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Purpose Endometriosis is a benign, but potentially serious gynaecological condition in terms of abdominal pain and impaired fertility. Laparoscopic excision techniques are considered the therapeutic standard. HybridAPC is presented as a novel technique for the non-contact thermal ablation of peritoneal endometriosis with simultaneous protection of the underlying thermosensitive structures by creating a needle-free elevated fluid cushion which enables a safer exposure and distance, as well as potentially improved peritoneal conditioning prior to APC. Methods In this prospective randomized clinical trial, 39 patients with 132 superficial endometriotic lesions in total were treated with HybridAPC or sharp excision in an initial laparoscopic procedure according to randomization. In a second-look laparoscopy, adhesion formation was rated macroscopically. Histologic samples were taken from previously treated areas for evaluation of eradication rate. Results The eradication rate was not significantly different between HybridAPC treatment and sharp excision (65 vs. 81%, p = .55). Adhesions formed in 5% of HybridAPC-treated lesions and in 10% after sharp excision (p = .49). HybridAPC treatment was significantly faster than sharp excision (69 vs. 106 s, p Conclusion This clinical trial demonstrates the feasibility of this novel surgical technique with a promising impact on adhesion prevention. Compared to sharp excision, HybridAPC is likely to be a safe, tissue-preserving, and fast method for the treatment of peritoneal endometriosis.

The interface between surgeon and the laparoscopic instrument is an important factor in biomechanical stress that may increase the risk of musculoskeletal complaints in surgeons. This article investigates the effect of a laparoscopic instrument with a rotatable handle piece (rot-HP) on muscular stress and fatigue during routine laparoscopic procedures (LP) as well as usability, wrist posture and working precision. 40 LP (subtotal hysterectomies) performed by 11 surgeons were investigated. 20 LP were carried out with the rot-HP and 20 with a fixed (standard) laparoscopic handle piece instrument. Shoulder and arm muscle activity was monitored via surface electromyography (sEMG). The electrical activity (EA) and median power frequency (MPF) were used to determine muscular stress and fatigue. Usability, wrist posture, and working precision between handle piece conditions were assessed by a survey. Using the rot-HP did not reduce muscular stress. A tendency of muscular fatigue (increasing EA, decreasing MPF) occurred in the upper trapezius, middle deltoid and extensor digitorum muscles; however, no differences were found between handle pieces. Wrist posture was more comfortable using the rot-HP and working precision and usability tended to be preferred using the standard handle piece. Although wrist posture seemed to be optimized by the rot-HP, no effect on muscular stress and fatigue was observed in routine LP (

Objective To evaluate the effect of a laparoscopic instrument with a 360° rotatable handle piece (rot-HP) on biomechanical stress and precision in different areas of a simulated operating field at two working heights. Background Surgeons performing laparoscopic procedures are exposed to biomechanical stress and have an increased risk of musculoskeletal complaints. Method Fifty-seven healthy subjects (27 men, median age 26) without experience in laparoscopy performed a precision task in four quadrants (A–D) of the operating field using the rot-HP or a common fixed handle piece (fixed-HP) at an individually adjusted lower or higher working height. Biomechanical stress was assessed by surface EMG, wrist joint angles, and arm postures and precision by the number of mistakes. Results Using the rot-HP reduced muscle activity of the biceps brachii and flexor carpi radialis muscle. An interaction of flexor activity and area of the operating field occurred with the lowest activity in Quadrant C. Wrist joint angles were more neutral using the rot-HP, especially when the lower working height was applied and in Quadrants B and C. However, increased wrist dorsal flexion occurred in Quadrant A while using the rot-HP. Arm postures and precision were less affected. Conclusion The rot-HP allows some reductions of stresses in the arm and hand region, whereas the stress in the shoulder neck region is not modified. Application The instrument’s position and the working height may have to be considered as mediatory factors when describing the effectiveness of an ergonomic handle design for laparoscopic instruments.

Evaluation of safety, feasibility, and possibilities of the thulium laser, Vela(®), with a wavelength of 1.9 μm for laser treatment of the portio, vagina, and/or vulva.Laser techniques have been used for many years in the gynecological setting for the treatment of cervical, vaginal, and vulval intraepithelial neoplasias (CIN, VAIN, VIN) and also for the treatment of condylomas. To date, the most commonly used laser for this treatment is the CO2 laser.After indication was made for laser treatment, the patients were treated using the thulium laser, Vela. Follow-up examination usually took place after 1-2 weeks, 3 months, and 6 months, when colposcopy and, where necessary, a cytological smear were performed.During the period from January 2012 to January 2014, 18 patients were treated using the thulium laser. Three patients had a CIN I, 12 had condylomas, two had CIN I and condylomas, and one had CIN II and condylomas. During the follow-up, 40% (n = 6) of patients had a relapse of condylomas. No relapse occurred in cases of CIN. Itching, burning, pain, bleeding, discharge, and skin irritation were listed as side effects of the procedure.This feasibility study shows that the use of the thulium laser for the treatment of cervical neoplasias and condylomas offers a good alternative to the standard treatment using a CO2 laser.

