 1 mg. Clinical and ultrasound data were collected every 3 months. Hysteroscopically standardized endometrial biopsies were taken after 1 year. Results In the single-agent therapy group, endometrial hyperplasia without atypia was found in six subjects and proliferative endometrium in eight after 1 year. No such cases occurred among women receiving combined therapy. Endometrial thickness and menstrual bleeding were significantly greater in the single-agent therapy group than in those receiving combined therapy. These differences between single-agent and combined therapy were statistically significant. Conclusion Fostmenopausal HRT in patients who have undergone transcervical resection of the endometrium should include progestagen for protection of the endometrium.

To evaluate the value of transcervical resection of endometrium and fibroids in clinical practice.A retrospective review of operative details of 412 transcervical resections of endometrium and fibroids and clinical outcome from 387 procedures performed over five years is reported.Patients referred due to bleeding disturbance, treated with a standard urological resectoscopes, controlled after 6 and 12 months. Subsequent follow up was performed by questionnaire and patient bleeding diary.Operative complications (perforation, hemorrhage, absorption and more than 1500 ml glycine irrigating fluid) arose in 72 patients (18%). In 52 (14.4%) of 366 patients the outcome was not considered acceptable by either ourselves or the patients. This led to a repeat resection procedure being performed in 31 cases (9.0%) with favorable result in 21 (68%) of these cases. Twenty-one patients (6.1%) underwent a hysterectomy because of a persistently poor outcome. A favorable outcome was then reported in subsequent follow up of 335 patients (91%). In addition, pain associated with menstruation was reduced after the procedure and correlates with achieved result on bleeding intensity.Endometrial resection is safe and acceptable treatment option for both menorrhagia and metrorrhagia associated with dysmenorrhoea.

LESS, or laparo-endoscopic single site surgery, is a promising new method in minimally invasive surgery. An increasing number of surgical procedures are being performed using this technique; however, its large-scale adoption awaits results of prospective randomized controlled studies confirming potential benefits. Theoretically, cosmetic outcomes, postoperative pain and complication rates could be improved with use of single site surgery. This study describes introduction of the method in a private hospital in Denmark in which 40 women were treated for benign gynecologic conditions. Although the operations described are the first of their kind reported in Denmark, favorable operating times and very low complication rates are seen. It is the authors' opinion that in addition to being feasible for hysterectomy, single port laparoscopy may become the preferred method for many simple gynecological procedures.

Case reports for uterine rupture subsequent to laparoscopic myomectomy were reviewed to determine whether common causal factors could be identified. Published cases were identified via electronic searches of PubMed, Google Scholar, and hand searches of references, and unpublished cases were obtained via E-mail queries to the AAGL membership and AAGL Listserve participants. Nineteen cases of uterine rupture after laparoscopic myomectomy were identified. The removed myomas ranged in size from 1 through 11 cm (mean, 4.5 cm). Only 3 cases involved multilayered closure of uterine defects. Electrosurgery was used for hemostasis in all but 2 cases. No plausible contributing factor could be found in one case [corrected]. It seems reasonable for surgeons to adhere to techniques developed for abdominal myomectomy including limited use of electrosurgery and multilayered closure of the myometrium. Nevertheless, individual wound healing characteristics may predispose to uterine rupture.

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We report 2 cases of laparoscopic gynecologic procedures, complicated by small bowel obstruction possibly related to use of a hemostatic agent. The cause was most likely from excess material not incorporated in the hemostatic clot at the site of application. Gentle irrigation and removal of excess material from the site of application is recommended by the manufacturer of FloSeal and may reduce the risk of postoperative adhesion formation and small bowel obstruction.

Study Objective To estimate the clinical effectiveness of transcervical resection of endometrial polyps. Design Randomized controlled trial (Canadian Task Force classification I). Setting University teaching hospital. Patients One hundred fifty premenopausal women with endometrial polyps. Interventions Either transcervical resection of the polyp or observation for 6 months. Measurements and Main Results There was no difference in periodic blood loss measured using the Pictorial Blood Assessment Chart between the study groups at 6-month follow-up. A significant difference between the groups was observed in favor of the intervention group for 2 secondary outcome measures: mean difference of periodic blood loss measured using a visual analog scale (score, 0.7; 95% confidence interval, 0.11–1.30; p = .02) and occurrence of gynecologic symptoms at follow-up (7 of 75 patients [9.3%] vs 28 of 75 [37.3%]; p Conclusion Transcervical resection of endometrial polyps seems to have minimal effect on periodic blood loss; however, the procedure seems to relieve symptoms such as intermenstrual bleeding in most premenopausal women.

