Peter O’Donovan

A valid model for testing and training laparoscopic psychomotor skills

This study aims to evaluate the face and construct validity of the Laparoscopic Skills Testing and Training (LASTT) model, developed by the European Academy of Gynaecological Surgery (EAGS) for assessing laparoscopic psychomotor skills (LPS). This study is designed based on the Canadian Task Force II-1. This study was conducted in workshops organised by the EAGS in 2008 and 2009. One hundred ninety-nine gynaecologists were classified in three groups according to their exposure to laparoscopy (G1: no/little, G2: intermediate, G3: important). Participants performed three repetitions of three exercises (E1: camera navigation, E2: hands–eyes coordination, E3: bimanual coordination) with measurable objectives to accomplish within a limited time frame. The face validity of the model was assessed by an 11-item questionnaire using a 10-cm visual analogue scale. Q1–Q8 evaluated its capacity for testing and training LPS and Q9–Q11 its relevance for actual laparoscopic surgery. The score of each exercise was obtained by dividing the time to correct performed exercise by the number of objectives effectively accomplished. The correlation between E1–E3 scores and the level of exposure to laparoscopy was evaluated, and the scores of the different groups were compared to assess the construct validity. Participants gave a favourable opinion about the model without inter-group differences. In E1–E3, the scores correlated with the level of previous exposure to laparoscopic procedures, more-experienced participants achieving better results than less-experienced participants. The data demonstrate the face and construct validity of the LASTT model, suggesting that it can be a useful tool for training and evaluation of LPS in surgical disciplines that perform laparoscopic procedures.

Prevention of intrauterine post-surgical adhesions in hysteroscopy. A systematic review

OBJECTIVE The purpose of the present review is to provide a survey of the various measures of preventing adhesions used in hysteroscopic surgery. STUDY DESIGN A systematic computerized literature search was conducted to provide a survey of the various measures used in hysteroscopic surgery to prevent adhesions. Finally, 29 studies were included in the analysis, showing a wide variety of methods and agents advocated in international literature. They are explained in various sections, based on the IUA prevention approach adopted (surgical technique, early second-look hysteroscopy, barrier method, pharmacological therapy). RESULTS The results of our review show that (i) use of surgical techniques which reduce the use of electrosurgery should be preferred whenever possible (Level of evidence: 4); (ii) an early second-look hysteroscopy would appear to be an effective preventive, as well as therapeutic, strategy regarding IUA but studies on the topic are too few for relevant evidence; (iii) barriers methods are the most widely used and, among these, gel barriers have been proven to have a significant clinical effect on IUA prevention, because of higher adhesiveness and prolonged residence time on the injured surface (Level of evidence: 1b); (iv) the role of hormonal and antibiotic therapy in the prevention of post-operative IUA is difficult to evaluate as it has been used in association with other prevention strategies in most studies included in our review. CONCLUSIONS Robust and high quality randomized trials to assess the effectiveness of different anti-adhesion therapies are still needed before one or more of these strategies may be strongly recommended for improving clinical outcomes in women treated by operative hysteroscopy.

