Invited presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S1–S92
I342 Laparoscopic entry complications A. Ternamian Endoscopy is less disabling and safer compared to laparotomy, estimated risk 8% versus 15%. However, major complications with serious consequences continue to occur (1 per 1000 procedures) often results in suggestion of substandard performance or litigation. Based on several large multicentre studies and meta-analyses, over 50% of bowel (0.4 per 1000) and major vessels (0.2 per 1000) injuries occur during initial peritoneal entry and of these, approximately 80% are attributed to primary trocar insertion. According to the Physicians Insurers Association of America, trocars are the most common type of device causing major laparoscopic injuries and more than two-thirds of these serious injuries are not recognized until sometime after conclusion of the operation. To avoid entry injuries, endoscopists adopted several port placement approaches with various techniques and instruments, depending on operator training, experience and bias. Currently, no one peritoneal entry method or instrument has demonstrated clear superiority and safety over another. Most gynecologists worldwide continue to teach and practice closed peritoneal entry. There is growing acknowledgement that visual primary access can reduce serious entry related complications by introducing three important Patient Safety redundancies that render laparoscopy less perilous: It allows real-time recognition of entry injury (situational awareness), offers mishap archiving for unbiased accident causation analysis (eliminates hind sight bias) and develops error aversion skills (warning annunciation) that trocar and cannula entry methods fail to offer. Moreover, visual primary peritoneal entry raises operating team access safety awareness, enhances understanding of port dynamics and improves entry error reporting and recording compliance among practitioners. I343 Surgical management of ectopic pregnancy A. Ternamian Over the years, the diagnosis and treatment of Ectopic Pregnancy has undergone considerable progress. Given our contemporary diagnostic, reproductive, chemotherapeutic and endoscopic capabilities, traditional methods and treatment have changed considerably and continues to evolve with introduction of Hysteroscopic treatment of Cornual Ectopic Pregnancies. Moreover, treatment of Ectopic Pregnancy remains a challenging and potentially a fatal condition that deserves continued awareness and clinical vigilance as more than three quarters of ﬁrst trimester deaths and about 10% of all pregnancy-related deaths are associated with Ectopic Pregnancies. It is estimated to occur in 2% of all pregnancies and remains a serious cause of maternal morbidity and mortality when misdiagnosed or left untreated and accounts for as much as 9% of maternal death in North America with the potential of medicolegal exposure and liability. Approximately 97.7% of all Ectopic Pregnancies occur in the fallopian tubes, with the rest in the ovaries, abdomen or cervix. The prevalence is estimated to be 1 in 40 pregnancies or approximately 25 cases per 1000 Pregnancies, with most occurring in multigravidas. Surgical treatment is indicated in several situations such as when the mother is unsuitable for medical therapy, medical therapy failure, heterotopic pregnancy with a viable intrauterine pregnancy and when the patient is unstable and requires immediate life saving surgery.
The main contraindication to surgical treatment is when the Ectopic Pregnancy is medically treatable and when her medical conditions make the operative risk unacceptable. I344 Scientiﬁc publications on the Internet J. Thornton Online publishing is cheaper, faster and makes scientiﬁc articles more widely available than paper. However the internet has many other potential beneﬁts. It allows online publication of supplementary material including study protocols, additional results tables or even the raw data on which the analyses were based. It allows readers to score, comment on, or provide a detailed review of manuscripts. Trial protocols are now routinely published online http://www.controlled-trials.com/. Electronic prepublication is long established in physics (example http://arxiv.org/) but relatively uncommon in medicine and other life sciences. In physics it has at least partially replaced some orthodox paper publication. Many academic institutions also maintain online research repositories of publications by staff members. Many of these are collected together in national and international consortia, such as such as ARROW in Australia http://www.arrow.edu.au/ and SHERPA in the UK http://www.sherpa.ac.uk/. The internet has also allowed the development of new search engines, in addition to the long established ones such as MEDLINE. These include Google’s SCHOLAR http://scholar.google.co.uk/ and Elsevier’s SCIRUS http://www.scirus.com/. Innovative online initiatives which will be presented include online registration of protocols for randomised controlled trials and other study designs (Lancet and many other journals), online peer review such as the McMaster Online Rating of Evidence (http://hiru.mcmaster.ca/more), Peer to Patent (www.peertopatent.org), Peer-democracy (www.peerdemocracy.com). Some examples of online initiatives which have failed such as Controlled Clinical Trials online and Wiser Wiki http://wiserwiki.com will also be presented. I345 HPV vaccination W.A.A. Tjalma A Human Papillomavirus is the casual factor for 2% and 8% of all cancers in respectively the developed and developing countries. Most prominent is cervical cancer with 500,000 new cases diagnosed and 250,000 deaths per year worldwide. It is estimated to be >1,000,000 in 2050. The statement “If a disease is caused by an infection then it can be prevented by vaccination” also became true for HPV. At the moment there are 2 prophylactic HPV vaccines available: Cervarix® (HPV-16/18 AS04-adjuvanted vaccine, GlaxoSmithKline) and Gardasil® (HPV quadrivalent [Types 6, 11, 16, and 18] recombinant vaccine, Merck). Both are focused on high risk HPV 16 & 18. They are safe and well tolerated with more then 60 million doses sold. The HPV vaccines do not contain HPV DNA and can be co-administered with other non-live and live vaccines using separate syringes and different injection sites. The efﬁcacy against high grade lesion caused by HPV 16 & 18 is 98% and against all high risk HPV types it is 70%. Cervical screening (pap smear +/− HPV testing) is therefore still needed. Modeling studies predict at least 20 years if not life long protection. In order to be successful there has to be a high coverage. The later can be reached if there is the political will and more importantly if there is vaccine acceptance by the public. The knowledge about HPV and the association with cancers is very limited. Improve knowledge and you will increase coverage. If we play it right now, then cervical cancer will become a disease for medical history books.