Pietro Gambadauro

The "tele" factor in surgery today and tomorrow: implications for surgical training and education.

New technological developments in the field of telecommunications have allowed a wide range of potentially novel surgical applications. The introduction of the World Wide Web in 1991 has been followed by a steep rise of the relevance of telemedicine, as it is witnessed in the latest scientific literature. There has been a consistent, positive trend in publications dealing, respectively, with telemedicine and the Internet. This article reviews telemedicine and other surgery-related innovations that benefit from telecommunication advances, and presents data from a quantitative bibliographic analysis. A number of applications, such as telementoring, teleproctoring and robotic telesurgery are described and their huge potentials are discussed. The integration between surgery and telecommunications could constitute one of the major achievements of modern medicine, and its safe integration into clinical practice should be a priority for modern surgeons.

Intrauterine Adhesions following Conservative Treatment of Uterine Fibroids

Uterine fibroids are common in women of reproductive age and various conservative treatments are available. In order to achieve a successful conservative treatment of fibroids, functional integrity of the uterus is as important as tumor removal or symptoms relief. In this context, intrauterine adhesions must be recognized as a possible complication of conservative management of uterine fibroids, but diagnostic pitfalls might justify an underestimation of their incidence. Hysteroscopic myomectomy can cause adhesions as a result of surgical trauma to the endometrium. The average reported incidence is around 10% at second-look hysteroscopy, but it is higher in certain conditions, such as the case of multiple, apposing fibroids. Transmural myomectomies also have the potential for adhesion, especially when combined with uterine ischemia. Uterine arteries embolization also carries a risk of intracavitary adhesions. Prevention strategies including bipolar resection, barrier gel or postoperative estradiol, might be useful, but stronger evidence is needed. In view of current knowledge, we would recommend a prevention strategy based on a combination of surgical trauma minimization and identification of high-risk cases. Early hysteroscopic diagnosis and lysis possibly represents the best means of secondary prevention and treatment of postoperative intrauterine adhesions.

Dealing with uterine fibroids in reproductive medicine

Women who wish to conceive are nowadays more likely to present with uterine fibroids, mainly because of the delay in childbearing in our society. The relationship between uterine fibroids and human reproduction is still controversial and counselling patients might sometimes be challenging. This paper is to assist those involved in the management of patients of reproductive age presenting with uterine fibroids. The interference of fibroids on fertility largely depends on their location. Submucous fibroids interfere with fertility and should be removed in infertile patients, regardless of the size or the presence of symptoms. Intramural fibroids distorting the cavity reduce the chances of conception, while investigations on intramural fibroids not distorting the cavity have so far given controversial results. No evidence supports the systematic removal of subserosal fibroids in asymptomatic, infertile patients. Myomectomy is still the ‘gold standard’ in fibroid treatment for fertility-wishing patients. In experienced hands, hysteroscopic myomectomy is minimally invasive, safe, and effective. Abdominal and laparoscopic myomectomy might be challenging, but potential risks could be reduced by new strategies and techniques.

Surgical Videos for Accident Analysis, Performance Improvement, and Complication Prevention : Time for a Surgical Black Box?

Conventional audit of surgical records through review of surgical results provides useful knowledge but hardly helps identify the technical reasons lying behind specific outcomes or complications. Surgical teams not only need to know that a complication might happen but also how and when it is most likely to happen. Functional awareness is therefore needed to prevent complications, know how to deal with them, and improve overall surgical performance. The authors wish to argue that the systematic recording and reviewing of surgical videos, a “surgical black box,” might improve surgical care, help prevent complications, and allow accident analysis. A possible strategy to test this hypothesis is presented and discussed. Recording and reviewing surgical interventions, apart from helping us achieve functional awareness and increasing the safety profile of our performance, allows us also to effectively share our experience with colleagues. The authors believe that those potential implications make this hypothesis worth testing.

Pain control in hysteroscopy : Finesse, not local anaesthesia

The take home message of the systematic review and meta-analysis on local anaesthesia during outpatient hysteroscopy is misleading.1 The conclusion, “Injectable, preferably paracervical, administration of local anaesthetic should be used for women undergoing hysteroscopy as outpatients to reduce the amount of pain experienced,” is based on five randomised trials, two of which found paracervical blocks to be ineffective. …

Is a Positive Family History of Endometriosis a Risk Factor for Endometrioma Recurrence After Laparoscopic Surgery

A total of 148 patients were followed up for an average of 30.1 ± 17 months following to laparoscopic excision of ovarian endometriomas by a single surgical team. Bivariate and multivariate analyses were used to investigate the association between endometrioma recurrence and several factors, age, body mass index, family history, cyst diameter, number and location, adhesions or peritoneal implants, occurrence of spillage, postoperative treatment with gonadotropin-releasing hormone agonist, or pregnancies. The overall recurrence rate of the endometriomas was 18.2%. At bivariate analysis, recurrence rate was significantly higher in patients with a positive family history of endometriosis (40% vs 14.8%). Recurrence was also more frequent, albeit nonsignificantly, in patients with a history of dysmenorrhea, intraoperative spillage, and postoperative hormonal suppression. At multivariate analysis with logistic regression, a positive family history of endometriosis was the only variable independently associated with endometrioma recurrence following laparoscopic removal (odds ratio 3.245; 95% confidence interval: 1.090-9.661).

