Study Objective The objectives of this video are to reinforce important principles of retraction for laparoscopy and demonstrate their application. Design This is a video compilation of several surgeries. Setting These surgeries were performed at a single academic center Patients or Participants Participants were patients undergoing surgery at our hospital Interventions N/A. Measurements and Main Results N/A. Conclusion Three fundamental principles of teaching surgical retraction are clear communication, maintaining tissue tension, and maximizing exposure. Standardized directional language should be used while performing and teaching surgery. Here we reinforce the above concepts and introduce standardized retraction language in order to optimize retraction in laparoscopic surgery.

Interventions: Office hysteroscopic polyp excision with concomitant transcervical ureteral stone basket

Study ObjectiveThe objectives of this video are to highlight the fundamentals of laparoscopic myomectomy for postgraduate learners, and to describe a low fidelity simulation model for fibroid enucleation during straight stick laparoscopic myomectomy.DesignSurgical simulation pilot.SettingSurgical simulation lab with use of laparoscopic box trainer.Patients or ParticipantsFeedback on the simulation model was obtained from 2 fellowship trained minimally invasive gynecologic attending surgeons (MIGS) and 17 OB/GYN residents evenly distributed across post-graduate year.InterventionsUsing the described model, we assessed user experience and face validity via pre- and post-tests.Measurements and Main ResultsOn post-test, 94% of post-graduate learners felt the tactile feedback on the fibroid to be realistic or very realistic. 100% felt starting the plane of enucleation to be realistic or very realistic. 88% felt as though the density of fibroid and number of tenaculum tear-offs was realistic or very realistic. Lastly, 94% of participants felt peeling fibers from the fibroid to be realistic or very realistic. Difficulties with the injection of vasopressin and excess mobility of the uterus during enucleation were cited as points for improvement. After the simulation, 76% felt comfortable or very comfortable with creating the hysterotomy and identifying the correct plane for enucleation as compared to 29% prior. Similarly, 82% of learners felt comfortable or very comfortable with enucleation via traction-counter traction approach as compared to only 35% prior.ConclusionThis proposed low-fidelity model for laparoscopic myomectomy realistically simulated the fundamental steps of fibroid enucleation and served as a promising method to teach the nuances of haptic feedback on pilot testing. As no historical data is available, in future studies we aim to measure construct validity with predictive validation techniques in a cohort of attending surgeons, MIGS fellows, and OB/GYN residents across several sites.

Study Objective In the past decade, recognition of late onset endometrial ablation failures - generally resulting from intra-uterine scarring around residual or recovered endometrium - has increased interest in alternative treatments for heavy menstrual bleeding, such as partial ablation. This video presents the history of this uncommon procedure, a case series, and a demonstration of our preferred technique. Design This retrospective case series illustrates operative indications and limited outcomes with an average of 1.4 years of follow-up. The surgical video demonstrates principles for a safe and effective procedure. Setting Minimally invasive gynecologic sub-specialty group within a suburban community teaching hospital system. Patients or Participants From 2010-2019, 11 of 132 (8%) patients identified by billing procedure codes met inclusion criteria that a partial endometrial ablation was performed for heavy menstrual bleeding. Interventions A 9mm bipolar resectoscope was used to remove 50-65% of the endometrium and superficial myometrium (at least 4mm depth), including the anterior or posterior surface and the lateral walls. Any concomitant focal pathology was also removed. Measurements and Main Results Seven of 11 patients were 45 years old or younger. All patients declined or failed hormonal therapies and declined hysterectomy. Operative time averaged 45 minutes. There were no intraoperative or postoperative complications. Of 9 patients with at least 1 year of follow-up, 6 reported eumenorrhea. Ultimately 3 of 11 patients underwent or desired hysterectomy to date. Conclusion This video reviews the limited literature and one center's experience with partial resectoscopic endometrial ablation as an alternative to global ablation and includes a demonstration of proper technique. In the past decade, recognition of late onset endometrial ablation failures - generally resulting from intra-uterine scarring around residual or recovered endometrium - has increased interest in alternative treatments for heavy menstrual bleeding, such as partial ablation. This video presents the history of this uncommon procedure, a case series, and a demonstration of our preferred technique. This retrospective case series illustrates operative indications and limited outcomes with an average of 1.4 years of follow-up. The surgical video demonstrates principles for a safe and effective procedure. Minimally invasive gynecologic sub-specialty group within a suburban community teaching hospital system. From 2010-2019, 11 of 132 (8%) patients identified by billing procedure codes met inclusion criteria that a partial endometrial ablation was performed for heavy menstrual bleeding. A 9mm bipolar resectoscope was used to remove 50-65% of the endometrium and superficial myometrium (at least 4mm depth), including the anterior or posterior surface and the lateral walls. Any concomitant focal pathology was also removed. Seven of 11 patients were 45 years old or younger. All patients declined or failed hormonal therapies and declined hysterectomy. Operative time averaged 45 minutes. There were no intraoperative or postoperative complications. Of 9 patients with at least 1 year of follow-up, 6 reported eumenorrhea. Ultimately 3 of 11 patients underwent or desired hysterectomy to date. This video reviews the limited literature and one center's experience with partial resectoscopic endometrial ablation as an alternative to global ablation and includes a demonstration of proper technique.

