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Resume Objectif Determiner l’interet ou non de la realisation de certains gestes prophylactiques en association a une procedure chirurgicale gynecologique. Conception Un comite de consensus de 19 experts a ete constitue. Une politique de declaration et de suivi des liens d’interets a ete appliquee et respectee durant tout le processus de realisation du referentiel. De meme, celui-ci n’a beneficie d’aucun financement provenant d’une entreprise commercialisant un produit de sante (medicament ou dispositif medical). Le comite de consensus devait respecter et suivre la methode GRADE (Grading of Recommendations Assessment, Development and Evaluation) pour evaluer la qualite des donnees factuelles sur lesquelles etaient fondees les recommandations. Les inconvenients potentiels de faire des recommandations fortes en presence de donnees factuelles de mauvaise qualite ou insuffisantes ont ete soulignes. Peu de recommandations ont ete non graduees. Methodes Le comite a etudie 22 questions concernant 7 thematiques. Les gestes associes a une procedure chirurgicale gynecologique etudies etaient les suivants : 1) Salpingectomie, 2) Realisation d’une fimbriectomie, 3) Annexectomie, 4) Destruction d’endometriose superficielle, 5) Adhesiolyse, 6) Destruction endometriale, 7) Ablation du col uterin. Resultats Le travail de synthese des experts et l’application de la methode GRADE ont abouti a 34 recommandations. Parmi les recommandations formalisees, six ont un niveau de preuve eleve (GRADE 1+/−) et 28 un niveau de preuve faible (GRADE 2+/−). Pour deux questions, la methode GRADE ne pouvait pas s’appliquer en raison d’une absence de litterature medicale, ne permettant pas d’aboutir a une recommandation. Conclusion Un accord important existait parmi les experts sur des recommandations fortes dans le but de d’ameliorer les pratiques pour la realisation ou non de certains gestes prophylactiques en association a une chirurgie gynecologique.

Major clinical incidents can impact the healthcare professionals involved. This is of particular relevance in surgery, with the operating room being a high-risk zone for complications; however, there is few available data on how surgeons may be affected. The current study examined the impact of surgical complications on surgeon traumatic stress levels, emotional state, job performance, and coping strategies.A questionnaire to evaluate the impact of surgical complications on surgeon traumatic stress levels, emotional state, and job performance was developed by our team and communicated via an online link to gynecological surgeons.A total of 72 gynecologic surgeons completed the questionnaire. Five percent had a Peritraumatic Distress Inventory (PDI) score of ≥15, revealing a high stress level, and 12% had an Impact of Event Scale-Revised (IES-R) score of ≥36, indicating acute traumatic stress. Our results show that following surgical incidents, surgeons receive support primarily from another surgical team member and that surgical practice may be impacted, leading in some cases to detrimental effects on patient care, notably reduced radicality in some surgical procedures.Surgeons may experience acute traumatic stress after serious surgical complications. Increased awareness of the negative consequences on surgeon emotional well-being is required, as well as improved access to support mechanisms. The study was approved by local ethics committee (IRB00013412, "CHU de Clermont Ferrand IRB #1," institutional review board number 2022-CF004).

Objective:Investigate the relationship between the structure of abdominal wall endometriotic nodules in MRI and their localisation in abdominal wall layers in order to better understand nodule origins.Design:Women who had an MRI prior to surgical treatment of an abdominal wall endometriotic nodule between 2005 and 2016.Population:Thirty-six patients including four patients with two nodules.Methods:MRI images were reviewed. Each nodule was analysed according to its structure (fibrous, cystic, mixed), localisation (subcutaneous fat, intra muscular, intermediary position), and size.Results:Forty nodules were analysed in MRI with no relationship found between localisation and nodule structure ( p = 0.48). 87.5% of mixed nodules were revealed to have a cystic superficial rim extending towards the subcutaneous fat layer. This finding suggests that the glandular part of the nodule is the active part of the disease from which nodule progression occurs. Intermediary and intramuscular nodules were respectively statistically larger than subcutaneous fat nodules indicating a relationship between nodule size and localisation (35 mm (22–53) vs 17 mm (17–23)) ( p = 0.03).Conclusion:Despite differences in environments surrounding the nodules, no significant relationship between nodule structure in imaging and abdominal wall localisation was found. Data from mixed nodules indicate however the possible role of nodule environment on structure and that the mechanism of nodule growth may be linked to development of cystic superficial rims, at the forefront of disease progression, abdominal wall nodules growing from deep to superficial. Studies are required to further investigate our findings and enable greater understanding of the origins of AWE.

Objective To assess the diagnostic and prognostic characteristics of borderline ovarian tumours (BOTs) detected during pregnancy, and to establish an inventory of French practices. Materials and methods A retrospective multi-centre case study of 14 patients treated for BOTs, diagnosed during pregnancy between 2005 and 2017, in five French pelvic cancerology expert centres, including data on clinical characteristics, histological tumour characteristics, surgical procedure, adjuvant treatments, follow-up and fertility. Results The mean age of patients was 29.3 [standard deviation (SD) 6.2] years. Most BOTs were diagnosed on ultrasonography in the first trimester (85.7 %), and most of these cases (78.5 %) also underwent magnetic resonance imaging to confirm the diagnosis (true positives 54.5 %). Most patients underwent surgery during pregnancy (57 %), with complete staging surgery in two cases (14.3 %). Laparoscopy was performed more frequently than other procedures (50 %), and unilateral adnexectomy was more common than cystectomy (57.5 %). Tumour size influenced the surgical approach significantly (mean size 7.5 cm for laparoscopy, 11.9 cm for laparoconversion, 14 cm for primary laparotomy; P = 0.08), but the type of resection did not. Most patients were initially diagnosed with International Federation of Gynecology and Obstetrics stage IA (92.8 %) tumours, but many were upstaged after complete restaging surgery (57.1 %). Most BOTs were serous (50 %), two cases had a micropapillary component (28.5 %), and one case had a micro-invasive implant. BOTs were bilateral in two cases (14.2 %). Mean follow-up was 31.4 (SD 14.8) months. Recurrent lesions occurred in two patients (14.2 %) and no deaths have been recorded to date among the study population. Conclusion BOTs remain rare, but this study – despite its small sample size – supports the hypothesis that BOTs during pregnancy have potentially aggressive characteristics.

