The Journal of Minimally Invasive Gynecology RSS feed: Articles in Press. The Journal of Minimally Invasive Gynecology , formerly titled The Journal of the American Association of Gynecologic Laparoscopists, is an international clinical forum for the exchange and dissemination of ideas, findings and techniques relevant to gynecologic endoscopy and other minimally invasive procedures. The Journal, which presents research, clinical opinions and case reports from the brightest minds in gynecologic surgery, is an authoritative source informing practicing physicians of the latest, cutting-edge developments occurring in this emerging field http://www.jmig.org//inpress?rss=yesElsevier Inc.en © 2012 AAGL. Published by Elsevier Inc. All rights reserved. The Journal of Minimally Invasive Gynecology1553-46502012-05-10 © 2012 AAGL. Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.jmig.org/article/PIIS1553465012001070/abstract?rss=yesAbstract: Prevention of adhesions, whether de novo or by re-formation, is one of the most important and surprisingly neglected aspect of the treatment of endometriosis. Adhesions may cause infertility, dyspareunia, chronic pelvic pain but also intestinal obstruction and complications at subsequent surgery. They may play a role in the development of some forms of the disease such as ovarian endometriomas and possibly also deep invasive nodules. Three randomized controlled trials have been published documenting some partial success with Interceed, Oxiplex/AP gel or Adept solution in reducing adhesions extent at second look laparoscopy performed a few weeks after initial surgery. However, data on relevant long-term outcomes such as fertility, pelvic pain or disease recurrences or other adhesions-related complications is lacking. Noteworthy, endometriosis is a chronic inflammatory disorder and the insult causing adhesions is expected to persist after surgery. Therefore preventing adhesion formation with exclusively agents at the time of surgery may be insufficient. Future studies should focus on a 2-step strategy that includes measures applied at the time of surgery and subsequent administration of agents able to prevent the development of new adhesions.Adhesion Prevention in Endometriosis: A Neglected Critical Challenge - Corrected ProofEdgardo Somigliana, Paola Vigano, Laura Benaglia, Andrea Busnelli, Paolo Vercellini, Luigi Fedele10.1016/j.jmig.2012.03.004The Journal of Minimally Invasive Gynecology (2012)2012-05-10The Journal of Minimally Invasive Gynecology2012-05-10REVIEW ARTICLEhttp://www.jmig.org/article/PIIS1553465012001069/abstract?rss=yesAbstract: Study Objective: To estimate the long-term complication rate of office hysteroscopy with the vaginoscopic approach.Design: Retrospective cohort study (Canadian Task Force classification II-A).Setting: University-affiliated teaching hospital with outpatient hysteroscopy facilities.Patients: Between January 2005 and October 2007, all consecutive patients undergoing office hysteroscopy with the vaginoscopic approach were analyzed, 1028 procedures in total.Interventions: Therapeutic or diagnostic office hysteroscopy with the vaginoscopic approach. The complication registration of the gynecology department and a random sample of one third of the medical records were analyzed for long-term complications.Measurements and Main Results: Of the 1028 hysteroscopic procedures, 622 (60%) were diagnostic, 328 (32%) were therapeutic hysteroscopic procedures, and 78 (8%) procedures failed. In the complication registration and in the medical charts, 1 significant complication could be identified.Conclusions: Office hysteroscopy with the vaginoscopic approach is a safe procedure. This study showed an extremely low risk of long-term complications.Long-Term Complications of Office Hysteroscopy: Analysis of 1028 Cases - Corrected ProofT.C. van Kerkvoorde, S. Veersema, A. Timmermans10.1016/j.jmig.2012.03.003The Journal of Minimally Invasive Gynecology (2012)2012-05-07The Journal of Minimally Invasive Gynecology2012-05-07ORIGINAL ARTICLEhttp://www.jmig.org/article/PIIS1553465012001112/abstract?rss=yesAbstract: Study Objective: To assess changes in uterine and umbilical arteries during laparoscopy in human pregnancy.Design: Case series (Canadian Task Force classification III).Setting: University tertiary care referral center for high-risk pregnancy and minimally invasive surgery.Patients: Nine pregnant women who underwent first- and second-trimester laparoscopic surgery because of an adnexal mass.Intervention: Laparoscopic cyst enucleation or annessiectomy.Measurements and Main Results: No maternal