The objective of this study was to examine the ability of preoperative transvaginal ultrasound (TVS) scanning to assess the severity of pelvic endometriosis.Consecutive women with clinically suspected or proven pelvic endometriosis, who were booked for laparoscopy, were invited to join the study. The severity of endometriosis was assessed preoperatively using TVS and the findings were compared with the results obtained by laparoscopy using the American Society for Reproductive Medicine (ASRM) classification.In total, 201 women had preoperative TVS and laparoscopies. Of these, no endometriosis was found at laparoscopy for 62/201 (30.8%; 95% CI, 24.8-37.5), whereas 33/201 (16.4%; 95% CI, 11.9-22.2) had minimal endometriosis, 31/201 (15.4%; 95% CI, 11.1-21.1) had mild endometriosis, 27/201 (13.4%; 95% CI, 9.4-18.8) had moderate endometriosis and 48/201 (23.9%; 95% CI, 18.5-30.2) had severe endometriosis. The sensitivity and specificity of the TVS diagnosis of severe pelvic endometriosis were 0.85 (95% CI, 0.716-0.934) and 0.98 (95% CI, 0.939-0.994), respectively, and the positive and negative likelihood ratios were 43.5 (95% CI, 14.1-134) and 0.15 (95% CI, 0.075-0.295), respectively. Overall, there was a good level of agreement between ultrasound and laparoscopy in identifying absent, minimal, mild, moderate and severe disease (quadratic weighted kappa = 0.786). The mean ASRM score difference between TVS and laparoscopy in assessing severity of endometriosis was -2.398 (95% CI, -4.685 to -0.1112) and the limits of agreement were -34.62 (95% CI, -38.54 to -30.709) to 29.83 (95% CI, 25.91-33.74).TVS is a good test for assessing the severity of pelvic endometriosis. TVS is particularly accurate in detecting severe disease, which could facilitate more effective triaging of women for appropriate surgical care.
Laparoscopic surgery is progressing rapidly is becoming the normal route for many abdominal operations, even for major complex surgery. The integrated laparoscopic theatre is a state-of-the-art system in which the laparoscopic equipment and multiple flat-screen monitors are permanently installed to be operational on demand inside the theatre. These expensive systems are being widely adopted, however very little research has been published regarding which features of these systems are desired by the surgeons who use them. The study objective was to assess the strength of preference for key attributes of integrated laparoscopic theatres and to compare these preferences between Gynaecologists and General surgeons.This was an electronically distributed discrete choice experiment survey of British practicing Laparoscopic Gynaecologists and General Surgeons (Through The British Society of Gynaecology Endoscopy and The Association of Laparoscopic Surgeons of Great Britain and Ireland). An electronic survey was designed and pre-tested. This was then sent to practicing British Laparoscopic Gynaecologists and General-Surgeons. There were structured questions regarding the seven key attributes of integrated laparoscopic theatres in the standard form for a discrete choice experiment.Questionnaires from 167 respondents were analysed. One hundred three were gynaecologists and 64 were general-surgeons. Adjustable screens for height and position was the most favoured attribute and it is 4.7 times more desirable than the next most desirable attribute, which was a wire free floor. The least desirable features were piped CO2, ceiling-mounted-screens and external-transmission-of-images.Both groups favour adjustable screens for position and height above all the other features. These findings are in contrast with previous research, which showed that when asked to rank the attributes in order, gynaecologists chose ceiling mounted screens first and adjustable screens fourth. When asked to "trade off" attributes in the discrete choice experiment the adjustability of the screens became much more important than how the screens were mounted. With new wireless technology the benefits of a fully integrated theatre could be delivered with floor mounted systems at a considerably reduced cost. This information is important to manufacturers and purchasers of these systems in order to design cost effective ergonomic theatres that are fit for purpose.
Gynaecological operative laparoscopy has progressed significantly over the past two decades. The process of laparoscopic surgery should be based on an appropriate risk management system that allows for improved quality of care. Regarding women with severe endometriosis, specialist referral centres should be developed. Units performing laparoscopic surgery should adopt recommendations and guidelines from scientific bodies (RCOG, NICE, BSGE) and should benchmark their audited activity against the national standards. The main components for consideration when developing models of service in laparoscopic surgery include: gynaecology outpatients, pre-operative preparation, operative and post-operative. Laparoscopic training can be developed and augmented with the use of simulators or laparoscopic trainers. Laparoscopic surgery necessitates a team approach between surgical, nursing and technical support staff. Audit of length of stay, analgesia requirement, complication rate and re-admission rate help to redesign and configure the service.
The surgical management of uterine prolapse in women who wish to retain their uterus remains a challenge. Several techniques have been reported using open abdominal, laparoscopic and vaginal approaches. The laparoscopic approach offers both excellent intraoperative visualisation of supportive and adjacent structures and quick postoperative recovery. Currently, laparoscopic suspension of the uterus to the round ligaments, uterosacral ligaments, suture and synthetic mesh suspension to the sacral promontory have been reported. This report describes a new surgical technique of laparoscopic uterine suspension, which has been performed successfully in eight women. Mersilene tape is used to suspend the uterus to the sacral promontory bilaterally and to recreate new uterosacral ligaments.
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