International audience; BACKGROUND: This study compares morbidity and mortality associated with retroperitoneal and transperitoneal para-aortic lymphadenectomy (PAAL) for pretherapeutic nodal staging of locally advanced cervical cancers (FIGO IB3-IVA). METHODS: Pre-, per- and postoperative data of patients treated for locally advanced stage cervical cancer between 1999 and 2018 in 12 French referral centers (FRANCOGYN Study Group) were retrospectively collected. RESULTS: The study was conducted using a sample of 448 patients, of whom 223 (49,8%) underwent retroperitoneal (group 1) and 225 (50,2%) had transperitoneal PAAL (group 2). No differences were noted concerning clinical and histological characteristics between the two groups. Among these 448 patients, 23 (5,1%) had an intraoperative complication (9 (2,0%) in group 1 and 14 (3,1%) in group 2, p = 0.28) and 47 (10,5%) had a postoperative complication (22 (4,9%) in group 1 and 25 (5,6%) in group 2, p = 0.44), only one of which required revision surgery but the patient died. The length of hospital stay was significantly shorter in group 1 than in group 2 (3.97 versus 4.88 days, p

INTRODUCTION: Recommendations for the management of patients with gynecological cancer during the COVID-19 pandemic period. MATERIAL AND METHOD: Recommendations based on the consensus conference model. RESULTS: In the case of a COVID-19 positive patient, surgical management should be postponed for at least 15 days. For cervical cancer, the place of surgery must be re-evaluated in relation to radiotherapy and Radio-Chemotherapy-Concomitant and the value of lymph node staging surgeries must be reviewed on a case-by-case basis. For advanced ovarian cancers, neo-adjuvant chemotherapy should be favored even if primary cytoreduction surgery could be envisaged. It is lawful not to offer hyperthermic intraperitoneal chemotherapy during a COVID-19 pandemic. In the case of patients who must undergo interval surgery, it is possible to continue the chemotherapy and to offer surgery after 6 cycles of chemotherapy. For early stage endometrial cancer, in case of low and intermediate preoperative ESMO risk, hysterectomy with bilateral annexectomy associated with a sentinel lymph node procedure should be favored. It is possible to consider postponing surgery for 1 to 2 months in low-risk endometrial cancers (FIGO Ia stage on MRI and grade 1-2 endometrioid cancer on endometrial biopsy). For high ESMO risk, it ispossible to favor the MSKCC algorithm (combining PET-CT and sentinel lymph node biopsy) in order to omit pelvic and lumbar-aortic lymphadenectomies. CONCLUSION: During COVID-19 pandemic, patients suffering from cancer should not lose life chance, while limiting the risks associated with the virus.

Resume Objectifs Editer, par le College national des gynecologues et obstetriciens francais (CNGOF), des recommandations fondees sur les preuves disponibles dans la litterature pour la prise en charge des tumeurs frontieres de l’ovaire (TFO) de stade precoce. Methodes Recherche bibliographique en langue francaise et anglaise effectuee par consultation des bases de donnees Pubmed, Cochrane, Embase et des recommandations internationales. Resultats Dans la prise en charge chirurgicale des TFO a un stade precoce, si une chirurgie sans risque de rupture tumorale avec extraction protegee des pieces operatoires est possible, la voie cœlioscopique est recommandee par rapport a la laparotomie (Grade C). Dans les TFO, il est recommande de prendre toutes les dispositions pour eviter la rupture tumorale, y compris la decision peroperatoire de laparoconversion (Grade C). Dans les TFO, une extraction de la piece operatoire a l’aide d’un sac endoscopique est recommandee (Grade C). En cas de TFO de stade precoce, uni- ou bilaterale, suspectee a l’imagerie preoperatoire chez une patiente menopausee et/ou sans de desir de preservation de fertilite et/ou de la fonction endocrine, il est recommande de realiser une annexectomie bilaterale (Grade B). En cas de TFO de stade precoce sereuse bilaterale avec desir de preservation de la fertilite et/ou de la fonction endocrine, il est recommande de realiser une kystectomie bilaterale dans la mesure du possible (Grade B). En cas de TFO de stade precoce mucineuse avec desir de preservation de la fertilite et/ou de la fonction endocrine, il est recommande de realiser une annexectomie unilaterale (Grade C). En cas de TFO de stade precoce endometrioide avec desir de preservation de la fertilite et/ou de la fonction endocrine, il n’est pas possible d’etablir une recommandation de choix de traitement entre kystectomie et annexectomie unilaterale. En cas de TFO de stade precoce mucineuse a l’analyse histologique definitive chez une femme ayant eu une kystectomie initiale, avec ou sans desir de preservation de la fertilite et/ou de la fonction endocrine, une reprise chirurgicale pour une annexectomie unilaterale est recommandee (Grade C). En cas de TFO de stade precoce sereuse a l’analyse histologique definitive chez une femme ayant eu une kystectomie initiale, avec desir de preservation de la fertilite et/ou de la fonction endocrine, il n’est pas recommande de reprise chirurgicale pour annexectomie en l’absence de lesion suspecte residuelle lors de la chirurgie et/ou a l’imagerie postoperatoire (echographie par referent ou IRM pelvienne) (Grade C). Une omentectomie est recommandee afin de realiser une stadification initiale chirurgicale complete lorsqu’une TFO est diagnostiquee a l’examen extemporane ou suspectee sur les elements radiologiques preoperatoires (Grade B). Il n’existe pas de donnees dans la litterature permettant de recommander le type d’omentectomie a realiser. Si une chirurgie de restadification est decidee pour une TFO a un stade presume precoce, une omentectomie est recommandee (Grade B). Des biopsies peritoneales multiples sont recommandees afin de realiser une stadification initiale chirurgicale complete lorsqu’une TFO est diagnostiquee a l’examen extemporane ou suspectee sur les elements radiologiques preoperatoires (Grade C). En cas de chirurgie de restadification pour une TFO a un stade presume precoce, l’exploration de la cavite abdominale doit etre complete et des biopsies peritoneales doivent etre realisees sur les zones suspectes ou de facon systematique (Grade C). Une cytologie peritoneale premiere est recommandee afin de realiser une stadification initiale chirurgicale complete lorsqu’une TFO est suspectee sur les elements radiologiques preoperatoires (Grade C). En cas de chirurgie de restadification pour une TFO a un stade presume precoce, une cytologie peritoneale premiere est recommandee (Grade C). Concernant les TFO sereuses ou mucineuses de stade precoce, il n’est pas recommande de realiser une hysterectomie a titre systematique (Grade C). Concernant les TFO de stade precoce de type endometrioide, et en l’absence de desir de conserver la fertilite, il est recommande de realiser une hysterectomie en chirurgie initiale ou si une chirurgie de restadification est indiquee (Grade C). Concernant les TFO de stade precoce de type endometrioide, en cas de desir de preservation de la fertilite, l’uterus peut etre conserve sous reserve d’une bonne evaluation de l’endometre par imagerie et prelevement endometrial (Grade C). Concernant les TFO de stade precoce, quel que soit le type histologique, il est recommande d’evaluer l’aspect macroscopique de l’appendice lors de la chirurgie (initiale ou de restadification si indiquee) (Grade B). Concernant les TFO de stade precoce, quel que soit le type histologique, il est recommande de ne realiser une appendicectomie qu’en cas d’aspect macroscopiquement pathologique de l’appendice (Grade C). Concernant les TFO de stade precoce, quel que soit le type histologique, la lymphadenectomie pelvienne et/ou lombo-aortique n’est pas recommandee dans le cadre d’une chirurgie initiale ou d’une chirurgie de restadification (Grade C). En cas de TFO diagnostiquee sur histologie definitive, l’indication de chirurgie de restadification doit etre discutee en Reunion de Concertation Pluridisciplinaire. Pour les TFO presumees de stade precoce, il est recommande de privilegier la voie cœlioscopique pour realiser une chirurgie de restadification (Grade C). Une chirurgie de restadification est recommandee en cas de TFO sereuse avec aspect micropapillaire et une inspection de la cavite abdominale non satisfaisante lors de la chirurgie initiale (Grade C). Une chirurgie de restadification est recommandee en cas de TFO mucineuse si seule une kystectomie a ete realisee ou que l’appendice n’a pas ete visualise, il sera alors realise une annexectomie unilaterale (Grade C). Si une chirurgie de restadification est decidee dans la prise en charge d’une TFO presumee de stade precoce, les gestes a realiser sont les suivants : une cytologie peritoneale (Grade C), une omentectomie (il n’existe pas de donnees dans la litterature permettant de recommander le type d’omentectomie a realiser) (Grade B), une exploration complete de la cavite abdominale avec biopsies peritoneales sur les zones suspectes ou de facon systematique (Grade C), la visualisation de l’appendice ± l’appendicectomie en cas d’aspect macroscopique pathologique (Grade C), une annexectomie unilaterale en cas de TFO mucineuse (Grade C).