Myoma morcellation and leiomyosarcoma panic

In a press release in April 2014, the US Food and Drug Administration [1] discourages doctors from using laparoscopic power morcellators in removing fibroids or myomatotic uteri in order to reduce the risk of sarcomatous cell escape. The USbased company Johnson & Johnson, the largest manufacturer of the devices, halted global sales and distribution of power morcellators, while many hospitals in USA ban the use of morcellation under these circumstances. Patients’ safety and wellbeing especially after surgery is a common and primary concern of surgeons and hospitals; however, there is no reliable way to determine if a uterine fibroid contains a sarcoma prior to removal. Patients should know that the use of laparoscopic power morcellation for hysterectomy or myomectomy may deteriorate their survival rate in case of a sarcoma, and they should discuss the risks and benefits of the available treatment options with their health care professionals. The incidence of uterine sarcomas is extremely low, 0.23% [2], or according to FDA analysis of currently available data (1:350), 0.29 %. They are classified according to histological subtypes in order of decreasing incidence: leiomyosarcomas, endometrial stromal sarcomas (ESS) and ‘other’ sarcomas. The ESS are lesions within the endometrial cavity and diagnosis can be established prior to surgery by endometrial biopsy [3]. The rarity of these tumours has prevented the performance of large epidemiological studies to identify risk factors. Assuming an incidence of uterine sarcomas of 0.23 % by applying the ‘inverse rule of 3’, a surgeonwill need to perform 1304 laparoscopic interventions to observe at least one case of uterine sarcoma with 95 % confidence. Imaging characteristics, tumour markers and other parameters indicating the risk of sarcoma are not available or not specific. In addition, the lack of uniform histologic criteria for diagnosing uterine leiomyosarcoma (ULMS) makes interpretation of the older studies difficult [4]. As the Stanford study [5] was the first to appreciate that the type of necrosis in a uterine smooth muscle tumour was of crucial importance, studies that preceded it did not evaluate the presence or absence of tumour cell necrosis. A leiomyosarcoma usually exhibits diffuse moderate-tosevere atypia, a mitotic count of >10 MFs/10 HPFs and tumour cell necrosis. A tumour with any two of these features V. Tanos :H. Brolmann : R. L. DeWilde : P. O’Donovan :R. Campo Head IVF and Reproductive Surgery, Aretaeio Hospital, Nicosia, Cyprus

Embryofetoscopy: a new “old” tool

Embryoscopy is the direct visualization of the embryo between 5 and 8 weeks’ gestational age. Fetoscopy is the direct visualization of the fetus after 8 weeks of gestation. Both are performed by inserting a fiber-optic scope, either transabdominally or transcervically, into the extracelomic space when the procedure is done before 11 weeks or inside the amniotic cavity when it is done after 11 weeks. Embryofetoscopy is likely to find applications in confirming and further clarifying our knowledge of embryonic development and in the prenatal investigation of high-risk pregnancies for recurrent genetic disorders. Further evolution of endoscopic instruments and embryoscopic technique could give embryofetoscopy a potential for early gene and cell therapy as well as for surgery in utero. We also present our preliminary experience using transcervical embryoscopy for direct visualization of the 1st-trimester embryo in women opting to terminate pregnancy.

Partial mole in ectopic pregnancy

Objective: To evaluate the incidence of molar pregnancy in the fallopian tube pregnancy. Setting: Outpatient clinic. Patient: 32-year-old Asian woman. Intervention: Left salpingectomy. Outcome: Molar ectopic pregnancy. Result: Ectopic partial mole pregnancy. Conclusion: Molar pregnancy can occur in ectopic pregnancy. Clinically, molar pregnancy mimics normal tubal ectopic pregnancy.

Changing trends in gynaecological surgery - a challenge for training.