complications and no miscarriages or adverse pregnancy outcome occurred. Mean (SD) gestational age at delivery was 39.1 (0.7) weeks, birth weight was 3390 (298) g, and Apgar score at 5 minutes was 9.6 (0.5). Mean uterine resistance index, umbilical artery pulsatility index, and fetal heart rate were measured using transvaginal ultrasonography at various times during surgery. Mean uterine resistance index and umbilical artery pulsatility index values remained constant during laparoscopy. Fetal heart rate was maintained in the normal range (120–160 bpm) but progressively decreased during the surgical procedure.Conclusion: In human pregnancy, laparoscopic techniques do not seem to modify uteroplacental perfusion evaluated using noninvasive ultrasonography.Adnexal Masses in Pregnancy: Fetomaternal Blood Flow Indices During Laparoscopic Surgery - Corrected ProofMassimo Candiani, Silvia Maddalena, Maurizio Barbieri, Stefano Izzo, Daniela Alberico, Stefania Ronzoni10.1016/j.jmig.2012.03.008The Journal of Minimally Invasive Gynecology (2012)2012-05-07The Journal of Minimally Invasive Gynecology2012-05-07ORIGINAL ARTICLEhttp://www.jmig.org/article/PIIS1553465012001124/abstract?rss=yesAbstract: Study Objective: To determine the incidence and clinical significance of iliohypogastric-ilioinguinal neuropathy from lower abdominal lateral port placement and fascial closure during laparoscopic gynecologic surgery.Design: Retrospective cohort study (Canadian Task Force classification II-2).Setting: University-based referral center specializing in minimally invasive gynecologic surgery and chronic abdominopelvic pain.Patients: Women who underwent a laparoscopic procedure because of benign gynecologic indications during a 3-year study period from 2008 to 2011. A total of 317 women met study criteria.Interventions: Operative laparoscopy using a lateral port in the lower abdomen. Closure of port-site fascial defects was achieved using either a Carter-Thomason or EndoClose suture device.Measurements and Main Results: Nerve injury was identified by symptoms, and was confirmed with a nerve block after a positive test for allodynia in the distribution of the iliohypogastric-ilioinguinal nerve. Of 173 cases that did not involve fascial closure of a port-site defect, none were associated with nerve injury. Of 144 cases that involved fascial closure, 7 (4.9%) included nerve injury that resulted in pain requiring treatment (p = .004). In 1 patient, symptoms improved with medical management alone. Six patients required surgical management, and 5 of them had resolution of pain after removal of the fascial suture. There was no statistically significant difference in the incidence of nerve injury between the Carter-Thomason and EndoClose groups (4.7% vs 5.4%; p = .87).Conclusions: There is an estimated 5% risk of clinically significant postoperative neuropathic pain due to injury of the iliohypogastric-ilioinguinal nerve with fascial closure of laparoscopic incisions in the lower abdomen. Pain seems to be due to suture entrapment of sensory fibers because it is usually resolved by removal of the suture. Prompt recognition and treatment may prevent subsequent development of chronic abdominopelvic pain.Abdominal Wall Nerve Injury During Laparoscopic Gynecologic Surgery: Incidence, Risk Factors, and Treatment Outcomes - Corrected ProofJa Hyun Shin, Fred M. Howard10.1016/j.jmig.2012.03.009The Journal of Minimally Invasive Gynecology (2012)2012-05-07The Journal of Minimally Invasive Gynecology2012-05-07ORIGINAL ARTICLEhttp://www.jmig.org/article/PIIS1553465012001021/abstract?rss=yesAbstract: We performed a search of PUBMED and MEDLINE for articles concerning surgical management of early stage endometrial cancer from 1950 to 2011. From the articles collected we extracted data such as estimated blood loss, operating room time, complications, conversion to laparotomy, and length of hospital stay. Forty-seven relevant sources were analyzed. The patients in the laparoscopy group had less blood loss, fewer complications, longer operating room times, and a shorter length of stay. Lymph node count was similar in both groups. Although obesity is not a contraindication to laparoscopy, it does lead to a higher conversion rate. Route of surgical treatment had no impact on recurrence or survival. Robotic surgery has significant advantages over laparotomy, but advantages over laparoscopy are not as distinct. Laparoscopic hysterectomy offers several advantages over laparotomy. These advantages relate to improvements in patient care with comparable clinical outcome. After careful analysis we believe