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Introduction: Endometriosis is a common, often-debilitating disease, affecting women of reproductive age. Pain is a common symptom of the disease and is commonly treated by surgery, medical therapy, or a combination of the two. This study aimed to evaluate the rates of ongoing pain post laparoscopic excision and the risk factors for ongoing pain symptoms. Method(s): This retrospective cohort study analyzed the medical records of all patients who underwent laparoscopic surgery for endometriosis in a large tertiary healthcare service in Australia between January 2009 and September 2016. Results were analyzed using SPSS statistics version 11. Result(s): A total of 972 patients met the inclusion criteria; of these, 398 had follow-up at our hospital network and were included in the final analysis. The median age was 34.5 years, 69.6% were of Caucasian ethnicity, and the median body mass index was 25.9; 70.6% of our patients reported decreased pain after surgery. Patients who suffered from chronic pain were twice as likely to experience ongoing pain, while patients with stage 3-4 endometriosis were found to have 65% reduced odds of pain at follow-up (95% confidence interval = 0.22-0.61, p < 0.001). In univariate analysis of non-Caucasian patients, those who had a specialist endometriosis surgeon perform the surgery had significantly higher incidence of symptom improvement (58% reduced odds of recurrent pain and 40% reduced odds, p < 0.05, accordingly). Conclusion(s): The prevalence and severity of pain associated with endometriosis mandates a thorough understanding of the effectiveness of current management. Our article highlights the utility of laparoscopic surgery in treating endometriosis-associated pain.Copyright © The Author(s) 2020.

Introduction Endometriosis is a debilitating chronic inflammatory condition highly burdensome to the healthcare system. The present trial will establish the efficacy of (1) yoga and (2) cognitive-behavioural therapy (CBT), above (3) education, on quality of life, biopsychosocial outcomes and cost-effectiveness. Methods and analysis This study is a parallel randomised controlled trial. Participants will be randomly allocated to yoga, CBT or education. Participants will be English-speaking adults, have a diagnosis of endometriosis by a qualified physician, with pain for at least 6 months, and access to internet. Participants will attend 8 weekly group CBT sessions of 120 min; or 8 weekly group yoga sessions of 60 min; or receive weekly educational handouts on endometriosis. The primary outcome measure is quality of life. The analysis will include mixed-effects analysis of variance and linear models, cost-utility analysis from a societal and health system perspective and qualitative thematic analysis. Ethics and dissemination Enrolment in the study is voluntary and participants can withdraw at any time. Participants will be given the option to discuss the study with their next of kin/treating physician. Findings will be disseminated via publications, conferences and briefs to professional organisations. The University's media team will also be used to further disseminate via lay person articles and media releases. Trial registration number ACTRN12620000756921p; Pre-results. Copyright © 2021 BMJ Publishing Group. All rights reserved.

IntroductionEndometriosis is a debilitating chronic inflammatory condition highly burdensome to the healthcare system. The present trial will establish the efficacy of (1) yoga and (2) cognitive–behavioural therapy (CBT), above (3) education, on quality of life, biopsychosocial outcomes and cost-effectiveness.Methods and analysisThis study is a parallel randomised controlled trial. Participants will be randomly allocated to yoga, CBT or education. Participants will be English-speaking adults, have a diagnosis of endometriosis by a qualified physician, with pain for at least 6 months, and access to internet. Participants will attend 8 weekly group CBT sessions of 120 min; or 8 weekly group yoga sessions of 60 min; or receive weekly educational handouts on endometriosis. The primary outcome measure is quality of life. The analysis will include mixed-effects analysis of variance and linear models, cost–utility analysis from a societal and health system perspective and qualitative thematic analysis.Ethics and disseminationEnrolment in the study is voluntary and participants can withdraw at any time. Participants will be given the option to discuss the study with their next of kin/treating physician. Findings will be disseminated via publications, conferences and briefs to professional organisations. The University’s media team will also be used to further disseminate via lay person articles and media releases.Trial registration numberACTRN12620000756921p; Pre-results.

Hysteroscopy is one of the most frequent procedures that a gynecologist will perform over their career. It is also one of the safest procedures. Operative hysteroscopy has an increased risk profile due to the nature of the surgery. The following review will address the issue of gas embolism in hysteroscopy. This review will look at the evidence regarding the likely causation, rates, and potential methods of minimizing risk to patients as well as treatment options available should this complication arise.Copyright © The Author(s) 2019.

