Background and Objectives: Skills-lab training is crucial for the development of advanced laparoscopic skills. In this study, we examined whether a systematic deconstructive and comprehensive tutoring approach improves training results in laparoscopic suturing and intracorporeal knot tying. Methods: Sixteen residents in obstetrics and gynecology participating in structured skills-lab laparoscopy training were randomized in 2 equal-sized groups receiving 1-on-1 tutoring either in the traditional method or according to the Peyton's 4-step approach, involving an additional training step, with the trainees instructing the tutor to perform the exercises. A validated assessment tool (revised Objective Structured Assessment of Technical Skills) and the number of completed square knots per training session and the mean time per knot were used to assess the efficacy of training in both groups. Results: Trainees in Peyton's group achieved significantly higher revised Objective Structured Assessment of Technical Skills scores (28.6 vs 23.9 points; P = .05) and were able to improve their scores during autonomous training repetitions, in contrast to the trainees not in Peyton's group (difference +4.75 vs –4.29 points, P = .02). Additionally, they seemed to be able to perform a greater number of successful knots during the exercise and to complete each knot quicker with the later observations failing to reach the threshold of statistical significance. Conclusion: Peyton's 4-step approach seemed to be superior for teaching laparoscopic skills to obstetrics and gynecology residents in the skills-lab setting and can be therefore proposed for training curricula.

To demonstrate how a heterotopic tubal stump pregnancy can be safely managed with laparoscopy, preserving the intrauterine pregnancy. Design: Stepwise demonstration of the technique by means of a video tutorial. Setting: The management of pregnancies in the tubal stump after salpingectomy involves either a surgical intervention or systemic therapy. In case of a simultaneous intrauterine pregnancy, although the prognosis for the fetus remains good with live births in approximately 70% of the cases, the surgical management of the tubal stump pregnancy is challenging owing to the risk of bleeding from the uterine horn [1−5]. We present an effective and reproducible laparoscopic technique on the basis of a 31-year-old patient with 2 prior right fallopian tube pregnancies, which were later treated with salpingectomy. The patient is now presenting in the sixth week of gestation after transfer from 2 oocytes with a pregnancy in the tubal stump and a concomitant vital intrauterine pregnancy. Interventions: The key steps of laparoscopic surgery include (1) continuous absorbable monofilament suture on the uterine horn around the tubal stump to achieve hemostasis and exposure of the proximal part of the tube, (2) removal of ectopic pregnancy, and (3) closure of the excision site with continuous absorbable polyfilament suture. The instillation of vasoconstrictive substances and the use of electrical coagulation should be avoided. Conclusion: The demonstrated laparoscopic technique is a feasible method of removal of a tubal stump pregnancy without interfering with the vital intrauterine pregnancy. The blood loss can be minimized, and laparotomy can be avoided.

Purpose Robotic surgery represents the latest development in the field of minimally invasive surgery and offers many technical advantages. Despite the higher costs, this novel approach has been applied increasingly in gynecological surgery. Regarding the implementation of a new operative method; however, the most important factor to be aware of is patient safety. In this study, we describe our experience in implementing robotic surgery in a German University Hospital focusing on patient safety after 110 procedures. Methods We performed a retrospective analysis of 110 consecutive robotic procedures performed in the University Hospital of Würzburg between June 2017 and September 2019. During this time, 37 patients were treated for benign general gynecological conditions, 27 patients for gynecological malignancies, and 46 patients for urogynecological conditions. We evaluated patient safety through standardized assessment of intra- and postoperative complications, which were categorized according to the Clavien–Dindo classification. Results No complications were recorded in 90 (81.8%) operations. We observed Clavien–Dindo grade I complications in 8 (7.3%) cases, grade II complications in 5 (4.5%) cases, grade IIIa complications in 1 case (0.9%), and grade IIIb complications in 6 (5.5%) cases. No conversion to laparotomy or blood transfusion was needed. Conclusion Robotic surgery could be implemented for complex gynecological operations without relevant problems and was accompanied by low complication rates.

Study question Feasibility of (ICG)-enhanced fluorescence in visualizing the atypical course of the ureter during surgery for (DIE) of pelvic sidewall with a concomitant crossed renal ectopia. Summary answer Near-infrared fluorescence after transurethral injection of ICG enables localization of the ureter during surgery, thus facilitating complete excision of the lesions while enhancing patient’s safety. What is known already Existing case series refer to the transurethral injection of ICG and visualization under near-infrared (NIR) light during robotic surgery for real-time delineation of the ureter, which helps to prevent iatrogenic ureteral injury during complex surgery. The ICG reversibly stains the inside lining of the ureter by binding to proteins on urothelial layer. The consequent green fluorescence allows its identification throughout the entire case. The presented case of a DIE of pelvic side wall along with an ipsilateral concomitant crossed renal ectopia (residual function 27%) resembles an utmost challenge for surgery. To our knowledge no similar case has been reported in literature. Study design, size, duration Demonstration of the Robotic technique by means of a step-by-step tutorial Participants/materials, setting, methods 29-year-old patient referred after preceding laparoscopic surgery for DIE of left pelvic sidewall and abortion of surgery due to lack of accessibility/ severeness of the case. We performed renal scintigraphy, pelvic MRI and urological consultation. Surgery was performed using an XI-da-Vinci robotic system. After cystoscopic placement of mono-Js we injected 4 ml. of ICG-solution (2,5 mg/ml). Visualization of the pelvic kidney was achieved 4 minutes after injection and of the complete ureter after 7–8 Minutes. Main results and the role of chance The robotic surgery could be completed safely and achieve a complete resection of the DIE of the pelvic sidewall including adhesiolysis of a broadly adherent bowel, opening of the rectovaginal space, ureterolysis of the distal portion of the ureter, partial excision of the left sacrouterine ligament and deperitonealization of the pelvic sidewall. Postoperative controle revealed normal renal function and an adequate postoperative course. Limitations, reasons for caution ICG cannot be used in patients with iodine allergy. Wider implications of the findings: Our report underlines the possibility to utilize indocyanine green (ICG)-enhanced fluorescence to localize the ureter during complex surgery for DIE, even in cases with atypical anatomy of the lower urinary tract. Trial registration number Not applicable

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