The objective of this video is to describe and demonstrate the use of a low-cost simulation model created for teaching dissection of an obliterated posterior cul-de-sac. 16 residents participated in this feasibility study. The participants watched a pre-test video that demonstrated techniques to be used while completing the simulation. Participants also took a survey querying past surgical experiences and specifically how comfortable they were with an obliterated posterior cul-de-sac dissection. After completing the simulation, a post-test survey was completed which again asked about comfort with this dissection as well as an assessment of the realism (face validity) of the model. All scores were collected on a Likert scale. Participants showed a statistically significant increase in comfort with posterior obliterated cul-de-sac dissection after a single 30 minute session from a mean Likert score of 1 (IQR 1–1.5) to 2.5 (IQR 2–3) p < .0001.

Leiomyomata are found in up to 80% of uteri examined at hysterectomy; symptoms are present in 20% to 50% of women. The preferred surgical procedure when uterine conservation is desired is myomectomy; when feasible, the laparoscopic approach is preferred. The major morbidity associated with myomectomy is intraoperative bleeding, which can be treated pharmacologically to minimize blood loss. Vasopressin, a synthetic analog of the posterior pituitary hormone antidiuretic hormone, is often injected into the uterus to reduce blood loss during surgery. This agent has vasoconstrictive effects within the uterus and also stimulates uterine contraction. In a number of placebo-controlled studies, vasopressin was shown to decrease blood loss, blood transfusion, and operative time during myomectomy. Moderate-quality evidence was found in a 2014 Cochrane review that support use of vasopressin at time of myomectomy to decrease blood loss. Because relatively few studies have examined the clinical pharmacokinetics of vasopressin, little is known about optimal dosing and concentration. There are also few data on administration technique or effectiveness of this agent compared with other interventions. It has been postulated that a higher-volume, fixed-dose administration of vasopressin could further reduce blood loss at the time of laparoscopic myomectomy. The aim of this multicenter randomized trial was to compare use of a dilute versus a concentrated vasopressin solution on blood loss at time of minimally invasive myomectomy. The trial was conducted between 2011 and 2015 at 4 tertiary care academic centers in the United States. All participants were planning to undergo either conventional laparoscopic or robotassisted laparoscopic myomectomy. All participants were randomly assigned to 1 of 2 groups receiving a 10-unit (U) dose of vasopressin: the first group received 200 mL of diluted vasopressin solution (20 U in 400 mL normal saline), and the second received 30 mL of concentrated vasopressin solution (20 U in 60 mL normal saline). Patients but not operative staff were blinded to their group assignment. Estimated blood loss as reported by the operating surgeon was the primary study outcome measure. Other outcome measures were suction canister-calculated blood loss, or change in hematocrit levels. Each group comprised 76 patients. There were no differences between groups in baseline characteristics (age, race, body mass index, parity, or surgical history). No significant difference was found between groups in either the amount of blood loss as measured by surgeon-estimated blood loss (mean blood loss 178 +/- 265 and 198 +/- 232 mL, P = 0.65 in dilute and concentrated groups, respectively), suction canister-calculated blood loss, or change in hematocrit levels. No vasopressin-related adverse events occurred. These findings show that both dilute and concentrated solutions of vasopressin appear effective and well-tolerated for both conventional and robotic laparoscopic myomectomy when the same dosing is used. These data fail to confirm a proposed compressive benefit of dilute high-volume vasopressin solution on myomectomy-associated intraoperative-blood loss with laparoscopic surgery.