Resume L’endometriose est une pathologie gynecologique frequente affectant 5 a 10 % des femmes en âge de procreer. Les symptomes associes a l’endometriose sont varies et peu specifiques (dysmenorrhees, dyspareunie profonde, douleurs pelviennes chroniques). L’ensemble de ces symptomes peut affecter severement la qualite de vie des femmes tant au niveau social que societal. La genese de la douleur liee a l’endometriose est tres complexe, faisant intervenir plusieurs mecanismes : inflammatoire, nociceptif, neuropathique, neurovasculaire, hormonal. Les lesions d’endometriose n’expliquent pas a elles seules la douleur ; leurs localisations, leurs degres d’infiltration ne sont pas forcement correles a la severite des douleurs, ce qui rend les profils des patientes heterogenes et la prise en charge des patientes complexe. La symptomatologie, le type de lesions, la localisation des lesions, l’intensite des douleurs, la qualite de vie et le retentissement social de la symptomatologie doivent etre evalues de facon precise pour un diagnostic et une prise en charge optimisee et adaptee de nos patientes. La douleur est multifactorielle, sa prise en charge doit donc etre multidisciplinaire (consultations avec des chirurgiens, radiologues et medecins specialises…, doivent etre associees a des soins de support [activite physique, soutien psychologique] et a des medecines alternatives [kinesitherapie, osteopathie, acupuncture…]) au risque sinon de n’etre que partiellement efficace.

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

Because of the peak incidence of cervical cancer between the ages of 35 and 44 and the increasing age of first pregnancy, the issue of fertility preservation in cases of early-stage cervical cancer in women in this reproductive age category arises. Early-stage cervical cancer patients have a good prognosis and are surgically treated in cases of mildly aggressive human papillomavirus-related histological type (squamous cell carcinoma, adenocarcinoma), FIGO stage IA to IB1 (i.e.,2 cm), with shallow stromal invasion (10 mm) and without the presence of lymph-vascular space invasion or lymph node or regional involvement. Under these conditions, conservative treatment by trachelectomy, which has recurrence-free and overall survival rates equivalent to that of hysterectomy, may be considered. After a complete pre-therapeutic assessment, including pelvic lymphadenectomy, to eliminate all contraindications to conservative treatment, a simple or enlarged trachelectomy can be chosen. According to some authors, the route of entry (vaginal, simple or robot-assisted laparoscopy, laparotomy) has no significant effect on survival or fertility, although the literature on the subject is limited. Trachelectomy offers good results in terms of fertility, with an estimated pregnancy rate of between 23% and 55% and a live birth rate of 70%. The significant reduction of the cervix associated with the procedure increases the risk of prematurity. However, this can be prevented by the use of a permanent cerclage. Close follow-up of these patients is essential for a minimum period of 5 years in order to detect any recurrence or postoperative complications.

International audience; Objective: To assess the surgical management and survival of severely obese patients with high-risk endometrial cancer.Materials and methods: Data from 269 patients with high-risk endometrial cancer who were treated between 2001 and 2018 were collected from a multicenter database (11 centers). We classified the patients according to their BMI and compared outcomes in two groups: a normal weight group of women with a BMI < 25 kg/m2, and a severe obesity group of women with a BMI ≥ 35 kg/m2. The groups were compared for epidemiologic, pathologic, management, relapse-free survival (RFS) and overall survival (OS) elements.Results: Patients in the severe obesity group were younger (64 years vs. 68 years, p < 0.05) and had more comorbidities (hypertension, diabetes). They also had more locally advanced tumors and pelvic lymph node involvement (47% vs 24%, p < 0.05). The severely obese patients were less likely to undergo recommended surgical staging, with fewer lumbar aortic dissections than women of normal weight (23% vs 36%, p < 0.05) and fewer pelvic sentinel lymph node biopsies (26.5% vs 12.1%, p < 0.05). No difference in RFS or OS were observed between the two groups.Conclusion: Patients with severe obesity and high-risk endometrial cancer have more locally advanced tumors, and are less likely to be managed according to surgical recommendations. However, RFS and OS do not seem to be affected.

STUDY OBJECTIVE To assess the impact of surgical treatment of endometriosis on quality of life and pain over a 3-year period of postoperative follow-up. DESIGN Prospective and multicenter cohort study (Canadian Task Force classification II-2). SETTING Five districts including a tertiary referral center and private and general public hospitals. PATIENT Patients (n = 981), aged 15 to 50years, underwent laparoscopic treatment (preferred approach) for endometriosis between January 2004 and December 2012. INTERVENTION Laparoscopic treatment for endometriosis. All revised American Fertility Society stages were included. MEASUREMENTS AND MAIN RESULTS The mean visual analog scale score for dysmenorrhea fell from 5.3 ± 3.7 (time 0) to 2.6 ± 3.3 at 6 months, and 2.3 ± 3.3 at 36 months of follow-up (p

Understanding the impact of the environment on temporal trends in the composition and abundance of deep-sea species is essential for forecasting evolution of the community in the context of climate change. The recent development of deep-sea observatories enables multidisciplinary studies of long duration and high temporal resolution. We used a platform at the Ocean Networks Canada NEPTUNE Observatory located in the axis of Barkley Canyon between June 2012 and January 2015 to: (1) characterize the megabenthic community and the environmental conditions in the canyon; (2) investigate temporal patterns in the faunal community; and (3) determine the influence of environmental conditions on the observed patterns. The megafaunal epibenthic community, which included commercially important species, was composed of species known to be able to adapt to low oxygen conditions. A strong seasonal pattern characterized wind speed and direction, wave height, temperature, and chlorophyll concentration at the sea surface. The megafaunal epibenthic community exhibited seasonal patterns which were influenced by in-situ benthic boundary layer currents and temperature, weather conditions and chlorophyll concentration at the sea surface. At inter-annual scales, the surface temperature anomaly event observed in 2013 in the region could potentially impact the community structure with significant changes in species’ densities, highlighting the need for long-term monitoring in the region.