To investigate the effect of a pistol grip laparoscopic instrument with a rotatable handle piece (rot-HP) on biomechanical stress and precision as well as a possible interaction between the instrument and working height (WH). Biomechanical stress induced by laparoscopic surgery (LS) is associated with work-related upper limb musculoskeletal disorders in surgeons. Ergonomic handle designs of laparoscopic instruments may reduce the risk of musculoskeletal disorders. Without LS experience, 57 healthy subjects (30 women; 27 men, median age: 26) were observed while performing a laparoscopic exercise. Subjects had to pick up coloured pins and place them into a colour-coded wooden set-up inside a pelvitrainer. The exercise was performed at two WHs using the rot-HP and a standard laparoscopic (fixed) handle piece in randomized sequence. Biomechanical stress was monitored via surface electromyography (sEMG) on fife muscles from the upper limb and shoulder region. Further, the wrist angle (palmar and dorsi flexion) and posture of the dominant upper arm were recorded. Precision was assessed using the number of validly placed pins and process time. sEMG parameters and upper arm postures indicated no differences in biomechanical stress related to either laparoscopic handle piece. The higher WH was associated with higher trapezius and deltoid activity and elevated arm postures (p

PURPOSE To delineate the relevance of pelvic and para-aortic node involvement in optimally cytoreduced (residual tumour 0-≤ 0.5) >0 and ≤ 50 % of affected nodes; (3) (>0.5-≤ 1) >50 % of affected nodes. Clinical parameters were retrospectively evaluated. Kaplan-Meier survival curve was used to evaluate the prognostic value. RESULTS Most often serous histology, histologic grade 3 and a node ratio >0-≤ 0.5 (61.1 %) were detected. Complete cytoreduction (R = 0 mm) has significant best prognostic impact compared to R > 0 mm-1 cm (OS: p = 0.047, PFS: p = 0.00). Node involvement was associated with serous histology and grade 3. Increasing node ratio leads to significant decreased OS (p = 0.019) and significant best OS was associated with node ratio >0-≤0.5. CONCLUSIONS The goal is optimal cytoreduction in advanced ovarian cancer. More extensive lymphadenectomy seems to play an important role in providing an accurate staging, and the node ratio might give prognostic information. Current prospective studies like the LION study (AGO-Ovar) had to investigate if these data have therapeutic implications and may be considered in future staging.

This prospective, randomized, controlled, single-blinded study investigates the peritoneal adhesion formation of HybridAPC (waterjet elevation of the peritoneum with subsequent argon plasma coagulation) versus only waterjet (elevation with the same instrument, but without subsequent argon plasma coagulation) in a rat model (24 female Wistar rats). Bilateral lesions were created on the abdominal wall with HybridAPC on one sidewall and waterjet elevation on the other sidewall of the peritoneum in a standard fashion. After 10 days, the rats were euthanized to evaluate the peritoneal trauma sites. Adhesion incidence, quantity, and quality were scored 10 days postoperatively and studied histopathologically. Incidence of adhesion formation was 2.3% for HybridAPC; no adhesions occurred for peritoneal elevation with saline (p = 1.00). Histologic evaluation revealed no acute inflammation in both groups. An overall moderate degree of granulation tissue formation and myonecrosis was observed in the HybridAPC group, whereas no chronic inflammation and myonecrosis occurred after elevation without thermal ablation (p

Objective To investigate peritoneal adhesion formation of monopolar contact coagulation (MCC) versus noncontact argon plasma coagulation (APC) in a rat model. Design Randomized, controlled, single-blinded animal study. Setting University laboratory. Animal(s) Sixteen female Wistar rats. Intervention(s) Bilateral lesions were created on the abdominal wall with MCC and APC in a standard fashion. After 10 days, the rats were euthanized to evaluate the peritoneal trauma sites. Main Outcome Measure(s) Adhesion incidence, quantity, and quality were scored 10 days postoperatively and studied histopathologically. Result(s) Average energy intake was 99.5 ± 7.39 J for APC and 95.7 ± 9.62 J for monopolar contact coagulation. Incidence of adhesion formation was 50.0% for noncontact APC and 85.4% for MCC. MCC induced significantly more vascular adhesions. Histological evaluation revealed no significant differences regarding average depth of lesions induced by APC and MCC. Both groups showed almost identical morphology of necrosis and granulation tissue formation. Conclusion(s) This study compares for the first time adhesion formation of MCC versus noncontact APC in a rat model. With a similar energy intake, contact coagulation induced a significantly higher rate of adhesion formation. APC-induced adhesions were significantly less vascularized compared with MCC adhesions. Besides the thermal effects of both coagulation methods, the direct mechanical contact of the MCC electrode with the highly sensitive peritoneum is thus determined to be a pivotal additional stimulus for adhesion formation.

To review a single-center experience over a 27-year period in the management of endometrial stromal sarcoma (ESS) and undifferentiated endometrial sarcoma (UES) for insight into clinical characteristics, pathological diagnosis, surgical practice, adjuvant therapy and clinical outcome. This was a retrospective study of women with histologically proven ESS and UES who were treated at the Department of Obstetrics and Gynecology, University of Tuebingen, Germany, between 1983 and 2010. Available tumor tissue, as well as inpatient and ambulatory records were reviewed; follow-up and survival data were ascertained. The study sample comprised ten patients with ESS and seven patients with UES. Primary surgical treatment consisted of total hysterectomy in nine patients (90.0 %) with ESS and six patients (85.7 %) with UES; one patient (10.0 %) with ESS and one patient (14.3 %) with UES underwent debulking surgery. All patients (100 %) from the ESS group and six patients (85.7 %) from the UES group underwent bilateral salpingo-oophorectomy. Seven women (70.0 %) with ESS and six women (85.7 %) with UES underwent lymphadenectomy. Median DFS was 83.8 months (95 % CI 80.6–87.0) and median OS was 232.6 (95 % CI 49.3–415.9) for patients with ESS; median DFS was 12.9 months (95 % CI 0–284.1) and median OS was 17.6 (95 % CI 0–37.0) for patients with UES. There was no significant difference in DFS between patients with ESS as compared with patients with UES. However, patients with ESS had a significantly better OS when compared to patients with UES (p = 0.011). ESS and UES are very rare uterine neoplasms. Surgery consisting of total hysterectomy with or without bilateral salpingo-oophorectomy is the most important treatment-element in patients with ESS or UES.