As gynaecology develops and grows, so does the range of surgical procedures we have to offer our patients. In the fields of both benign gynaecology and gynaecological oncology, there are many examples of the value of endoscopic procedures, both for diagnoses and therapy [1, 2]. How do we learn surgery, and how does it influence what we do? Traditionally, we have learnt from our teachers during our training, but increasingly this approach must be complemented by the foundation of evidence-based practice, structured formal training and careful supervised surgical technique. In the first issue of Gynecological Surgery it was suggested that the ESGE educational project is focussing specifically on delivery of quality educational programmes in the field of endoscopy and is well on the way to achieving this. As we move forward with this project, it is therefore timely to review where we have come from to reach the surgical standards we achieve today. In addition, it would be useful to reflect on the challenges ahead and how we can continue to improve our techniques to offer the highest level of care to our patients. The first consideration is the question, “What is the best place for surgery?” Traditionally, surgical procedures have always taken place in an operating theatre. Increasingly, we are seeing procedures that may be performed in the outpatient or office setting. As technology improves and the morbidity and pain of surgical procedures can be reduced, it may be that more operations need no longer be performed in the operating theatre setting. There has been a growth in “day surgery units”, “officebased procedure units” and the like, as the benefits of less medically invasive treatments are appreciated. Hysteroscopy is increasingly performed under local anaesthetic in the outpatient setting. It is even possible to perform relatively major surgery in some cases under local anaesthetic [3]. Diagnostic and therapeutic colposcopy is nearly always performed in the outpatient setting. Other procedures such as some bladder neck suspensions can be performed away from the traditional operating theatre environment. Global ablative technology in the treatment of menorrhagia is also another area where the treatment is increasingly leaving the operating theatre and moving into the office environment. Such fundamental changes in operating practice have many advantages. Firstly for the patient, not going into the operating theatre may be less stressful and anxiety provoking. For the surgeon, there is often a greater turnaround in the out-patient setting where the patients are waiting outside rather than the operating theatre where patients may have to travel from hospital wards, meaning a greater work-rate is possible. Secondly, there have been major changes in the need for general anaesthetic. The majority of gynaecological surgical procedures are still performed under general anaesthetic. As these procedures develop, and as our understanding of analgesia grows, so it is becoming increasingly possible to undertake many procedures under local or regional anaesthetic. Endometrial ablation, anterior colporraphy and bladder neck procedures can now all be performed under local anaesthetic [4]. Not only does this reduce the need for conventional anaesthetic support by avoiding general anaesthetic, but also the sickness and postoperative nausea can be abolished. Fifteen years ago patients undergoing hysterectomy would routinely spend up to 12 days in hospital, now it is only 3 or 4 days, and some colleagues perform the operation on a “day case” basis [5]. There has been an explosion in the development of new instrumentation for gynaecological surgery. One only has to wander through a medical exhibition at a conference to be aware of the massive developments in medical instrumentation over the last 10 years. Are we as surgeons being “hoodwinked” by the equipment companies that all of these new instruments, many of them disposable, are E. Downes Barnet and Chase Farm Hospital, Enfield, London, UK

Complications in Hysteroscopic Surgery: Prevention and Management

There is little doubt that minimal-access surgery (MAS) presents many advantages over conventional surgery: smaller scars, reduced postoperative pain, shorter hospital stay, and speedier recovery.

Christopher Sutton, Kevin Jones, David Adamson (eds): Modern management of endometriosis

This beautifully illustrated book covers the whole field of endometriosis, particularly focussing on the background and mainly the endoscopic treatment of this chronic condition. The editors have assembled a number of very fine articles that review the whole area from a strong international field. The book is divided into a number of subsections covering general background, surgical treatment, surgical treatment by laparoscopy, different power sources in laparoscopic surgery, pelvic pain and infertility associated with endometriosis, nonsurgical management of endometriosis, and controversies in endometriosis surgery. Particularly strong are the chapters on surgical treatment by laparoscopy. This book gives an up-to-date overview of the management of this difficult condition, and it should be read widely not only by practising clinicians but also by residents in training. I feel that an extra dimension could be added to the book by including a CD-ROM to illustrate actual operations in real time; however, this would probably increase the book’s cost. Finally, I must congratulate Professor Sutton, Kevin Jones, and David Adamson on being able to edit the book so well and make it not only informative but also interesting to read.