This video shows a complete left lateral laparoscopic surgical approach for the treatment of endometrial carcinoma in a patient with major pelvic adhesions due to previous surgeries. In a French university tertiary care hospital, a 73-year-old patient presented with post-menopausal bleeding and was

International audience; A major research area in Computer Assisted Intervention (CAI) is to aid laparoscopic surgery teams with Augmented Reality (AR) guidance. This involves registering data from other modalities such as MR and fusing it with the laparoscopic video in real-time, to reveal the location of hidden critical structures. We present the first system for AR guided laparoscopic surgery of the uterus. This works with pre-operative MR or CT data and monocular laparoscopes, without requiring any additional interventional hardware such as optical trackers. We present novel and robust solutions to two main sub-problems: the initial registration, which is solved using a short exploratory video, and update registration, which is solved with real-time tracking-by-detection. These problems are challenging for the uterus because it is a weakly-textured, highly mobile organ that moves independently of surrounding structures. In the broader context, our system is the first that has successfully performed markerless real-time registration and AR of a mobile human organ with monocular laparoscopes in the OR.

Resume La tumeur de la granulosa est connue pour ses manifestations hyperoestrogeniques mais peut secreter de la testosterone dans de tres rares cas. Nous rapportons ici un cas de tumeur de la granulosa androgenosecretante chez une patiente de 47 ans.

Objective To demonstrate the advantages of the fluorescence-guided surgery using indocyanine green (ICG) in the management of deep endometriotic nodules toward more complete and safe excision of the disease in cases when rectal shaving is performed. Design Surgical video demonstrating the result of the application of a fluorescent dye (ICG) during deep endometriosis surgery. The local institutional review board was consulted and ruled that approval was not required for this video article because the video describes a technique and the patient cannot be identified. Setting Tertiary-care university hospital. Patient(s) The patient underwent rectal shaving due to a deep endometriotic nodule located at the level of the rectovaginal septum. Intervention(s) The procedure started with exploration of the lesion and the anatomical structures. The nodule is approached using the “reverse technique.” As the nodule is infiltrating the vagina, complete resection of the posterior vaginal wall is performed. At the start of the rectal shaving, ICG is injected and its fluorescence effect is used to provide navigation for the surgeon during the excision. At the end of the procedure the vascularization of the bowel wall and the vagina are evaluated with the help of the ICG. Main Outcome Measure(s) Visual assessment and distinction between the borders of the endometriotic nodule and the rectal wall as a result of the fluorescence effect of the ICG. Result(s) After injection of the ICG, the borders of the healthy rectum are delineated and a clear distinction between the endometriotic nodule and the bowel wall is demonstrated. In addition, the effect of the ICG was used to assess the vascularization of the infiltrated organs (vagina and rectal wall). Conclusion(s) Deep endometriosis at the level of the rectum usually represents a solid fibrotic nodule. The fibrosis plays a major role in the development of the disease. Indocyanine green is a fluorescent contrast agent, routinely used in a wide range of specialties to assess the blood supply and vascularization of different organs and tissues. Based on the fibrotic nature of the disease, the fluorescence could facilitate the distinction between healthy vascularized tissues and the endometriotic nodule. In the presented case, using ICG, a clear difference between the nodule and the rectum is demonstrated, as well as the vascularization of the bowel wall and the vagina. The implementation of ICG during endometriosis surgery could provide navigation for the surgeon toward a more complete and safer treatment of the disease, reducing the risk of complications and reinterventions. Additional studies are needed to further evaluate ICG fluorescence-guided surgery in the management of deep endometriosis.

Study Objective Laparoscopic termino-terminal ureteral anastomosis has all the advantages of a minimally invasive approach in addition to the treatment of the pathologic condition [ 1 ]. Ureteral deep endometriosis can lead to severe consequences, such as hydroureteronephrosis and renal failure [ 2 , 3 ]. The main objective of this video is to present our surgical strategy and technique for cases of ureteral deep infiltrating endometriosis, which could help surgeons to understand and perform this surgery in a safe way in patients. Design Video demonstration of the technique. Setting French university tertiary-care hospital. Interventions This video presents a termino-terminal laparoscopic ureteral anastomosis and shows our team's strategy for surgical treatment in a 42-year-old woman with deep infiltrating ureteral left endometriosis, with consequent stenosis and left hydroureteronephrosis. A full resection of the endometriotic ureteral nodule was performed, followed by a termino-terminal anastomosis of the ureter. The use of intravenous indocyanine green to assess the postanastomotic ureteral perfusion and its risk of leakage or fistula are described in the video [ 2 , 3 , 4 , 5 ]. Conclusion Ureteral endometriosis can lead to severe consequences, and the surgical treatment can be difficult and, most times, incomplete. This video gives a detailed example of the strategy our team used to perform a termino-terminal ureteral laparoscopic anastomosis in a structured way.