laparoscopy should be the standard of care for surgical management of early stage endometrial cancer.Laparoscopy for the Management of Early-Stage Endometrial Cancer: From Experimental to Standard of Care - Corrected ProofUchenna C. Acholonu, Shao-Chun R. Chang-Jackson, A. Reza Radjabi, Farr R. Nezhat10.1016/j.jmig.2012.02.006The Journal of Minimally Invasive Gynecology (2012)2012-05-01The Journal of Minimally Invasive Gynecology2012-05-01REVIEW ARTICLEhttp://www.jmig.org/article/PIIS155346501200101X/abstract?rss=yesAbstract: From August 2010 to June 2011, 10 consecutive patients underwent transvaginal NOTES of the adnexa, including tubal sterilization in 3, salpingectomy because of ectopic pregnancy in 3, and ovarian tumor enucleation in 4. The mean (SD; 95% CI) age of the patients was 34.8 (9.7; 27.9–41.8) years, and their body mass index was 21.6 (2.8; 19.4–23.8). In 9 of the 10 patients, the procedure was completed. The 3 tubal sterilization procedures were completed in 18 to 30 minutes, with negligible blood loss. Operative time for the 3 salpingectomies because of ectopic pregnancy was 62 to 116 minutes. One of these procedures included management of 2000 mL hemoperitoneum. Three of the 4 attempts at ovarian enucleation were successfully completed within 64 to 162 minutes, with estimated blood loss ≤50 mL. One NOTES procedure failed because of a misdiagnosed peritoneal mucinous tumor located anterior to the uterus and inaccessible, leading to subsequent conversion to transabdominal laparoscopy. Our preliminary results show that purely transvaginal NOTES is feasible and safe for use in performing uterine adnexal procedures in selected patients. However, the procedure cannot be used in patients with cul-de-sac disease, and could have limited use in treating lesions located anterior to the uterus.Transvaginal Natural-Orifice Transluminal Endoscopic Surgery (NOTES) in Adnexal Procedures - Corrected ProofChyi-Long Lee, Kai-Yun Wu, Hsuan Su, Shir-Hwa Ueng, Chih-Feng Yen10.1016/j.jmig.2012.02.005The Journal of Minimally Invasive Gynecology (2012)2012-03-19The Journal of Minimally Invasive Gynecology2012-03-19INSTRUMENTS AND TECHNIQUEShttp://www.jmig.org/article/PIIS1553465012000556/abstract?rss=yesAbstract: Study Objective: To determine feasibility and efficacy of direct aspiration endometrial biopsy via the fluid channel of a flexible diagnostic hysteroscope.Design: Retrospective review (Canadian Task Force classification II-3).Setting: Abnormal uterine bleeding clinic in a tertiary care center.Patients: All women who underwent direct aspiration endometrial biopsy from January 2007 through August 2011 via a flexible diagnostic hysteroscope because traditional office-based endometrial biopsy using a suction piston device was not technically possible.Interventions: Diagnostic hysteroscopy followed by direct aspiration endometrial biopsy, accomplished by applying suction to the fluid channel of a 3.1-mm flexible diagnostic hysteroscope via a 10-mL syringe. The hysteroscope tip was agitated within the uterine cavity to obtain a tissue sample.Measurements and Main Results: The median age of the 32 identified patients was 50 years; 18 women (56%) were nulliparous, and 10 (31%) were postmenopausal. Thirty-one patients underwent hysteroscopy/direct aspiration biopsy because of abnormal uterine bleeding or postmenopausal bleeding. The vaginoscopic approach was used in 19 patients (59%). Indications for direct aspiration endometrial biopsy included cervical stenosis, inability to pass the endometrial biopsy instrument into the uterine cavity, and patient intolerance of endometrial biopsy. Adequate endometrial samples were obtained in 28 patients (87.5%). In 3 of 4 patients in whom direct aspiration endometrial biopsy did not provide sufficient tissue, hysteroscopy revealed an atrophic-appearing endometrium. The direct aspiration endometrial biopsy diagnosis was confirmed in 5 of 7 patients who subsequently underwent dilation and curettage or hysterectomy.Conclusion: Direct aspiration endometrial biopsy is a simple and effective endometrial sampling method when traditional office-based endometrial biopsy is not feasible. Further prospective studies including larger populations are needed to confirm these results.Direct Aspiration Endometrial Biopsy Via Flexible Hysteroscopy - Corrected ProofDaniel M. Breitkopf, Matthew R. Hopkins, Shannon K. Laughlin-Tommaso, Douglas J. Creedon, Abimbola O. Famuyide10.1016/j.jmig.2012.02.002The Journal of Minimally Invasive Gynecology (2012)2012-03-15The Journal of Minimally Invasive Gynecology2012-03-15ORIGINAL ARTICLE