Frank Willem Jansen

Saline contrast hysterosonography in abnormal uterine bleeding: a systematic review and meta-analysis

Objective To assess the diagnostic accuracy of saline contrast hysterosonography in the evaluation of the uterine cavity in women complaining of abnormal uterine bleeding.

Diagnostic hysteroscopy in abnormal uterine bleeding: a systematic review and meta‐analysis

Background  This study was conducted to assess the accuracy and feasibility of diagnostic hysteroscopy in the evaluation of intrauterine abnormalities in women with abnormal uterine bleeding.

Hysteroscopic morcellator for removal of intrauterine polyps and myomas: a randomized controlled pilot study among residents in training.

The purpose of this randomized controlled study was to compare conventional resectoscopy and hysteroscopic morcellation among residents in training (Canadian Task Force classification I). Sixty women with an intrauterine polyp or myoma were randomized to either hysteroscopic removal by conventional resectoscopy or hysteroscopic morcellation performed by 6 residents in training for obstetrics and gynecology (10 procedures per resident). The mean operating time for resectosocpy and morcellation was 17.0 (95% confidence interval [95% CI] 14.1-17.9, standard deviation [SD] 8.4) and 10.6 (95% CI 7.3-14.0, SD 9.5) min, respectively (p = .008). Multiple linear regression analysis showed that operating time increased significantly, for both resectoscopy and morcellator, when volume of intrauterine disorder increased. The use of the hysteroscopic morcellator reduced operating time more than 8 min in comparison to conventional resectoscopy (p < .001) when correction for volume was applied. Subjective surgeon and trainer scores for convenience of technique on a visual analog scale were in favor of the morcellator. No learning curve was observed. In conclusion, the hysteroscopic morcellator for removal of intrauterine polyps and myomas offers a good alternative to conventional resectoscopy for residents in training.

Predictors of successful surgical outcome in laparoscopic hysterectomy.

OBJECTIVE: To estimate, after correction for patient factors, to what extent blood loss, operative time, and adverse events are decisive factors for the successful outcome of laparoscopic hysterectomy. A secondary objective was to estimate to what extent a successful outcome can be predicted from surgical experience or other measures of surgical skill. METHODS: A nationwide multivariate 1-year cohort analysis was conducted with gynecologists who perform laparoscopic hysterectomy. The primary outcomes were blood loss, operative time, and adverse events. The procedures were corrected for multiple covariates in a mixed-effects logistic regression model. Furthermore, all primary outcomes were related to experience and the influence of individual surgical skills factors. RESULTS: One thousand five hundred thirty-four laparoscopic hysterectomies were analyzed for 79 surgeons. The success of the surgical outcome was significantly influenced by uterus weight, body mass index, American Society of Anesthesiologists Physical Status Classification, previous abdominal surgeries, and the type of laparoscopic hysterectomy. Surgical experience also predicted the successful outcome of laparoscopic hysterectomy with respect to blood loss and adverse events (P=.048 and .036, respectively). A significant improvement in surgical outcomes tends to continue up to approximately 125 procedures. Independently from surgical experience, an individual surgical skills factor was identified as odds ratio 1.67 and 3.60 for blood loss and operative time, respectively. CONCLUSION: After adjusting for risk factors, it was shown that an increase in experience positively predicted a successful outcome in laparoscopic hysterectomy with respect to blood loss and adverse events. However, the independent surgical skills factor shows a large variation in proficiency between individuals. The fact that a surgeon has performed many laparoscopic hysterectomies does not necessarily guarantee good surgical outcome. LEVEL OF EVIDENCE: II

The Clinical Value of 3-Dimensional Saline Infusion Sonography in Addition to 2-Dimensional Saline Infusion Sonography in Women With Abnormal Uterine Bleeding Work in Progress

