Ante el descubrimiento de una masa anexial, conviene ante todo descartar una urgencia quirúrgica que pueda comprometer la función ovárica. Estas urgencias están dominadas por las torsiones anexiales. En ausencia de urgencia terapéutica, un estudio completo (clínico, pruebas de imagen y biológico) debe permitir estimar el riesgo de malignidad y discutir la indicación operatoria, así como la vía de abordaje quirúrgica. Otros elementos pueden entrar en juego en la indicación terapéutica: la existencia de infertilidad, en particular en caso de endometriosis, y el riesgo de torsión, sobre todo en caso de quistes de gran tamaño. Este artículo revisa de manera práctica los principales problemas que se plantean ante el descubrimiento de un tumor ovárico supuestamente benigno.

OBJECTIVE:To evaluate the reliability of endocervical curettage (ECC) in patients previously treated for CIN. PATIENTS AND METHODS:Retrospective analysis of data from 85 patients between January 1985 and December 2011 who received an ECC during monitoring after treatment of CIN. The reliability of the ECC was evaluated by comparison with the final histological analysis of the surgical specimen or the data for subsequent cyto-colpo-histological follow-up. RESULTS:Patients were referred to colposcopy either within the immediate post-treatment monitoring (n=42), meanly 9.7±5.3 months after treatment, or if cytological abnormalities were detected during long-term monitoring, meanly 78.6±52.4 months after treatment. Colposcopy was unsatisfactory in 75.3% of patients and normal colposcopic findings were found in 80% of patients. A perfect agreement between the ECC and the endocervical final diagnosis was noted in 68 patients (80%). For the diagnosis of severe cervical lesions (CIN 2+) ECC had a sensitivity of 86.2% (68.3-96.1), a specificity of 94.6% (85.1-98.9) and positive and negative predictive values of 61.4% (47.6-74.0) and 93% (83.0-98.1), respectively. CONCLUSION:The high sensitivity and negative predictive value of ECC for the diagnosis of severe post-therapeutic endocervical lesions avoid iterative treatment without increasing the risk of progression of a lesion to cancer.

Recent epidemiological data suggest an increase of the incidence and prevalence of CIN as well as a decrease of the mean age of the patients presenting these lesions. Large loop electrosurgical procedure (LEEP) is the most commonly used treatment method. According to recent studies LEEP provides a 1.4 to 7.0 fold increase of preterm delivery. Cervical cerclage does not show efficiency in reducing this risk, even if cervical shortening is measured by transvaginal ultrasound. Considering histological severity of lesions and the age of patients, number of currently conducted conizations in France could be avoided and so their obstetrical consequences prevented, just because no treatment is necessary or could be done by ablative procedures.

The obstetrical consequences of conisation for cervical intraepithelial neoplasia (CIN) should be considered since patients affected by these lesions are actually younger and most often desire further pregnancies. The loop electrosurgical excision procedure (LEEP), which is currently mostly used, achieves cure rate varying according to the authors between 80 and 95%. However, the most recent data show an increase of obstetrical morbidity, especially prematurity, after LEEP excision. As the frequency and severity of prematurity is correlated to the size and depth of the LEEP, we should minimize as much as possible the resection for these young patients.

Study Objective: Instruments are crucial for the progress of laparoscopy. However, changing instruments during laparoscopic procedures leads to loss of time. Multi function instruments would resolve this issue. We present a short video showing the use of a new grasper with three functions in gynecologic laparoscopic procedures. We used the new grasper (Robby type ®, Karl Storz ®, Germany) in uterosacral endometriotic nodule excision and cystectomy for endometrioma. This grasper allows to perform cyst stripping by providing a good grasping feature, to keep good hemostasis maintaining a clean vision of the operative field by the bipolar coagulation and to have good dissection of anatomic plans. A study comparing the use of classical bipolar grasper, toothed grasper and scissors to the use of the new bipolar grasper in ovarian cystectomies is ongoing. Primary results show a reduced operative time and reduced blood loss. Reusable multifunction instruments would also reduce surgical procedures' cost.

