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Big myoma

Dear prof. Koninckx, I have a uterine fibroid and one part has passed through cervix into vagina, but the larger part is still in the uterus. I have no pain, no temperature, I can walk and behave as usual. Ultrasound showed that a fibroid is 11 cm big.   MRI  showed 19 cm. For the last two months I have a huge yellow, brown vaginal disharge, and doctors said it is necrotizing. I really wish to do a laparoscopic surgery, since I’m 40 and I haven’t give birth, so I just want to preserve the uterus. In attachment I sent  an Ultrasound pictures, and I can send you MRI image, too. *********************************************************** Dear Mrs The diagnosis is not clear to me A fibroid passing the cervix will give the discharge you have - such a fibroid is rarely bigger than 5-6 cm and generally a pedunculated intracavitary fibroid which can be removed vaginally - if the fibroid is avascular and necrotisising the risk of an infection of this mass becomes real. This is not without risk and will need urgent surgery, probably hysterectomy My guess is that the large 11 or 19 cm fibroid is 1 or more other fibroids.Our approach would be - let us confirm the diagnosis by clinical exam/ultrasound and proceed to surgery - I hope we first can remove the intracavitary fibroid  vaginally/by hysteroscopy - then a laparoscopy should be performed and decisions taken : what I anticipate is first clip the uterine arteries to prevent too much blood loss if a 10 cm fibroid : can probably be taken care off by laparosopy if a 19...

Where endometriosis patients find surgeons and solutions

The list  on Endozone.org  “Where endometriosis patients find surgeons & solutions”   is misleading and not helpful for patients, at least for Belgium. . First since solutions and surgeons are mixed,  it does not help the patient to find a surgeon.  This is clearly so for Belgium since it lists at least 2 gynecologists,  1  who was forbidden to do surgery now 13 years ago by his institution and 1 who is no longer practicing. Second, the list seems to be self-declared  since I was unable to find the criterions to be listed .   If not self-declared the question arises  who is  responsible for the  listing,  for  inaccuracies and for completeness. The list does not help a patient to find a surgeon, nor his skills or expertise,  since this cannot be identified from the list. Thus the risks are real   of seeing a gynecologist who is not a surgeon and the risk of postponing surgery and getting hormone therapy for a long period, or the risk of having incomplete surgery because of lack of skills for deep endometriosis, or having an unnecessary bowel resection for deep endometriosis instead of a discoid excision.  The latter is a debated topic with many so-called scientific arguments, often ending with the magic word “individualization”. The reality, however, is that some groups almost systematically perform bowel resections while others perform bowel resection in less than 5%. The list – if complete- might be useful if used as suggested before. ‘http://www.gynsurgery.org” –          After identifying a gynecologist the patient should turn to pubmed  (http://www.ncbi.nlm.nih.gov/pubmed/)  and enter “ name-of-gynecologist  AND endometriosis”  to have a list of publications. From the...

Bowel prep for endometriosis surgery : why february 2013 we stopped MBP

Bowel prep for endometriosis surgery remains a debated topic. Date: Sun, 27 Jan 2013 07:41:06 -0500 Larry R Glazerman wrote There was an interesting paper in Fertility and Sterility in 2006 (Muzii et al. Bowel preparation before laparoscopy, Fertility and Sterility Vol. 85, No. 3, March 2006) that assessed visualization of the surgical field as a primary endpoint. Surgeons were blinded to whether the patient had a bowel prep. Their conclusion: Bowel preparation with oral NaP does not offer any significant advantage in patients undergoing laparoscopy for benign gynecologic conditions. In addition, MBP significantly increases preoperative discomfort. Regarding bowel prep and bowel injury, my recommendation to my residents always has been to find out where their local general or colon-rectal surgeons stand. If the surgeon would open someone who had an injury to an unprepped bowel, I’d prep these patients. If the surgeon agrees with the current literature that bowel prep isn’t necessary, I wouldn’t. Larry R. Glazerman, MD, MBA, FACOG, Department of Obstetrics and Gynecology, Mainline Health, Reply by Jason Abbott (Associate Professor Jason Abbott,  School of Women’s and Children’s Health, University of New South Wales, Sydney, Australia) Our group has just completed the fourth RCT of bowel preparation at gynaecological laparoscopy. This will be published in Obstetrics and Gynaecology in March this year. The findings from our’s and other studies in gynaecological laparoscopy: Muzii et al 2006 Mechanical bowel preparation (oral NaP solution) vs no mechanical bowel preparation 140 women • No difference in surgical field, operative difficulty, operative time, and postoperative complications between two groups • Mechanical bowel preparation increases patient discomfort • Mainly diagnostic or...