It is recommended to classify Borderline Ovarian Tumors (BOTs) according to the WHO classification. Transvaginal and suprapubic ultrasonography are recommended for the analysis of an ovarian mass (Grade A). In case of an undetermined ovarian lesion on ultrasonography, it is recommended to perform a pelvic MRI (Grade A) with a score for malignancy (ADNEX MR/O-RADS) (Grade C) included in the report and to formulate a histological hypothesis (Grade C). Pelvic MRI is recommended to characterize a tumor suspected of being BOT (Grade C). It is recommended to evaluate serum levels of HE4 and CA125 and to use the ROMA score for the diagnosis of indeterminate ovarian mass on imaging (grade A). If there is a suspicion of a mucinous BOT on imaging, serum levels of CA 19-9 may be proposed (Grade C). For Early Stages (ES) of BOT, if surgery without risk of tumor rupture is possible, laparoscopy with protected extraction is recommended over laparotomy (Grade C). For treatment of a bilateral serous ES BOT with a strategy to preserve fertility and/or endocrine function, bilateral cystectomy is recommended where possible (Grade B). For mucinous BOTs with a treatment strategy of fertility and/or endocrine function preservation, unilateral salpingo-oophorectomy is recommended (grade C). For mucinous BOTs treated by initial cystectomy, unilateral salpingo-oophorectomy is recommended (grade C). For serous or mucinous ES BOTs, routine hysterectomy is not recommended (Grade C). For ES BOTs, lymphadenectomy is not recommended (Grade C). For ES BOTs, appendectomy is recommended only in case of a macroscopically pathological appendix (Grade C). Restaging surgery is recommended in cases of serous BOTs with micropapillary architecture and an incomplete abdominal cavity inspection during initial surgery (Grade C). Restaging surgery is recommended for mucinous BOTs after initial cystectomy or in cases where the appendix was not examined (Grade C). If restaging surgery is decided for ES BOTs, the following procedures should be performed: peritoneal washing (grade C), omentectomy (grade B), complete exploration of the abdominal cavity with peritoneal biopsies (grade C), visualization of the appendix and appendectomy in case of a pathological macroscopic appearance (grade C) as well as unilateral salpingo-oophorectomy in case of a mucinous BOT initially treated by cystectomy (grade C). In advanced stages (AS) of BOT, it is not recommended to perform a lymphadenectomy as a routine procedure (Grade C). For AS BOT in a patient with a desire to fall pregnant, conservative treatment involving preservation of the uterus and all or part of the ovary may be proposed (Grade C). Restaging surgery aimed at removing all lesions, not performed initially, is recommended for AS BOTs (Grade C). After treatment, follow-up for a duration greater than 5 years is recommended due to the median recurrence time of BOTs (Grade B). It is recommended that a systematic clinical examination be carried out during follow-up of a treated BOT (Grade B). If the determination of tumor markers is normal preoperatively, the routine dosage of tumor markers in BOT follow-up is not recommended (Grade C). In case of an initial elevation in serum CA 125 levels, it is recommended to monitor CA 125 during follow up (Grade B). In case of conservative treatment, it is recommended to use transvaginal and transabdominal ultrasound during follow up of a treated BOT (Grade B). In the event of a BOT recurrence in a woman of childbearing age, a second conservative treatment may be proposed (Grade C). A consultation with a physician specialized in Assisted Reproductive Technique (ART) should be offered in the case of BOTs in women of childbearing age (Grade C). When possible, a conservative surgical strategy is recommended to preserve fertility in women of childbearing age (Grade C). In the case of optimally treated BOT, there is no evidence to contraindicate the use of ART. The use of hormonal contraception after serous or mucinous BOT is not contraindicated (Grade C). After management of mucinous BOT, for women under 45 years, given the benefit of Hormonal Replacement Therapy (HRT) on cardiovascular and bone risks, and the lack of hormone sensitivity of mucinous BOTs, it is recommended to offer HRT (Grade C). Over 45 years of age, HRT can be prescribed in case of a climacteric syndrome after individual benefit to risk assessment (Grade C).

Objective To evaluate the feasibility of using indocyanine green (ICG) to estimate the vascularization of the resected zone during a laparoscopic rectal shaving. Design Indocyanine green can highlight blood vascularization when injected intravenously. There is no relevant, objective, intraoperative method to assess the vascularity of the resected zone during a laparoscopic rectal shaving for deep infiltrating endometriosis (DIE) to prevent fistula. We conducted a registered clinical trial examining the feasibility of the use of ICG to evaluate the bowel vascularization after endometriosis rectal shaving (Institutional Review Board number 2016-002773-35). Setting Tertiary university hospital. Patient(s) Twenty-one patients underwent laparoscopic surgery for DIE with a rectal shaving. Intervention(s) Patients undergoing laparoscopic surgery for DIE received ICG intravenously at the end of the endometriosis resection. Main Outcome Measure(s) The main evaluation criteria was the fluorescence degree in the operated rectal area and in the vaginal suture. We used a visual assessment with a Likert-type scale from 0 to 4 (0 = no fluorescence; 4 = very good fluorescence). Result(s) No adverse reaction was recorded. Most of the patients (81%) showed very good fluorescence levels at the rectal shaving area. The protocol did not increase the operating time. In one patient we changed the surgical strategy making two stitches to bring the rectal muscularis closer together, which improved the degree of fluorescence. There was no case of digestive fistula. Conclusion Indocyanine green fluorescent imaging is feasible in endometriosis surgery and may be considered as a potential candidate to further enhance patient safety in endometriosis bowel surgery. Clinical Trial Registration Number NCT03080558.

Many studies have shown a global efficacy of laparoscopic surgery for patients with endometriosis in reducing painful symptoms and improving quality of life (QoL) in the short and long-term. The aim of this study was to analyze the different trajectories of long-term evolution in QoL and symptoms following surgical treatment for endometriosis, and to identify corresponding patient profiles. This prospective and multicenter cohort study concerned 962 patients who underwent laparoscopic treatment for endometriosis. QoL was evaluated using the Short Form (SF)-36 questionnaire and intensity of pain was reported using a visual analog scale prior to surgery and at 6, 12, 18, 24 and 36 months after surgery. Distinctive trajectories of pain and QoL evolution were identified using group-based trajectory modeling, an approach which gathers individuals into meaningful subgroups with statistically similar trajectories. Pelvic symptom trajectories (models of the evolution of dysmenorrhea, dyspareunia and chronic pelvic pain intensity over years) correspond to (1) patients with no pain or pain no longer after surgery, (2) patients with the biggest improvement in pain and (3) patients with continued severe pain after surgery. Our study reveals clear trajectories for the progression of symptoms and QoL after surgery that correspond to clusters of patients. This information may serve to complete information obtained from epidemiological methods currently used in selecting patients eligible for surgery.

Background and objective: Elderly and/or frail women with ovarian cancer are often undertreated. The aim of the study is to compare the effects of age and frailty on surgical approaches, postoperative complications, and prognosis in elderly women with ovarian cancer. Methods: A retrospective multicenter study of women &ge, 70 years were treated for ovarian cancer at seven French university hospitals between 2007 and 2015. Results: Of the 1119 women treated for ovarian cancer during the study period, 147 were &ge, 70 years and had complete data. Of these women, 65 were aged 70&ndash, 74 years, and 82 were aged &ge, 75 years. Overall, 77% of the younger women (49/65) received optimal treatment compared with 51% (40/82) of the older women (p = 0.018). Women &ge, 75 years underwent fewer bowel resections (32% vs. 67%, p &lt, 0.001) and experienced fewer postoperative complications (22.6% vs. 38.9%, p &lt, 0.001), 53.2% of the women in this age group were treated by primary surgery or surgery only. These women also received more chemotherapy with platinum only (15% [9/56] vs. 2% [1/57], p = 0.007) and less bevacizumab (9% [5/56] vs. 32% [18/57], p = 0.003). Patients with greater frailty (a modified Charlson Comorbidity Index [mCCI] score &gt, 3) had a five-year survival rate of 30% versus 62% for those with a score &le, 3 (p &lt, 0.001). Conclusions: Surgeons modify their approach to treating ovarian cancer in women &ge, 75 years probably to reduce immediate postoperative complications. The prognosis is significantly worse in patients with greater frailty. Improvements to the sequence of treatments administered, with priority given to neoadjuvant chemotherapy in patients with greater frailty, could help increase the number of women who receive optimal treatment and improve their prognosis.

