Dr. Greenberg is Chief, Division of Gynecology, Brigham & Women’s Faulkner Hospital, and Associate Professor, Harvard Medical School, Boston, Massachusetts.

James Greenberg, MD

As a proud wound closure materials geek, I view 3 patents as the most significant modern inventions in the field: US patent 3,297,033

  for polyglycolic acid suture (1967), US patent 8,721,681 B2

  for barbed suture (2014) and US patent 5,530,037

  for sterilizing cyanoacrylate (1996). The last of the triad essentially enabled Krazy® Glue (Elmer’s Products, Westerville, OH) to become Dermabond® (Ethicon, Inc., Somerville, NJ) and changed the way millions of wounds have been and will be reapproximated.

 Topical Skin Adhesive is sterile 2-octyl cyanoacrylate contained in a 0.8-g ampoule encased in a proprietary dispenser for single use. While each manufacturer of a 2-octyl cyanoacrylate topical skin adhesive claims their version is the best due to special additives and processes that alter the viscosity, as a user, the biggest differences seem to be in the dispensers. With its unique felt tip and pressure-producing wings, the LiquiBand Exceed

 dispenser was by far the best topical skin adhesive dispenser I have ever used. It consistently produced an even distribution of adhesive over wounds without clogging, enabling me to use all 0.8 g of glue.    

Advanced Medical Solutions, Ltd., neither invented cyanoacrylate nor figured out how to sterilize it so I can’t give them too many cleverness points. However, their felt-tipped, winged dispenser is a big improvement over the competition so kudos to them.

2-octyl cyanoacrylate is essentially a commodity product that will usually be subject to bundled pricing and thus highly variable in its cost. From my perspective, the real value discriminator between products is the dispensers. With some dispensers, the tips clog before all of the adhesive is delivered, often necessitating opening a second applicator and doubling the cost. With the LiquiBand Exceed

 dispenser I was able to use all of the adhesive in the ampoule every time. THAT…is good value.

This is simple. If you use topical skin adhesives for wound closure, you should try LiquiBand Exceed

 to see for yourself and your institution whether this is a good alternative to what you are currently using.

The views of the author are personal opinions and do not necessarily represent the views of 

Schmitt EE, inventor; American Cyanamid Company, assignee. Surgical Sutures. US patent 3,297,033. January 10, 1967.

Ruff, GL, inventor; Ethicon, Inc. assignee. Barbed suture in combination with surgical needle. US patent 8,721,681 B2. May 13, 2014.

McDonnell PF, inventor; Loctite, Ltd, assignee. Sterilized cyanoacrylate adhesive composition, and a method of making such a composition. US patent 5,530,037. June 25, 1996.

Articles

Dr. James Greenberg gives his review of the LiquiBand Exceed Topical Skin Adhesive.

Tools Test Drive: LiquiBand Exceed Topical Skin Adhesive

I am as tormented by suboptimal laparoscopic views as I am about greasy fingerprints on my glasses and it is with this hate-inspired passion that I evaluated Buffalo Filter’s LaparoVue

 Visibility System is a single-use, disposable system designed to eliminate fogging while cleaning laparoscopes and trocars during a procedure. The system is actually three-fold: a hub with warming and cleaning ports, 2 VueTip

 trocar swabs and a microfiber cleaning cloth. The meat of the system is a molded silicone, battery-powered box with 2 ports (1 for warming and white balancing, 1 for cleaning and defogging) and a detachable scope cradle. The battery provides the energy for both the warming unit and projecting LED light that accentuates the ports. The base of the hub is detachable to cradle the scope horizontally while it is being warmed. Both ports have flexible seals that accommodate scopes from 3 mm to 12 mm without an adapter. The 2 VueTip

 trocar swabs are plunger-like, radiopaque swabs designed to fit into 5-mm and 12-mm trocars. Finally, the microfiber cleaning cloth is…a microfiber cleaning cloth. 