Objective. To evaluate the clinical relevance of 3‐dimensional saline infusion sonography (3D‐SIS) in addition to conventional SIS in women with abnormal uterine bleeding suspected of having intrauterine abnormalities. Methods. All women suspected of having intrauterine abnormalities were eligible. Before 3D‐SIS, conventional SIS was performed. The results of these techniques were compared with the “combined method reference standard” (hysteroscopy, endometrial sampling, and clinical follow‐up in cases with normal SIS findings). Diagnostic characteristics (with 95% confidence intervals [CIs]) of 3D‐SIS and SIS were calculated as well as their respective accuracy in evaluating the histologic nature, the intrauterine extension, and the location of intrauterine abnormalities. Moreover, the reliability (κ value) and clinical relevance of 3D‐SIS were assessed. Results. A total of 49 women were included, and 4 women were excluded. The positive predictive values of 3D‐SIS and SIS were, respectively, 1.00 and 0.86 (95% CI, 0.72–0.99; P = .15), and the diagnostic accuracy values were 0.98 (95% CI, 0.94–1.0) and 0.91 (95% CI, 0.83–0.99; P = .08). Saline infusion sonography and 3D‐SIS were equally accurate in evaluating the histologic nature, intrauterine extent, and location of intrauterine abnormalities (respective κ values: 0.85 versus 0.93; P = .88; 0.83 versus 0.83; and 0.77 versus 0.80; P = .81). The reliability of 3D‐SIS was good: intraobserver and interobserver agreement (κ) were 0.78 and 0.72. Three women (6.7%) had the benefit of additional 3D‐SIS: in these women, SIS wrongly led to a diagnosis of intrauterine abnormalities (P = .08). Conclusions. Three‐dimensional saline infusion sonography is valid and reliable in women suspected of having intrauterine abnormalities and may indeed have relevant clinical value in addition to conventional SIS.

Value of an objective assessment tool in the operating room

BACKGROUND Concerns about the achievement of surgical proficiency during residency are increasing. To objectify surgical skills, the Objective Structured Assessment of Technical Skills (OSATS) was developed and proven valid, feasible and reliable for use in laboratory settings. This study aimed to evaluate the value of this tool for intraoperative use. METHODS Residents were assessed with an OSATS after every procedure they performed as the primary surgeon during a 3-month clinical rotation in gynecological surgery. We mapped individual learning curves (OSATS scores plotted against experience) and established the average procedure-specific learning curve. We used linear mixed models to assess the relation between performance and experience. RESULTS Nine residents were recruited and 319 OSATS analyzed. Individual learning curves revealed progression beyond 24 of 30 OSATS points for 7 residents. Performance on the average procedure improved with experience, and the OSATS score increased by an average of 1.10 points per assessed procedure (p=0.008, 95% confidence interval 0.44-1.77). Median OSATS scores ranged from 18 to 30 among the 21 assessors. CONCLUSION Intraoperative implementation of OSATS seems to offer important advantages: structured feedback is facilitated, and learning curves enable insight into individual progression. However, doubts have been raised about the objectivity of the tool. Therefore, caution is warranted in using it for graduation and certification.

Preoperative predictors of postsurgical adhesion formation and the Prevention of Adhesions with Plasminogen Activator (PAPA-study): results of a clinical pilot study