Objective: To evaluate the prevalence of unsuspected uterine sarcomas undergoing morcellation at the time of hysterectomy or myomectomy. Design(s): A retrospective cohort study. Setting(s): A teaching health service in Melbourne, Australia, consisting of four hospitals which provide gynecology and gynecology oncology services including one tertiary referral center. Population: All women undergoing any form of hysterectomy or myomectomy from 1998 to 2016. Method(s): Patient demographics and the presence of morcellation were collected. All cases of confirmed uterine sarcomas were further examined and their histological subtype, patient demographics, preoperative investigations, and surgical indication were also identified. Result(s): A total of 7584 cases were studied. Overall, 33 uterine sarcomas were identified. Of these, seven cases were unsuspected malignancies. All seven cases were leiomyosarcomas. None of the malignant specimens underwent morcellation. The overall prevalence of uterine sarcomas in the total study population was 0.44%. The rate of unsuspected uterine sarcomas in women undergoing hysterectomy or myomectomy for presumed benign indications was 0.13% or 1 in 769. The rate of unintended morcellation of a uterine sarcoma in our center was 0%. The diagnosis of endometrial sarcoma was prompted by endometrial sampling in 58% of the cases when performed. Conclusion(s): The risk of inadvertent morcellation of unsuspected uterine sarcomas is low. Patients should be appropriately selected with adequate investigations and a detailed history and examination prior to surgery. Further studies are needed to identify effective preoperative screening methods for uterine sarcomas.Copyright © The Author(s) 2018.

The presence of fibroids and endometrial polyps is associated with reduced endometrial receptivity and subsequent fertility outcomes. The following review explores the molecular mechanisms behind reduced endometrial receptivity, with a focus upon homebox genes, basic transcription element binding proteins, transforming growth factor beta-3, and bone morphogenetic protein 2. A better understanding of these processes is essential for future targeted therapy.Copyright © 2017 Wichtig Publishing.

Introduction: Colorectal involvement occurs in up to 12% of cases of endometriosis. Various surgical options for its management have been described, including segmental resection and disc excision, with debate surrounding indications for surgery and the impact of such procedures. The current study aimed to describe the experiences of three Australian gynaecologists regarding laparoscopic bowel surgery for colorectal endometriosis. Method(s): The records of three gynaecological surgeons were analysed for patients who underwent surgical removal of colorectal endometriosis by way of appendicectomy, bowel disc excision and/or segmental resection, between 1999 and 2012. Result(s): A total of 307 patients were identified. Sixteen (5.2%) underwent appendicectomy, 146 (47.6%) underwent disc excision, 126 (41.0%) underwent segmental resection and 19 (6.2%) underwent simultaneous procedures. The majority of procedures were performed laparoscopically (265 of 307; 86.3%). Nineteen procedures (6.2%) were planned laparotomies due to the known extent of disease. Twenty-three procedures were converted from laparoscopy to laparotomy (conversion rate of 7.5%). Complications occurred in 35 of the 307 cases (11.4%). Sixty-seven women amongst the 122 wishing to conceive post-operatively achieved at least one pregnancy (pregnancy rate of 54.9%). Of the 84 pregnancies achieved amongst the 67 women who conceived, 49 (58.3%) were achieved through assisted reproductive technologies, and 31 pregnancies (36.9%) were conceived spontaneously. This information was unavailable for 4 pregnancies (4.8%). Conclusion(s): The current series demonstrates that laparoscopic surgery for severe disease is feasible in specialised centres. Furthermore, such surgery may have a positive impact upon post-operative fertility.Copyright © 2017 Wichtig Publishing.

In this presentation I will present the evidence for surgery in women infertility and endometriosis. I will cover the evidence for surgery relating to AFS stage 1 & 2, Endometriomas and AFS stage 3 & 4. Currently there is varied data on the place of surgery in the above groups. There are obviously advocates for and against surgery worldwide. This lecture will present a balanced approach and emphasize the value of individualisation of treatment in these varied patient groups, in particular the more complex patient group with stage 3&4 DIE. Surgery and IVF should not be seen as conflicting management modalities but rather complimentary and often vital together in the management of the more complex endometriosis situations. Not only is surgery a critical component of management but correct application of skills and training to minimize complications and maximise fertility outcomes are vital. I will also present our most recent data in our patient cohort with colorectal endometriosis and infertility. To facilitate surgical training and management into future AGES is proud to announce the adaptation of its two year fellowship in advanced gynaecological endoscopy. I will briefly touch on the development of this programme and the vital role it will play in the development of our future leaders in gynaecological endoscopy in Australia.

