PURPOSE OF REVIEW:Climate change has immediate impacts on women's health. Hospitals and operating rooms are large contributors to greenhouse gas (GHG) emissions and waste. This article will review current green initiatives designed to minimize environmental impact in the operating room and highlight areas for future improvement. RECENT FINDINGS:From a materials perspective, reusable goods result in less GHG emissions while being just as efficacious, well tolerated, and easy to use. Materials should be opened judiciously, only as necessary. Processing regulated medical waste produces greater GHG emissions, so waste should be properly sorted, and items which are not biohazard waste should be processed separately. Choosing appropriate anesthesia and utilizing an 'off' setting, in which operating rooms are shut down when not in use, can also drastically decrease the environmental impact of surgery. Further research is needed to determine effective implementation in hospitals. SUMMARY:This article summarizes current attempts to make operating rooms more sustainable. Many practices result in a decreased carbon footprint and cost savings without adversely affecting patient outcomes. Gynecologic surgeons and the hospitals in which they practice need to focus on implementing these changes in a timely fashion.

Gynecologic surgery outcome research during the SARS-CoV-2 (COVID-19) pandemic is lacking. There exists limited investigation regarding the impact of mental health, social support, and socioeconomic status on gynecology patients during the pandemic.

Objective:To establish descriptive observations associated with prolonged hospitalization after laparoscopic hysterectomy prior to the implementation of a department-wide Enhanced Recovery After Surgery protocol.Methods:A retrospective cohort study at three academic affiliated hospitals in the southeastern United States was conducted evaluating length of hospitalization by patient, surgical, and physician factors for 384 patients who underwent total laparoscopic hysterectomy, laparoscopic assisted vaginal hysterectomy, and robotic assisted total laparoscopic hysterectomy for benign conditions by general and subspecialized gynecologists from 2010 to 2015.Results:Among 384 patients, 19.5% experienced prolonged hospitalization, defined as greater than one day. After adjusting for covariates, robotic assisted total laparoscopic hysterectomy (aOR 3.13), dietary restrictions on postoperative day 1 (aOR 4.42), postoperative nausea or vomiting (aOR 2.01), and postoperative complications (aOR 3.58) were associated with prolonged hospitalization.Conclusion:Data from this study were collected prior to implementation of department-wide enhanced recovery after surgery protocols and highlights areas for improvement. Implementation of specific aspects of these protocols, including aggressive prevention of postoperative nausea and vomiting and early feeding, are easily made changes which may help to effectively decrease length of stay after laparoscopic hysterectomy. Patient and provider education on enhanced recovery protocols is also key to reducing length of stay.

BACKGROUND AND OBJECTIVES:Vaginal cuff dehiscence may be a vascular-mediated event, and reports show a higher incidence after robot-assisted total laparoscopic hysterectomy (RATLH), when compared with other surgical routes. This study was conducted to determine the feasibility of using laser angiography to assess vaginal cuff perfusion during RATLH.METHODS:This was a pilot feasibility trial incorporating 20 women who underwent RATLH for benign disease. Colpotomy was made with ultrasonic or monopolar instruments, whereas barbed or nonbarbed suture was used for cuff closure. Time of instrument activation during colpotomy was recorded. Images were captured of vaginal cuff perfusion before and after cuff closure. Reviewers evaluated these images and determined areas of adequate cuff perfusion.RESULTS:Indocyanine green (ICG) was visible at the vaginal cuff in all participants. Optimal dosage was determined to be 7.5 mg of ICG per intravenous dose. Mean time to appearance for ICG was 18.4 ± 7.3 s (mean ± SD) before closure and 19.0 ± 8.7 s after closure. No significant difference (P = .19) was noted in judged perfusion in open cuffs after colpotomy with a monopolar (48.9 ± 26.0%; mean ± SD) or ultrasonic (40.2 ± 14.1%) device. No difference was seen after cuff closure (P = .36) when a monopolar (70.9 ± 21.1%) or ultrasonic (70.5 ± 20.5%) device was used. The use of barbed (74.1 ± 20.1%) or nonbarbed (66.4 ± 20.9%) sutures did not significantly affect estimated closed cuff perfusion (P = .19). Decreased cuff perfusion was observed with longer instrument activation times in open cuffs (R2 = 0.3175).CONCLUSION:Laser angiography during RATLH allows visualization of vascular perfusion of the vaginal cuff. The technology remains limited by the lack of quantifiable fluorescence and knowledge of clinically significant levels of fluorescence.