 Visibility System was excellent. Mindlessly easy to use, it kept my laparoscopes defogged and smudge-free and provided a good platform on which to rest the scopes while they were not in use. In short, it did exactly what it was supposed to do and did it very well. 

, it is hard to give the engineers at Buffalo Filter too much ingenuity credit since this system is simply an improved D-HELP (now, ClearifyTM from Medtronic, LLC). With regard to the improvements, Buffalo Filter did a nice job fine-tuning this product but the real innovation points still have to go to the D-HELP peeps for coming up with the  original idea.

I am somewhat biased against single-use devices. Their cost never goes down with amortization and creating more medical waste landfill is not a good idea. However, there is little point in spending a fortune on an expensive laparoscopy system only to have condensation and drops of blood and fat blur your 4K picture. For small cases, the LaparoVue

 is probably not worth it. But, for more complex procedures it seems like short money. 

Consistent, high-quality imaging is essential for laparoscopic procedures. As optical technology evolves, advances in both resolution and lighting will likely offer future surgeons pictures that will make current technology seem like black and white TV. Regardless of how it’s done, each OR team needs an efficient system to keep their scopes clean. For quick cases, a moist sponge is probably fine. For longer, more complex cases, the LaparoVue

: The author reports no conflicts of interest with regard to the content of this review.

James Greenberg, MD, reviews the LaparoVue Visibility System, a single-use, disposable system designed to eliminate fogging while cleaning laparoscopes and trocars during a procedure.

LaparoVue Visibility System

Creating a hysterotomy during cesarean delivery is as basic a skill as exists in the practice of obstetrics. Unfortunately, about 0.7% to 1.9% of the time while cutting into the uterus, babies are cut as well.

 While at first glance that percentage may seem low, when one takes into consideration that about 1.5 million cesarean deliveries are performed every year in the United States, this small percentage amounts to about 10,500 unnecessary injuries, especially when the appropriate number should be closer to zero!

To minimize the risk of iatrogenic scalpel injuries to babies at the time of cesarean delivery, Ecomed Solutions has introduced the Sureglide cesarean delivery safety scalpel. Its straightforward design offers a stainless steel surgical blade encased in a plastic handle that extends past the blade and forms into a pointed tip. The idea is to use the plastic tip to enter the uterus and then extend the hysterotomy by cutting up and away from the baby. Not surprisingly, in trial use in the operating room, Sureglide worked exactly as expected. With the blade facing up, the tip is pushed through the serosa and myometrium. The hand holding the device is then gently rocked back and pushed forward while the blade safely and efficiently creates a hysterotomy. Easy. Quick. Safe.

On the innovation front, Sureglide is a little wanting as its doppelgÃ¤nger C Safe has been on the market for several years. In my opinion the 2 devices look, feel and perform almost identically and because C Safe was first, it gets all the innovation points.

By medical device standards, Sureglide is pretty inexpensive ($18 each) but it is still more costly than a #10 scalpel blade. That said, the value play is really about how many cut babies you and your hospital are willing to tolerate.

I have opined before that I think it is time we made newborn lacerations at the time of cesarean delivery a “never” event because we have the technology to essentially eliminate the problem. While rising healthcare costs are always an issue, I am pretty confident most parents would pay for this device themselves out-of-pocket if they knew it could prevent an accidental laceration to their baby.

1. Alexander JM, Leveno KJ, Hauth J, et al. Fetal injury associated with cesarean delivery. 

2. Smith JF, Hernandez C, Wax JR. Fetal laceration injury at cesarean delivery. 


Vaginal dryness and dyspareunia are issues for which every gynecologist needs suggestions and options to provide to patients. By at least one account, genitourinary syndrome of menopause (GSM) and GSM-like symptoms affect about 15% of premenopausal women and 40% to 54% of postmenopausal women

 and those numbers do not fully encompass the entire universe of sexual lubricant needs. While estrogens may serve as the prescription cornerstone of therapy to address GSM, over-the-counter (OTC) lubricants found in the pharmacy are more widely used by patients and their partners than prescription solutions and therefore, providers should be aware of what is on the shelves in this niche. One of those products is Ã¼berlube.