Surgical treatment for pelvic congestion syndrome is still controversial. We suggest that in patient's selection and good surgical techniques are important factor for treatment's success. We present a short video showing three operative laparocscopic techniques: 1. Simple round ligament plicature: its indication is distal atrophy of the round ligament associated with a normal proximal part and uterine retroversion. 2. Retrouterine round ligaments plicature: this tecnique is used for proximal atrophy of the round ligament with a normal distal part and for uterine retroflexion. 3. Anterior fixation of round ligaments to the aponeurosis: it is indicated in distal atrophy of the round ligament with a normal proximal part and for uterine retroversion. These techniques are easy to learn and perform. Dyspareunia and chronic pelvic pain is dramatically reduced postoperatively, but there is no effect on dysmenorrhea.

In laparoscopy, as in conventional surgery, exposure is the key factor for the success of the procedure. We demonstrate exposure techniques, different tips and tricks to achieve good and stable exposure all through the surgery, adapted to the surgical steps required in the treatment of various pathologies. We show the benefits and advantages that the surgeon can expect from adequate exposure.

Performed for more than 15 years, laparoscopic promontofixation has shown its ability to achieve perfect anatomical correction and remarkable functional results. The time has now come to simplify the techniques andto make them reproducible, with acceptable operating times. In this video, we show the technique, our tips and tricks, in a promotofixation procedure performed in a 51 years old women presenting with complete genital prolapse, affecting the 3 levels of the pelvic floor.

En la actualidad, la histerectomía es la intervención quirúrgica que más se practica en las mujeres de edad fértil, después de la cesárea. Aunque comenzó a efectuarse en 1989, la histerectomía por vía laparoscópica tuvo dificultades para imponerse y hoy en día menos del 5% de las histerectomías se llevan a cabo por esta vía. Sin embargo, después de un período de entrenamiento adecuado, la práctica de la laparoscopia presta utilidad en las histerectomías efectuadas por afecciones benignas o malignas, con un índice de complicaciones comparable al de las demás vías de acceso. Los límites actuales de la técnica son úteros muy voluminosos, contraindicación de la fragmentación uterina, prolongación del tiempo quirúrgico y la carencia de instructores con experiencia.

Today, hysterectomy is, after caesarean section, the most frequent surgical intervention performed in fertile women. Introduced in 1989, laparoscopic hysterectomy remains poorly diffused: today, less than 5% of all hysterectomies remain done by laparoscopy. Nevertheless after a correct learning curve, laparoscopic hysterectomy finds perfect indications in benign and even some malignant indications. In these conditions, the complication rate is similar to those of the other surgical routes. Currently the limitations of this technique are the very bulky uterus, contraindicated uterine morcellation, the lengthening of the operative time potentially generated by this technique, and the lack of experienced instructors.

De nos jours, l'hysterectomie reste, apres la cesarienne, l'intervention chirurgicale la plus frequemment realisee chez la femme en âge de procreer. Introduite en 1989, l'hysterectomie cœlioscopique a du mal a s'implanter, et actuellement moins de 5% des hysterectomies sont realisees par coelioscopie. Pourtant, apres une formation adaptee, la coelioscopie trouve parfaitement sa place au sein des hysterectomies realisees pour pathologies benignes, voire malignes, avec un taux de complications comparable a celui des autres voies d'abord. Actuellement les limitations de cette technique sont les uterus tres volumineux, la contre-indication a la morcellation uterine, l'allongement du temps operatoire qu'elle peut engendrer et le manque de formateurs experimentes.

A uterovaginal fistula was reported after an uneventful laparoscopic excision of a left uterosacral endometriotic nodule in a young woman. Indirect thermal injury to the left ureter by the bipolar grasping forceps was the main cause of the injury. Contributing factors are analyzed and preventive measures pertinent to this case are discussed.

Congenital granular epulis is a rare benign tumour situated on the alveolar ridge, which usually presents as a single tumour of variable size. Prenatal diagnosis of epulis has rarely been reported in medical literature. A possible complication is airway obstruction, which is essentially determined by the size of the tumour. Because of the potential risk of neonatal respiratory distress, prenatal diagnosis is valuable in the organization of a safe delivery. The case presented here is the prenatal diagnosis of a congenital epulis discovered in the 32nd week of pregnancy.