Yuji Hiramatsu

Cesarean section is the ultimate method of successful delivery of infants under various circumstances and is an indispensable operation in obstetrics. However, the degree of difficulty varies greatly depending on the gestational weeks, number of fetuses, number of previous cesarean sections, degree of placental adhesion, presence of uterine myomas, maternal obesity, and other factors. In addition, emergency cesarean section is a battle against time, and prompt surgery is required. During training in cesarean section, surgeons must master the basic techniques in cases of term head presentation first. They must then master the techniques in cases involving complications such as malpresentation, preterm birth, placenta previa, abruptio placentae, uterine myomas, and other conditions. Cesarean section itself is a simple operation. However, there are many difficult cases, and many complications such as placenta accreta and defects of the incision scar may occur after cesarean section. The present report describes the basic procedures and cautionary points to perform the cesarean section without complications.

It is a great pleasure to publish the second issue of Precision Surgery in Obstetrics and Gynecology (PSOG), a supplement to The Surgery Journal. The second issue of PSOG focuses on “Surgical Approaches for Various Uterine Fibroids.” We previously published a Japanese book series (24 volumes), entitled Obstetric and Gynecologic Surgery Now (OGS Now)[1] with the Japanese medical publisher, Medical View, Inc. In PSOG, we are selecting representative operations from OGS Now series and demonstrating the updated operative techniques. The operation for uterine fibroids is the most frequent and essential gynecological surgery. When performing a total hysterectomy or myomectomy, the difficulty of the operation varies greatly depending on the location, size, and number of fibroids. This time, we selected seven particularly difficult operations for uterine fibroids. All of the papers published in this volume were written by the experts in this field in Japan and are explained using easy-to-understand illustrations and photographs that show the surgical techniques, tips, and precautions. We hope that the procedures listed in PSOG will be helpful in performing difficult uterine fibroid operations. Finally, I would like to express my sincere thanks to Medical View for allowing us to use the illustrations and photos used in the OGS Now series.

Myomectomy for diffuse leiomyomatosis and giant fibroid exceeding 30 cm in length is a particularly difficult operation. For diffuse leiomyomatosis, what kind of incision is put in and nucleated, how to suture the wound is a problem. In the case of giant fibroids, the degree of difficulty varies greatly depending on the site, size, and number of fibroid. The points should be taken into account at the time of surgery are as follows: (1) how to incision because incision becomes long, (2) how to remove multiple fibroids together, reduce incisional wounds, and reconstruct the uterus, (3) how to reduce the bleeding, how to suture not to leave a dead space. From the preoperative magnetic resonance imaging findings for each case, we will conduct surgery as far as possible to simulate, but, in fact, it is necessary to judge instantaneously at the time of laparotomy. It is necessary to see many difficult operations and acquire the judgment ability.

I'm delighted to be publishing the inaugural issue of Precision Surgery in Obstetrics and Gynecology (PSOG), a supplement to The Surgery Journal, with the editorial cooperation of Professor Ikuo Konishi, Professor Noriaki Sakuragi, and Professor Satoru Takeda. PSOG is created with the following policies: (1) Explaining the basics and applications of obstetric and gynecologic surgery using beautiful, easy-to-understand illustrations in a simple manner; (2) Explaining the tips of surgery and the methods to avoid complications of surgery. We have previously published a Japanese book series (24 volumes), entitled Obstetric and Gynecologic Surgery Now (OGS Now) [1] with the Japanese medical publisher, Medical View, Inc. The beautiful illustrations and concepts of OGS Now caught the eye of The Surgery Journal published by Thieme Medical and Scientific Publishers, and thanks to Medical View, we were able to publish this English supplement by using illustrations from OGS Now. In PSOG, the concept of OGS Now publication is inherited, and further modifications are made to the representative surgical articles published in OGS Now. We will take up typical obstetrics and gynecology surgery in every time and explain it in an easy-to-understand manner. Our inaugural issue focuses on “Abdominal Hysterectomy,” with four manuscripts, demonstrating individualized operative techniques. We sincerely thank Medical View for supporting this project and for providing illustrations used in OGS Now. The articles published in this supplement will be read by several obstetricians and gynecologists around the world, and we hope to contribute to the provision of safe surgery.

The basic procedure of abdominal hysterectomy is extrafascial hysterectomy, and intrafascial hysterectomy (Aldridge operation) and retrograde hysterectomy are performed as applied surgical procedures. The Aldridge operation and retrograde hysterectomy are performed when strong adhesion is present around the uterus. Retrograde hysterectomy is also useful when the cervicovaginal junction is not clearly felt by palpation, such as when uterine rupture immediately occurs after vaginal delivery or when a large tumor mass is present in the vagina.