According to company lore, in 2002 childhood friends Stephen Magnusen and Frank Zwergel came up with the idea of Ã¼berlube with the intention of creating “a lightweight lubricant with log-lasting performance… that doesn’t leave a sticky residue.” Though they set out to make a lubricant with a broad variety of applications including massage oil, moisturizer, hair gel, lock grease or even shoe polish, Ã¼berlube found its way into sex-product stores, where it soon became a “go to” for couples seeking a lubricant for using during sex.

Ãberlube has 4 ingredients: dimethicone, dimethiconol, cyclomethicone and tocopheryl acetate. The first 3 are all polymeric organosilicon compounds commonly referred to as silicones, and tocopheryl acetate is the ester of acetic acid and vitamin E. All the ingredients are non-toxic and can even be ingested. The formula naturally does not harbor bacteria, yeasts or molds so it needs no preservatives, alcohols or antimicrobial additives. It is sold in 3 sizes: a 14-mL travel size, a standard 50-mL clear spray bottle or a larger 100-mL clear spray bottle.

In testing between my ungloved fingers and on my gloved fingers during bimanual exams, Ã¼berlube had a silkier feel and was lubricious without being messy. In my non-scientific, uncontrolled, un-blinded survey of patients to whom I had recommended Ã¼berlube as a lubricant option for intercourse with their partners, every one thought it was better than anything they had previously tried.

Though I am no chemist, I am pretty sure Ã¼berlube is different from almost everything else out there. Its combination of safety, excellent lubrication and lack of mess is unique and might earn it a spot in the lubricant hall of fame.

For sexual lubricants, the value of the product has to be individualized because each person is going to have a different degree of discomfort and a different desire to fix the problem. That said, a 50-mL bottle of Ã¼berlube at $18 is not the same financial commitment as investing in a 4-year college education, so I think it is money well spent on trying a bottle if GSM is a significant problem.

The world of lubricants goes well beyond car engines, bars and Washington, DC. In the sexual lubricant niche, silicone-based Ã¼berlube is a newer option that many patients may find helpful. A bottle sits on my desk for patients to sample and I have recommended it many times with many satisfied users.

1. Gandhi J, Chen A, Dagur G, et al. Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management. 

NEXT: TruClear ULTRA Mini tissue removal device

TruClear ULTRA Mini tissue removal device

Circa 1998, Dr Mark Hans Emanuel in the Netherlands went into his garage with an orthopedic shaver and came out with the first hysteroscopic mechanical tissue morcellator. Five years later in 2003, Smith & Nephew received 510(k) clearance from the FDA and the Smith & Nephew IUR Morcellation System (now TruClear, owned by Medtronic) was ready for clinical use in the US. Some 14 years and tens of thousands of hysteroscopic morcellation procedures later, hysteroscope mechanical tissue morcellation is a standard for many gynecologists for resecting intracavitary uterine pathology.

For those physicians who have been practicing in a cave and are unfamiliar with hysteroscopic mechanical morcellation here is a quick primer. Hysteroscopic mechanical morcellators utilize device-specific operating hysteroscopes with integrated optics, inflow and outflow channels and large open central lumens through which proprietary morcellator devices can pass. They function best with high inflow/outflow fluid management systems that can accommodate the large fluid burdens that accompany the procedures due to the need to replace the distention media that is suctioned off removing morcellated tissue. The TruClear system is available in 2 sizes: TruClear 8.0, a 9 mm (27 Fr) hysteroscope for larger pathology and the nimbler TruClear 5C or 5.0, a 5.7 mm (17 Fr) hysteroscope for smaller pathology. The business ends of these systems are single-use tissue removal devices that pass through the central lumens and simultaneously morcellate and aspirate targeted tissues. They come in 2 designs: a rotating serrated blade for softer tissues (i.e. polyps, retained POCs) and a more robust reciprocating, guillotine-style cutting blade for denser tissues (i.e. submucus myomas). Until now, only the larger TruClear 8.0 had a reciprocating cutting bladder but the Ultra Mini changes that.