STUDY QUESTIONCan the baboon uterus support a gestation to livebirth with an angiosome using microsurgically anastomosed utero-ovarian vessels and lacking uterine arteries and veins?SUMMARY ANSWEROur angiosome model allows healthy livebirth albeit with risk of fetal growth restriction and stillbirth.WHAT IS KNOWN ALREADYUterine transplant can provide livebirth in humans, but requires a living donor to undergo a prolonged laparotomy for hysterectomy. In an attempt to avoid the time-consuming dissection of the uterine vein, our group has previously shown maintenance of baboon uterine menstrual function after ligation of the uterine vein and after ligation of both the uterine artery and uterine vein.STUDY DESIGN, SIZE, DURATIONIn a 19-month timespan, three baboons underwent laparotomy to surgically alter uterine perfusion, and pregnancy outcomes were monitored after spontaneous mating in a breeding colony.PARTICIPANTS/MATERIALS, SETTING, METHODSThree nulligravid female Papio hamadryas baboons in a breeding colony underwent laparotomy to ligate uterine arteries and veins along with colpotomy and cervico-vaginal anastomosis. During the same surgery, the utero-ovarian arteries and veins were microsurgically transected and re-anastomosed to themselves. Intraoperative organ perfusion was confirmed with laser angiography. After a recovery period, monitoring of menstrual cycling via menstrual blood flow and sex-skin cycling occurred, as well as uterine viability via sonography and cervical biopsy. Each baboon was released to the breeding colony for spontaneous mating and pregnancies dated by menstrual calendar and compared with early ultrasound. Delivery outcomes were monitored in each including neonate weight and placental pathology. In the event of a stillbirth, the animal was returned to the breeding colony for repeat mating attempts. After achieving a livebirth, the maternal baboon was removed from the study.MAIN RESULTS AND THE ROLE OF CHANCEEach baboon in the trial underwent successful surgery with all uteri demonstrating viability and return of menstrual function within 10 weeks of surgery. Pregnancies occurred within two menstrual cycles in breeding colony. Baboons one and two initially had vaginal breech stillbirths, both with appearance of placental insufficiency, and one with fetal growth restriction. Baboon three underwent scheduled cesarean delivery resulting in a normally grown livebirth. Baboon one had a subsequent pregnancy resulting in a livebirth via cesarean delivery.LIMITATIONS, REASONS FOR CAUTIONStillbirth in two of four gestations, and fetal growth restriction in one of four, are the largest concerns in our perfusion model. It remains uncertain whether the stillbirths resulted from placental insufficiency, or birth trauma from breech deliveries.WIDER IMPLICATIONS OF THE FINDINGSThe success of two livebirths warrants further attempts at improving consistency of our proposed uterine angiosome. This may allow living uterine donors to undergo less-invasive and shorter donor hysterectomy procedures.STUDY FUNDING/COMPETING INTEREST(S)The study had no external sponsors, and was supported by the Cleveland Clinic Foundation. Some equipment was loaned without cost to the research team including a laser angiography system courtesy of Novadaq Technologies, Inc. (Missaugua, ON, Canada) and a surgical microscope courtesy of DB Surgical (Coral Springs, FL, USA). B.B., K.A., M.S., K.R., M.M., P.F.E., A.T. and T.F. have no conflicts of interest. M.L.S. and S.Z. report activity as consultants for Medtronic-Covidien, and S.Z. also is a consultant to Applied Medical.