Elderly women with ovarian cancer are often undertreated due to a perception of frailty. We aimed to evaluate the management of young, elderly and very elderly patients and its impact on survival in a retrospective multicenter study of women with ovarian cancer between 2007 to 2015. We included 979 women: 615 women (62.8%) &lt, 65 years, 225 (22.6%) 65&ndash, 74 years, and 139 (14.2%) &ge, 75 years. Women in the 65&ndash, 74 years age group were more likely to have serous ovarian cancer (p = 0.048). Patients &gt, 65 years had more &gt, IIa FIGO stage: 76% for &lt, 65 years, 84% for 65&ndash, 74 years and 80% for &ge, 75 years (p = 0.033). Women &ge, 75 years had less standard procedures (40% (34/84) vs. 59% (104/177) for 65&ndash, 74 years and 72% (384/530) for &lt, 65 years (p &lt, 0.001). Only 9% (13/139) of women &ge, 75 years had an Aletti score &gt, 8 compared with 16% and 22% for the other groups (p &lt, 0.001). More residual disease was found in the two older groups (30%, respectively) than the younger group (20%) (p &lt, 0.05). Women &ge, 75 years had fewer neoadjuvant/adjuvant cycles than the young and elderly women: 23% &ge, 75 years received &lt, 6 cycles vs. 10% (p = 0.003). Univariate analysis for 3-year Overall Survival showed that age &gt, 65 years, FIGO III (HR = 3.702, 95%CI: 2.30&ndash, 5.95) and IV (HR = 6.318, 95%CI: 3.70&ndash, 10.77) (p &lt, 0.001), residual disease (HR = 3.226, 95%CI: 2.51&ndash, 4.15, p &lt, 0.001) and lymph node metastasis (HR = 2.81, 95%CI: 1.91&ndash, 4.12, 0.001) were associated with lower OS. Women &gt, 65 years are more likely to have incomplete surgery and more residual disease despite more advanced ovarian cancer. These elements are prognostic factors for women&rsquo, s survival regardless of age. Specific trials in the elderly would produce evidence-based medicine and guidelines for ovarian cancer management in this population.

Objective Laparoscopic cystectomy for endometrioma has the advantages of a minimally invasive approach. The standardization and description of the technique are the main objectives of this video . We described the surgery in 10 steps, which could help to make this procedure easier and safer. Design Step-by-step video demonstration of the technique. Setting A French university tertiary care hospital. Intervention Two standardized laparoscopic cystectomy were recorded to realize the video . The local institutional review board ruled that approval was not required because the video describes a technique and does not report a clinical case. This video presents a systematic approach to cystectomy for endometrioma clearly divided into 10 steps: (1) preoperative evaluation [1] ; (2) diagnosis and exploration [2] ; (3) adhesiolysis, mobilization of the ovary; (4) cyst rupture, exposition of the entry site; (5) identification of the cleavage plan; (6) endometrioma easy dissection; (7) endometrioma difficult dissection; (8) hemostasis, reconstruction of the ovary [3] ; (9) exploration of the ovarian fossa; and (10) washing, extraction of the cyst 3 , 4 . Conclusion Standardization of laparoscopic cystectomy for endometrioma could make this procedure easier and safer to perform. The 10 steps presented help to perform each part of the surgery in a logical sequence, making the procedure easier to realize. Moreover, the standardization of the surgical techniques may reduce the learning curve.

Study Objective Laparoscopic cystectomy for ovarian teratomas has the advantages of a minimally invasive approach [1] . The standardization and description of the technique are the main objectives of this video ( Video 1 ). We described the surgery in 10 steps [2] , which could help make this procedure easier and safer. Design A step-by-step video demonstration of the technique. Setting A French university tertiary care hospital. Patients Patients with ovarian teratomas with indication for laparoscopic cystectomy [3] . The local institutional review board ruled that approval was not required for this video article because the video describes a technique and does not report a clinical case. Interventions Standardized laparoscopic cystectomies were recorded to realize the video. Measurements and Main Results This video presents a systematic approach to cystectomy for teratoma clearly divided into 10 steps: (1) planning of the surgery, (2) ergonomy and materials, (3) exploration and cytology, (4) prevention of peritoneal spillage [4] , (5) mobilization of the ovary, (6) incision of the ovary, (7) dissection, (8) hemostasis, (9) exteriorization of the cyst, and (10) washing and exploration. Conclusion Standardization of laparoscopic cystectomy for ovarian teratoma could make this procedure easier and safer to perform. The 10 steps presented help to perform each part of the surgery in a logical sequence, making the procedure ergonomic and easier to adopt and learn. Moreover, the standardization of the surgical techniques could reduce the learning curve.

Objective Transvaginal tension-free vaginal tape-obturator (TVT-O) is an effective surgical treatment for stress urinary incontinence in women [1] . A correct preoperative urodynamic study has a role in obtaining the best results. However, some complications still occur during and after this surgical procedure. These complications cause a high burden for patients, who frequently have to receive other invasive treatments subsequently. The main objective of this video is the standardization and accurate description of this surgical procedure while adding some tips and tricks. Design Step-by-step description of the technique through a video. Setting A French tertiary care teaching hospital. Interventions `The local institutional review board was consulted and ruled that approval was not required. Patients cannot be identified and they signed a written consent to use video-recording for research, scientific and teaching purposes. We provided this video of TVT-O procedures to identify more delicate steps of this surgical procedure to clarify managing them successfully. We assessed 10 rational steps in the procedure to standardize it. This video presents clearly the standardization of this technique in 10 steps: (1) patient's ergonomy, (2) anesthetic infiltration, (3) single vaginal incision, (4) creation of the pathway for device placement, (5) placement of the device, (6) check flat position of the tape, (7) obtain the correct tension of the mesh, (8) cut both lateral arms of the tape emerging from the skin, (9) urinary drainage to exclude stenosis, and (10) suture vaginal mucosa and skin. Conclusion Together with an appropriate preoperative study, the standardization of this surgical procedure and the application of tips and tricks suggested could make this technique easier to learn for beginners [2] and could help experienced surgeons in reducing, as much as possible, the most frequent complications as well [3] .