TruClear ULTRA Mini tissue removal device is a single-use, stainless steel, 2.9 mm OD instrument designed to function with the TruClear 5C or 5.0 hysteroscope set. Like its 4.0-mm OD cousin, the TruClear ULTRA Plus device has a reciprocating, guillotine-style cutting blade designed to resect denser tissues. But unlike its zaftig relative, the ULTRA Mini fits through a 5.7 mm hysteroscope.

In use in the OR, the ULTRA Mini was a tissue-chomping beast. The company claims that ULTRA Mini resects tissue at 4.4 grams/minute. While this is Usain Bolt range speed (typical myoma resection rates for morcellators are more in the range of 1.87-3.77 grams/minute

), nothing in my initial OR experience left me doubting it. In this niche, ULTRA Mini is best-in-class. If Medronic can just redesign the TruClear 5C or 5.0 hysteroscopes with glass-rod rather than fiber optic lens, the whole system would be close to perfect.

While the bulk of users may not appreciate it, ULTRA Mini is an impressive innovative accomplishment. As these devices get smaller and smaller, the engineering challenges get exponentially greater. Reciprocating speeds, blade angles, tissue clearance etc. all have narrow tolerances with each component potentially killing performance. I have no idea exactly how the engineers used this combination of stainless stain tubes and blades with silicone and chromium coatings to make this device work but they did and they did it well.

ULTRA Mini is not cheap. If fact, at $1097 it is the Bentley of hysteroscopic instruments. That said, there are two considerations. First, nobody pays list. Second, we are talking value not cost. In that regard the real questions should be, “does this device allow surgeons to accomplish what they set out to accomplish, how efficiently were they able to do it and was it worth it?” In a recent metaanalysis, Shazly et al. demonstrate that as compared with hysteroscopic loop resections, hysteroscopic morcellation procedures were faster and more complete.

 So, depending on your hospital’s OR costs and your surgeons’ skill sets, this device may be a better value than it first appears. While this hardly ends the argument, I do think it is an important consideration when valuing this technology.

In my opinion, hysteroscopic mechanical morcellation is an evolving alternative to traditional loop resectoscopy that just got even more enticing with the introduction of the TruClear™ ULTRA Mini tissue removal device. With the combination of its small size and large tissue resecting potential, I think ULTRA Mini will alter the hysteroscopy landscape as surgeons assimilate this new technology’s potential into their practices.

1. Meulenbroeks D, Hamerlynck TW, Saglam-Kara S, Van Rijssel NK, Van Vliet HA, Schoot BC. Hysteroscopic Tissue Removal Systems: A Randomized In Vitro Comparison. 

2. Shazly SA, Laughlin-Tommaso SK, Breitkopf DM, Hopkins MR, Burnett TL, Green IC, Farrell AM, Murad MH, Famuyide AO. Hysteroscopic Morcellation Versus Resection for the Treatment of Uterine Cavitary Lesions: A Systematic Review and Meta-analysis. 

Dr Greenberg reports his thoughts on the Sureglide device and preventing lacerations during cesarean, Überlube and helping women with vaginal dryness and dyspareunia, and TruClear ULTRA Mini tissue removal device for mechanical morcellation.

Tools Test Drive: Sureglide, Überlube, and TruClear

	This anti-stick solution is designed to keep instruments clean.