Study ObjectiveTo describe the type and quantity of bacteria found intraoperatively on the abdomen, vagina, surgical gloves, instrument tips, and uterus at distinct time points during total laparoscopic hysterectomy (TLH).DesignObservational study (Canadian Task Force classification III).SettingAcademic affiliated hospital.PatientsThirty-one women undergoing TLH for benign indications in 2016.InterventionsAfter antibiotic prophylaxis and chlorhexidine preparation, swabs were collected from the vaginal fornices and abdomen. During subsequent TLH, additional swabs were collected from the following sites: surgeon's gloves after placement of the uterine manipulator, tips of instruments used to close the vaginal cuff, uterine fundus after extraction, and surgeon's gloves after removal of the uterus. A calibrated loop was used to inoculate each specimen onto 5% blood and chocolate agars for growth of aerobes and onto Brucella blood, phenylethyl alcohol, kanamycin vancomycin, and Bacteroides bile esculin agars for growth of anaerobes. Manual colony counts were tabulated for all positive cultures and reported in colony-forming units per milliliter (CFU/mL).Measurements and Main ResultsAnaerobic growth was not seen on the instrument tips, in the vagina, or on the abdomen of any patient. Aerobic bacterial growth was not seen in the vagina of any patient. On the surgeon's gloves after uterine manipulator placement, no patients demonstrated sufficient bacterial growth to potentially cause surgical site infection (≥5000 CFU/mL). On the surgeon's gloves following uterine extraction, 1 patient demonstrated sufficient growth to potentially cause infection. None of the patients developed surgical site infections postoperatively.ConclusionCultures from multiple operative sites yielded bacterial growth, but the bacterial concentrations did not exceed the threshold for infection in 98.9% of cultures. Given absent growth from vaginal cultures and rare growth from abdominal cultures, chlorhexidine gluconate 4% is considered an appropriate surgical preparation for use in laparoscopic hysterectomy.

Study ObjectiveUterine transplantation has proven feasible since the first live birth reported in 2014. To enable attachment of the uterus in the recipient, long vascular pedicles of the uterine and internal iliac vessels were obtained during donor hysterectomy, which required a prolonged laparotomy to the living donors. To assist further attempts at uterine transplantation, our video serves to review literature reports of internal iliac vein anatomy and demonstrate a laparoscopic dissection of cadaver pelvic vascular anatomy.DesignObservational (Canadian Task Force Classification III).SettingAcademic anatomic laboratory. Institutional Review Board ruled that approval was not required for this study.InterventionLiterature review and laparoscopic dissection of cadaveric pelvic vasculature, focusing on the internal iliac vein.Measurements and Main ResultsAlthough the internal iliac artery tends to have minimal anatomic variation, its counterpart, the internal iliac vein, shows much variation in published studies 1, 2. Relative to the internal iliac artery, the vein can lie medially or laterally. Normal anatomy is defined as some by meeting 2 criteria: bilateral common iliac vein formed by ipsilateral external and internal iliac vein at a low position and bilateral common iliac vein joining to form a right-sided inferior vena cava [2]. Reports show 79.1% of people have normal internal iliac vein anatomy by these criteria [2]. The cadaver dissection revealed internal iliac vein anatomy meeting criteria for normal anatomy.ConclusionUnderstanding the complexity and variations of internal iliac vein anatomy can assist future trials of uterine transplantation.

A 15-year-old nulligravida female underwent laparoscopic ovarian cystectomy for an incidentally discovered complex ovarian mass. At surgery, the intact cyst was retrieved in a bag, ensuring no intraperitoneal spillage occurred. Pathology revealed a mature cystic teratoma (MCT) (Fig. 1). Sixteen months later the patient presented with pain and a palpable soft tissue mass in the left upper quadrant, just beneath a laparoscopic port site. Magnetic resonance imaging showed a recurrent abdominal wall MCT (Fig. 2). En bloc excision of the mass was performed (Fig. 3, Fig. 4), and pathology was again consistent with MCT. Fig. 2T2 weighted magnetic resoance image demonstrating a heterogeneous extraperitoneal mass (arrow) located between the internal oblique and tranversus abdominis muscles. View Large Image Figure Viewer Download Hi-res image Fig. 3Intraoperative image of recurrent MCT at left upper quadrant laparoscopic port site. View Large Image Figure Viewer Download Hi-res image Fig. 4Recurrent MCT contained cystic components, solid components, and hair (arrow). View Large Image Figure Viewer Download Hi-res image