Total abdominal hysterectomy (TAH) is commonly referred to as extrafascial hysterectomy. This article explains the basic surgical procedure of TAH as taught to residents. TAH is an operation to remove the uterus with the outer wall of the uterus, and is a fundamental operation that gynecologists must master. Possible complications during TAH include ureteral injury, intestinal damage, and bladder injury. To avoid operative complications, it is important to follow the correct release layer procedure and ensure that “the uterus has been naturally removed.” The two most important points of the authors' method to avoid complications are as follows: (1) cut sequentially from the ligament away from the ureter which moves the ureter further away from the cervix with each transection stage; (2) cut the parametrial tissue along the circumference of the cervix in the next three steps: First step: clamping and cutting the uterine artery and upper part of the cardinal ligament; second step: clamping and cutting the sacrouterine ligament and the posterior half of the cardinal ligament; third step: clamping and cutting the vesicouterine ligament and anterior half of the cardinal ligament.

Gynecologic cancer is one of the most common malignant diseases in working-age women. This study investigated whether several characteristics influence return to work after treatment of gynecologic cancer. We investigated the correlations between return to work and several other characteristics in 199 gynecologic cancer survivors. Questionnaires were distributed to patients with cancer (≥1 year after treatment and age of <65 years) who visited Okayama University. Logistic regression analysis and receiver operating characteristic curves were used to determine whether each characteristic influenced return to work (no return to work or job change) in these gynecologic cancer survivors. For all patients, the mean age at the time of diagnosis was 47.0 years, and the average number of years after treatment was 4.5. Forty-four patients (53.7 %) who were non-regular employees continued to be employed at the same workplace. Non-regular employment had a significantly higher area under the curve (AUC) (0.726) than other characteristics in terms of negatively affecting return to work. Additionally, non-regular employment tended to have a higher AUC (0.618) than other characteristics in terms of job changes. Non-regular employment was the variable most likely to negatively affect return to work and job changes in employed patients who underwent treatment for gynecologic cancer.

Extracellular matrix metalloproteinase inducer (Emmprin/CD147) is a transmembrane glycoprotein that belongs to the immunoglobulin superfamily. Enriched on the surface of many tumor cells, emmprin promotes tumor growth, invasion, metastasis and angiogenesis. We evaluated the clinical importance of emmprin and investigated its role in endometrial cancer.

We generated novel truncated insulin-like growth factor I receptors (IGF-IRs) designated as 126/STOP, 223/STOP and 325/STOP in order to establish shorter soluble IGF-IRs than previously reported 486/STOP without abrogating the same antitumor effects. Stable transfection of 223/STOP and 325/STOP, but not 126/STOP caused inhibition of anchorage-independent growth of CaOV-3 ovarian cancer cells in vitro. This antitumor effect was reproduced when we used recombinant proteins of these constructs, suggesting a bystander effect of these shorter truncated IGF-IRs. Tumorigenesis in vivo of CaOV-3 cells tranfected with 223/STOP or 325/STOP was strictly inhibited, and inoculation of these cells in nude mice caused massive apoptosis exclusively in vivo. Phosphorylations of IGF-IR and Akt, but not Erk were attenuated in 223/STOP- or 325/STOP-transfected CaOV-3 cells, and downregulations of IGF-IR and Akt phosphorylation seemed to play at least a partial role in the anti-tumor effect of these novel truncated IGF-IRs. Since 223/STOP and 325/STOP are smaller in size than previously reported 486/STOP, and they retain the same antitumor effects, they could be good candidates for clinical application in the future.

Glycemic control is an important issue in gestational diabetes mellitus (GDM) and in diabetic pregnant women. We determined the reference intervals of glycated albumin (GA) and hemoglobin A1c (HbA1c) as glycemic control markers in healthy Japanese pregnant women and analyzed their time courses and factors that influence these variables during pregnancy. 676 women were screened for the present study. After the exclusion of non-pregnant and puerperal women, 574 women were studied to determine the reference intervals. HbA1c, GA, casual plasma glucose, urinary glucose, urinary protein, and body mass index (BMI) (non-pregnancy) were measured. HbA1c levels significantly decreased in the second trimester of pregnancy and increased in the third trimester, while GA levels significantly decreased towards the third trimester. Casual plasma glucose levels decreased in the first trimester and subsequently remained constant. The reference intervals of GA and HbA1c in the healthy pregnant women were 11.5-15.7% and 4.5-5.7%, respectively. GA levels were lower (p<0.01) and HbA1c levels were higher (p<0.05) in pregnant women with proteinuria. In the obese group, GA levels were lower (p<0.01) than those of the control group (18.5≤ BMI <25kg/m2), and HbA1c levels were higher (p<0.01) than those of the control group. On the basis of the results of this multicenter study, the reference intervals of GA and HbA1c in healthy Japanese pregnant women were determined. Strict glycemic control is essential to reduce perinatal complications. GA appears to be a useful marker for pregnant women, since it can be measured easily and changes rapidly and markedly.