International audience; This work was carried out under the aegis of the CNGOF (Collège national des gynécologues et obstétriciens français) and proposes guidelines based on the evidence available in the literature. The objective was to define the diagnostic and surgical management strategy, the fertility preservation and surveillance strategy in Borderline Ovarian Tumor (BOT). No screening modality can be proposed in the general population. An expert pathological review is recommended in case of doubt concerning the borderline nature, the histological subtype, the invasive nature of the implant, for all micropapillary/cribriform serous BOT or in the presence of peritoneal implants, and for all mucinous or clear cell tumors (grade C). Macroscopic MRI analysis should be performed to differentiate the different subtypes of BOT: serous, seromucinous and mucinous (intestinal type) (grade C). If preoperative biomarkers are normal, follow up of biomarkers is not recommended (grade C). In cases of bilateral early serous BOT with a desire to preserve fertility and/or endocrine function, it is recommended to perform a bilateral cystectomy if possible (grade B). In case of early mucinous BOT, with a desire to preserve fertility and/or endocrine function, it is recommended to perform a unilateral adnexectomy (grade C). Secondary surgical staging is recommended in case of serous BOT with micropapillary appearance and uncomplete inspection of the abdominal cavity during initial surgery (grade C). For early-stage serous or mucinous BOT, it is not recommended to perform a systematic hysterectomy (grade C). Follow up after BOT must be pursued for more than 5 years (grade B). Conservative treatment involving at least the conservation of the uterus and a fragment of the ovary in a patient wishing to conceive may be proposed in advanced stages of BOT (grade C). A new surgical treatment that preserves fertility after a first non-invasive recurrence may be proposed in women of childbearing age (grade C). It is recommended to offer a specialized consultation for Reproductive Medicine when diagnosing BOT in a woman of childbearing age. Hormonal contraceptive use after serous or mucinous BOT is not contraindicated (grade C).

Study Objective Laparoscopic resection of diaphragmatic endometriosis has the advantages of a minimally invasive approach [ 1 ]. The standardization and description of the technique are the main objectives of this video. We described the procedure in 10 steps to make it easier and safer. Design A step-by-step video demonstration of the technique (Video 1). Setting A French university tertiary care hospital. Patients Patients with diaphragmatic endometriosis confirmed by magnetic resonance imaging [ 2 ]. The local institutional review board ruled that approval was not required for this video article because the video describes a technique and does not report a clinical case. Intervention There are no guidelines on the surgical treatment of diaphragmatic endometriosis [ 3 ]. We propose a laparoscopic approach using a right lateral access with the patient in the left lateral decubitus position [ 4 ]. Measurements and Main Results This video presents the procedure divided into the following 10 steps: step 1, set up; step 2, patient position; step 3, installation of the trocars; step 4, releasing the liver; step 5, exposure of the diaphragmatic endometriosis; step 6, making a diaphragmatic defect; step 7, exploring the thoracic cavity; step 8, resection of diaphragmatic endometriosis; step 9, inserting the suction catheter; and step 10, closing the diaphragmatic defect. Conclusion Standardization of laparoscopic resection of diaphragmatic endometriosis could make this procedure easier and safer to perform. The left lateral decubitus position helps to have complete exposure of the right diaphragmatic muscle and endometriosis. We presented 10 steps to help perform each part of the surgery in logical sequence, making the procedure ergonomic and easier to adopt and learn [ 5 ]. Standardization of laparoscopic techniques could help to reduce the learning curve.

La laparoscopia e una tecnica chirurgica moderna minimamente invasiva. Ha specificita e vincoli che e importante conoscere bene, per intraprenderla nelle migliori condizioni e per prevenire complicanze specifiche. Inoltre, la chirurgia laparoscopica dipende in gran parte dall’attrezzatura e dalla tecnologia che la accompagnano. Questo ambiente specifico richiede un apprendimento adeguato da parte del chirurgo.

In this chapter we have examined the possibilities of screening endometriosis, both in the general population as well as in the target population. We then proposed decision trees, for primary and secondary care. Currently, there is not enough data in the literature to develop or organize a screening test for endometriosis. Screening for endometriosis is not recommended in the general population (level A). There is also no evidence to support systematic screening in a population with genetic risk factors (endometriosis in a relative), or with other clinical risk factors (increased menstrual volume, short cycles, early menarche) (level A). However, it is possible to propose a decision tree for the management of chronic pelvic pain symptoms (dysmenorrhea, dyspareunia, non-menstrual pelvic pain). The search for symptoms suggestive of endometriosis (intense dysmenorrhea [visual analogue scale >7/10, frequent abstention, resistance to level 1 analgesics], infertility) should be systematic. The search for localizing symptoms of deep endometriosis (deep dyspareunia, cyclic defecation pain, cyclic urinary signs) enables to orient the patient to second line evaluation. We propose a decision tree for second and third line evaluations, according to the suspicion and/or the discovery of deep lesions with specific locations, or the suspicion of superficial lesions.

Study Objective To study the correlation between age and the severity (assessed with the rAFS score, deep nodule ≥ 2 cm) of the disease in patients newly and histologically diagnosed with endometriosis. Design A prospective multicenter cohort study. Setting Public and private gynecologic departments of Auvergne (geographical area). Patients or Participants A prospective multi-center cohort of patients leaving in 3 French departments, aged 15 to 50 years, newly and histologically diagnosed with endometriosis. Interventions At surgery, the endometriosis was treated thus allowing an adequate staging of the disease. Measurements and Main Results The severity of endometriosis was assessed using the RAFS score and the diameter of the largest deep nodule. The R-FS stage and the presence of a ≥ 2 cm nodule was correlated with age. The 981 patients were divided in 6 groups according to age: ≤ 20, 20-25, 26-30, 31-35, 36-40 and > 40. The percentage of patients with stage I endometriosis was respectively 76%, 26%, 24%, 24%, 33%, 19%. The percentage of stage II was 17%, 30%, 27%, 28%, 27%, 33%. The percentage of stage III was 6%, 26%, 22%, 22%, 18%, 14%. The percentage of stage IV was 0%, 16%, 25%, 24%, 20%, 32%. The percentage of patients with a deep nodule ≥ 2cm was respectively 0%, 23%, 19%, 22%, 16%, 10%. Patients with stage I disease were found in all age groups. The percentage of each stage and of patients with large nodules was similar and did not increased in all age groups after 20. Conclusion Prospective data obtained in patients newly diagnosed with endometriosis did not confirmed that endometriosis is always a progressive disease.