Study Objective: To evaluate the incidence and severity of recurrent endometriosis, success rate of surgery, medical treatment and associated risk factors for recurrence. Design(s):Aretrospective review of patients diagnosed with endometriosis from July 2009 to June 2016. Setting(s):AMulti-centre medical centre with a tertiary level endometriosis unit Patients: Patients who underwent surgery for endometriosis-associated pain, were followed-up in our unit and had complete computerized medical records available. A total of 385 patients were included in the assessment. Intervention(s): N/A Measurements and Main Results: The demographic characteristics, stage of endometriosis, associated medical conditions; type of surgery and other medical treatments were evaluated. Student T-Test and Chi Square Test were used to compare variables. The number of patients diagnosed with stage 1 and 2 endometriosis was 223 (57.9%) and 162(42.1%) stages 3& 4. Pain was an indication for surgery in 330 (85.7%) patients, endometrioma in 136(35.3%) and infertility+/-pain in 63 (16.4%). In patients with preoperative pain, 99 (30%) had complete resolution, 143 (43.3%) had improvement in their symptoms & 71 (21.5%) had no change at the 6-8 week post-operative review. On further follow-up, recurrent pain symptoms were reported in 73 of 242 (30.1%). The average time for symptom recurrence was 14.7 months (range 1-72 months, SD 14.9). Of those patients, 39 (53.4 %) were diagnosed as having stage 1&2 and 34 (46.6%) stages 3&4. All patients were offered post-operative hormonal treatment, 139 (42.1%) chose not to have any. Conclusion(s): Our study confirms the high rate of symptom improvement after laparoscopic excision of endometriosis. However, in accordance with previous studies, the risk of recurrence is high. Our results show no correlation of endometriosis stage and recurrence of pain. Medical treatment did not affect chance of pain recurrence, however, this could be due to the relatively small

Study Objective: The aim of the current study was to evaluate the effect that high BMI (>=30) had on the surgical outcomes of patients undergoing operative laparoscopy for endometriosis. Design(s): Retrospective Cohort Study. Setting(s): Monash Health hospitals in Melbourne, Australia. Patient(s): All patients who underwent surgical treatment of endometriosis between July 1st 2009 and June 31st 2016. Intervention(s): None. Measurements and Main Results: 831 patients were included. The median age of the patients was 33 years (15-64, SD 8.6). The average BMI in our patient population was 25.8 (13.1-52.1, SD 6). 163 patients had a BMI >=30 (19.6%). 668 patients had a BMI <30 (80.4%). We did not find a significant impact of BMI on the stage of endometriosis in our study population. The main indication for surgery in both groups was pain (BMI >=30: 83.4%, BMI <30: 82.9%). Obese patients had more chronic pain (13.5% vs 8.4%, p = .04). Low BMI patients had infertility as a more frequent indication for surgery than obese patients (20.98% vs 14.11%, p = .04). Both groups had similar complication rates (4.9% for obese patients vs 3.14%). Obese patients had an increased conversion to laparotomy rate (3.06% vs 1.6%), however, this was not statistically significant (p = .1). We also did not find a difference in operating time between the two groups. Length of stay was not significantly longer for patients with BMI >=30 compared to BMI <30 (1.4 vs 1.5 days, p = .2). Conclusion(s): In this study we found that there was no difference in operating time or complication rates in women with BMI >=30. These findings suggest that when advanced laparoscopic surgery for endometriosis is performed in a unit with a high volume of obese patients, the complication rate is comparable to those with a BMI <30.

Endometriosis is one of the most common gynaecological conditions affecting 6% to 12% of women in the reproductive age group. It can be found in 35% to 45% of women who are trying to conceive and are infertile. Infertility is one of the most common problems associated with endometriosis. This review will look at the evidence that endometriosis may lead to infertility and the data looking at whether surgical correction of endometriosis may improve fertility outcomes.Copyright © 2017 Wichtig Publishing.