Photo courtesy of Eagle Surgical Products

	Core surgical rule: hemorrhage bad; hemostasis good. With that insightful gem out of the way, let’s turn our focus to electrosurgery, in which electrical current is employed to coagulate bleeding blood vessels by denaturing blood and blood vessel proteins. While that technique is generally effective, the process often results in unwanted sticking and char build-up on the coagulating device. Because both of those effects are detrimental to achieving hemostasis, preventing them is important. Electro Lube

	Approved by the US Food and Drug Administration in 2004, Electro Lube

is typically recognized by surgeons as “that yellow goop” that is applied to Da Vinci monopolar scissors to minimize the risk of current arcing. While it is helpful for minimizing arcing, its real modus operandi is preventing sticking and char buildup during electrosurgery. Derived from soybean oil, it is a lecithin-based phospholipid mixture that is non-synthetic, non-flammable, and non-allergenic. It comes in a sterile single-use 8-cc plastic vial and is applied to the tip of any electrosurgical instrument prior to the instrument’s use.

worked exactly as expected. In my parlance, it was just like good sports referees: If you don’t notice them, they are doing their job. In our operating room (OR), the Storz RoBi bipolar Maryland forceps is our go-to coagulation workhorse. With Electro Lube

applied, I have yet to need to clean an instrument during a case or to experience sticking to tissues. 

	Instrument sticking and char build up is definitely a real problem in certain coagulation-heavy procedures. When there is active bleeding, you really want a fully functional coagulation instrument and Electro Lube

is the “grease that helps the wheel turn.” In addition, less char build-up means less scraping and less scraping means less damage to expensive, delicate surgical instruments. Given all these pluses, I think this soybean oil byproduct is pretty clever.

	I don’t think that a bottle of Electro Lube

needs to be opened for every OR case but I do think every OR needs to stock it. In this day and age, surgery-particularly minimally invasive surgery-is too refined to allow something as common as char build-up to reduce an instrument’s functionality when something as simple as Electro Lube

NEXT: WiCAM Wireless Digital Endoscope Camera & LED Light Source

	WiCAM Wireless Digital Endoscope Camera & LED Light Source

	Through the generosity of the Greek deity Prometheus, man was introduced to fire. Let there be no doubt, fire was a major enabling technology in humankind’s evolution and ranks only below the iPhone as the most significant advance since we arose from primordial muck. Given this legacy, it should be of little surprise that once again, Prometheus is trying to change mankind; only this time, instead of fire, we are getting an untethered endoscopic camera and light source.

CAM Wireless Digital Endoscope Camera and LED Light Source has multiple components that integrate to make any standard endoscope (cystoscope, hysteroscope, laparoscope, etc.) cordless. The camera is a standard-sized, lightweight (.35 lb, 158 g) device with a standard c-coupler that fits onto any standard eyepiece. Real-time images are wirelessly transmitted from the camera head to a USB receiver plugged into a monitor, laptop or tablet and a rechargeable battery screws a lightweight LED light source directly onto any standard light port.

	In use for an office hysteroscopy, the Prometheus wireless digital endoscope camera and LED light source was pretty “wow.” When stationary, the picture was excellent with full 640 x 480 resolution and the light was comparable to what I am used to. There were only 2 buts. But #1: During rapid movement of the camera there were occasions when the image deteriorated as the transmission speed lagged behind the image. This problem is minimized by keeping the camera and tablet at high power and selecting another channel on the camera and receiver if there is interference but it is still a little annoying. But #2: The company is a little vague about the cleaning and sterilization protocols for the devices. The company says they intend to remedy this issue with proprietary sterile drapes or bags but, as of this writing, they are not available.

	Game changer alert! This wireless product may be the first of its kind that you use but it will not be the last. Rather, I suspect within short order most of our wired cameras and light cords will go the way of wooden teeth, iron lungs, and written medical records.

	The Prometheus wireless digital endoscope camera and LED light source is super cool. After years of using scopes with camera heads connected to cameras via wires and illuminated by light transmitted through fiber-optic cords, the fully wireless Prometheus almost defies belief. For those of us old enough to remember our first mobile phone experience, this camera has that same otherworldly feel. The device does present some challenges. It has some digital lagging issues when it is moved too quickly and the company definitely needs to clarify its cleaning and sterilization procedures. But overall, I am convinced this is the future of office endoscopy and perhaps OR endoscopy as well.