More than 50% of major laparoscopic complications occur during the initial entry into the abdomen. We investigated the efficacy and the safety of two laparoscopic access techniques: the direct optical access (DOA) versus the classical open entry, as described by Hasson.Two hundred and two premenopausal women, homogeneous in age, parity, and body mass index undergoing laparoscopic surgery for simple ovarian cysts, were prospectively, randomly assigned to either open or DOA abdominal entry for laparoscopic surgery. The following parameters were compared: duration of access for entry into the abdomen, occurrence of vascular and/or bowel injury, and blood loss. The results were analyzed by using SAS software (SAS Institute, Inc., Cary, NC), considering a P-value of0.05 as significant.No statistically significant differences were observed in the occurrence of major vascular and/or bowel injury between the two techniques. However, time for establishment of abdominal entry was significantly reduced in the DOA group, as was the blood loss (P0.05).The results of this preliminary comparison on the DOA and the Hasson methods, commonly used by general surgeons and less frequently by gynecologists, suggest that the visual entry system confers a little statistical advantage over the traditional Hasson entry, in terms of safety, minimal time saving, and in reducing blood loss, allowing a safe, fast, visually guided entry.

To compare long-term symptom recurrence and 6-month magnetic resonance (MR) imaging results after two different treatments for uterine leiomyomas.Sixty-six women with uterine leiomyomas were randomized to undergo uterine artery embolization (UAE) or laparoscopic bilateral occlusion of uterine arteries. Contrast-enhanced MR imaging was performed before treatment and after 6 months.Fifty-eight patients received treatment. Median follow-up time was 48 months (range, 8-73 months). Clinical failure and symptom recurrence occurred in 14 patients after laparoscopy (48%) and in five after UAE (17%; P = .02, log-rank test). Hysterectomy was performed in two patients after UAE (7%) and in eight after laparoscopy (28%; P = .041). Six-month MR imaging results were available for 26 patients treated with UAE and 22 treated with laparoscopy. The mean uterine volume was reduced by 51% (range, 16%-86%) after UAE treatment, compared with 33% (range, 6%-77%) after laparoscopy (P = .001). Complete leiomyoma infarction was seen in all 26 patients in the UAE group and in only five patients in the laparoscopy group (P.001). Eleven patients experienced symptom recurrence later than 6 months. Uterine volume reduction at 6 months was 24% in this group, compared with 48% in the 37 patients with no recurrence (P = .004). Incomplete infarction of leiomyomas was seen in eight of the 11 cases of recurrence (73%) versus nine of 37 cases without recurrence (24%; P = .009).Recurrence rate was significantly lower after UAE than after laparoscopic treatment. Larger volume reduction and more complete devascularization of leiomyomas were found after UAE treatment and among patients with no recurrence.

Hysteroscopy is the current gold standard for evaluating intrauterine pathology, including submucous fibroids, polyps, hyperplasia and cancer. However, there are still problems and complications connected to hysteroscopy. Fluid overload of 1-2l occurs in approximately 5.2% and >2l in 1% of cases. This article discusses the physiology, implications and treatment of these cases. Uterine perforation is encountered in nearly 1% of cases. We describe the precautions to avoid this perforation and the methods to treat it. The article also discusses excessive bleeding, which occurs in 3% of operative hysteroscopies and describes strategies to avoid and to deal with this complication. Emergency hysterectomy and other surgical interventions are rarely indicated and are seen in 2% of cases. Finally, death due to septicaemia or fluid overload has been reported only very rarely (0.1%). These different complications are discussed in detail.

Study Ojective To estimate the prevalence, 1-year regression rate, and clinical significance of endometrial polyps in women aged 45 to 50 years. Design Cross-sectional study (Canadian Task Force II-2). Setting University teaching hospital. Patients Two hundred fifty-seven of 1000 randomly selected women aged 45 to 50 years. Interventions Transvaginal ultrasonography and saline infusion sonography were performed in all study participants and were repeated in women with endometrial polyps after 12 months. Polyps present at follow-up were removed by hysteroscopic polyp resection. Measurements and Main Results Endometrial polyps were diagnosed in 31 women (12.1%). At 1 year, the polyp regression rate was 27%. Myomas occurred more often in women with endometrial polyps, and women with polyps experienced significantly heavier periodic bleeding compared with women without polyps. Conclusion Our study findings suggest that endometrial polyps are common in women aged 45 to 50 years and that women with such polyps experience heavier periodic bleeding. Although some polyps seem to regress spontaneously during 1-year follow-up, most seem to persist.

Objective : Complications associated with initial abdominal entry are a prime concern for laparoscopic surgeons. In order to minimize first access-related complications in laparoscopy, several techniques and technologies have been introduced in the past years. This investigation compares two laparoscopic access techniques. Study design : 194 women underwent laparoscopic surgery for simple ovarian cysts: 93 were assigned to direct optical access (DOA) abdominal entry (group I), and 101 women to classical closed method by Verres needle, pneumoperitoneum and trocar entry (group II). The following parameters were compared: time required for entry into abdomen, occurrence of vascular and/or bowel injury, blood loss. The results were analyzed using SAS software. p -value Results : No statistically significant differences were observed in the occurrence of blood loss and minor vascular injury between the two techniques, as well as minor bowel injuries; time for of abdominal entry, instead, were significantly reduced in the DOA group. Conclusions : The results of the preliminary comparison between the DOA and the Verres methods, commonly used by gynecologists, suggests that the visual entry system confers a statistical advantage over closed entry technique with Verres needle, in terms of time saving and due to the minor vascular and bowel injuries, thus enabling a safe and expeditious, visually-guided, entry for surgeons.