To compare the EnSeal device with standard bipolar coagulation forceps in laparoscopic supracervical hysterectomy (LASH).Prospective, randomized, controlled trial (Canadian Task Force classification I).University hospital.One hundred sixty patients who underwent LASH.Eighty patients underwent LASH using the EnSeal device (experimental group), and 80 patients underwent LASH using standard bipolar coagulation forceps (control group) (www.clinicaltrials.gov; study identifier NCT01806012).Mean (SD) total operative time was 78.18 (33.96) minutes in the experimental group and 86.30 (35.34) minutes in the control group (p = .03). Documented blood loss was50 mL in 72 patients in the experimental group and 62 patients in the control group (p = .03), and was 50 to 100 mL in 8 patients in the experimental group and 18 patients in the control group (p.001). Postoperative hospital stay was significantly shorter for patients in the experimental group compared with the control group: 2.01 (0.44) days vs 2.17 (0.47) days, respectively (p = .03). There was no difference in postoperative pain scores and complications between the two treatment groups.Total resection time was shorter in the experimental group, and the other investigated clinical parameters were not inferior in the experimental group compared with the control group. The results of the present study indicate that use of the EnSeal device is at least as reliable as the conventional electrocoagulation technique in LASH.

Purpose: Evidence regarding distinguishing characteristics of women with symptomatic leiomyomas during pregnancy who undergo myomectomy during pregnancy and those who respond to conservative treatment is sparse because it mostly derives from case reports and small patient series. As the first of its type, the present study analyzed the characteristics of women with symptomatic leiomyomas treated with myomectomy during pregnancy and those treated conservatively. Methods: We performed a computer search of medical records from 1 January 2001 to 31 March 2011 using the International Classification of Diseases Codes for pregnancy, myomectomy and leiomyomas during pregnancy. Results: 27 patients were admitted during pregnancy directly related to leiomyomas; 17 of the 27 patients received conservative treatment for symptomatic leiomyomas, and 10 patients had surgery during pregnancy: 3 had undergone diagnostic surgical procedures and 7 myomectomy. Perioperative and postoperative morbidity was low in all women in our sample. Conclusion: In our pilot study, myomectomy during pregnancy was safely performed in carefully selected patients, with subserosal or pedunculated leiomyomas that failed to respond to conservative treatment, with low perioperative and postoperative morbidity.

Objective To determine obstetric variables associated with the long-term prevalence of flatal and/or fecal incontinence among women who sustained obstetric anal sphincter injuries (OASIS). Methods In a retrospective study of women who gave birth between January 1974 and December 1983 at the University Women's Hospital, Tuebingen, Germany, women with OASIS (n = 460) were identified on the basis of chart review. Eligible women were recruited to participate in a telephone interview regarding symptoms and their retrospective preference about elective cesarean delivery. Results The records of 20 999 deliveries, including all modes of delivery, within the 10-year study period were reviewed, and 99 women who sustained OASIS agreed to participate. The mean follow-up was 27.5 ± 2.4 years. Among the participants, 39.4% reported fecal or flatal incontinence. Operative vaginal delivery (forceps and/or vacuum) was significantly associated with fecal but not flatal incontinence (odds ratio, 3.27; 95% confidence interval, 1.12–9.56, P = 0.026). Only 9% of women with flatal incontinence and 13% of women with fecal incontinence would have opted retrospectively for cesarean delivery. Conclusion Operative vaginal delivery was significantly associated with fecal but not flatal incontinence. No other obstetric variables tested were associated with the long-term prevalence of fecal or flatal incontinence.

Hintergrund/Zielsetzung: Wahrend laparoskopischer Eingriffe kommt es bei den Chirurgen zu biomechanischen Belastungen und somit zu einer erhohten Pravalenz von Muskel-Skelett-Beschwerden im Schulter-Nacken-Bereich und Hand-Arm-Bereich. In diesem Forschungsprojekt wurde ein spezifisches Unterstutzungssystem zur Belastungsreduktion fur laparoskopisch tatige Chirurgen entwickelt und auf vorklinischer Ebene evaluiert. Methode: 14 laparoskopische Eingriffe in Gynakologie und Urologie wurden hinsichtlich der Belastung analysiert. Dabei wurden Muskelaktivitaten ausgewahlter Muskeln von Rucken, Schulter und Arm (Oberflachenelektromyografie), Korperhaltungen (2-D Videoanalyse und Lagesensoren) und subjektive Belastungswahrnehmung der Operateure erfasst. Nach Bewertung dieser Belastungsdaten wurde in einem Ideenworkshop ein Konzept eines Arm-Stutz-System (Assyst) entwickelt. Ein entsprechendes Funktionsmuster wurde von der Universitat Stuttgart und den Industriepartnern Trumpf Medizintechnik und Fest AG & Co. Kg angefertigt. Danach fand die Evaluation auf vorklinischer Ebene mit 12 laparoskopieerfahrenen Chirurgen, die simulierte laparoskopische Aufgaben mit bzw. ohne Assyst durchfuhrten, statt. Bei den Aufgaben wurde die Fehlerhaufigkeit (Arbeitsprazision) und Bearbeitungsdauer (Arbeitsgeschwindigkeit) erfasst sowie die muskulare Beanspruchung (M. Trapezius, M. Erector Spinae) oberflachenelektromyographisch gemessen. Ergebnisse: Die Analyse identifizierte biomechanische Belastungen aufgrund erhohter Muskelaktivitat im Schulter-Nacken-Bereich sowie unergonomische Korperhaltungen. Die Ergebnisse der Evaluation zeigen, dass der Einsatz des Assysts zu einer verringerten Arbeitsgeschwindigkeit bei unveranderter Fehlerhaufigkeit fuhrt. Die bisherige Datenanalyse zeigt eine deutliche Reduktion der Muskelaktivitat im rechten M. Trapezius und im linken M. Erector Spinae durch Verwendung des Assysts. Diskussion: In der Folge sollte die praktische Bedeutung einer verlangerten Operationsdauer fur die Implementierung des Assysts in ein klinisches Setting betrachtet werden. Zudem sollte geklart werden, inwieweit die verringerte Muskelaktivitat von der reduzierten Arbeitsgeschwindigkeit beeinflusst wird.