Dr Greenberg reports on his results with an anti-stick solution for electrosurgery and a wireless endoscope camera.

Tools Test Drive: Electro Lube and WiCAM

	The views of the author are personal opinions and do not necessarily represent the views of 

	Dr Greenberg personally tests all the products he reviews. He has no conflicts of interest with these products or the companies that produce them.

	The LED revolution is upon us and it is high time that operating rooms opened their eyes to the reality that illuminating the deepest crevices of the human body is no longer the domain of the classic over-hanging OR lights but rather the cool, white lumens emitted by disposable LED “bulbs” on point-of-contact instruments.

	Whether on retractors, suction-irrigators, speculums, or headlamps, short-life LED devices will soon be to surgeons what wifi is to electronics: results without wires. The Clear-Trac V vaginal retractor is part of this burgeoning niche market.

	It is hard to imagine a simpler medical device than Clear-Trac V. In essence it is an L-shaped piece of rigid plastic with an LED-bulb welded to it. It comes in one size: 140 mm x 53 mm, and it is powered by a low-voltage mercury-free alkaline button battery that allows the device to be disposed of as regular, nontoxic medical waste (after exposure to bodily fluids, etc). Don’t look for more, that’s it. The device is intended as a single-use product and comes in an individual sterile packet with 25 devices per box. It is simple, lightweight, and intuitive.

More: CryoProbe and OptiSpec product reviews

	In clinical use, Clear-Trac V provided outstanding light and tissue retraction. I used it during a vaginal hysterectomy to retract the sidewalls and for the first time in many years, I actually saw all the deeper tissues without having to shift my fat head out of the light. While it is not sufficient to completely replace overhead lights, Clear-Trac V is more than adequate to replace the headlamps with the Twenty Thousand Leagues Under the Sea umbilical cords that these require. As the product catches on, I would expect a broader line of retractor options, but for now this is a pretty good start.

	My biggest complaint is the relatively short battery life (only about 30 minutes of peak power). While the battery life can be preserved by replacing the tab, this is annoying and I took away a star for this reason. Also, my green soul prefers reusables to disposables but, given the importance of good light in surgery, I think this small contribution to the landfill is worth it.

	Clear-Trac V is not overwhelmingly innovative. In fact, I was blown away that this technology is not already available from a broad array of vendors. That said, until there was Velcro there was no Velcro, so hats off to OBP for coming up with this because I do believe it will change the market.

	Clear-Trac V is a really good device for getting light into deep spaces. It is simple, intuitive, and relatively inexpensive. For pelvic surgeons who don’t get the light they want or are still using headlamps, this product is definitely worth a try. When coupled with one of the illuminated suction-tips on the market, Clear-Trac V will provide better visualization of deeper spaces than most of what is being used today.

NEXT: MiniLap Percutaneous System with MiniGrip Handle

	MiniLap Percutaneous System with MiniGrip handle

	In the MIGS, SILS, LESS, NOTES race to the smallest and fewest, I am not sure what counts. A 5-mm trocar definitely counts as a port. A 20-G (0.9081 mm) spinal needle definitely does not count as a port. What about 2.4 mm? We’ll need to decide because Teleflex’s MiniLap Percutaneous System is ready to grab some attention.

	With an outer diameter of 2.4 mm, the MiniLap instruments with the MiniGrip are amazingly thin but surprisingly strong and versatile. All the instruments in the line are sterile, single-use, and come with an integrated, retractable needle tip that allows for direct percutaneous insertion of the device without a trocar. The line comes with 2 handle styles-MiniGrip pistol style or standard 3-finger grip. There are also 4 jaw options, each with a wingspan of 12.5 mm that is more than adequate to grasp most tissues.