STUDY QUESTION Which essential items should be recorded before, during and after endometriosis surgery and in clinical outcome based surgical trials in patients with deep endometriosis (DE)? SUMMARY ANSWER A DE surgical sheet (DESS) was developed for standardized reporting of the surgical treatment of DE and an international expert consensus proposal on relevant items that should be recorded in surgical outcome trials in women with DE. WHAT IS KNOWN ALREADY Surgery is an important treatment for symptomatic DE. So far, data have been reported in such a way that comparison of different surgical techniques is impossible. Therefore, we present an international expert proposal for standardized reporting of surgical treatment and surgical outcome trials in women with DE. STUDY DESIGN, SIZE, DURATION International expert consensus based on a systematic review of literature. PARTICIPANTS/MATERIALS, SETTING, METHODS Taking into account recommendations from Consolidated Standards of Reporting Trials (CONSORT), the Innovation Development Exploration Assessment and Long-term Study (IDEAL), the Initiative on Methods, Measurement and Pain Assessment in Clinical trials (IMMPACT) and the World Endometriosis Research Foundation Phenome and Biobanking Harmonisation Project (WERF EPHect), a systematic literature review on surgical treatment of DE was performed and resulted in a proposal for standardized reporting, adapted by contributions from eight members of the multidisciplinary Leuven University Hospitals Endometriosis Care Program, from 18 international experts and from audience feedback during three international meetings. MAIN RESULTS AND THE ROLE OF CHANCE We have developed the DESS to record in detail the surgical procedures for DE, and an international consensus on pre-, intra- and post-operative data that should be recorded in surgical outcome trials on DE. LIMITATIONS, REASONS FOR CAUTION The recommendations in this paper represent a consensus among international experts b

Introduction Endometriosis is a gynaecological condition affecting women of reproductive age with cyclical pelvic pain and subfertility being common presenting complaints. Though usually encountered within the pelvis, rare cases of extra-pelvic endometriosis have been reported in the literature. This case report details the unexpected finding of pleural endometriosis following pleural biopsy during surgical treatment of a persistent pleural effusion. Case A 38-year-old, previously well, woman presented to the emergency department with acute-on-chronic dyspnoea caused by a large left-sided pneumothorax and bilateral pleural effusions. She was admitted for investigation and management after initial treatment only partially resolved her symptoms. Pleural biopsies were taken during complete decortication of the right lung by the cardiothoracic surgeons and returned an unexpected finding of endometriosis with associated pleurisy and anthracosis. Gynaecological opinion sought after this result revealed a history of dysmenorrhoea with no sonographic cause found on previous investigation. The patient was commenced on the oral contraceptive pill with complete resolution of her symptoms. Six months later, she returned to hospital for a diagnostic laparoscopy which showed ASRM (American Society for Reproductive Medicine) stage IV endometriosis. She remains asymptomatic and has no immediate plans for future fertility. Conclusion Pelvic endometriosis is a familiar condition encountered by gynaecologists thought to result primarily from retrograde menstruation. Extra-pelvic deposits question this aetiological theory and raise the possibility of vascular or lymphatic spread in the development of these ectopic endometriotic lesions. Response to hormonal suppression in extra-pelvic sites does not appear to differ compared with pelvic endometriosis and should continue to be the mainstay of treatment in affected women.

Endometriosis is a common, chronic and oestrogen dependant condition. It is commonly associated with both infertility and pelvic pain. One of the most challenging and difficult management issues is severe Deep Infiltrating endometriosis with bowel disease. Surgical excision of severe colorectal endometriosis may improve patients' symptoms and fertility outcomes. The laparoscopic approach is feasible and safe. It requires a multidisciplinary team approach and extensive surgical training. The surgical techniques are detailed in this short video. An outline on the evolution of training for this surgery will be discussed.

Endometriotic nodules are commonly in close proximity to the pelvic ureter. Tissue planes are often distorted by the disease making this surgery complex. Safe resection of these nodules requires advanced surgical skill. The laparoscopic surgical approach to skeletalisation of the ureter is demonstrated in this short video presentation, which highlights the fundamental principles required for advanced endometriosis surgery. This presentation would include an introduction to the pelvic ureter and it's place in sidewall dissection as well as a video presentation of ureterolysis and excision of endometriosis.