The objective of this study was to examine the relevance of pelvic and para-aortic lymph node involvement and the tumour characteristics affecting nodal metastases and survival in primary advanced ovarian cancer. A total of 130 consecutive patients were retrospectively investigated. All the patients received stage-related surgery with pelvic and para-aortic lymphadenectomy. The median follow-up was 53.5 months. The clinicopathological parameters and distribution pattern of nodal metastases were evaluated. Lymph node metastases were detectable in 74.62% of the cases. Overall, both pelvic and para-aortic nodes were affected in 35.9% of the patients, whereas 13.3% had metastases only in the pelvic and 13.3% only in the para-aortic lymph nodes. Histological grade 1/2 and 3, serous and endometrioid histology were independent predictors of nodal metastasis. Serous and endometrioid cancers have shown a predilection for metastasis to the pelvic lymph nodes alone, both to the pelvic and the para-aortic nodes, or the para-aortic nodes alone. Overall survival was significantly positively affected by serous histology with positive nodes (P=0.043). It is crucial to investigate the risk factors and metastatic patterns of such patients in a multicenter analysis to evaluate individual subgroups. Prospective studies are required to investigate the prognostic effect of lymphadenectomy in advanced ovarian cancer and its association with histology and distribution pattern of nodal metastasis.

Significant improvement in the survival rates of children with pediatric cancers has been achieved over the last 25 years, so the number of long-term survivors is increasing and their subsequent quality of life is of increasing importance. One of the most serious side effects of chemotherapy or radiotherapy is damage to the ovarian function, which can lead to loss of fertility. The degree of this damage depends on the substances used, the dose of radiotherapy reaching the ovaries, and the age of the girl at the time of treatment. Up to now, the only established method of fertility preservation has been cryoconservation of fertilized egg cells or embryos, but this is not possible in prepubertal girls because of their sexual immaturity. Removal of ovarian tissue and subsequent cryoconservation with the option of later orthotopic retransplantation is therefore an option to these girls. This method can lead to pregnancy and birth in adult women. Up to now there are no studies about the retransplantation of ovarian tissue which was removed before puberty. Displacement of the ovaries away from the radiation field before radiation to the pelvic area can be considered; however, the data is controversial. One problem in the use of fertility preservation methods in these very young patients is that they undergo procedures which, because of their age, they mostly do not understand and the parents must make a decision based on the assumed later wishes of their daughter.

Purpose: The aim of our study was to investigate the rate of secondary carcinomas in patients with endometrial carcinoma (EC). In particular, we wanted to describe the subset of patients with endometrial and simultaneous ovarian carcinoma (OC), including outcomes. The study also compared patients with EC and ovarian metastasis with patients with EC and simultaneous OC. Patients and Methods: Data from 251 patients with primary endometrial carcinoma who underwent surgery in the years 2005–2009 at the Department of Obstetrics and Gynaecology, University of Tübingen, were analysed retrospectively. Results: A total of 28 patients (11.1 %) had a secondary carcinoma: 18 patients (7.1 %) had OC; 9 (3.5 %) patients had a history of breast cancer, and one patient (0.4 %) respectively had simultaneous carcinoma of the vulva or bladder. 14 patients (5.5 %) had advanced stage EC with ovarian metastasis or, in one case, metastasis to the ovarian tube. Patients with ovarian metastasis had a mean age of 71.2 ± 9.2 years at primary diagnosis, making them significantly older compared to patients with EC and simultaneous OC (55.3 ± 11.8 years, p

Shoulder dystocia is the term used to describe failure to progress in labour after the head has been delivered due to insufficient rotation of the shoulders. It is unpredictable and cannot be prevented by the midwife or the obstetrician. We report here on a severe case of shoulder dystocia, where delivery of the shoulder was finally achieved through direct pressure on the anterior shoulder after laparotomy and uterotomy with concurrent vaginal Woods screw manoeuvre and was followed by vaginal delivery. The patient presented risk factors like maternal obesity and administration of labour-inducing drugs. After different manoeuvres like McRoberts manoeuvre and several manoeuvres for internal rotation were carried out unsuccessfully, an emergency laparotomy was performed. The newborn was in need for reanimation and artifical ventilation postpartum but recovered fast during the following days. An Erb's palsy of the posterior arm improved during the hospital stay. The German Guideline of the DGGG 8 recommends a risk management plan and regular training to all birth attendants for obstetric clinics. Beside the vaginal manoeuvres one should have at least theoretical expertise in operative manoeuvres to be able to perform them in emergency cases.Die Schulterdystokie beschreibt einen Geburtsstillstand nach Geburt des Kopfes aufgrund unzureichender Schulterdrehung. Das Ereignis trifft die geburtshilflich tätige Person in der Regel völlig unerwartet. Es wird hier über einen Fall einer schweren Schulterdystokie berichtet, bei dem die Schulterlösung durch direkten Druck auf die vordere Schulter nach Laparotomie und Uterotomie bei gleichzeitigem Woods-Screw-Manöver von vaginal mit anschließender vaginaler Entbindung gelang. Die Patientin wies eine Adipositas und die Gabe von wehenfördernden Mitteln als Risikofaktoren auf. Nach erfolgloser Ausführung des McRoberts-Manövers und diverser Manöver zur inneren Rotation wurde eine Notlaparotomie durchgeführt. Das Neugeborene musste direkt postpartal reanimiert und für einige Stunden beatmet werden, erholte sich im weiteren Verlauf jedoch rasch. Eine Erbʼsche Armplexuslähmung des hinteren Armes besserte sich während des stationären Aufenthalts. Die Leitlinie der DGGG 8 sieht einen Risikomanagement-Plan sowie regelmäßiges Training aller beteiligten Personen für alle geburtshilflich tätigen Kliniken vor. Hierbei sollten nicht nur die vaginalen Manöver geübt werden, sondern auch zumindest theoretische Kenntnisse der operativen Manöver vermittelt werden, um sie im Notfall anwenden zu können.

