Rudy Leon De Wilde

Prevention of adhesions in gynaecological surgery: the 2012 European field guideline.

Postoperative adhesions have become the most common complication of open or laparoscopic abdominal surgery and a source of major concern because of their potentially dramatic consequences. The proposed guideline is the beginning of a major campaign to enhance the awareness of adhesions and to provide surgeons with a reference guide to adhesion prevention adapted to the conditions of their daily practice. The risk of postoperative adhesions should be systematically discussed with any patient scheduled for open or laparoscopic abdominal surgery prior to obtaining her informed consent. Surgeons should adopt a routine adhesion reduction strategy with good surgical technique. Anti-adhesion agents are an additional option, especially in procedures with a high risk of adhesion formation, such as ovarian, endometriosis and tubal surgery and myomectomy. We conclude that good surgical practice is paramount to reduce adhesion formation and that anti-adhesion agents may contribute to adhesion prevention in certain cases.

A review of the problematic adhesion prophylaxis in gynaecological surgery

BackgroundAdhesions lead to considerable patient morbidity and are a mounting burden on surgeons and the health care system alike. Although adhesion formation is the most frequent complication in abdominal and pelvic surgery, many surgeons are still not aware of the extent of the problem. To provide the best care for their patients, surgeons should consistently inform themselves of anti-adhesion strategies and include these methods in their daily routine.MethodsSearches were conducted in PubMed and The Cochrane Library to identify relevant literature.FindingsVarious complications are associated with adhesion formation, including small bowel obstruction, infertility and chronic pelvic pain. Increasingly, an understanding of adhesion formation as a complex process influenced by many different factors has led to various conceivable anti-adhesion strategies. At present, a number of different anti-adhesion agents are available. Although some agents have proved effective in reducing adhesion formation in randomised controlled trials, none of them can completely prevent adhesion formation.ConclusionTo fulfil our duty to provide best possible care for our patients, it is now time to regard adhesions as the most common complication in surgery. Further research is needed to fully understand adhesion formation and to develop new strategies for adhesion prevention. Large clinical efficacy trials of anti-adhesion agents will make it easier for surgeons to decide which agent to use in daily routine.

DNA damage induced by cis- and carboplatin as indicator for in vitro sensitivity of ovarian carcinoma cells

BackgroundThe DNA damage by platinum cytostatics is thought to be the main cause of their cytotoxicity. Therefore the measurement of the DNA damage induced by cis- and carboplatin should reflect the sensitivity of cancer cells toward the platinum chemotherapeutics.MethodsDNA damage induced by cis- and carboplatin in primary cells of ovarian carcinomas was determined by the alkaline comet assay. In parallel, the reduction of cell viability was measured by the fluorescein diacetate (FDA) hydrolysis assay.ResultsWhile in the comet assay the isolated cells showed a high degree of DNA damage after a 24 h treatment, cell viability revealed no cytotoxicity after that incubation time. The individual sensitivities to DNA damage of 12 tumour biopsies differed up to a factor of about 3. DNA damage after a one day treatment with cis- or carboplatin correlated well with the cytotoxic effects after a 7 day treatment (r = 0,942 for cisplatin r = 0.971 for carboplatin). In contrast to the platinum compounds the correlation of DNA damage and cytotoxicity induced by adriamycin was low (r = 0,692), or did not exist for gemcitabine.ConclusionThe measurement of DNA damage induced by cis- and carboplatin is an accurate method to determine the in vitro chemosensitivity of ovarian cancer cells towards these cytostatics, because of its quickness, sensitivity, and low cell number needed.

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.

Recommendations by the gynecologic endoscopy working group of the german society of obstetrics and gynecology for the advancement of training and education in minimal-access surgery

Endoscopic minimal-access operative techniques have gained increasing significance in gynecology so that the most gynecological operations in health centers and clinics are now performed via an endoscopic approach: Endoscopy has proven beneficial for patients by reducing morbidity rates, reducing postoperative pain symptoms and shortening hospital stay. The German healthcare system is undergoing a process of change with increasing integration of ambulatory and inpatient care and a fundamental reform of the DRG-based hospital financing system. Economic restructuring of the healthcare system through personnel and time cutbacks in conjunction with increasing sub-specialization has clearly had a negative impact on the quality of medical training received by the next generation of young doctors. In particular, for specialist surgical areas the average training clinic has insufficient time or capacity to adequately teach surgical techniques, including minimal-access surgery. Unfortunately, this undesirable development lowers the standard of the surgical techniques required to become a specialist. The German Gynecologic Endoscopy Working Group (AGE) wish to redress this situation by offering young doctors the opportunity to participate in a structured training plan and a step-by-step guide to endoscopic minimal-access surgery. AGE will name endoscopic training centers throughout Germany—according to the pre-defined criteria—which will offer courses and the opportunity to attend lectures. Doctors may receive a certified graded qualification from the AGE to determine their knowledge and experience of endoscopy. This concept was first presented at the second “Forum operative gynecology” conference in November 2005 in Berlin. It was discussed and optimized by the AGE council and accepted at the AGE general meeting on 19 May 2005 by the executive committee, advisory board and members of the general meeting. With this concept, we wish to make a contribution to improving the training of young gynecologists and, in the long term, to lower the amount of avoidable surgical complications in gynecological endoscopy. The concept is sub-divided into a personal qualification (MIS I–III) and an institutional qualification as approved certified training centers.

Adhesions are the major cause of complications in operative gynecology

Adhesion formation has been found to be highly prevalent in patients with a history of operations or inflammatory peritoneal processes. These patients are at a high risk of serious intraoperative complications during a subsequent operation if adhesiolysis is performed. These complications include bowel perforation, ureteral or bladder injury, and vascular injury. In order to minimize the risk of these complications, adhesiolysis should only be performed by experienced surgeons, and intraoperative strategies must be adopted. The reduction of the overall incidence of adhesions is essential for subsequent surgical treatments. Anti-adhesion strategies must be adopted for preventing the reoccurrence of adhesions after abdominopelvic operations. The strategies employed to reduce the risk and the overall incidence of adhesions have been elucidated in this article.

