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   Table of Contents - Current issue
Coverpage
July-September 2022
Volume 11 | Issue 3
Page Nos. 139-191

Online since Friday, August 5, 2022

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EDITORIAL  

Establish the certification system of gynecologic endoscopists Highly accessed article p. 139
Chyi- Long Lee, Kuan- Gen Huang, Chi- Chang Chang
DOI:10.4103/gmit.gmit_75_22  
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PERSPECTIVE ARTICLE Top

Innovating to succeed in the now normal p. 141
Maria Antonia E. Habana
DOI:10.4103/gmit.gmit_20_22  
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REVIEW ARTICLE Top

Patient Safety in Hysteroscopic Procedure p. 145
Wachyu Hadisaputra, Cindikia Ayu Sholekha Hani, Nidya Annisa Putri
DOI:10.4103/gmit.gmit_144_21  
This article aims to explain about outpatient hysteroscopy, where this procedure is currently being carried out. However, this procedure is also widely chosen by patients, because of its convenience, fast procedure, minimal complications, and of course more economical than day-case hysteroscopy. Before taking the procedure, it is important to explain to the patient about the disease, therapy, and the procedure to be carried out. Consent needs to be obtained voluntarily. We searched related publications using “patient safety” and “office hysteroscopy” and “informed consent” and “medical procedure” and “patient safety” and “injury” and “operative hysteroscopy” as keywords. This search had considered articles that had been published between 2002 and 2021. The conclusion from this library is that patient's convenient and safety is the top priority of outpatient hysteroscopy. Outpatient hysteroscopy showed higher satisfaction results than day-case hysteroscopy. Because it is more comfortable, faster, patients can immediately return to their activities and of course more efficient.
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ORIGINAL ARTICLES Top

