Abstract Introduction Operative morbidity of laparoscopic myomectomy largely relates to the potential for intraoperative blood loss. We sought to determine whether blood loss varies according to the menstrual cycle. Material and methods A retrospective study of 268 women who underwent a laparoscopic myomectomy from 2007 to 2012. Patients were categorized into five menstrual groups: follicular phase, luteal phase, oligomenorrheic or amenorrheic on hormonal therapy, postmenopausal or other. Patient and procedure characteristics were compared for the follicular phase group, luteal phase group, and hormonal therapy group. The estimated blood loss was compared across the five groups using a regression model. Results A total of 268 women underwent a laparoscopic myomectomy: 108 (40.3%) were in the follicular phase, 92 (34.3%) were in the luteal phase, 44 (16.4%) were on hormonal therapy, nine (3.4%) were postmenopausal, and 15 (5.6%) could not be classified. Baseline patient characteristics were similar between the groups with the exception of endometriosis. Geometric mean estimated blood loss was 91.9 mL in the follicular phase group, 108.7 mL in the luteal phase group, 114.1 mL in the hormonal therapy group, and 39.8 mL in the postmenopausal group. There was no significant difference in the geometric mean estimated blood loss when comparing the follilcuar phase, luteal phase, and hormonal phase groups ( p = 0.41). Upon adjusted multivariable analysis of all five menstrual groups, there was also no difference in estimated blood loss. Conclusions Intraoperative blood loss during laparoscopic myomectomy does not vary significantly with the phase of the menstrual cycle.
Autonomous robotic suturing has the potential to improve surgical outcomes compared to manual operations due to better accuracy and consistency of suture placement. In this letter, we develop an autonomous system with model-based planning and markerless tissue tracking techniques for autonomous vaginal cuff closure. The proposed planning method constructs an optimal suture plan that minimizes tissue collisions with the robotic suturing tool. Moreover, DeepLabCut is utilized for autonomous markerless soft-tissue tracking in robotic vaginal cuff closure. Furthermore, an instruction-based autonomous surgery interface (ASI) is designed to automate the complex suturing workflow. The proposed planning method is evaluated via a robotics simulator and real-world suture-placement tests. End-to-end vaginal cuff closure via Smart Tissue Autonomous Robot (STAR) on synthetic tissues was carried out and compared to the suturing results via conventional laparoscopic and robot-assisted approaches performed by experienced surgeons. The comparison results indicate that by using the proposed planning pipeline, STAR outperforms conventional laparoscopic and robotic-assisted methods with better accuracy and consistency, thus achieving a higher success rate of autonomous suture placement.
Hysterectomy (i.e., surgical removal of the uterus) requires severing the main blood supply to the uterus (i.e., the uterine arteries) while preserving the nearby, often overlapping, ureters. In this paper, we investigate dual-wavelength and audiovisual photoacoustic imaging-based approaches to visualize and differentiate the ureter from the uterine artery and to provide the real-time information needed to avoid accidental ureteral injuries during hysterectomies. Dual-wavelength 690/750 nm photoacoustic imaging was implemented during laparoscopic and open hysterectomies performed on human cadavers, with a custom display approach designed to visualize the ureter and uterine artery. The proximity of the surgical tool to the ureter was calculated and conveyed by tracking the surgical tool in photoacoustic images and mapping distance to auditory signals. The dual-wavelength display showed up to 10 dB contrast differences between the ureter and uterine artery at three separation distances (i.e., 4 mm, 5 mm, and 6 mm) during the open hysterectomy. During the laparoscopic hysterectomy, the ureter and uterine artery were visualized in the dual-wavelength image with up to 24 dB contrast differences. Distances between the ureter and the surgical tool ranged from 2.47 to 7.31 mm. These results are promising for the introduction of dual-wavelength photoacoustic imaging to differentiate the ureter from the uterine artery, estimate the position of the ureter relative to a surgical tool tip, map photoacoustic-based distance measurements to auditory signals, and ultimately guide hysterectomy procedures to reduce the risk of accidental ureteral injuries.
To our knowledge, the JH-GPS is among the first surgical prioritization tools with inclusion of gynecologic specificity, patient-centered considerations, and a numeric scoring system to help surgeons and hospital systems rank medically indicated, nonurgent procedures. Compared with existing systems, including the MeNTS tool [8Prachand VN Milner R Angelos P et al.Medically necessary, time-sensitive procedures: scoring system to ethically and efficiently manage resource scarcity and provider risk during the COVID-19 pandemic.J Am Coll Surg. 2020; S1072–7515: 30317-30323Google Scholar], the JH-GPS offers a more comprehensive array of prioritization criteria (Table 2) that may be more relevant to gynecologic surgery patients and their providers. Although the JH-GPS contains both evidence-based and common sense surgical prioritization elements that may already be in use, in part, by obstetrics and gynecology departments, the systematization of these elements allows for a more objective prioritization process that may help prevent disputes or avoid competition for resources among surgical services. In addition, it is the only tool incorporating the patient's perspective in the delay and rescheduling process, emphasizing the importance of shared decision-making between a patient and her physician. Furthermore, it also incorporates timely socioeconomic patient considerations. Given the rapid rise in US unemployment rates during the pandemic [14U.S. Department of Labor. The employment situation — April 2020. Available at: https://www.bls.gov/news.release/pdf/empsit.pdf. Accessed May 10, 2020.Google Scholar], the loss of insurance benefits may be a legitimate concern for patients.Table 2Comparison of the Medically Necessary, Time-Sensitive tool and Johns Hopkins Gynecologic Prioritization System in the coronavirus disease eraPrioritization criteriaMeNTS20209JH-GPS 2020SpecialtyAgnosticGynecologySurgery acuity tiersYesYesResource utilizationYesYesGynecology-specific criteria__YesPsychosocial/socioeconomic considerations—YesPatient comorbiditiesYesYesCOVID-19 status and/or riskYes__Numeric scoring systemYesYesCOVID-19 = coronavirus disease; GI = gastrointestinal; JH-GPS = Johns Hopkins Gynecologic Prioritization System; MeNTS = Medically Necessary, Time-Sensitive tool. Open table in a new tab
Abstract Uterine fibroids feature excessive deposition of types I and III collagen. Previous ex vivo studies showed an FDA-approved collagenase (EN3835)-digested types I and III collagen fibers in fibroid tissues; however, collagenase had not been evaluated in vivo for effects on uterine fibroids. The objective was to assess the safety and tolerability of collagenase injection directly into uterine fibroids. This was a prospective, open label, dose escalation study. The study participants were fifteen women aged 35–50 years with symptomatic uterine fibroids planning to undergo hysterectomy. Three subjects received saline and methylene blue, three subjects received a fixed dose of EN3835, and 9 subjects received stepped, increasing dosages of EN3835, all by transvaginal, ultrasound-guided injections. Primary outcome measures were safety and tolerability of the injection and change in collagen content between treated and control tissues. There were no significant adverse events following injection of EN3835 into uterine fibroids. Masson’s trichrome stains revealed a 39% reduction in collagen content in treated samples compared to controls ( p <0.05). Second harmonic generation (SHG) analysis showed treated samples to have a 21% reduction in density of collagen compared to controls. Picrosirius-stained collagenase-treated fibroids showed collagen fibers to be shorter and less dense compared to controls. Subjects reported a decrease in fibroid-related pain on the McGill Pain Questionnaire after study drug injection in Group 2 at both 4–8 days and 60–90 days post-injection. The findings indicated that injection of collagenase was safe and well tolerated. These results support further clinical investigation of collagenase as a minimally invasive treatment of uterine fibroids. NCT0289848.