	In the OR, the MiniLap generally performed better than I expected (which is rare). The shaft was much more durable than I anticipated and the grip on the tissues was superb. I liked the rotatable functionality and I thought the pistol-grip was ergonomically comfortable. And the incision -forget about it (because I almost did it was so unnoticeable)!

Next: Pro-Nox and Alexis CES product reviews

	The only thing I did not like was the mechanism to retract the grasper and arm the needle for percutaneous insertion. I thought it was sticky, somewhat persnickety, and in general felt a little fragile. Because I suspect this will be easily remedied in future iterations, I am not too concerned.

	MiniLap is a game-changer in disposable laparoscopic instruments. Its incredible strength-to-shaft ratio makes it very useful as a surgical tool and its 2.4 mm-ness is amazing. The device looks and feels so similar to other devices that it is difficult to give it that fifth star but that should not diminish the accomplishment of getting all that punch into such a small package.

	The MiniLap Percutaneous System is a real winner. For surgeons looking to do more with less this is a must. Want better triangular for “single-port” procedures? Use this. Struggling and need another hand to move tissues out of the way? This is your answer. Does 2.4 mm count as a port? I say no. Should your hospital be stocking this device? I say yes.

Dr Greenberg test drives 2 new products to see if they can be of use in your practice.

Product Reviews: Clear-Trac V Vaginal Retractor and MiniLap Percutaneous System with MiniGrip handle

	The views of the author are personal opinions and do not necessarily represent the views of 

. Dr. Greenberg personally tests all the products he reviews. He has no conflicts of interest to report with respect to the content of this article.

, many ideas need to be foreign standards for a long time before Americans cotton to them. Such was the case in obstetrics with inhaled anesthetics for relief of labor pain. Use of nitrous oxide for analgesia during childbirth was first described by Dr. Stanislav Klikovich in Russia in 1881.

 Although inhalational N2O for parturients has been in wide use in the UK for well over 100 years, it was almost nonexistent in the United States until recently. In July 2013, the Pro-Nox Nitrous Oxide Delivery System was cleared by the FDA for sale in the United States and it is now readily available for American women.

	The Pro-Nox Nitrous Oxide Delivery System is a patient-controlled inhaled analgesia system that delivers a 50% oxygen and 50% nitrous oxide mixture for the relief of pain and anxiety. While at first glance the system’s tanks and tubing give it the appearance of a miniature petrochemical refinery, the system is actually fairly simple and has several important safety features built in. First, the system is 100% pneumatically driven, which means that it is fully portable without the need for plug-ins and can be easily moved as needed. Second, it is designed with a single-patient-use circuit that attaches to an internal demand valve to ensure minimal risk of infection between patients. Third, it comes with a variety of options (such as an active or passive scavenger system or wall mounts) to accommodate different labor settings. And, most importantly, it has an automated safety shut-off system that prevents improper gas mixtures in the event that either the oxygen or nitrous oxide tanks are empty or fail.

	In use on our labor floor, the Pro-Nox has pretty much been a winner. 

, it is great and provides the labor analgesia option that we had been lacking (something between intravenous/intramuscular narcotics and an epidural). It is portable and easy to set up in cases such as the multip with active labor. It is safe and, it is effective 

. The only real complaints surround the tanks and valves, which can be persnickety to change over. But, the system is pretty gas-frugal so these changeovers are not too frequent.

	It seems a bit awkward to call a technology introduced in 1881 innovative in 2015 but the people at CAREstream do deserve some “attaboys” for building a system that fits comfortably on a modern labor floor governed by rigorous patient-safety and Occupational Safety and Health Administration regulations. Although Pro-Nox is far from the first system to deliver nitrous oxide for analgesia, it has lowered the bar sufficiently to encourage universal use of this option in the United States.

	Pro-Nox has tremendous clinical transformative potential in that it has helped our obstetric service change our practice within our comfort zone to include a labor analgesia option that had previously not been available to our patients with older nitrous oxide delivery systems.