Training in laparoscopic surgery: From the lab to the or

Abstract Training in laparoscopic gynaecological surgery is challenged by the boundaries of the traditional apprentice-tutor model and the ethical objective of limiting the complication rates. The European Academy for Gynaecological Surgery (The Academy) has focussed their scientific work in the last 6 years on defining the standards a future laparoscopist must meet in order to operate, either independently or under supervision. The Laparoscopic Skills Testing and Training (LASTT) model has been proved feasible and to have face and construct validity. Furthermore, it has been proved in this model that basic laparoscopic psychomotor skills (LPS) require proper training and that proficiency in those skills cannot be acquired by only training more complex tasks, such as intra-corporeal knotting. The observation that the LPS are retained over long periods is very important for the structure of a training program, being therefore comparable to swimming or biking skills. The data gathered over these years by the Academy, and supported by reports from other groups, strongly recommend that an in-house in vitro model for training and testing laparoscopic skills should be available in every teaching centre. Only those who reach proficiency in these practical skills, and who demonstrate sufficient theoretical knowledge, will have access to the “Green Card” that defines the minimum requirements prior to training for surgical procedures with patients. Following this strategy, we postulate that the morbidity and mortality rate associated with laparoscopic procedures in training centres will be reduced and the efficiency of one-to-one teaching will be improved. Izvleček Izpopolnjevanje v spretnosti endoskopske ginekološke kirurgije vodijo meje, ki jih postavlja model tradicionalnega odnosa vajenec-mojster ter etični cilj operirati s čim manj zapletov. Evropska akademija za ginekološko kirurgijo (The Academy) je zadnjih 6 let svoje znanstveno delo osredotočila na definiranje standardov, ki jih mora izpolnjevati bodoči laparoskopski kirurg, da bo lahko operiral samostojno ali pod nadzorom. Model LASTT (The Laparoscopic Skills Testing and Training) je pokazal, da je izvedljiv, da ima realno vrednost in da pokaže tudi na razlike med različno sposobnimi operaterji. Z modelom je bilo tudi dokazano, da je za osnovne laparoskopske psihomotorične veščine (LPS) treba vaditi in da se do izvrstnosti v teh veščinah ne da priti z vadbo bolj zapletenih veščin kot je intra-korporealno vezanje vozlov. Izjemno pomembna za strukturo tečajev vadb je ugotovitev, da LPS znanje zadržimo dolgo časa, kar lahko primerjamo z obvladovanjem veščin kot sta vožnja kolesa ali plavanja. Podatki, ki jih je v zadnjih letih zbrala The Academy in jih podpirajo rezultati drugih skupin, zelo priporočajo, da ima vsak center za poučevanje svoj model za vadbo in testiranje laparoskopskih veščin. Le tisti, ki bodo dokazali, da so vešči v praktičnih veščinah in bodo pokazali dovolj teoretičnega znanja, bodo imeli dostop do »Zelene karte«, ki definira minimalne zahteve pred začetkom operiranja bolnikov. Naš postulat je, da če sledimo tej strategiji, se bo obolevnost in smrtnost po laparoskopskih operacijah v centrih za edukacijo zmanjšala in učinkovitost učenja eden-na-enega izboljšala.

Decreasing strain on the surgeon in gynecologic minimally invasive surgery by using semi-active robotics

To assess the advantages of a surgeon‐controlled robotic endoscope holder in gynecologic minimally invasive solo‐surgery as compared with conventional assistance with a second surgeon.

Adhesions after abdominal, pelvic and intra-uterine surgery and their prevention

We here present the full text of a patient leaflet we have designed, and routinely use, to provide preoperative education about adhesions to patients undergoing open or laparoscopic gynaecological surgery. The leaflet presents appropriate, patient-orientated information on the nature of adhesions, their causes and the health risks they may involve as well as on adhesiolysis and modern methods of adhesion prevention. As adhesion formation is not specific to gynaecological surgery, the leaflet can also be adapted for the purposes of general abdominal surgery.

Insufflation with Humidified and Heated Carbon Dioxide in Short-Term Laparoscopy: A Double-Blinded Randomized Controlled Trial

Background. We tested the hypothesis that warm-humidified carbon dioxide (CO2) insufflation would reduce postoperative pain and morphine requirement compared to cold-dry CO2 insufflation. Methods. A double-blinded, randomized, controlled trial was conducted to compare warm, humidified CO2 and cold-dry CO2. Patients with benign uterine diseases were randomized to either treatment (n = 48) or control (n = 49) group during laparoscopically assisted vaginal hysterectomy. Primary endpoints of the study were rest pain, movement pain, shoulder-tip pain, and cough pain at 2, 4, 6, 24, and 48 hours postoperatively, measured by visual analogue scale. Secondary outcomes were morphine consumption, rejected boli, temperature change, recovery room stay, and length of hospital stay. Results. There were no significant differences in all baseline characteristics. Shoulder-tip pain at 6 h postoperatively was significantly reduced in the intervention group. Pain at rest, movement pain, and cough pain did not differ. Total morphine consumption and rejected boli at 24 h postoperatively were significantly higher in the control group. Temperature change, recovery room stay, and length of hospital were similar. Conclusions. Warm, humidified insufflation gas significantly reduces postoperative shoulder-tip pain as well as morphine demand. This trial is registered with Clinical Trial Registration Number   DRKS00003853 (German Clinical Trials Register (DRKS)).