We sought to determine feasibility of identifying contractile mechanisms underlying menstrual pain utilizing functional MRI imaging.

Excision of endometriosis is a commonly performed surgery that requires a set of fundamental surgical skills that can be broadly applicable to laparoscopic surgery. Simulation based training has been shown to be an effective method for teaching surgical skills outside the operating room. Our goal was to create a cost-effective, inanimate model to teach residents basic procedural skills for excision of peritoneal endometriosis. Using an inanimate model with a prescribed task list, we were able to teach these fundamental skills and basic laparoscopic principles. Sixteen residents participated in the simulation. 7/16 had never performed excision of endometriosis prior to the study. Nevertheless, all residents were able to identify the lesions, pick up the proper instruments, and properly undermine the tissue. 70% of cohort thought the endometriosis model was realistic and valid.

Describe resident prior experience/attitudes towards tissue morcellation and assess competency on a simulated morcellation model.

To determine differences in pain sensitivity and psychological risk factors between women reporting improvement in pelvic pain from prior surgery vs. no improvement. The mechanisms responsible for underlying variable improvement in pain after surgery are poorly understood.

The causes of uterine pain are poorly understood and the development of optical diagnostics provides an opportunity to improve surgical outcomes. One hypothesis is that some conditions manifest with ischemia and others via inflammation with elevated perfusion. Our own preliminary animal models support the concept that different types of pain result in divergent effects on uterine perfusion and oxygenation. The objective of this study is to evaluate the significance of uterine oxygenation/perfusion and feasibility of optical monitoring adapted to laparoscopic cameras. Feasibility study. NorthShore University HealthSystem. 3 videos of laparoscopic myomectomy utilizing vasopressin. We analyzed spectrographic data obtained from surgical video of vasopressin injection into uteri of women undergoing laparoscopic myomectomy. To test whether oxygenation could be measured in humans laparoscopically, colormetric video analysis (red/blue pixel intensity) was performed in the uterus and adjacent lining. To examine precision, we examined the variability between adjacent frames. Within consecutive video frames there was never more than1.5% variation in spectrographic measurements. To validate accuracy, we examined the time course of vasopressin mediated oxygenation desaturation estimated from the spectrographic signal. During the baseline period the average normalized uterine oxygen-related spectrographic signal was steady (100 +- 0.4 %). Vasopressin injection resulted in a 30% +- 10 drop in this signal that was maintained over a two minute period (30% +- 5 after 2 minutes). In contrast, only minimal spectrographic changes in the tissue and organs adjacent to the uterus occurred (100 +- 6 %). Optical spectrography is feasible and with additional study may prove to be an additional diagnostic tool that could be utilized to differentiate pain of ischemic or inflammatory origin.

To demonstrate antepartum surgical management of an unusual case of severely painful anterior cul-de-sac obliteration from a prior history of a cesarean section. Case Report. NorthShore University HealthSystem. Laparoscopic lysis of adhesions. Measurement and Main results: Laparoscopic evaluation revealing the prior uterine scar was adherent to the anterior abdominal wall, rectus muscle, and fascia resulting in a completely obliterated anterior cul-de-sac. Careful, meticulous dissection of the uterus was then performed. Patient recovered well and noted complete resolution of pain. Laparoscopic evaluation and lysis of adhesions for an obliterated anterior cul-de-sac can result in resolution of acute abdominal pain during pregnancy. Symptomatic uterine scaring should be considered a rare cause of acute pain in early pregnancy when other conventional diagnoses are ruled out.