Risk factors associated with perineal and vaginal lacerations and vaginal removal in total laparoscopic hysterectomy p. 150
Kenro Chikazawa, Ken Imai, Hiroyoshi Ko, Naoki Ichi, Masahiro Misawa, Tomoyuki Kuwata
DOI:10.4103/gmit.gmit_118_21  
Objectives: This study aimed to identify risk factors associated with perineal and vaginal lacerations related to vaginal removal during total laparoscopic hysterectomy (TLH). Materials and Methods: We retrospectively assessed 134 patients who underwent TLH, of whom 44 (32.8%) had vaginal lacerations. Results: Univariate analysis revealed that for patients with myomas and adenomyosis, gonadotropin-releasing hormone agonist use and myomas with a transverse diameter of ≥5 cm were significant risk factors, while multiparity (vaginal delivery) was a protective factor for perineal and vaginal lacerations. Moreover, multivariate analysis indicated that multiparity was the only statistically significant protective factor. For cervical intraepithelial neoplasia, endometrial cancer, and endometrial hyperplasia, only a uterine transverse diameter of ≥5 cm was a significant risk factor for perineal or vaginal lacerations. Conclusion: For patients with large myomas, multiple vaginal delivery was a protective factor, and in patients with normal-sized uteri, a uterine transverse diameter of ≥5 cm was a risk factor for perineal or vaginal lacerations.
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Lin's Self-Retaining Abdominal Ultrasound Probe Method for Hands-Free Ultrasound-Guided Hysteroscopic Procedures: A Single-Operator Study p. 155
Bao- Liang Lin, Aizura- Syafinaz Adlan, Jerilee M K. Azhary
DOI:10.4103/gmit.gmit_52_21  
Objectives: Conventionally, an assistant would be required to hold the ultrasound probe during therapeutic hysteroscopy. To manage without a skilled assistant, Lin developed a self-retaining hands-free probe method that can be used to hold an abdominal ultrasound probe. One can now perform ultrasound-guided hysteroscopic procedures single-handedly. The purpose of this study is to report the successful development of a method to keep an abdominal ultrasound probe self-retained without an assistant's help. Materials and Methods: A technique derived from improvisation with available equipment. Results: The hands-free ultrasound probe was used successfully in 2680 cases needing therapeutic hysteroscopy management for various endometrial pathologies. We only encountered one case of latex allergy, which serves as a reminder to ask about latex allergy before the procedure. Upon notification, the handle can be improvised to a latex-free solution. Compression indentation marks were of negligible concern as they resolved spontaneously within 1–2 h postsurgery. We have used this method successfully and to good effect, particularly in guiding us to avoid uterine perforations during dilation of the cervix as well as during the therapeutic hysteroscopy surgery itself. This device facilitates efficient and safe therapeutic hysteroscopic surgeries. In addition, this method encourages the reuse and recycling of plastic water bottles. Conclusion: The usage of Lin's self-retaining ultrasound probe method is practical, cheap, and not dependent on an assistant's participation during procedures.
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Laparoscopic simulation training for residents in obstetrics and gynecology over 12 months p. 159
Ryan A Raffel, Joshua Fogel, Petr Itzhak
DOI:10.4103/gmit.gmit_85_21  
Objectives: As gynecology surgical cases are declining across the country, residency programs can benefit by training residents with simulation. We evaluate five Fundamentals of Laparoscopic Surgery (FLS) tasks over 12 months. Materials and Methods: This was a retrospective study of 16 obstetrics and gynecology residents. Residents practiced on a FLS simulation box trainer. They were evaluated on completion time and pass/fail performance for the five tasks of peg transfer, precision cutting, loop ligation, suture with extracorporeal knot, and suture with intracorporeal knot. Resident satisfaction with FLS simulation box training was evaluated. Results: We found improvement of reduced time from baseline to 12 months for the tasks of peg transfer, precision cutting, suture with extracorporeal knot, and suture with intracorporeal knot. No time improvement was noted for loop ligation. We only found increased passing rates for the precision cutting task from baseline to 12 months. Residents agreed that simulation training improves surgical skills, improves patient safety, and improves confidence level in the operating room. Conclusion: We found improvement of decreased time with FLS simulator box training for FLS tasks of peg transfer, precision cutting, suture with extracorporeal knot, and suture with intracorporeal knot. We recommend that routine practice with the FLS simulator box trainer will increase resident confidence level and potentially improve surgical outcomes when in the operating room. We recommend including a dedicated portion of the academic curriculum for simulation training. FLS box training can be an essential tool for residency programs in obstetrics and gynecology.
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A comparative analysis of nondescent vaginal hysterectomy, laparoscopy-assisted vaginal hysterectomy, and total laparoscopic hysterectomy for benign uterine diseases at a rural tertiary care center p. 164
Vaibhav Kanti, Vandana Verma, Mamta Singh, Soniya Vishwakarma, Nupur Mittal, NP Singh
DOI:10.4103/GMIT.GMIT_111_20  
Objectives: The aim of this study was to compare operative data and postoperative complications among nondescent vaginal hysterectomy (NDVH), laparoscopy-assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy (TLH) at a rural tertiary care center. Materials and Methods: This is a prospective analytical study, of 145 hysterectomies for benign conditions with or without salpingo-oophorectomy in women from 30 to 60 years, over 3 years from January 2016 to December 2019, with 60 cases of NDVH, 46 cases of LAVH, and 39 cases of TLH. The three groups were compared intraoperatively in terms of blood loss, operating time, and intraoperative complications and postoperative complications and postoperative duration of hospital stay. Results: There was no significant difference between the three groups in terms of age, parity, body mass index, and indications for hysterectomies. The mean operative time was significantly shorter (P = 0.000) in the NDVH group (54.67 ± 15.67 min) as compared to the LAVH (102.45 ± 10.53 min) and TLH (126.79 ± 8.7 min) groups. Intraoperative blood loss was greater (P = 0.000) in the TLH group (111.025 mL ± 20.8) as compared to the NDVH (59.50 mL ± 16.7) and LAVH (91.85 mL ± 10.66) groups. The intraoperative complications and postoperative complications were higher in the TLH group as compared to the LAVH and NDVH groups. The duration of hospital stay was almost similar in all the groups. Conclusion: NDVH may be the preferred approach for experienced surgeons, as it is less time-consuming, has a small amount of blood loss, and is a scarless surgery, whereas LAVH and TLH may be the preferred approaches in the cases of presence of adnexal masses and adhesions or whenever salpingo-oophorectomy is indicated.
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SHORT COMMUNICATION Top

Variations in procedures for ureterolysis with sharp dissection in minimally invasive hysterectomy p. 171
Yasuhito Tanase, Mayumi Kobayashi Kato, Masaya Uno, Mitsuya Ishikawa, Tomoyasu Kato
DOI:10.4103/gmit.gmit_129_21  
To safely perform minimally invasive hysterectomy (MIH), including laparoscopic hysterectomy and robot-assisted hysterectomy, partial ureterolysis, or visualizing only the ureter without dissection is often inadequate. Moreover, careless blunt dissection could injure the blood vessels. We present our surgical method for ureterolysis using sharp dissection during MIH. First, the outer portion of the ureter is dissected. Dissecting between the pelvic sidewall and the posterior leaf of the broad ligament creates a pararectal space outside the ureter, enabling the easy identification of the ureter running on the posterior leaf. Second, the inner portion of the ureter is dissected. After determining the location of the ureter, a better partial dissection of the ureter can be performed from the posterior leaf, instead of dissecting along the entire circumference. If fine surgery has to be performed, the ureter can be dissected by enclosing it within its sheath. We primarily perform dissections using a monopolar device, which allows a sharp dissection. Furthermore, in our method, we often include the dissection of the ureteral tunnel. It is important to understand the anatomy and membrane structure of the ureter in each patient and adjust the extent of ureterolysis based on individual differences.
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VIDEO ARTICLE Top

A Self-Made Bag-Assisted Laparoendoscopic Single-Site Surgery in Ovarian Teratomectomy during Pregnancy p. 174
Qing Li, Fang Fang, Chunhua Zhang
DOI:10.4103/gmit.gmit_19_22  
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CASE REPORTS Top