The use of energy-based tissue-sealing and cutting instruments is becoming more and more popular in visceral, urological, and gynecological surgery. For their safe and efficacious use in clinical practice, such instruments have to reliably seal vessels with a minimal sealing failure rate, cause minimal thermal damage to adjacent tissue, and have good cutting qualities.The efficacy and safety of the novel energy-based instrument for dissection, hemostasis and cutting (BiCision(®), ERBE) was compared to a commercially available device (EnSeal(®), Ethicon Endo-Surgery). We investigated vessel-sealing reliability (success rate), sealing quality and sealing time, lateral thermal damage cutting quality, tissue sticking to the instrument, burst pressure and delayed complications in an acute and chronic pig model after splenectomy, small bowel resection, nephrectomy, salpingo-oophorectomy, and sealing of peripheral vessels.For all parameters investigated, BiCision(®) was at least equivalent to EnSeal(®). BiCision(®) was even superior to EnSeal(®) with respect to the burst pressure in arteries (p = 0.044) and veins (p = 0.023) and the cut quality in all locations (arteries, p = 0.0009; veins, p = 0.043). The course of the 7-day chronic study was uneventful except for one animal that developed an intestinal obstruction. None of the animals showed any signs of postoperative bleeding. On second-look laparotomy at day 7, macroscopic inspection of the sealed tissue and vessels did not show any signs of complications or evidence that bleeding had occurred. Histologically, the integrity of vessel wall fusion, thermal alterations, and inflammatory reactions were comparable, confirming substantial equivalence.We demonstrated that the efficacy and quality of vessel sealing with BiCision(®) is at least equivalent to those of EnSeal(®) for vessel diameters up to 7 mm. Since EnSeal(®) has already been shown to be safe in clinical practice, BiCision(®) should be as reliable as EnSeal(®) under clinical conditions.

Electrosurgical vessel sealing produces seals that can withstand intraluminal pressures well above the physiological range. In many cases it is more efficient than other methods, such as sutures, hemoclips, and ultrasonic coagulation devices, but bears lateral thermal damage as a side effect. The overall aim of this study was to compare the thermal lateral damage (TL) in vivo versus ex vivo using two different bipolar vessel sealing instruments in an epigastric vein animal model.A total of 96 thermofusions of bilateral epigastric veins were carried out in a prospective, randomized and controlled study design. The laparoscopic BiClamp (type Maryland) and the bipolar clamp Kelly model Clermont-Ferrand were used for ex vivo versus in vivo investigation. After exposure of the two bilateral epigastric veins the proximal sections were bilaterally coagulated in vivo with the two different instruments. For ex vivo coagulation, the uncoagulated section of the vein was removed and coagulated ex vivo. The TL was investigated by infrared measurement, light microscope and histological analysis.The comparison of the extent of coagulation damage between ex vivo and in vivo coagulation did not differ significantly: no differences between in vivo and ex vivo measurements were found for the Kelly clamp. In the case of the Maryland clamp only a significant greater TL in vivo was shown for stereomicroscopic measurements.Ex vivo TL results are comparable with in vivo results. This might prospectively spare in vivo studies with respect to TL and might facilitate the design of future experiments for the development of bipolar electrocoagulation devices.

Purpose: To review a single-center experience over a 27-year period in the management of uterine leiomyosarcoma (LMS) for insight into surgical practice, adjuvant therapy and clinical outcome. Material and Methods: This was a retrospective study of women with histologically proven uterine LMS who were treated at the Department of Obstetrics and Gynecology, University of Tuebingen, Germany, between 1983 and 2010. Inpatient and ambulatory records were reviewed; follow-up and survival data were ascertained. Results: The study sample comprised 32 patients with uterine LMS. Primary surgical treatment consisted of total abdominal hysterectomy in 28 patients (88 %) and laparoscopic total hysterectomy in 4 patients (12 %). Lymph nodes were dissected and evaluated in 17 women (53 %); positive lymph nodes were present in 1 patient (6 %). A total of 17 patients (53 %) received adjuvant therapy. Median follow-up for disease-free survival (DFS) was 35.6 months and median DFS was 27.0 months for all patients. The median follow-up for overall survival (OS) was 51.3 months and the median OS was 28.0 months for our study group. The 5-year survival rate was 30 %. There was no significant difference in DFS (p = 0.76) and OS (p = 0.51) between patients who received adjuvant therapy and those who did not. Conclusion: Uterine LMS are rare and aggressive uterine neoplasms with high recurrence rates and metastatic potential. Surgery consisting of total hysterectomy with or without bilateral salpingo-oophorectomy is the most important treatment-element in patients with uterine LMS. Lymphadenectomy should be reserved for patients with clinically suspicious nodes.