Unusually rapid growth of bilateral endometriomas and acute bilateral hydronephrosis

Ultrasonography can detect ovarian endometriomas, but negative findings cannot exclude other localizations of endometriosis, especially in symptomatic patients. We describe a case of sudden development of large bilateral endometriomas after a series of negative ultrasound scans, causing bilateral hydronephrosis. Our patient is a 32-year-old nulligravida with long-lasting dysmenorrhea, urinary symptoms, and familiarity for endometriosis, who had voluntarily discontinued oral contraceptives. Various pelvic scans had not shown pathological findings. Five months following the last negative scan, she presented with pain and increase of abdominal girth. Ultrasonography and computed tomography showed large ovarian cysts (16 cm right – 10 cm left) and hydronephrosis bilaterally. She underwent conservative surgery followed by GnRH analogs. At a 6-months follow-up, she was symptom-free and ultrasonography showed no recurrence. Endometriosis has still an unknown mechanism of proliferation and its clinical behavior or progression is highly unpredictable. Severe uropathy is commonly related to direct ureteral involvement, but can also depend on an ab-extrinseco compression by large, rapidly growing endometriomas. Women at risk of endometriosis, who are not receiving empirical medical treatment, should be adequately and regularly assessed via pelvic ultrasonography and/or submitted to diagnostic laparoscopy in order to prevent serious consequences such as silent renal loss.

How Predictable Is the Operative Time of Laparoscopic Surgery for Ovarian Endometrioma

Endometriosis is a tricky albeit common disease whose management largely relies on laparoscopy. We have studied the operative times of laparoscopic endometrioma surgery in order to assess their predictability and possible predictors. One hundred forty-eight laparoscopies were included, with a median operative time of 70 minutes (mean 75.14; 95% CI: 70.03–80.24). Half of the cases had a duration within 15–20 minutes above or below the median (IQR: 55–93.75), but the whole dataset ranged from 20 to 180 minutes, and the standard deviation was relatively large (31.4). Surgical times were significantly related to technical (number and size of the cysts) and nontechnical factors (age, parity, dysmenorrhea, and family history). At multiple logistic regression, after adjusting for number and size of the cysts, surgical times below the first quartile were associated with older age (>30 years old: aOR: 3.590; 95% CI: 1.417–9.091) and parity (≥1 delivery: aOR: 3.409; 95% CI: 1.343–8.651). Longer times, above the third quartile, were instead predicted by a familial anamnesis of endometriosis (aOR: 3.639; 95% CI: 1.246–10.627). Our findings indicate highly variable surgical times, which are predicted by unexpected nontechnical factors. This is consistent with the complexity of endometriosis and its treatment. Productivity and efficiency in endometriosis surgery should focus on the quality of healthcare outcomes rather than on the time spent in the operating theatres.

Endoscopic loops for laparoscopic myomectomy

This combined approach was effective in reducing bleeding during myomectomy for large fibroids. A double technique was needed because the pseudocapsule globally surrounds the fibroids with its perimyomatous vessels. Therefore, the loop at the surgical base of the fibroid deals with the vessels there located, whereas those overlying the fibroid, the first ones to be incised by the surgeon, are pharmacologically ligated by the vasopressin. Unfortunately, the intramyometrial injection of vasopressin implies risks due to potential intravasation, and serious complications have been reported with its use (2).

Ovarian Sertoli–Leydig cell tumours: How typical is their typical presentation?

Abstract Ovarian Sertoli–Leydig cell tumours (OSLCT) are rare and typically present with androgenic manifestations in women of the 2nd–3rd decade. Out of 228 diagnoses of ovarian sex cord-stromal tumours recorded at an academic institution during a 14-year period, eight women were surgically treated for OSLCT. Patient mean age was 54.8 years (range 19–81), five women being in the postmenopausal stage (62.5%). Only one woman presented with androgenic manifestations (12.5%), four with abnormal/postmenopausal uterine bleeding (50%), and three with abdominal pain (37.5%). Fertility sparing or radical surgery was performed depending on patient age and stage of disease. The only patient with an advanced disease (FIGO stage IV) was referred to palliative care postoperatively. The other seven were at FIGO stage I. Five of them were free from disease at a mean follow-up of 67 months, while the remaining two were lost at follow-up. The youngest woman of the series, treated with fertility-preserving unilateral salpingo-oophorectomy at the age of 19, had two spontaneous pregnancies and deliveries of healthy babies during a 10-year follow-up period. In conclusion, our single institution 14-year experience demonstrates that the diagnosis of OSLCT is particularly challenging since many patients are older than expected and lack androgenic manifestations. Impact statement • What is already known on this subjectOvarian Sertoli–Leydig cell tumours (OSLCT) are rare and are thought to typically present with androgenic manifestations in women of the 2nd–3rd decade. • What the results of this study addOur single institution 14-year experience shows that a high proportion of women with ovarian Sertoli–Leydig cell tumours may not present with androgenic manifestations, and many of them also are in the postmenopausal stage. Most patients have a good prognosis and fertility-preserving surgery in younger women can lead to spontaneous pregnancies and deliveries of healthy children after treatment. • What are the implications of these findings for clinical practice and/or further researchThe diagnosis of OSLCT is particularly challenging and therefore not reached before surgery in most of the cases. However, while hysterectomy with bilateral salpingo-oophorectomy and surgical staging are recommended for women with higher stage or no fertility wish, fertility-sparing surgery should be considered in younger women with early disease. Therefore, further research should focus on non-invasive diagnosis possibly by means of laboratory or imaging techniques.