Primary pure large-cell neuroendocrine carcinoma of the ovary: A rare case report p. 176
Reena Yadav, Kanika Chopra, Nishtha Jaiswal, Shilpi Aggarwal
DOI:10.4103/gmit.gmit_105_21  
Primary pure large-cell neuroendocrine carcinoma is a rare entity with 17 cases reported till now. A 48-year-old, Para6 Live4, postmenopausal woman presented with complaints of pain abdomen, constipation for 6 months, and postmenopausal bleeding for 1 month. On per abdominal examination, an irregular, hard, fixed, and tender mass was felt in the pelvis corresponding to 32 weeks size gravid uterus. Her magnetic resonance imaging findings were suggestive of a large abdominopelvic mass of size 10.2 cm × 12.7 cm × 14.2 cm with inferior extension into the left adnexa and 3.1 cm × 2.2 cm × 2.1 cm right adnexal mass. Debulking surgery was done. The intraoperative findings were of a large abdominopelvic mass adhered to the sigmoid colon and retroperitoneal space. Histopathological and immunohistochemistry findings were suggestive of bilateral large-cell neuroendocrine carcinoma of ovaries with strong positive for Bcl2, CD56, NSE, PR, and P53. The patient was started on tablet etoposide as adjuvant treatment. After 5 months of primary surgery, contrast-enhanced computed tomography of the chest, abdomen, and pelvis revealed recurrence. She succumbed to her illness 6 months after primary surgery. Owing to its rarity and difficulty in diagnosis, it is suggested that all such cases should be registered at national level and critically analyzed to find the high risk and associated prognostic factors.
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Laparoscopic management of cesarean scar pregnancy after medical treatment failure using laparoscopic bulldog clamps p. 179
Maria Claudia Alzamora, Stella Lii Blosser
DOI:10.4103/GMIT.GMIT_19_21  
Cesarean scar pregnancies are a rare complication of pregnancy, with an incidence rate of approximately 1 in 2000 pregnancies. Numerous treatment alternatives have been proposed and published for cesarean scar pregnancies (CSPs), including medical management with local or systemic methotrexate injection, resection through hysteroscopic, vaginal, abdominal or laparoscopic approach, and dilation and curettage. Concomitant strategies for achieving hemostasis/bleeding control have been attempted, including uterine artery embolization, the placement of a Foley balloon catheter, injection of vasopressin, and less commonly reported, the use of vascular clamps. We describe a case of failed medical management of a CSP, followed by laparoscopic resection with the use of vascular clamps to minimize bleeding. This approach can be considered for minimizing blood loss in the laparoscopic management of cesarean ectopic pregnancies.
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Cellular leiomyoma versus endometrial stromal sarcoma: A report of a rare case presenting a diagnostic challenge on intraoperative frozen section p. 182
Charu Agarwal, Mukta Pujani, Varsha Chauhan, Raina Chawla, Anu Agarwal, Reetika Menia
DOI:10.4103/GMIT.GMIT_53_20  
Endometrial stromal sarcomas (ESSs) account for approximately 0.2% of all uterine malignancies. Cellular leiomyoma (CL) often simulates low-grade ESS due to similar cytology. We report the case of a 34-year-old female with a mass per abdomen. Frozen sections showed a tumor with many thin- and thick-walled vessels along with hyaline material. A differential diagnosis of CL and endometrial stromal tumor was suggested. The index case was diagnostically challenging to pathologists. Paraffin sections supplemented by immunohistochemistry (smooth muscle actin, CD10, and beta-catenin) favored CL. Frozen section sometimes leads to over/underestimation of tumor in view of small sampling area of tumor.
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Angiomyofibroblastoma of the Vulva p. 185
G Shilpa, Shivani Sharma, S R Raja Parthiban, Uzma Khan
DOI:10.4103/GMIT.GMIT_29_20  
Angiomyofibroblastoma (AMF) is a rare benign soft-tissue tumor that most frequently affects the lower genital tract of young to middle-aged women. It mainly consists of two components: stromal cells and prominent vasculature. Clinically, it is usually asymptomatic and resembles Bartholin's cyst. Although it is a benign tumor, cases with recurrence and sarcomatous transformation have been reported. Due to the overlapping of histopathological picture, diagnostic perplexity often arises between AMF and aggressive angiomyxoma (AAM). AMF being benign in nature is treated by local excision, whereas AAM is a more infiltrative lesion that has a higher tendency for local recurrence.
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CLINICAL IMAGE Top

A novel technique for applying interceed® in laparoscopic surgery: The triangle I-CEED method p. 188
Ken Imai, Kenro Chikazawa, Masahiro Misawa, Tomoyuki Kuwata
DOI:10.4103/gmit.gmit_86_21  
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LETTER TO EDITOR Top

An ectopic ovary: A unicornuate uterus with a rudimentary horn: Is there a connection? p. 190
Luay Ibrahim Abu Atileh, Mhd Anas Murad, Laith Kaylani, Abeer Hamdan
DOI:10.4103/gmit.gmit_82_21  
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