Prognostic impact of nodal status or lymphadenectomy in advanced ovarian cancer is still unclear. Known best prognostic impact in advanced ovarian cancer has the residual tumor mass. The aim of this retrospective study is to examine the importance of nodal status in correlation with residual tumor mass. One hundred and fifty-seven consecutive patients with primary stage III ovarian cancer underwent surgery between 01/2000 and 06/2007 at the Department of gynecology and obstetrics, University Hospital, Tubingen, Germany. All patients got stage-related surgery and platin-based chemotherapy. Median follow-up time was 53.5 months, and all patients were included in the study. Resection status and nodal status are significant prognostic factors in our study (P

There are conflicting opinions in the literature about whether pregnancy influences maternal bone density or osteoporosis development. The study aim was to investigate whether there is a significant alteration in maternal bone density during normal pregnancy.Bone mass of 200 pregnant women aged 22-42 years was measured twice with quantitative ultrasonometry (QUS) of the heel (Os calcaneum). The first measurement was performed between the 10th and 22nd week of pregnancy, follow-up of 149 women took place 0-9 days postpartum. A questionnaire focusing on data affecting bone metabolism and bone turnover was handed out at the first visit.Median reduction in speed of sound (SOS) was 11 m/s at follow-up indicating a decline of the stiffness during pregnancy. No significant correlation was found between lactation period and the obtained values for stiffness, SOS, T score and Z score. For broadband ultrasonographic attenuation, there was a statistically significant difference (p0.05) between women who had and had not breastfed. Parameters from patients with a family history of osteoporosis (n = 30) compared to patients without did not reveal statistical significance during pregnancy. Glucocorticoid therapy, nicotine consumption, physical exercise and nutrition was not statistically significant (p0.05). SOS value of women with a twin pregnancy was different over the study period (p0.05).A reduction in bone mass is possible during pregnancy. Routine evaluation of the bone density in all pregnant women does not seem to be justified; however, it is reasonable in women who present with risk factors. These women could be screened with QUS.

Cervical cancer is the third most common cancer occurring in women worldwide. The therapy for advanced stage cervical cancer is a particular challenge. There are no evidence-based recommendations for the therapy of advanced cervical cancer FIGO stage IV in the guidelines of the German Working Group on Gynecological Oncology nor in the international literature. Large randomised and prospective studies on treatment are missing. We present a patient with cervical cancer (FIGO stage IV B) with bulky metastatic lymph nodes in the obturator fossae and the paraaortic area. In accordance with existing studies, laparoscopic lymphadenectomy and tumour debulking with excision of the metastases was performed after clinical staging. Postoperatively, radiochemotherapy was initiated with boost in the area of the bulky lymph nodes. Laparoscopic lymphadenectomy improved the prognosis of this patient and is, according to existing studies, superior to laparotomy with regard to convalescence time, blood loss and hospital stay. But it is absolutely necessary that the procedure is performed by an experienced surgeon who is well acquainted with the technique.

Recent studies have shown that the detection of circulating tumor cells (CTC) pre and postoperatively in the peripheral blood of primary breast cancer patients may be an indicator for poor survival. This study aimed to investigate the influence of removal of the primary tumor on incidence and phenotype of circulating tumor cells in primary breast cancer. 209 primary breast cancer patients could be included into this analysis. Blood sampling was performed both pre and postoperatively. The blood specimens were immunomagnetically enriched using AdnaTest BreastCancerSelect within 4 h after blood withdrawal, followed by RNA isolation and subsequent gene expression analysis by reverse transcription and multiplex PCR using AdnaTest BreastCancerDetect. Three breast cancer-associated tumor markers and two hormone receptor genes were amplified: GA733-2, Muc-1, Her-2, ER, PR. In addition, bone marrow (BM) status was intraoperatively determined. Forty-three of 209 patients (21%) had pre and/or postoperatively circulating tumor cells. The positivity rates after surgery were higher but did not differ significantly (12% pre and 16% postoperatively, P = 0.264). Disseminated tumor cells in BM were seen in 32 of 209 cases (15%). Patients with positive BM status had significantly higher CTC positivity rates both pre and postoperatively compared to those with negative BM status. The most common CTC phenotype was triple negative (24 patients) followed by HER2+/ER-/PR- subtype (10) and ER and/or PR positive (9). Interestingly, 41 of 43 primary tumors (95%) were ER and PR positive. Removal of the primary tumor did not alter the phenotype of CTC. Surgery does not significantly influence the tumor cell load in the blood stream. CTC phenotype before and after the surgery generally remains identical but may differ from that of the primary tumor.

Tumor cell dissemination in bone marrow (BM) and lymph nodes is considered an important step in systemic disease progression and is associated with poor prognosis. Only invasive cancers are assumed to shed isolated tumor cells (ITC) into the bloodstream and infiltrate lymph nodes. However, latest studies indicate that tumor cell dissemination may occur before stroma invasion, i.e., in ductal carcinoma in situ (DCIS). Therefore, the purpose of this study was to examine the incidence of ITC in bone marrow and sentinel lymph nodes (SN) in patients diagnosed with DCIS and its correlation with clinicopathological factors. 266 patients who were treated at the Department of Gynecology and Obstetrics (University Hospital Tuebingen, Germany) between 2003 and 2009 with DCIS were included into this study. BM aspirates were analyzed by immunocytochemistry (pancytokeratin antibody A45-B/B3) using ACIS system (Chromavision) according to the ISHAGE evaluation criteria. SN were analyzed in 221 of these patients by extensive step sectioning and hematoxylin-eosin staining. In 34 of 266 patients (13%), ITC in BM could be detected. There was no correlation found between tumor size, grading, histology, or Van Nuys Prognostic Index and tumor cell dissemination. In two cases, metastatic spread into lymph nodes was observed (pN1mi), whereas in one case, ITC in lymph nodes were detected; however, additional sectioning and immunohistochemical staining of the primary lesion in the cases with positive SN did not reveal invasive cancer. Interestingly, all the three patients were BM negative. Tumor cell dissemination may be detected in patients diagnosed with DCIS. Either these cells have started already to disseminate from preinvasive mammary lesions or from occult invasive tumors or represent the earliest step of microinvasion in a preinvasive lesion. The clinical relevance of these cells has to be further evaluated.