	Nitrous oxide for labor analgesia is nothing to laugh at. A 2012 Cochrane review concluded, “All women in labour should have the opportunity to choose some non-invasive method of relatively effective and safe analgesia at short notice when they wish it during labour. Inhaled pain relief, such as nitrous oxide ... may be a very useful additional method for pain relief.”

 Nitrous oxide for labor analgesia is not a panacea and will not universally replace epidurals. However, in my opinion, it should be an option everywhere from sea to shining sea. The Pro-Nox Nitrous Oxide Delivery System offers a safe, convenient starting place for this technology and I think it is worth a try.

	1. Richards W, Parbrook GD, Wilson J. Stanislav Klikovich (1853-1910). Pioneer of nitrous oxide and oxygen analgesia. 

	2. Klomp T, van Poppel M, Jones L, Lazet J, Di Nisio M, Lagro-Janssen AL. Inhaled analgesia for pain management in labour. 

	In the last 2 years, contained tissue extraction (CTE) has dominated professional discourse in minimally invasive gynecologic surgery from both philosophical and technical perspectives. For a surgical discipline focused over the last 40-odd years on get bigger out through smaller incisions, the sudden move away from open morcellation has left many eyes seeking the next technical edge to help get the MIGS train back onto a safer track. To that end, seemingly every quarter, a new bag in which to place to-be-extracted tissues appears on the market to address this latest challenge. This review will focus on Applied Medical’s Alexis Contained Extraction System.

	The Alexis Contained Extraction System is a clever extension of Applied’s well-established Alexis retractor technology. With the same semi-rigid rim attached to a heavyweight PVC bag, the Alexis Contained Extraction System has a comfortable feel for anyone who has previously used Alexis retractors. The 6500-cc bag is big enough to accommodate almost all pathology that is typically removed, while rolling the rim over the bag allows it to shrink as needed. The bag comes with a tag on a string attached to the rim, which is strong enough that is can be used to pull the bag out through the incision once the specimen is inside. In addition to the bag, the “system” comes with a 12-mm Hassan-style Kii balloon fixation trocar as well as a flexible neck guard to protect the lining from tears from the knife used for morcellation.

	In use in the operating room, the Alexis Contained Extraction System worked much as expected. The bag’s sturdy rim nicely facilitated insertion of the bag through a 3-cm skin incision and, once inside the body, the rim kept the bag opened, which again made getting the specimen into it easier. The polymer membrane was hefty enough to endure a lot of tugging and to resist tearing. The only caveat is that the bag’s size (6500 cc) coupled with the rim’s large mouth fill most of the pelvis and lower abdomen and can limit visibility when large specimens are involved. But large specimen cases are always challenging and, overall, this bag did make it easier. Separate from the bag itself, I was less impressed with the neck guard. Conceptually, it seems like a great idea, but in practice, it just added bulk to the already narrow incision and hindered rather than helped the tissue extraction process. Finally, the addition of the trocar was completely superfluous for me. I never used it in any of my cases and would prefer to see it removed from the system to help lower the cost of the device.

	I generally liked the Alexis Contained Extraction System and think is a clever adaption of the company’s standard Alexis technology, especially considering the short timeline in which it was developed and brought to market. I love the way Applied tweaked what they had to give us what we needed.

	While the Alexis Contained Extraction System is an excellent tissue extraction bag, it isn’t going to transform the MIGS world. In the end, it is just another bag and more technology is still needed in this space to help solve the challenges the discipline is now facing with contained tissues extraction.

	For today, for cold-knife contained tissue extraction, the Alexis Contained Extraction System is as good a product as can be found on the market. At 6.5 L, I think it is bigger than it needs to be for universal appeal but smaller iterations likely will soon appear. I suspect some surgeons will swear by it while other will favor a different product. Either way, for those looking for contained tissues extraction solutions, I highly recommend giving it a try to see if this is the bag you seek.

Hands-on ratings of a patient-controlled inhaled analgesia system and a bag for contained tissue extraction.

James Greenberg, MD

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