Introduction The coronavirus SARS-CoV-2 (COVID-19) pandemic has put tremendous pressure on the French healthcare system. Almost all hospital departments have had to profoundly modify their activity to cope with the crisis. In this context, the surgical management of cancers has been a topic of debate as care strategies were tailored to avoid any delay in treatment that could be detrimental to patient wellbeing while being careful not to overload intensive care units. The primary objective of this study was to observe changes in the surgical management of pelvic cancers during the COVID-19 pandemic in France. Material and Methods This study analyzed data from the prospective multi-center cohort study conducted by the French Society for Pelvic and Gynecological Surgery (SCGP) with methodological support from the French (FRANCOGYN) Group. All members of the SCGP received by e-mail a link allowing them to include patients who were scheduled to undergo gynecological carcinologic surgery between March 16th 2020 and May 11th 2020. Demographic data, the characteristics of cancers and the impact of the crisis in terms of changes to the usual recommended coarse of care were collected. Results A total of 181 patients with a median age 63 years were included in the cohort. In total, 31 patients had cervical cancer, 76 patients had endometrial cancer, 52 patients had ovarian or tubal cancer, 5 patients had a borderline tumor of the ovary, and 17 patients had vulvar cancer. During the study period, the care strategy was changed for 49 (27%) patients with postponed for 35 (19.3%) patients, and canceled for 7 (3.9%) patients. Surgical treatment was maintained for 139 (76.8%) patients. Management with neoadjuvant chemotherapy was offered to 19 (10,5%) patients and a change in surgical choice was made for 5 (2,8%) patients. In total, 8 (4,4%) patients tested positive for COVID-19. Data also shows a greater number of therapeutic changes in cases of ovarian cancer as well as a cancelation of a lumbo-aortic lymphadenectomy in one patient with cervical cancer. Hospital consultants estimated a direct detrimental impact of the COVID-19 pandemic for 39 patients, representing 22% of gynecological cancers. Conclusion This study provided observational data of the impact of the COVID-19 health crisis on the surgical management of gynecological cancers.

Augmented Reality (AR) guidance is a technology that allows a surgeon to see sub-surface structures, by overlaying pre-operative imaging data on a live laparoscopic video. Our objectives were to evaluate a state-of-the-art AR guidance system in a tumor surgical resection model, comparing the accuracy of the resection with and without the system. Our system has three phases. Phase 1: using the MRI images, the kidney’s and pseudotumor’s surfaces are segmented to construct a 3D model. Phase 2: the intra-operative 3D model of the kidney is computed. Phase 3: the pre-operative and intra-operative models are registered, and the laparoscopic view is augmented with the pre-operative data. We performed a prospective experimental study on ex vivo porcine kidneys. Alginate was injected into the parenchyma to create pseudotumors measuring 4–10 mm. The kidneys were then analyzed by MRI. Next, the kidneys were placed into pelvictrainers, and the pseudotumors were laparoscopically resected. The AR guidance system allows the surgeon to see tumors and margins using classical laparoscopic instruments, and a classical screen. The resection margins were measured microscopically to evaluate the accuracy of resection. Ninety tumors were segmented: 28 were used to optimize the AR software, and 62 were used to randomly compare surgical resection: 29 tumors were resected using AR and 33 without AR. The analysis of our pathological results showed 4 failures (tumor with positive margins) (13.8%) in the AR group, and 10 (30.3%) in the Non-AR group. There was no complete miss in the AR group, while there were 4 complete misses in the non-AR group. In total, 14 (42.4%) tumors were completely missed or had a positive margin in the non-AR group. Our AR system enhances the accuracy of surgical resection, particularly for small tumors. Crucial information such as resection margins and vascularization could also be displayed.

Study Objective Laparoscopic myomectomy has the advantages of a minimally invasive approach for the surgical treatment of myomas. The standardization and description of the technique are the main objectives of this video. We described laparoscopic myomectomy in 10 steps, which could help make this procedure easier and safer [1] . Setting A French university tertiary care hospital. Patients Patients with indication for laparoscopic myomectomy. The local institutional review board ruled that approval was not required for this video article because the video describes a technique and does not report a clinical case. Intervention Standardized laparoscopic myomectomies were recorded to realize the video. Measurements and Main Results This video presents a systematic approach to myomectomy clearly divided into 10 steps: (1) prepare your surgery, make selection and prehabilitation of patient [2] , provide a good cartography of the myoma(s), and plan the surgery 3 , 4 ; (2) ergonomy and material; (3) preventive hemostasis: triple occlusion; (4) hysterotomy; (5) enucleation by fast dissection and traction; (6) bipolar hemostasis; (7) check for missing myomas; (8) suture; (9) extraction/morcellation; and (10) prevent adhesions [5] . Conclusion Standardization of laparoscopic myomectomy could make this procedure easier and safer to perform. The 10 steps presented help to perform each part of surgery in logical sequence making the procedure ergonomic and easier to adopt and learn. Standardization of laparoscopic techniques could help to reduce the learning curve.

Augmented reality (AR) is a surgical guidance technology that allows key hidden subsurface structures to be visualized by endoscopic imaging. We report here 2 cases of patients with adenomyoma selected for the AR technique. The adenomyomas were localized using AR during laparoscopy. Three-dimensional models of the uterus, uterine cavity, and adenomyoma were constructed before surgery from T2-weighted magnetic resonance imaging, allowing an intraoperative 3-dimensional shape of the uterus to be obtained. These models were automatically aligned and “fused” with the laparoscopic video in real time, giving the uterus a semitransparent appearance and allowing the surgeon in real time to both locate the position of the adenomyoma and uterine cavity and rapidly decide how best to access the adenomyoma. In conclusion, the use of our AR system designed for gynecologic surgery leads to improvements in laparoscopic adenomyomectomy and surgical safety.

Augmented reality is a technology that allows a surgeon to see key hidden subsurface structures in an endoscopic video in real-time. This works by overlaying information obtained from preoperative imaging and fusing it in real-time with the endoscopic image. Magnetic resonance diffusion tensor imaging (DTI) and fiber tractography are known to provide additional information to that obtained from standard structural magnetic resonance imaging (MRI). Here, we report the first 2 cases of the use of real-time augmented reality during laparoscopic myomectomies with visualization of uterine muscle fibers after DTI tractography–MRI to help the surgeon decide the starting point incision. In the first case, a 31-year-old patient was undergoing laparoscopic surgery for a 6-cm FIGO type V myoma. In the second case, a 38-year-old patient was undergoing a laparoscopic myomectomy for a unique 6-cm FIGO type VI myoma. Signed consent forms were obtained from both patients, which included clauses of no modification of the surgery. Before surgery, MRI was performed. The external surface of the uterus, the uterine cavity, and the surface of the myomas were delimited on the basis of the findings of preoperative MRI. A fiber tracking algorithm was used to extrapolate the uterine muscle fibers’ architecture. The aligned models were blended with each video frame to give the impression that the uterus is almost transparent, enabling the surgeon to localize the myomas and uterine cavity exactly. The uterine muscle fibers were also displayed, and their visualization helped us decide the starting incision point for the myomectomies. Then, myomectomies were performed using a classic laparoscopic technique. These case reports show that augmented reality and DTI fiber tracking in a uterus with myomas are possible, providing fiber direction and helping the surgeon visualize and decide the starting incision point for laparoscopic myomectomy. Respecting the fibers’ orientation could improve the quality of the scar and decrease the architectural disorganization of the uterus.