Background: Surgical treatment of deep infiltrating endometriosis (DIE) is complex, and preoperative diagnosis benefits both surgeon and patient. Studies in expert centres have reported high accuracy for transvaginal ultrasound (TVUS) diagnosis of DIE. External validation of these findings has been limited, and no information is available on how quickly these skills can be acquired. The aim of this study was to measure the learning curve of DIE-TVUS and to identify the causes for inaccuracies in the diagnosis of bowel lesions and Pouch of Douglas (POD) obliteration. Method(s): Following one week of training at the University of Sao Paulo (Brazil), 205 consecutive women with a history of endometriosis symptoms were prospectively assessed by TVUS after minimal bowel preparation. TVUS findings were correlated with laparoscopic findings in eighty-five cases to assess the accuracy. The LC-CUSUM and CUSUM were used to assess the learning curve and maintenance of competency, respectively. Result(s): The sensitivity and specificity for DIE of the bladder, vagina and bowel were 33% and 100%, 80% and 100%, and 88% and 93%, respectively. The sensitivity and specificity for the presence of POD obliteration were 88% and 90%, respectively. LC-CUSUM analysis confirmed that competency for DIE-TVUS was achieved within 38 scans for the detection of POD obliteration and within 36 scans for the detection of bowel nodules. Competency was maintained for the remainder of the scans as assessed by the CUSUM. Conclusion(s): After one week of DIE-TVUS training, competency can be achieved within forty procedures, allowing diagnosis of DIE with similar diagnostic accuracy as reported by centres of excellence.Copyright © 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Objective: To determine whether accuracy of visual diagnosis of endometriosis at laparoscopy is determined by stage of disease. Design(s): Prospective longitudinal cohort study (Canadian Task Force classification II-2). Setting(s): Tertiary referral centers in three Australian states. Patient(s): Of 1439 biopsy specimens, endometriosis was proved in at least one specimen in 431 patients. Intervention(s): Laparoscopy with visual diagnosis and staging of endometriosis followed by histopathologic analysis and confirmation. Operations were performed by five experienced laparoscopic gynecologists. Measurements and Main Results: Histopathologic confirmation of visual diagnosis of endometriosis adjusted for significant covariates. Endometriosis was accurately diagnosed in 49.7% of American Society for Reproductive Medicine (ASRM) stageI, which was significantly less accurate than for other stages of endometriosis. Deep endometriosis was more likely to be diagnosed accurately than superficial endometriosis (adjusted odds ratio, 2.51; 95% confidence interval, 1.50-4.18; p< .01). Lesion volume was also predictive, with larger lesions diagnosed more accurately than smaller lesions. In general, lesion site did not greatly influence accuracy except for superficial ovarian lesions, which were more likely to be incorrectly diagnosed visually as endometriosis (adjusted odds ratio, 0.16; 95% confidence interval, 0.06-0.41; p < .01). There was no statistically significant difference in accuracy between the gynecologic surgeons. Conclusion(s): The accuracy of visual diagnosis of endometriosis was substantially influenced by American Society of Reproductive Medicine stage, the depth and volume of the lesion, and to a lesser extent the location of the lesion. © 2013.

Study Objective: To compare operating time, intraoperative blood loss, postoperative analgesia, and length of hospital stay using ultrasonic shears vs traditional suture ligature in vaginal hysterectomy. Design(s): Randomized controlled trial (Canadian Task Force classification I). Setting(s): Gynecology units within a single health network, university hospital. Patient(s): Forty women requiring vaginal hysterectomy because of benign disease. Intervention(s): Vaginal hysterectomy performed using either ultrasonically activated shears (USS) or traditional suture ligatures. Measurements and Main Results: Twenty-one patients were randomized to the USS arm, and 19 patients to the traditional suture ligature arm. Patient characteristics were comparable. Mean (SD) hysterectomy time and was similar in both the USS and traditional arms, 28.66 (4.0) minutes vs 32.37 (3.18) minutes (p=.47), as was total operating time, 97.38 (8.9) minutes vs 91.63 (7.69) minutes (p=.63). Operative blood loss was significantly decreased in the USS group: 62.63 (12.46) mL vs 136.05 (21.54) mL (p=.006). There was, however, no significant change in hemoglobin concentration between the 2 groups: 19.53 (1.79) g/L vs -16.72 (2.5) g/L. There was no significant difference in mean oxycodone use: 9.29 (2.66) mg vs 8.06(3.19) mg (p=.77). Length of hospital stay was similar in both groups: 58.98 (3.27) hours vs 60.05 (6.48) hours (p=.88). There was no significant difference in overall complication rates between the groups. Conclusion(s): Although the Harmonic scalpel system, compared with the traditional suture ligation method, seems to be a safe alternative for securing the pedicles in vaginal hysterectomy, it offers no benefit insofar as operative time, reduction in clinically significant blood loss, and analgesic requirements. © 2013 AAGL.