Objective To investigate the peritoneal adhesion formation of two pulsed noncontact argon plasma coagulation (APC) modes in a rat model. Design Prospective, randomized, controlled, and blinded study. Setting Laboratory facilities of a university department of obstetrics and gynecology. Animal(s) Ten female Wistar rats. Intervention(s) Bilateral lesions were created on the abdominal wall with low and high APC energy in a standard fashion. After 10 days the rats were killed to evaluate the peritoneal trauma sites. Main Outcome Measure(s) Adhesion incidence, quantity, and quality were scored 10 days after surgery and studied by histopathologic analysis. Result(s) The area of coagulation was 30 ± 8.4 mm 2 in the case of high APC energy and 12 ± 5.6 mm 2 (low APC energy). Macroscopic thermal damage of the peritoneum is significantly higher when applying high APC energy. Adhesions due to APC with high energy occurred in 64% and with low energy in 6% of cases. High energy results mainly in dense adhesions. The lesions in the high-energy group showed intense granulation tissue formation with centrally located myocyte necrosis with intense neutrophilic inflammation. Conclusion(s) This study describes for the first time that different noncontact APC energy settings induce peritoneal adhesions in a reproducible rat model. Higher energy produced significantly deeper tissue defects and adhesions of higher grade. A plasma coagulation system that develops fewer adhesions can be achieved by lower temperature and a more homogeneous application and if the application area desiccates more slowly.

Die wichtigsten Entwicklungen in der modernen operativen Gynakologie der letzten Jahre basieren auf der Minimierung des operativen Traumas durch elektrochirurgische Operationsverfahren und den minimal-invasiven Zugang. Die daraus resultierenden zunehmend komplexer werdenden minimal-invasiven Operationsverfahren erfordern eingebettete Operationssysteme zur Beherrschung der zentralen Schnittstelle nach intern und extern. Wahrend die Entwicklungen der letzten Jahre die funktionelle Ebene betrafen, so liegen die Schwerpunkte heute in der Verbesserung der Arbeitsablaufe und der Integration des Arbeitsplatzes Operationssaal in das Gesamtsystem Klinik. Masgebliche Parameter sind dabei die Erhohung der Patientensicherheit und die Verbesserung der Qualitatsstandards als Grundvoraussetzung fur Kosteneffizienz und Wirtschaftlichkeit zum Wohle der Patienten. Moderne minimal-invasive Operationsverfahren werden in Zukunft noch starker auf die Vorteile innovativer integrierter Operationssysteme (IOPS) angewiesen sein, wobei die weiteren Entwicklungsperspektiven noch ein groses Potenzial offenlassen, ganz besonders auch im Hinblick auf die Moglichkeiten der modernen Telemedizin.

Purpose: The objective of the study was to determine whether the various breast biopsy procedures specified in the S3 guidelines are sensibly represented within the current German health system as considered from a cost evaluation perspective. Materials and Methods: This prospectively designed multicenter study analyzed 221 breast biopsies at 7 institutions from 04/2006 to 01/2007. Core needle biopsies, vacuum-assisted biopsies and surgical open biopsies under sonographic or mammographic guidance were evaluated. During an analysis of process costs, the individual process steps were recorded in diagrammatic form and assigned to the true consumption of resources. The actual resource consumption costs were entered. A process-related breakeven analysis was conducted to check whether the reimbursement of individual biopsy types covers the costs. Results: Only sonographically guided core needle biopsy and surgical open biopsy are adequately reimbursed in the current German health system. All other breast biopsies indicate a negative profit margin. The principal reasons for underfunding are found in the area of reimbursement of investment and non-personnel costs. Conclusion: The reimbursement of breast biopsies must be improved in order to guarantee nationwide care of the population using the breast biopsy methods recommended in the S3 guidelines and to avoid disincentives with respect to breast biopsy indications.

The formation of peritoneal adhesions is an issue for surgical research. Different adhesion-inducing models with subsequent scoring systems are descriptively published. The lack of uniformity is a problem as the reproducibility of experimental adhesion research depends strongly on the employed scoring system. A uniform, widely-used score that seeks to describe this relevant surgical condition would be beneficial for inter-surgeon comparability. We present and contrast six scoring systems after the traumatisation of the parietal peritoneum in the rat model. Advantages, disadvantages and statistical considerations of these systems are highlighted. Experimental adhesions were created bilaterally in n = 11 Wistar rats. This resulted in n = 22 adhesion areas. Standardised trauma was inflicted to the parietal peritoneum in a linear shape (20 × 5 mm) using bipolar electrocautery at 40 W. The defect was closed using five interrupted 3/0 Vicryl sutures placed equidistantly. After 14 days, second look laparotomy was performed and number of adhesions, adhesion coverage, adhesion strength, adhesion quality and the attachment to target organs were scored. A total of 43 adhesions formed at the traumatised areas. All of these adhesions could be scored using the six systems described. The correlation coefficient for adhesion coverage as assessed by a measuring stick versus digital computer analysis of the area was 0.649. Every single scoring approach describes different characteristics of adhesions with non-uniform clinical relevance. A multi-dimensional approach that takes account of statistical considerations is inevitable rather than just the use of limited scoring approaches in the experimental setting.