Educators face challenges for resident laparoscopic training including the inherent limitations of laparoscopic surgery, time restriction of residents, and limited availability of clinician instructors. This study proposes to assess ob/gyn residents in their ability in endoscopic suturing and knot tying with the aide of a non-physician proctor. Prospective cohort study. NorthShore University HealthSystem. 13 Ob/gyn residents - 5 junior residents (pgy1&2) and 8 senior residents (pgy 3&4). An initial survey was obtained assessing the participant's prior experience with laparoscopic suturing. The residents initially performed the endoscopic suturing tasks without any instruction. They next watched a 5 minute instructional video and then underwent 4 repeated 15 minute sessions with a non-physician instructor who was trained by advanced endoscopic surgeons. A final suturing task was videotaped and viewed by 2 faculty judges skilled in advanced endoscopic procedures who were blinded to the participant's level of training and experience. The residents were evaluated on technique of loading a needle driver, placing a running stitch, and intracorporeal knot tying. Assessments were based on a 5-point likert scale. Technical skill was scored using a modified global assessment scale. Prior to the lab participants felt uncomfortable with laparoscopic suturing and knot tying (2.69/10). The self-assessment scores rose to 5.5 & 5.75 respectively after completing the exercise. The scores for all three tasks and global assessment scores for technical skills improved (p < 0.01) with the final exercise. The residents universally felt the exercise was very applicable/helpful (9.08/10). A trained non-physician proctor using brief deliberate practice sessions, can effectively improve the laparoscopic suturing skills of ob/gyn residents. This is an attractive, low cost, and consistent alternative to using clinician experts and may increase the likelihood that residents are able to obtain structured practice sessions for this type of task.

Factors underlying chronic pelvic pain remain poorly understood. Prior studies have suggested that parity may confer a greater risk of developing chronic pelvic pain. The objective of this study was to determine if an association exists between parity and pain impact and quality of life in women with pelvic pain. Retrospective cohort. Gynecologic pain and minimally invasive surgery clinic. The study population is comprised of new patients with a primary complaint of at least 3 months of pelvic pain. Data was obtained by self-administered questionnaires assessing demographics, self-reported pain history, quality of life, present pain rating and impact, trait anxiety, and depression. Of 125 eligible women, 64 were nulliparous (mean age 32 ± 10) and 61 were parous (mean age 44 ± 12). Most participants were white, worked outside the home, and were in a higher socioeconomic bracket regardless of parity. Rates of self-reported endometriosis, irritable bowel syndrome, and interstitial cystitis were similar in both groups. Overall, parity was unrelated to initial pain impact or quality of life scores (all Wilcoxon rank-sum p > 0.05). McGill pain scores between the groups were comparable (12 [25-75th% 7-22] vs. 13 [25-75% 7-20]). Depression scores on the CES-D were similar (10.5 [25-75% 6-18] vs. 13.5 [25-75% 7-21]) demonstrating moderate distress levels. Neither group had high anxiety scores on the STAI (14 [25-75% 8-19] vs 16 [25-75% 7-24]) or somatic complaints on the MSPQ (4 [25-75% 1-8] vs. 4 [25-75% 2-7]). SF-12 quality of life scores were also similar between the two groups (38.0 [25-75% 24.6-45.2] vs. 37.6 [25-75% 30.1-46.8] for the physical assessment and 49.5 [25-75% 38.1-53.7] vs. 46.1 [25-75% 35.0-56.7] for the mental assessment). Parity is not associated with self-reported pain impact or quality of life in women presenting initially to our pelvic pain clinic.