Objectives Our purpose was to review all the major complications of laparoscopy in 6500 consecutive laparoscopies from one centre. We also felt it was important to conduct this study because of the current debate on the use of the Veress needle or the Hasson cannula. Design All the major complications from laparoscopies performed from June 1 1991 to March 31 1995 were documented. This is the largest series from one centre. Each laparoscopy was registered on computer. A distinction between operative and diagnostic laparoscopies was not made by the computer. Results A major complication was defined as one that required laparotomy. In this series eight major complications were recorded. The incidence of major complications was 1.23 per 1000. No vascular injury occurred as a result of using a Veress needle or closed trocar entry. Conclusion Despite advances in operative and diagnostic laparoscopy, complications still occur. From this study there is currently no evidence to suggest that the Veress needle should be banned in favour of the open Hasson technique. The gynaecologist, anaesthetist and consumer need to be aware of the complication rates for gynaecological day surgery laparoscopy.

A retrospective review of medical records was performed to assess the incidence and type of significant complications encountered during laparoscopic hysterectomy. Two hundred and sixty-five consecutive patients were reviewed between the years 1994 and August 2001. Two hundred and thirty-two laparoscopic vaginal hysterectomies and 33 total laparoscopic hysterectomies were performed. The operations were performed at Monash Medical Centre, a Melbourne tertiary public hospital, and two Melbourne private hospitals, by three surgeons. Ten significant complications occurred. There were two cases of ureteric fistula, two bladder injuries, two bowel obstructions, two postoperative haematomas, one case of a bladder fistula and one superficial epigastric artery injury In-patient stay ranged from two to six days. Our complication and in-patient stay rates are consistent with previously reported rates.

In June, 1995 a postal questionnaire was distributed to all 232 women who had an endometrial ablation at Monash Medical Centre between July, 1989 and December, 1994. Data was analyzed from the 149 who responded. Length of follow-up ranged from 6 months to 6 years 6 months. Of these 78% were satisfied with their ablation and 84% found their menses to be lighter or to have stopped. The repeat ablation rate was 13% and the hysterectomy rate was 17%.

Objective: The purpose of this pilot study was to develop an assessment instrument to evaluate the level of skill of laparoscopic surgeons with regard to operative laparoscopy. Subjects: A total of 16 doctors working in obstetrics and gynaecology were tested on the Monash University gynaecological laparoscopic pelvi-trainer. Eight candidates were consultants with 9-28 years of practice in operative laparoscopy, and eight were registrars with up to 6 years of practice in operative laparoscopy. Six consultants and one registrar were from rural Australia. Design(s): Subjects were asked to complete 10 laparoscopic tasks. Nine of these were designed to test manual dexterity skills and the correct use of laparoscopic instruments. One task tested theoretical knowledge of electrosurgery by means of four short-answer questions. Candidates were marked on the basis of precision and speed. Heart rate measurements were taken 20 min prior to the test, at 5-min intervals, and at the start and end of each task thereafter. Result(s): The highest pass rate (81.25%) was recorded for task 1, i.e. setting up the endoscopic visualization system. The median time to complete this task was 168 s. No candidate could repair a severed ovarian ligament with an intracorporeal knot within 5 min. No candidate could successfully answer all four electrosurgery questions. Conclusion(s): It is possible to objectively evaluate basic operative skills of laparoscopists by means of well-structured tasks and marking criteria.

This case illustrates that when a dermoid cyst is punctured, an immediate operative laparoscopy or laparotomy should be performed, along with lavage, to avoid the problems associated with dermoid cyst contents spillage.

A single cause for the development of endometriosis is unknown. Of the historical hypotheses for the development of endometriosis, coelomic metaplasia and transplantation of retrograde endometrium have been the most widely accepted. Of the modern factors, which appear significant in the subsequent development of endometriosis, genetic predisposition and disturbed angiogenesis are the most intriguing. Active studies are in progress to attempt to identify genes relevant to the development of endometriosis. Active research is also studying the vascular supply to areas of endometriosis and the role of angiogenesis, or new blood vessel formation? in the pathogenesis of this disease. The availability of molecular biology probes, as well as medicines, which inhibit angiogenesis are direct consequences of the application of this basic research to this common clinical problem.