OBJECTIVE To identify predictors of postsurgical adhesion formation in peritoneal fluid and plasma, and assess efficacy and safety of reteplase (recombinant plasminogen activator [r-PA]). DESIGN Prospective randomized study. SETTING University Medical Center. PATIENT(S) Twenty-six abdominal myomectomy patients with early second-look laparoscopy (ESL). INTERVENTION(S) Randomization to IP treatment with 1 mg reteplase in 300 mL Ringers lactate or 300 mL Ringers lactate only. Scoring of adhesions and collecting peritoneal fluid during both surgical procedures and collecting plasma samples at ten time points. MAIN OUTCOME MEASURE(S) Incidence, severity, and extent of adhesions at ESL. Concentrations of C-reactive protein (CRP), tissue-type plasminogen activator (tPA), plasminogen activator inhibitor 1 (PAI-1), and fibrin degradation products (FbDPs). RESULT(S) Significant correlation between the extent of uterine adhesion formation and preoperative plasma levels of CRP (r(s) = 0.558), PAI-1 (r(s) = 0.413), and the change in tPA concentration in peritoneal fluid from initial surgery to ESL (Delta+PA: r(s) = -0.636). No significant differences in adhesion scores between treatment and control groups. CONCLUSION(S) Our finding that preoperative plasma CRP and PAI-1-levels are significantly correlated with extent of adhesion formation points to a role of chronic inflammation in the disease process. Results are highly indicative for the paradigm that adhesions are caused by an insufficiency in peritoneal fibrinolytic capacity. For successful adhesion prevention therapy relatively high amounts of r-PA are required.

Retracting and seeking movements during laparoscopic goal-oriented movements. Is the shortest path length optimal?

AimsMinimally invasive surgery (MIS) requires a high degree of eye–hand coordination from the surgeon. To facilitate the learning process, objective assessment systems based on analysis of the instruments’ motion are being developed. To investigate the influence of performance on motion characteristics, we examined goal-oriented movements in a box trainer. In general, goal-oriented movements consist of a retracting and a seeking phase, and are, however, not performed via the shortest path length. Therefore, we hypothesized that the shortest path is not an optimal concept in MIS.MethodsParticipants were divided into three groups (experts, residents, and novices). Each participant performed a number of one-hand positioning tasks in a box trainer. Movements of the instrument were recorded with the TrEndo tracking system. The movement from point A to B was divided into two phases: A-M (retracting) and M-B (seeking). Normalized path lengths (given in %) of the two phases were compared.ResultsThirty eight participants contributed. For the retracting phase, we found no significant difference between experts [median (range) %: 152 (129–178)], residents [164 (126–250)], and novices [168 (136–268)]. In the seeking phase, we find a significant difference (<0.001) between experts [180 (172–247)], residents [201 (163–287)], and novices [290 (244–469)]. Moreover, within each group, a significant difference between retracting and seeking phases was observed.ConclusionsGoal-oriented movements in MIS can be split into two phases: retracting and seeking. Novices are less effective than experts and residents in the seeking phase. Therefore, the seeking phase is characteristic of performance differences. Furthermore, the retracting phase is essential, because it improves safety by avoiding intermediate tissue contact. Therefore, the shortest path length, as presently used during the assessment of basic MIS skills, may be not a proper concept for analyzing optimal movements and, therefore, needs to be revised.

A randomised comparison of vaginoscopic office hysteroscopy and saline infusion sonography: a patient compliance study

Objective  The purpose of this study was to compare patient discomfort during saline infusion sonography (SIS) and office hysteroscopy performed according to a vaginoscopic approach.

Assessment of Laparoscopic Skills Based on Force and Motion Parameters

Box trainers equipped with sensors may help in acquiring objective information about a trainees performance while performing training tasks with real instruments. The main aim of this study is to investigate the added value of force parameters with respect to commonly used motion and time parameters such as path length, motion volume, and task time. Two new dynamic bimanual positioning tasks were developed that not only requiring adequate motion control but also appropriate force control successful completion. Force and motion data for these tasks were studied for three groups of participants with different experience levels in laparoscopy (i.e., 11 novices, 19 intermediates, and 12 experts). In total, 10 of the 13 parameters showed a significant difference between groups. When the data from the significant motion, time, and force parameters are used for classification, it is possible to identify the skills level of the participants with 100% accuracy. Furthermore, the force parameters of many individuals in the intermediate group exceeded the maximum values in the novice and expert group. The relatively high forces used by the intermediates argue for the inclusion of training and assessment of force application during tissue handling in future laparoscopic skills training programs.