Study Objective: Estimate the protective effect of prior OCP use on future development of endometriosis in previously healthy women.Design: Longitudinal prospective cohort with 10 year followup.Setting: Retrospective analysis of national database.Patients: Participants in the young woman subset of the Australian Longitudinal Study of Women's Health.Measurements and Main Results: Data was analyzed from the young woman subset (age 18-23 at entry) at four survey time points (1996, 2000, 2003, and 2006). Confounders and effect modifiers were determined by extensive review of the literature and bivariable analyses. We estimated the risk of endometriosis after OCP exposure using a Cox proportional hazards (PH) regression with time-dependent covariates. A total of 536 new endometriosis cases occurred over the 10 years, with an incidence rate of 697/100,000 person-years of risk. The final multivariable Cox PH regression model included BMI, parity, geographical location, OCP use for other reason, urinary pain, marital status, SF-36 pain score, dysmenorrhea, total years of OCP use and its interaction with parity. Nulliparous women with a history of < 5 years (or ≥ 5 years) of prior OCP use had a 1.8 (or 2.3) times higher risk for subsequent diagnosis of endometriosis. Parous women with 5 years or more (or <5 years) exposure had 59% (55%) reduced risk (hazard ratio 0.41, 95% CI [0.15-0.56] and 0.45 (0.16-1.23], respectively) compared to those who never used OCPs.Conclusion: While our study revealed that longer OCP use plus parity were protective against endometriosis, rigorous mechanistic studies are needed to validate if use of exogenous sex hormones are a risk factor for development of endometriosis and pelvic pain conditions among nulliparous women. Among nulliparous women, prior exposure to OCPs appear to have a dose-dependent increased risk of developing endometriosis, while among parous women, prior exposure to OCPs was protective. Study Objective: Estimate the protective effect of prior OCP use on future development of endometriosis in previously healthy women. Design: Longitudinal prospective cohort with 10 year followup. Setting: Retrospective analysis of national database. Patients: Participants in the young woman subset of the Australian Longitudinal Study of Women's Health. Measurements and Main Results: Data was analyzed from the young woman subset (age 18-23 at entry) at four survey time points (1996, 2000, 2003, and 2006). Confounders and effect modifiers were determined by extensive review of the literature and bivariable analyses. We estimated the risk of endometriosis after OCP exposure using a Cox proportional hazards (PH) regression with time-dependent covariates. A total of 536 new endometriosis cases occurred over the 10 years, with an incidence rate of 697/100,000 person-years of risk. The final multivariable Cox PH regression model included BMI, parity, geographical location, OCP use for other reason, urinary pain, marital status, SF-36 pain score, dysmenorrhea, total years of OCP use and its interaction with parity. Nulliparous women with a history of < 5 years (or ≥ 5 years) of prior OCP use had a 1.8 (or 2.3) times higher risk for subsequent diagnosis of endometriosis. Parous women with 5 years or more (or <5 years) exposure had 59% (55%) reduced risk (hazard ratio 0.41, 95% CI [0.15-0.56] and 0.45 (0.16-1.23], respectively) compared to those who never used OCPs. Conclusion: While our study revealed that longer OCP use plus parity were protective against endometriosis, rigorous mechanistic studies are needed to validate if use of exogenous sex hormones are a risk factor for development of endometriosis and pelvic pain conditions among nulliparous women. Among nulliparous women, prior exposure to OCPs appear to have a dose-dependent increased risk of developing endometriosis, while among parous women, prior exposure to OCPs was protective.

Study Objective: Characterize differences between visceral and non-visceral presentations of chronic female abdominal and pelvic pain. Design: Retrospective cross-sectional study of differences between pelvic pain patients with and without visceral components. Data was collected from the clinic's new patient intake questionnaire packet including medical history, the Medical Outcomes Trust's Short-Form Health Survey (SF-12), McGill Pain Inventory, and the Coping Strategies Questionnaire (CSQ) subscale. Two research assistants independently abstracted this data. Two physicians then characterized each woman's pain as either visceral or non-visceral. Group comparisons were performed using t-tests, Wilcoxon-rank sum and X2 test of proportions. A multivariate linear model was performed to model the relationship between visceral pain history and SF-12 scores. Setting: Tertiary gynecological pain clinic patients seen between October 1, 2004 and April 1, 20080. Patients: Women aged 18-55 presenting with the complaint of pelvic and/or abdominal pain. Intervention: N/A Measurements and Main Results: 214 women (mean age = 36.3 ± 11.6 years) were identified with abdominal or pelvic pain. 55% were defined as having visceral pain. Duration of pain was higher among visceral pain patients, but not statistically significant (means, SD, 47.3 ± 55.4 mths vs. 35.5 ± 51.1 mths, p = 0.12). A higher proportion of these women had concurrent diagnoses of endometriosis (32.8% vs. 15.5% of women with non-visceral pain, p = 0.004). Higher affective pain reports, depression, anxiety, and catastrophizing are associated with visceral pain. Adjusted SF-12 Mental Component scores (means, SE) were worse in visceral pain patients (n = 177, 41.8 ± 1.00 vs. 45.1 ± 1.15, p = 0.03.) SF-12 Physical component scores did not differ by visceral pain status. Conclusion: Our study suggests that visceral pelvic pain has higher morbidity than non-visceral pelvic pain, but this assocation is overestimated when not controlling for concomitant depression and catastrophizing. Studies of pelvic pain should account for emotional influences on pain symptomatology.

