Philippe Robert Koninckx

Poor knot security when closing running sutures with three threads - Facts, Views and Vision in ObGyn

Objectives: The peritoneal cavity is a cavity outside the bloodstream, with a specific hormonal, immunological and microbiological micro-environment distinct from plasma. The mesothelial cells lining the peritoneal cavity react within seconds to minor trauma, such as blood, with retraction, acute inflammation and later inflammation. This mesothelial cell retraction exposes the basal membrane, facilitating the implantation of tumour cells. Acute inflammation enhances adhesion formation after surgery and causes pain. The aim of the review was to check the hypothesis that retrograde menstruation, occurring in most women, is sufficient to cause some peritoneal irritation. Design: A systematic review of menstrual C-reactive protein (CRP) concentrations, a non-specific marker of peritoneal inflammation (PROSPERO ID 536306). Results: All articles (n = 8) showed a variable increase in CRP concentrations during the menstrual and early follicular phase of 80 ± 36%. Conclusions: CRP concentrations are slightly increased during menstruation and the early follicular phase. This increase is likely due to retrograde menstruation, causing mesothelial cell retraction and acute pelvic inflammation. It seems logical that mesothelial cell retraction facilitates endometrial cell implantation and accounts for the anatomical distribution of endometriosis lesions. Acute pelvic inflammation may enhance postoperative adhesion formation.

Objectives: Retrograde menstruation occurs in most women and could cause some peri-toneal irritation. The peritoneal cavity is a cavity outside the bloodstream, with a specific hormonal, immunological and microbiological micro-environment distinct from plasma. The mesothelial cells lining the peritoneal cavity react within seconds to minor trauma, such as blood, with retraction, causing acute inflammation and later inflammation. This mesothelial cell retraction exposes the basal membrane and facilitates implantation of tu-mour cells. The acute inflammation enhances adhesion formation after surgery, and causes pain. Design: A systematic review of menstrual C-reactive protein (CRP) concentrations, a non-specific marker of peritoneal inflammation (PROSPERO ID 536306). Results: All articles (n=8) showed a variable increase in CRP concentrations during the men-strual and early follicular phase of 80±36%. Conclusions: CRP concentrations are slightly increased during menstruation and the early follicular phase. This increase is likely due to retrograde menstruation, causing mesothelial cell retraction and acute pelvic inflamma-tion. It seems logical that the mesothelial cell retraction facilitates endometrial cell im-plantation and explains the anatomical distribution of endometriosis lesions. Acute pelvic inflammation may enhance postoperative adhesion formation.

Objectives: The aim of this study was to review the importance of peritoneal fluid steroid hormone concentrations to understand the mechanism of hormonal medical treatment of endometriosis-associated pain. Design: The study included a PubMed search and a pilot trial in 8 adolescents. Results: Oral contraceptives (OCs) were designed to inhibit ovulation in all women, and doses are much higher than the mean ovulation-inhibiting dose. Therefore, in most women, half a dose and in some women, even less is sufficient to inhibit ovulation. The inhibition of ovarian function and ovulation decreases estrogen and progesterone concentrations in plasma and peritoneal fluid. Surprisingly, the effect on peritoneal fluid steroid hormone concentrations has not been considered to explain the impact on endometriosis-associated pain. The lowering of the high estrogen concentrations in peritoneal fluid is sufficient to explain the pain decrease in superficial and ovarian endometriosis. A direct progesterone effect is unlikely, given the high progesterone concentrations in the peritoneal fluid of ovulatory women. In 8 adolescents, half an OC dose resulted in an apparently similar pain relief as a full dose (personal observation). Conclusions: The decrease in ovarian and superficial pelvic endometriosis-associated pain with OCs can be explained by lowering the intra-ovarian and the high estrogen concentrations in peritoneal fluid after ovulation. A direct progesterone effect is unlikely. Since OCs are severely overdosed in most women, half a dose is sufficient in most with fewer side effects, permitting individualization of therapy in women not requiring contraception. Understanding peritoneal fluid also explains that hormone replacement therapy is not contraindicated in most women with a history of endometriosis. Since the mechanisms of medical therapy of endometriosis-associated pain and the prevention of progression might be different, the growth of lesions must be monitored during treatment.

Background/Objectives: The diagnosis and treatment of endometriosis should be based on the best available evidence. Emphasising the risk of bias, the pyramid of evidence has the double-blind, randomised controlled trial and its meta-analyses on top. After the grading of all evidence by a group of experts, clinical guidelines are formulated using well-defined rules. Unfortunately, the impact of evidence-based medicine (EBM) on the management of endometriosis has been limited and, possibly, occasionally harmful. Methods: For this research, the inherent problems of diagnosis and treatment were discussed by a working group of endometriosis and EBM specialists, and the relevant literature was reviewed. Results: Most clinical decisions are multivariable, but randomized controlled trials (RCTs) cannot handle multivariability because adopting a factorial design would require prohibitively large cohorts and create randomization problems. Single-factor RCTs represent a simplification of the clinical reality. Heuristics and intuition are both important for training and decision-making in surgery; experience, Bayesian thinking, and learning from the past are seldom considered. Black swan events or severe complications and accidents are marginally discussed in EBM since trial evidence is limited for rare medical events. Conclusions: The limitations of EBM for managing endometriosis and the complementarity of multivariability, heuristics, Bayesian thinking, and experience should be recognized. Especially in surgery, the value of training and heuristics, as well as the importance of documenting the collective experience and of the prevention of complications, are fundamental. These additions to EBM and guidelines will be useful in changing the Wild West mentality of surgery resulting from the limited scope of EBM data because of the inherent multivariability, combined with the low number of similar interventions.

The translation of impedance (R), current (I), and voltage (V) into tissue effects and the understanding of the settings of electrosurgical units is not obvious if judged by the many questions during live surgery. Below 200 V, the current heats the tissue until the steam of boiling stops the current. Thus, slower heating, because of less energy or a larger contact area, results in deeper coagulation. Above 200 V and a duty cycle (per cent of time electricity is delivered) of >50% (yellow pedal), sparks become electric arcs, and the heat causes the explosion of superficial cells, i.e. cutting. With higher voltages, cutting is associated with coagulation, i.e. blended current. With even higher voltages and a duty cycle <10% preventing arching, only coagulation occurs (blue pedal; forced coagulation). Voltage being crucially important for tissue effects, newer electrosurgical units deliver a constant voltage and limit the energy output (Maximal Watts: W=I*V= joules/sec). Unfortunately, the electrosurgical units indicate the combination of voltage and duty cycles as a force of cutting (pure cutting or blended) or coagulation (soft, forced or spray) current. It is important that the surgeon understands whether electrosurgical units control voltages or output, as well as the electrical basics of the different settings and programs used.