Objective To assess, in two separate groups of baboons, uterine viability after ligation of the uterine veins and uterine viability after ligation of both the uterine arteries and veins, respectively. Design Prospective, observational study. Setting Baboon breeding colony. Animal(s) Six naïve female Papio hamadryas baboons with indicators of normal reproductive function. Intervention(s) Three baboons underwent surgical interruption of the uterine veins bilaterally, and three baboons underwent surgical interruption of the uterine arteries and the uterine veins bilaterally. All baboons also underwent colpotomy, cervico-vaginal reanastomosis, and intraoperative near-infrared fluorescence imaging after vessel ligation. In the postoperative period, transabdominal sonography, vaginoscopy, and endocervical biopsy were performed on all animals. Main Outcome Measure(s) Postoperative uterine and ovarian viability. Result(s) Near-infrared imaging confirmed intraoperative perfusion of the uterus and cervico-vaginal anastomosis in all cases. In all subjects, sonography revealed normal uteri, and vaginoscopy revealed well-healed anastomoses. Endocervical biopsies (five of six) demonstrated pathologically normal endocervical tissue without evidence of necrosis. Cyclical sex skin turgescence and menstruation were unanimously observed. Conclusion(s) Disruption of bilateral uterine vessels does not affect uterine or ovarian viability in the baboon. Bilateral uterine artery and vein ligation furthers development of a minimally invasive approach to donor hysterectomy.

To determine uterine and ovarian viability with microsurgical anastomoses of utero-ovarian vessels alone in a baboon model for translation to future human uterine transplantation efforts. Prospective observational study of uterine and ovarian viability in Papio hamadryas baboons with surgically-altered uterine perfusion. Three baboons underwent laparotomy to alter uterine perfusion. Bilateral uterine arteries and veins were surgically ligated. A circumferential colpotomy was made and repaired. One utero-ovarian artery and vein were identified on each side, divided, and re-anastomosed end-to-end using a microsurgical technique. Intra-operative perfusion of the uterus was documented with near-infrared perfusion angiography. Resumption of menstrual blood flow with appearance of uterus on transabdominal ultrasound and cervical biopsies performed 6-10 weeks post-laparotomy showed viability of the uterus, while cyclical changes of the sex skin demonstrated continued ovarian function. All surgeries occurred without incident, and near-infrared perfusion angiography confirmed intra-operative uterine perfusion after completion of microsurgical anastomoses. One baboon acquired cellulitis of the skin incision which resolved with antibiotics. Trans-abdominal ultrasound confirmed presence of uterus in all animals 6-10 weeks after surgery, and simultaneous cervical biopsies verified normal cervical tissue. Within the first 60 days post-laparotomy, all animals demonstrated at least one menstrual bleed, and cyclical pattern of sex-skin changes in accordance with normal baboon physiology. The baboon uterus can be adequately perfused by bilateral microsurgical anastomosis of the utero-ovarian vessels in the absence of the uterine artery and veins, and cervico-vaginal vessel branches. This technique did not disrupt ovarian function and shows promise for future human transplantation trials to occur without meticulous uterine artery and vein dissection, and instead to rely solely on utero-ovarian vasculature.

To contribute to a novel surgical approach for uterine transplantation by assessing uterine viability after interruption of the bilateral uterine arteries and veins in a baboon model. Prospective observational study of uterine viability in Papio hamadryas baboons undergoing surgical interruption of the bilateral uterine arteries and veins. Three baboons underwent laparotomy during which uterine arteries and veins were isolated, ligated, and transected bilaterally. A circumferential colpotomy was made and the cervix was reattached to the vagina. Intra-operative perfusion of the uterus and the cervico-vaginal junction was documented with near-infrared perfusion angiography following intravenous administration of indocyanine green dye. Postoperatively the animals were monitored for resumption of menses and changes in sex skin turgescence. All baboons underwent transabdominal ultrasonography, vaginoscopy, and cervical biopsy 7 weeks post-laparotomy. Surgeries were performed without complication and intraoperative near-infrared angiography in all cases confirmed prompt blood flow throughout the entire uterus and along the cervico-vaginal anastomosis. Recovery of all animals was also uncomplicated. A normal appearing uterus with a thin and homogenous endometrial stripe was visualized on ultrasound performed 7 weeks after surgery in all subjects. Post-operative vaginoscopy permitted visualization of well approximated cervico-vaginal anastomoses and cervical biopsies revealed normal cervical tissue without evidence of necrosis. For each of the baboons, the first post-operative menstrual bleed occurred within 30 days of surgery and lasted for 2-3 days, consistent with normal baboon menses. Sex skin turgescence occurred in predictable cyclic patterns postoperatively, in accordance with each baboon’s respective menstrual cycle. Histopathology results, ultrasound imaging, and resumption of menstrual cycles demonstrated postoperative uterine viability in all 3 baboons, establishing that bilateral uterine artery and vein ligation does not affect uterine function. The surgical technique of interrupting uterine vasculature, combined with disconnection and reanastamosis of the cervix and vagina, is designed to simulate implantation of a donor uterus that is connected to the recipient exclusively by utero-ovarian vessels. Eliminating dissection of the uterine artery and vein from donor hysterectomy shows great potential for future human uterine transplant trials, as it offers a more efficient, less risky, and less technically challenging technique to live donor uterus procurement.