OBJECTIVE: Il-6 and TNF-α have been implicated in the initiation and maintenance of endometriosis implants; however, their role in the development of pelvic pain remains unclear. This study seeks to evaluate the relationship of these cytokines to pain perception in women with endometriosis and chronic pelvic pain (CPP).DESIGN: This is a cross-sectional study to assess serum IL-6 and TNF-α levels and pelvic pain symptoms in women with endometriosis and CPP, endometriosis without CPP, and pain-free controls.MATERIALS AND METHODS: 38 women with surgically-confirmed endometriosis and 39 controls underwent medical interviews, physical exams, and validated questionnaires to assess pain severity. CPP was defined as ≥6 months of pelvic pain, occurring for >7 days per month. Serum IL-6 and TNF-α levels were measured via standard enzyme-linked immunosorbent assay (ELISA). The relationship between serum cytokine levels and pain severity was evaluated with the Kruskall-wallis test and Spearman's correlation coefficient, as appropriate, using STATA 10.0.TableSerum cytokine levels in women with endometriosis and pain-free controlsEndometriosis with CPP (n=18)Endometriosis without CPP (n=14)Pain-free controls (n=39)K-wallis p-valueTNF-α8.6 (4.9, 14.2)7.8 (5.1, 12.5)5.2 (4.6, 7.0)0.07IL-62.2 (0, 2.9)2.7 (1.8, 3.0)2.2 (0, 2.5)0.28Values expressed as median (95% CI) Open table in a new tab However, neither TNF-α nor IL-6 correlated with overall pain intensity, or with severity of dysmenorrhea, dypareunia, dyschezia, or dysuria.CONCLUSIONS: Although it appears as though serum TNF-α (but not IL-6) is elevated in women with endometriosis, it was elevated in women with and without CPP, and neither of these measures appear related to severity of pain symptoms in this cohort. OBJECTIVE: Il-6 and TNF-α have been implicated in the initiation and maintenance of endometriosis implants; however, their role in the development of pelvic pain remains unclear. This study seeks to evaluate the relationship of these cytokines to pain perception in women with endometriosis and chronic pelvic pain (CPP). DESIGN: This is a cross-sectional study to assess serum IL-6 and TNF-α levels and pelvic pain symptoms in women with endometriosis and CPP, endometriosis without CPP, and pain-free controls. MATERIALS AND METHODS: 38 women with surgically-confirmed endometriosis and 39 controls underwent medical interviews, physical exams, and validated questionnaires to assess pain severity. CPP was defined as ≥6 months of pelvic pain, occurring for >7 days per month. Serum IL-6 and TNF-α levels were measured via standard enzyme-linked immunosorbent assay (ELISA). The relationship between serum cytokine levels and pain severity was evaluated with the Kruskall-wallis test and Spearman's correlation coefficient, as appropriate, using STATA 10.0. Values expressed as median (95% CI) However, neither TNF-α nor IL-6 correlated with overall pain intensity, or with severity of dysmenorrhea, dypareunia, dyschezia, or dysuria. CONCLUSIONS: Although it appears as though serum TNF-α (but not IL-6) is elevated in women with endometriosis, it was elevated in women with and without CPP, and neither of these measures appear related to severity of pain symptoms in this cohort.

Study Objective: To evaluate the surgical experience and impressions of surgical training of fellows from an AAGL/SRS fellowship in their current practice setting. Design: Survey assessing demographics and practice patterns such as the structure of the practice including obstetrics and office based procedures, the number and variation of surgeries performed, and the continued involvement in educational and research activities. Attitudes regarding surgical training of endoscopic procedures were also assessed. Setting: Fellows and former fellows of the AAGL/SRS Fellowship in Gynecologic Endoscopy programs. Patients: n/a Intervention: n/a Measurements and Main Results: 29 responses were received. Former fellows were distributed across the country with largest percentage on the east coast (38%). 62% practice in a university or an academic affiliate setting and two thirds in an urban environment. 76% identified themselves as current faculty members. One third of responders had an obstetric practice and 38% took obstetrics call. 48% perform hysteroscopy in the office and 38% perform office cystoscopy. Gynecologic practices were on average composed of 19% general gynecology, 30% fibroids and abnormal uterine bleeding, 18% pelvic pain and endometriosis, 23% urogynecology, 2% oncology, and 5% infertility. Hysterectomy was the first or second most common endoscopic procedure performed in 67% of practices with surgical treatment of endometriosis and adnexal surgery also being common procedures. 90% and 66% of graduates remain active in resident and medical student education respectively. The majority of graduates were also involved in research activities. Most of the former fellows felt that increased surgical load was the most important factor in laparoscopic training. 76% believed that a proctor is necessary when performing new laparoscopic procedures independently. Conclusion: AAGL/SRS fellowship programs successfully train gynecologists to provide less invasive surgical options for women as evidenced by practices of former fellows where 93% of hysterectomies are performed in a minimally invasive fashion (via laparoscopy, vaginally, or a combination of the two).