Objective: The purpose of this study was to assess the level of skill of laparoscopic surgeons in electrosurgery. Design(s): Subjects were asked to complete a practical diathermy station and a written test of electrosurgical knowledge. Setting(s): Tests were held in teaching and non-teaching hospitals. Sample: Twenty specialists in obstetrics and gynaecology were randomly selected and tested on the Monash University gynaecological laparoscopic pelvi-trainer. Twelve candidates were consultants with 9-28 years of practice in operative laparoscopy, and 8 were registrars with up to six years of practice in operative laparoscopy. Seven consultants and one registrar were from rural Australia, and three consultants were from New Zealand. Method(s): Candidates were marked with checklist criteria resulting in a pass/fail score, as well as a weighted scoring system. We retested 11 candidates one year later with the same stations. Main Outcome Measure(s): No improvement in electrosurgery skill in one year of obstetric and gynaecological practice. Result(s): No candidate successfully completed the written electrosurgery station in the initial test. A slight improvement in the pass rate to 18% was observed in the second test. The pass rate of the diathermy station dropped from 50% to 36% in the second test. Conclusion(s): The study found ignorance of electrosurgery/diathermy among gynaecological surgeons. One year later, skills were no better.

Objective. To compare postoperative pain and recovery of patients undergoing surgery with the 2-mm microlaparosope and the 10-mm standard laparoscope. Design. A double-blind prospective randomized clinical study to assess pain. Setting. Monash Medical Centre Women's Health Program, Melbourne, Australia. Subjects. 29 women of reproductive age (24-45 years) undergoing diagnostic procedures for fertility were randomly allocated to either microlaparoscopy (ML) or standard laparoscopy (SL). Interventions. Of these patients 13 received a microlaparoscopy and 16 received standard laparoscopy. All patients agreed to complete the self- administered Short-Form McGill Pain Questionnaire (SF-MPQ), immediately after surgery before any analgesia and at 48 h after surgery, in order to assess pain and recovery. Main outcome measures. Pain intensity and recovery time for patients undergoing microlaparoscopy were compared with those for standard laparoscopy. Results. There was no significant difference between the two groups when the effective, sensory and visual analogue scale (VAS) pain scores, immediately after recovery and at 48 h, were compared. However there was a significant difference in the time to return to normal activity as perceived by the patients, with the ML group scoring a quicker return to normal activity (mean +/- SD, 3.6 +/- 3.6 compared with the SL group (7.1 +/- 3.3) (P = 0.01). This was despite a significant difference in operating times between the two groups. The mean operating time for the ML group was 22.6 min (95% confidence interval (CI) 18.8-26.5), compared with a mean for the SL group of 16.4 min (95% CI, 13.9-18.8) (P = 0.01). The ML group required no narcotic postoperative analgesia. Conclusion. There was no significant difference in pain scores between groups in whom the microlaparoscope or the standard laparoscope were used. However the microlaparoscopy group experienced a quicker post-surgical recovery, required less analgesia and were more satisfi

Objective: To introduce the concept of simulator training to gynaecological surgeons and to inform them of the current state of worldwide research into the development of a laparoscopic simulator. Attributes: Virtual-reality technology enables the surgeon not only to perform diagnostic procedures, but also to practice entire surgical operations on a mannikin, while observing and interacting with a realistic computer-generated gynaecological environment on-screen. The benefits of such simulator training are twofold: surgeons will be at a higher point on the learning curve before their first operation on a patient, and patients should enjoy better quality of care. Research: Great confidence in the potential of virtual-reality technology in gynaecology, and medicine in general, has generated considerable international interest. As a result, much research and development effort is going into the creation of a gynaecological endoscopy simulator. Although several laparoscopic simulators are near their completion stage, there are no commercially available systems as yet. Medical education: A plan for the successful implementation of simulator training in gynaecology through preceptorship and credentialling programs, is outlined. Use of simulator training in gynaecology and other medical fields, is expected to become mole popular with further advances in technology.