Goodbye and hello—editorial changes in gynaecological surgery

I am writing to inform you of some changes in the editorial board of Gynaecological Surgery. I am resigning as Editorin-Chief with effect from the end of June 2006. Since I became the first Editor-in-Chief of Gynaecological Surgery with the first edition at the beginning of 2004 I had planned to remain in post for only 2 years. As you can see, I have stayed slightly longer than was initially intended. The new Editor-in-Chief I am delighted to say is Professor Ivo Brosens who will take over the position on 1 July 2006. We are very fortunate that someone of his calibre will take over as Editor-in-Chief as he has wide interests in the field of gynaecology having been Professor of Obstetrics and Gynaecology at the University of Leuven for a number of years. He was founder and director of the Division of Reproductive Medicine and the Centre of Surgical Technologies at the University of Leuven. He was awarded honorary membership of over 15 National and International Societies including an honorary fellowship of the RCOG (Royal College of Obstetricians and Gynaecologists) and the first honorary membership of the World Endometrial Society and the IFFS 30th Anniversary Recognition Award for significant contributions to infertility and reproductive medicine. Since 1996 he joined the Leuven Institute for Fertility and Embryology where with his collaborators the new culdoscopic technique of transvaginal hydrolaparoscopy was developed. He is co-editor and reviewer of several international journals. He was editor of ten specialised text books and published over 300 papers in peer-reviewed journals. I am sure he will be an excellent Editor-in-Chief. Since it was first published in 2004, Gynaecological Surgery has gone from strength to strength. It is currently the official journal of the ESGE. In addition to the Editor-inChief we are going to create associates to the Editor-in-Chief in the fields of oncology, urogynaecology, perinatology, new technologies, medicine and statistics and hysteroscopy. It is intended this will broaden the interests of the Journal to appeal to a much wider audience. It is also suggested that the following changes will be implemented as soon as possible. Firstly the case reports will be published only by abstract. Society news will be limited to one page. Two types of review articles will be included: a full-length review of recent developments with the author’s research work combined with a review of the literature and insight and a mini review with sharply focussed topics of recent investigations in the various fields. Plans for the future strategy will be discussed at the next Annual Meeting of the ESGE in Strasbourg in October 2006. I wish Professor Brosens well in his new role. I will be concentrating on research but also I have recently joined the European Academy and hope to remain on the Board of this helping with education, training and research. I also hope to remain on the Executive Board of the ESGE. To support my colleagues both in the Society and also in the Academy. I would finally encourage you to keep sending in highquality articles to Gynaecological Surgery as it is only by this method that we can improve the quality of the Journal. I would like to thank DiethelmWallwiener, past President of the ESGE, Jacques Dequesne, current President of the ESGE, Rudi Campo, Chairman of the European Academy, and finally Rachel Costigan, who has worked extremely hard for 2 1/2 years accepting papers from all over the world on behalf of Gynaecology Surgery and certainly she has contributed in a major way towards the success of the Journal. A special word of thanks to Ute Heilman from Springer for all the technical support she provided me in the initial phases of setting up of the Journal. Gynecol Surg (2006) 3:235 DOI 10.1007/s10397-006-0255-4

Why another journal

Welcome to the first issue of Gynecological Surgery. Many of you might well ask why we will be publishing another journal. For example, in obstetrics and gynecology alone there are no less than 57 specialist journals indexed in Medline, as well as much relevant literature published in general journals. It was felt by many gynecologists that there was a need for a journal focussing on endoscopy, imaging and allied techniques in the field of pelvic surgery. I plan, with the help of the Editorial Board, to develop the journal into a ‘must read’ publication for clinical gynecologists, trainees, teachers and researchers in the field of gynecology and pelvic surgery. The journal’s main focus will remain the timely publication of topical papers with subjects throughout the field of pelvic surgery and covering both benign pathology and oncology. Although some of the articles may be commissioned, the main focus would be to obtain spontaneous submissions of high-quality papers in the above areas. The journal will focus and assess new practices, medical devices and possibly also pharmaceuticals. It is also likely that separate supplements will be published on conferences and workshops in key areas of interest. I look forward to working with Professor Wallwiener in the position of Editor-in-Chief Elect, and currently new appointments are being made to the International Editorial Board to cover a wide geographical area. This will increase the journal’s ability to publish contributions from both a wide subject and geographical range as possible. My aim is to maintain a rigorous peer review of published material. The journal has become the official journal of the European Society of Gynecological Endoscopy, which currently has 24 national member societies with a readership of over 3,000. I do hope to attract as many papers as possible from a global authorship and would welcome manuscripts from the Americas, Africa, Australasia and Asia, including Japan, along with a strong representation from Europe. I hope that Gynecological Surgery will present the reader with articles written by expert contributors who have drawn upon their knowledge of the state of the art in their specialist field to identify the key issues for clinicians to assimilate. Although the focus of the journal would be in the field of pelvic surgery, I would like to attract many papers from diverse areas looking at allied techniques. Furthermore, I would welcome practitioners to share personal experience that would make this journal an informative read in both established and evolving areas of our speciality.