Study Objective: Although surgical treatment is effective for some women with chronic pelvic pain, a substantial proportion report persistent pain postoperatively. Factors that predict treatment failure remain largely unknown. Experimental pain sensitivity, as a surrogate marker of central nervous system pain processing, has been shown to predict both acute and chronic postoperative pain in other settings. The objective of this study was to determine if preoperative pressure-pain sensitivity correlates with long-term postoperative pelvic pain severity among women who undergo a surgical treatment for chronic pelvic pain. Design: IRB-approved prospective pilot observational study of women undergoing surgical therapy for chronic pelvic pain between 2/1/2007 and 11/30/2007. Setting: University hospital tertiary referral center. Patients: Twelve women scheduled to undergo a laparoscopic surgical treatment for a primary indication of chronic pelvic pain. Intervention: Peripheral pressure-pain sensitivity was assessed within 30 days of surgery by applying discrete pressure stimuli to the thumb. Both an ascending and random sequence of varying pressures, developed to minimize the influence of anxiety and depression on pain sensitivity, were used. Clinical pain severity was then measured with the McGill Pain Questionnaire 6 months following surgery. Measurements and Main Results: Mean age of participants was 33.8 years (SD 7.7). 4 underwent hysterectomy +/- adnexectomy, 6 excision/ablation of endometriosis, 2 lysis of adhesions, 1 unilateral oophorectomy. Preoperative pressure-pain sensitivity was positively correlated with pelvic pain intensity 6 months following surgical treatment of chronic pelvic pain (Pearson's r = 0.55, p = 0.06), although not reaching statistical significance in this small pilot study. Conclusion: Preliminary results suggest that women with increased peripheral pain sensitivity may be more likely to have persistent pelvic pain following surgical therapy for chronic pelvic pain. Further research is necessary to explore the utility of preoperative pain sensitivity testing as a tool for predicting which patients are most likely to benefit from surgical therapy for chronic pelvic pain.

OBJECTIVE: Abnormal uterine bleeding is a common complaint presenting to gynecology clinics. Work-up of this is varied given the multiple diagnostic tools that can be utilized. Studies have demonstrated that saline infusion sonography (SIS) and office hysteroscopy have similar diagnostic ability. Few studies have examined which procedure is better tolerated. The purpose of this study is to determine if there is a difference in pain perception and satisfaction in patients undergoing SIS compared to flexible office hysteroscopy (fOHS). DESIGN: Prospective, randomized, cross-over study. MATERIALS AND METHODS: Women who were scheduled to have fOHS from 6/2006-4/2008 were eligible. Following enrollment, participants were randomized to either having the fOHS first or the SIS. A fifteen minute washout period was allowed prior to the subsequent procedure. After each procedure, participants completed a questionnaire regarding their experience. Pain and tolerance were analyzed with a Visual Analogue Scale (VAS). RESULTS: 42 women enrolled. Average age was 40.5 years. No significant difference was noted in demographics between the two groups.76% Caucasian, 79% parous, and 12% menopausal. Average time taken for fOHS was 255 seconds vs. 296 seconds for SIS. There was no significant difference between identification of pathology between with the two imaging modalities. Overall pain and tolerance scores were significantly lower for fOHS than SIS. When performing the sub-analysis, pain and tolerance scores for subjects undergoing fOHS first were lower than those undergoing it secondarily. SIS scores did not differ between the two groups. No participants were unsatisfied with fOHS whereas 9 were unsatisfied with SIS. If requiring this type of procedure again, 78% of women preferred to have the fOHS. Six women preferred the SIS, all of whom were in the group that had the SIS first. Comfort during the procedure was most important for 74%. Time for the procedure was least important for 43%.Table 1VAS of Pain and Tolerance During and After the ProceduresfOHS (cm)SIS (cm)p valuePain during1.723.74<0.05Tolerance during1.293.04<0.05Pain after1.122.31<0.05Overall tolerance0.782.8<0.05 Open table in a new tab CONCLUSIONS: Consistent with the reported literature, there was no significant difference in diagnosis of pathology for SIS and fOHS in this study. fOHS is the preferred procedure with respect to patient tolerance, pain levels, and satisfaction.