MIS privileges and videoregistration on AAGL-ENDO-EXCHANGE Digest

MIS privileges, training and  and videoregistration remains a debated subject. Maurice K Chung started the discussion by asking : I have some questions. I am in the process of recommending the Delineation of Privileges of MIS in my institution. I want to know what are CCBL requirement for Robotics &/or advanced laparoscopic procedures?  What is the policy for a General Gynecologist who want to apply for Robotic privilege? After He/she has obtained the Robotic privilege what procedures can they perform?  When she/he has never performed a Robotic Colposacralpexy in training, and once she obtains the Robotic privilege eventhough she could perform a RTLH, can she perform the Colposacralpexy? Tubal re anastomoses, etc. If not, how many cases she has to be proctored? Dr. Maurice K. Chung, RPh. MD.,Chairman, The Global Society of Endometriosis, Pelvic and Pain Surgeons (GSEPS).President 2012, The Society of Laparoendoscopic Surgeons (SLS).President 2011, International Pelvic Pain Society (IPPS).Board Member, International Society of Gynecology Endoscopy (ISGE).Clinical Associate Professor,Dept. OBG, University of ToledoSchool of Medicine, Ohio. Date: Mon, 14 Jan 2013 19:24:33 -0500 answer by  Philippe R Koninckx and Anastasia Ussia  MIS privileges, accreditation and training remain a difficult topic with very different opinions and several country specific aspects. Bottom line however is how to judge and to define quality of surgery. - Quality of surgery obviously comprises the indication. A perfectly performed bowel resection for endometriosis in a women who does not have endometriosis can hardly be regarded as quality surgery. - Complications and accidents of an individual intervention cannot be judged without videoregistration of the entire intervention. Clearly the overall published rates do not give information...

Vaginal closure after hysterectomy

The AAGL listserv has an ongoing discussion on techniques of cuff closure during hysterectomy. The main conclusion is that we have several opinions but no data Below a comment written by the Gruppo Italo Belga. Date: Mon, 17 Dec 2012 18:38:49 -0500 From: Philippe R Koninckx and Anastasia Ussia Subject: Recurrent prolapse following LSH/cervicosacropexy Vaginal Cuff This has been a nice discussion. * We have to realize that we are discussing rare events of a few percent incidence, for which RCT are vitually impossible to perform. Indeed the rule of thumb that meaningful statistics need 30 cases, learns that to evaluate a 1% event a rct of 6000 (3000 cases and 3000 comparators) interventions would be necessary. * Most comments therefore reflect opinions based on personal experience, meetings and ‘table’ discussions. These not only are the best we have, these opinions reflect honest experience and should be considered thoughtfully. In addition we should try to understand them based upon our growing knowledge of surgery. Let us try. * What has emerged over the last decades for prolapse prevention/surgery is the importance of the support structures and of the vagina resting on the levator plate. This knowledge has not been the consequence of MIS but development was simultaneous. As an example, I did see for the first time the levator ani muscle at the Rome meeting in the early nineties during a lecture by Harry. It made me think and probably others too. My translation today is that repair/attachment of the pubo vesical fascia to the uterosacrals is important. When we realized the importance of the vagina resting on the...

How does a digital operating room improve quality of surgery ?

“Digital Operating Room” is used to suggest better surgery through a better surgical environment. In a recent article we discussed this in detail . –The basic “Digital operating room” integrates 1 operating room. This generally indicates that in 1 operating room endoscopic images can be shown to the surgeon on any screen in that room (routing and switching). In addition images from previous exams such as X-rays, or the patient file can be displayed for review by the surgeon. For the surgeon it is useful if more information is easily available. In addition most digital operating rooms offer the possibility of recording operating images, and of broadcasting surgery. The latter however, generally need dedicated assistance for conferencing. The underlying technology is similar to a television studio where a technician chooses which image of the several camera’s will be shown to the public. Since a (video) cable needs to connect every source and every screen with the broadband switch, this results in a bunch of cables and a rather static configuration with little intelligence. Indeed a new device or screen will need a new cable set of cables. - The advanced digital operating room integrates the hospital . Similar to the intranet of most hospitals, which connects every computer, printer etc with the computer room, the advanced digital operating room will use an internet platform to connect all devices from 1 or all operating rooms using the IT network of the hospital. The advantages and the differences from the older solution are obvious. Since many signals can be transported over 1 internet cable, this system needs only 1 cable instead...

Shiny Trinket

Shiny trinkets are shiny.