To assess uterine viability after disruption of the uterine vein (UV) for the purpose of uterine transplant. Prospective observational study of three female Papio hamadryas baboons undergoing interruption of the UV, cervical detachment and repair. Three baboons underwent laparotomy during which the uterine arteries and veins were isolated and the UV was ligated and transected bilaterally. Colpotomy was performed and the cervix was reanastomosed to the vaginal cuff. Following this, Indocyanine green (ICG) was administered and the SPY Elite imaging system (Novadaq Tech Inc.) documented vascular perfusion of the uterus and the cervicovaginal (CV) junction in real time. 6 weeks postoperatively, the subjects underwent transabdominal sonography, vaginoscopy and endocervical biopsy. The baboons were released into the primate colony and observed. Three baboons underwent uncomplicated suture ligation and transection of the left and right uterine vein followed by colpotomy with cervicovaginal anastomosis. Near-infrared perfusion confirmed blood flow throughout the uterus and CV anastomosis in all cases. The operative time was 115 ± 20 min. On transabdominal ultrasound 6 weeks postoperatively, a normal appearing uterus was visualized in all subjects and vascular color flow was confirmed at both ovarian and uterine vascular insertions. Vaginoscopy showed a well-healed CV anastomosis and all endocervical biopsies showed non necrotic tissue. Postoperatively, cyclical sex skin turgescence and menstruation was observed in all animals between 7 and 13 days and they continued normal menstrual cycles since. In published series of uterine transplantation, the UV was dissected from the internal iliac vein to the uterus. This was responsible in part for the lengthy surgical intervention in the donor. In this alternative approach, where the UV was ligated, the uterus remains viable through the uterine artery and uteroovarian vessels with venous drainage only through the uteroovarian vein. All baboons developed sex skin turgescence, deturgescence and menstruation in the average time expected for a baboon menstrual cycle [1]. This suggests that disruption of UV and reanastomosis of the cervix did not hinder the baboon's ability to continue normal menstruation. Intraoperative uterine perfusion was confirmed by near-infrared perfusion. A limitation of the study is that the syngeneic experimental condition with no immunosuppression did not test a true uterine transplant surgery, though this has been successfully performed in the human [2]. If the donor procedure for uterine transplant could be simplified by avoiding dissection of the UV and instead, using the uteroovarian vein for venous outflow, this could facilitate the technique and shorten surgical time for live donors.

A prospective study was performed to determine whether the Centers for Disease Control (CDC) risk factors for hepatitis B are reliable predictors of the hepatitis B surface antigen carrier state in an obstetric population. At their initial obstetric visit, 1466 consecutive patients had their serum screened for hepatitis B surface antigen by radioimmunoassay. During the initial interview, the physician obtained information regarding the presence of any of the CDC risk factors for hepatitis B (ethnicity or history of venereal disease, blood transfusion, hepatitis exposure, hepatitis, drug abuse, or occupational exposure). Twelve women were found to have positive hepatitis B surface antigen, for a prevalence of 0.82%. Six of these 12 had risk factors. Five had high-risk ethnic background, two of whom also had a history of hepatitis. One health care worker, a nurse, was also positive for hepatitis B surface antigen. The other six patients had no recognized risk factors. If hepatitis B surface antigen had been evaluated according to the CDC risk-factor guidelines, half of hepatitis B surface antigen-positive patients would not have been identified.