Background: Colorectal resection for severe endometriosis has been increasingly described in the literature over the last 20 years. Aim(s): To describe the experiences of three gynaecological surgeons who perform radical surgery for colorectal endometriosis. Method(s): The records of three surgeons were reviewed. Relevant information was extracted and complied into a database. Result(s): One hundred and seventy-seven women were identified as having undergone surgery between February 1997 and October 2007. The primary reason for presentation was pain in the majority of women (79%). Eighty-one segmental resections were performed, 71 disc excisions, ten appendicectomies and multiple procedures in ten women. The majority of procedures (81.4%) were performed laparoscopically. Histology confirmed the presence of disease in 98.3% of cases. A further 124 procedures to remove other sites of endometriosis were conducted, along with an additional 44 procedures not primarily for endometriosis. A total of 16 unintended events occurred. Conclusion(s): Our study adds to the growing body of literature describing colorectal resection for severe endometriosis. Overall, the surgery appeared to be well tolerated, demonstrating the role for this surgery. © 2009 The Authors.

Objective. We report a case of successful outcome in a pregnancy following endometrial ablation. We also review the 10 previous reported pregnancies following this procedure and try to suggest guidelines for the management of this condition, based upon the cases reported to date and by drawing from the clinicopathologically related condition Asherman's syndrome. Outcome. The case reported in this paper had a successful outcome with minimal intervention. The patient became pregnant following an ablation that had achieved excellent symptom relief of her menorrhagia. Conclusion. Although our case had a succesful outcome with minimal intervention, ideally pregnancy following endometrial ablation should be avoided. Pregnancies following endometrial ablation should continue to be reported to allow the establishment of a database to ascertain the real risk of pregnancy and third-stage problems. This will assist practitioners with management and in counselling their patients.

This prospective observational study aimed to assess the feasibility of adapting peritoneal hyperdistention to 25 mmHg during laparoscopy in an Australian hospital environment. A total of 1150 consecutive diagnostic or operative laparoscopies were performed. All cases were monitored for early detection of untoward physiological changes. All patients had Veress needle insufflation with distension to 25 mmHg prior to insertion of the primary trocar. No patients experienced any surgical entry complications or adverse clinical effects noted during anaesthetic. The aim of the current study is to assess the feasibility and safety of increasing the peritoneal insufflation pressure to 25 mmHg for primary trocar insertion.

Objectives: The purpose of this study was to perform an audit continuing from the first series of 6500 consecutive laparoscopies from one centre. Since that time there have been a further 4448 consecutive laparoscopies at the same centre, making the total number 11 448 laparoscopies. The debate continues to rage concerning entry techniques at laparoscopy. One of the objectives of this study was to look again at the risks involved with the use of Veress needle and closed trocar entry techniques. Design(s): All the major complications from laparoscopies performed between 1 April 1995 and 28 February 1999 were documented. This is again the largest series to date from any one centre. Each laparoscopy was registered on computer. A distinction between operative and diagnostic laparoscopy was not made. Result(s): A major complication was defined as one which required laparotomy. In this second series, there was only one complication. The incidence of major complications was thus 0.2 per 1000. The incidence in our previous series was 1.23 per 1000. The combined incidence from both series is 0.78 major complications per 1000 cases. In neither series was there a vascular injury as a result of using a Veress needle or closed trocar entry technique. Conclusion(s): This ongoing audit, and in particular the combined figures from both our audits, shows that there is currently no evidence to suggest that the Veress needle should be banned in favour of the open Hasson technique.

A retrospective review of medical records was performed to assess the incidence and types of significant complications encountered during laparoscopic hysterectomy which would affect the use of a laparoscopic approach versus other routes of hysterectomy. A total of 526 consecutive patients' medical data between January 1994 and August 2007 were reviewed. Two hundred and thirty-two laparoscopic-assisted vaginal hysterectomies and 294 total laparoscopic hysterectomies were performed at Monash Medical Centre, a Melbourne tertiary public hospital, and three Melbourne private hospitals, by or under the supervision of three surgeons. Sixteen significant complications occurred. There were two cases of ureteric fistula, two bladder injuries, two bowel obstructions, four postoperative haematomas, one case of a bladder fistula, four conversions to laparotomy and one superficial epigastric artery injury. Inpatient stay ranged from two to six days. Our complication and inpatient stay rates are consistent with the previously reported rates, although there has been a reduction of incidence of visceral injuries with experience and introduction of new equipment. © 2009 The Authors.

A novel objective assessment method in reproductive endoscopic surgery could advance surgical education. © 2004 by American Society for Reproductive Medicine.