Endometriosis is one of the most common benign diseases in premenopausal women. The extent of disease can vary from small disseminated lesions in the peritoneum to infiltration of the rectum or vagina. Deep infiltrating endometriosis is associated with typical clinical symptoms including pain and sterility. Moreover, patients suffer from painful defecation, dysuria and urinary tract obstruction. The most effective therapy is complete resection of the deep infiltrating endometriosis. The extent of surgical treatment depends on the stage and severity of the endometriosis. In the past few years, specialized centers have developed endoscopic approaches for the surgical treatment of endometriosis. These endoscopic techniques require specialized interdisciplinary teams including a gynecologist, visceral surgeons and urologists. The interdisciplinary team should be able to perform endoscopic rectal resection followed by end-to-end anastomosis. The time needed for the endoscopic technique does not differ significantly from that of the conventional approach when performed by a well trained interdisciplinary team. In addition, the benefit to the patient is higher due to the shorter hospital stay and shorter convalescence time.

We report on two pregnant women with dyspnoe and thoracic pain in the context of an ovarian hyperstimulation syndrome.Both patients had pleural effusions. The first patient was diagnosed with pulmonary embolism via computer tomography. In the second patient, thrombosis of the upper part of the body including intracranial thrombosis was revealed via magnetic resonance and ultrasound imaging. In both cases, thrombosis was caused by ovarian hyperstimulation.Therapy included anticoagulation with low molecular weight heparin and a drainage of the pleural effusions. One patient had an abortion in the 8th week of pregnancy, the second patient gave birth to two healthy children.Ovarian hyperstimulation syndrome is a potentially life-threatening disease, which should be considered as a differential diagnosis of causes of thromboembolic events in early pregnancy.

Bipolar electrothermal vessel sealing is a widely used method for the sealing of blood vessels and tissue of up to several millimeters diameter. Despite their wide-spread usage, instruments and generator modes are often traditionally developed and enhanced. A systematic investigation of the thermofusion process and the subsequent derivation of new model-based control strategies have the potential to improve the vessel sealing process and reduce unwanted side-effects. Based on a previously developed mathematical model of bipolar vessel sealing, optimization based control strategies are developed that could possibly reduce the thermal damage to the lateral tissue. Assuming that it is sufficient to ensure a certain tissue temperature for successful thermofusion, it is shown that the lateral damage could be significantly reduced by optimizing the generator voltage. Furthermore it is shown, that an optimized voltage trajectory may still reduce the lateral damage to some extent if it is assumed that tissue desiccation is required. Additionally, optimally pulsed voltage strategies are presented and compared to currently employed typical generator modes. The results illustrate that optimized control strategies can potentially reduce the thermal damage to the lateral tissue and thus make bipolar vessel sealing more suitable for surgical procedures in the vicinity of sensitive structures, particularly nerves.

Radiofrequency-induced thermofusion is a frequently used electrosurgical procedure for the sealing of blood vessels. A disadvantage of vessel sealing instruments is that the generated thermal energy spreads to the surrounding tissue and may irreversibly damage it. This is particularly problematic when operating close to sensitive structures such as nerves. Given their advantages, there is nonetheless a lot of interest in using bipolar vessel sealing for surgical procedures. To select instruments that may be safely used in such cases, it is important to reliably quantify the thermal spread to the surrounding tissue. Mathematical models can help to evaluate the transient behavior, that is the evolution of the thermal spread over time, more precisely. A finite element model allows for a detailed analysis of inhomogeneities in the spatial temperature distribution. As a first step towards a finite model of the bipolar vessel sealing process, a model of the coagulation of chicken egg white is presented here. Egg white has thermal and electrical properties that are very similar to tissue, making it suitable as a substitute for the analysis of the coagulation process. It has the additional advantage, that the spatial and temporal evolution of the thermal spread can be visually gauged. The presented model describes the experimentally observed spatial temperature distribution, the shape of the coagulated egg white, and the formation of hotspots. Furthermore, it is shown that the model can correctly predict the shape of the coagulated egg white in further experiments.

To delineate the relevance of pelvic and para-aortic node involvement in optimally cytoreduced (residual tumour1 cm) stage IIIC ovarian cancer patients.Ninety-five consecutive optimally cytoreduced (R ≤ 1 cm) patients with primary stage IIIc ovarian cancer underwent stage-related surgery and got adjuvant platinum-based chemotherapy. Median follow-up: 53.5 months. All patients got systematic lymphadenectomy. On average, 24.7 pelvic and para-aortic lymph nodes were removed per patient (range 1-60 nodes). Patients were stratified into three groups to evaluate node involvement (ratio: affected to resected nodes): (1) (=0); (2) (0-≤ 0.5)0 and ≤ 50 % of affected nodes; (3) (0.5-≤ 1)50 % of affected nodes. Clinical parameters were retrospectively evaluated. Kaplan-Meier survival curve was used to evaluate the prognostic value.Most often serous histology, histologic grade 3 and a node ratio0-≤ 0.5 (61.1 %) were detected. Complete cytoreduction (R = 0 mm) has significant best prognostic impact compared to R0 mm-1 cm (OS: p = 0.047, PFS: p = 0.00). Node involvement was associated with serous histology and grade 3. Increasing node ratio leads to significant decreased OS (p = 0.019) and significant best OS was associated with node ratio0-≤0.5.The goal is optimal cytoreduction in advanced ovarian cancer. More extensive lymphadenectomy seems to play an important role in providing an accurate staging, and the node ratio might give prognostic information. Current prospective studies like the LION study (AGO-Ovar) had to investigate if these data have therapeutic implications and may be considered in future staging.