“Why not?” said Aaron Caughey, a professor and chair of the Department of Obstetrics and Gynecology at Oregon Health & Science University in Portland, who is presenting on timing of induction of labor Oct. 30 at the American College of Obstetricians and Gynecologists (ACOG) 

“We know that the optimal gestational age to deliver is full-term: between 39 and 40 weeks,” Dr. Caughey told 

. “However, some pregnancies extend beyond this point.”

Dr. Caughey said that although all women could be induced in the 39- to 40-week range, “there has been a concern that intervening will lead to more cesareans and be too costly.”

In 2006, Dr. Caughey and his associates started showing that despite most clinicians’ beliefs, perhaps early induction does not cause more cesareans. Other investigators have found similar findings, and the recent large, randomized trial, ARRIVE, demonstrated that induction of labor at 39 weeks in nulliparous women as compared to expectant management leads to a lower rate of cesareans.

“The evidence suggests outcomes are as good or better for delivery at 39 to 40 weeks gestation as opposed to waiting until 41 weeks,” Dr. Caughey said.

Dr. Caughey believes the revelation that induction of labor might actually reduce the risk of cesarean delivery will be a surprise to many clinicians. And while he has conducted some of this research, he believes that “healthy suspicion of the findings is well-founded as studies should be replicated and studied in a range of clinical environments.

For many clinicians, “when one spends time on the labor floor, women being induced have a higher risk of cesarean. Thus, when one compares women with induction to women with spontaneous labor, induction of labor does have a higher risk of cesarean,” Dr. Caughey said. 

“But when one compares induction of labor to expectant management of the pregnancy in the full term (39 to 40 weeks gestation) and post-term (41 weeks gestation) periods, it appears that there are enough developments with expectant management that induction of labor does not increase the risk of cesarean.”

A 2018 cost-effectiveness analysis of induction of labor at 39 weeks of gestation versus expectant management among a theoretical cohort of 1.6 million low-risk nulliparous women found that induction of labor resulted in 54,498 fewer cesarean deliveries and 79,152 fewer cases of hypertensive disorders of pregnancy, again consistent with the ARRIVE trial. The analysis also concluded that induction of labor resulted in 795 fewer cases of stillbirth.

“Despite induction of labor being associated with increased costs, there was an increase in quality-adjusted life-years (QALYs), with an incremental cost-effectiveness ratio of $87,691.91 per QALY,” said Dr. Caughey, who spearheaded the analysis.

However, if the cost of induction of labor was increased by $180, elective induction would no longer be cost-effective.

Hence, while induction of labor in the full-term period is not a violation of the standard of care, the evidence is still evolving and local practice patterns can impact these outcomes.

“Whether individual clinicians and healthcare systems offer routine induction of labor at 39 weeks is dependent on local capacity and careful evaluation and allocation of healthcare resources, along with patient preferences,” Dr. Caughey said. “Going forward, we will have to see how early induction of labor plays out in a variety of settings.”

The ACOG 2020 Virtual Conference will be held on October 30 and 31 from noon to 4 pm ET. 

Dr. Caughey reports no relevant financial disclosures.

Articles

ACOG

Is 39 the new 41 when it comes to weeks of gestation for induction of labor?

Timing of induction of labor

Presentations will be given through Saturday, Oct. 31. Check out the full schedule 

 and register to attend. It will stream live and on-demand.

The guidelines, developed by a consensus of 19 national organizations convened by ASCCP, are an update to 2012 consensus guidelines. New guidelines emphasize reducing invasive procedures while maintaining high standards of cancer prevention.

New guidance for managing further testing in patients with minimal abnormalities detected during cervical cancer screenings will be shared at the American College of Obstetricians and Gynecologists (ACOG) 2020 Virtual Conference.

“Although the older guidelines represented a conceptual breakthrough in risk-based management, those recommendations retained a continued reliance on complicated algorithms and insufficiently incorporated past screening history,” said Rebecca Perkins, MD, first co-author of the new guidelines. “Since their issuance, we have developed a more nuanced understanding of how prior results affect risk, and more variables to consider, such as the natural progression of human papillomavirus (HPV) and cervical carcinogenesis.”

Screening outcomes among 1.5 million people revealed that 90% of test results were normal and only 0.75% were severely abnormal.

“Colposcopy is still recommended if the estimated risk of currently having a precancer or cancer is from 4% to 24% or if testing results are positive for the HPV types 16 or 18, which are most highly associated with cervical cancer,” said Dr. Perkins, an associate professor of ob/gyn at Boston University School of Medicine and Boston Medical Center.

If the risk of currently having a precancer is from 25% to 59%, the patient may choose either a colposcopy with biopsy or proceed directly to treatment. But if the risk is 60% or higher, it is preferred that patients undergo treatment without requiring a biopsy first, according to Dr. Perkins. 

“This was an option in the prior guidelines, but has been more clearly defined in the new guidelines,” she said.

In addition, patients with minor abnormalities, such as Pap test results that indicate low-grade or atypical squamous cells of undetermined significance (ACS-US) or HPV infections, “can defer colposcopy, if these results were preceded by negative screening with either HPV testing or co-testing within the past 5 years or if preceded by a colposcopy at which precancer was not found in the past year,” Dr. Perkins told 

. “Previously, colposcopy was always recommended for these outcomes, but new data indicate that follow-up in 1 year is safe for many patients.”

Adhering to the new guidelines will result in fewer patients being referred to colposcopy, “and those who are referred are at higher risk for precancer,” Dr. Perkins said. “The new guidelines are also designed to minimize unnecessary biopsies where precancer is not found, reduce patient harm and allow resources to be concentrated on high-risk patients.”

Hence, colposcopists should have a high level of suspicion and biopsy all abnormal-appearing areas, typically two to four biopsies per colposcopy. 

“They should also expect that a higher proportion of their colposcopy patients will have precancer requiring treatment,” Dr. Perkins said.

The guidelines’ framework is based on a patient's risk of precancer rather than a specific combination of test results. 

“This will allow more personalized recommendations for patients, and more streamlined incorporation of new screening and diagnostic technologies into clinical practice,” Dr. Perkins said. “Management of abnormal test results will shift from paper algorithms to electronic decision aids, which will further facilitate patient care predicated on the best available data.”

Dr. Perkins reports no relevant financial disclosures.

The American College of Obstetricians and Gynecologists’ (ACOG) 2020 Virtual Conference starts this Friday, Oct. 30, with presentations by preeminent experts in ob/gyn. 

New ASCCP consensus guidelines for managing abnormal cervical cancer screening test results

However, the analysis, which was presented at the 2020 virtual annual meeting of the North American Menopause Society (NAMS), found that two or more moderate or severe menopausal symptoms are associated with an increased risk for cardiovascular disease and stroke.

Matthew Nudy, MD, a cardiology fellow at Penn State Hershey Medical Center, is the principal investigator on the analysis and he had completed prior research on cardiovascular disease in postmenopausal women for the WHI-CaD study. “We were interested in better understanding what is associated with cardiovascular disease in postmenopausal women and if calcium and vitamin D supplementation could alter those associations,” he said.

The multicenter WHI-CaD study across the United States was conducted from the early 1990s to 2005, and funded by the National Heart, Lung, and Blood Institute (NHLBI).

The double-blind, randomized, placebo-controlled study was designed to test the effects of 400 IU of 25-hydroxyvitamin-D and 1000 mg of elemental calcium per day on incident hip fracture and other health outcomes in women between the ages of 50 and 79. A total of 20,050 women were followed for a median of 7 years.

The outcomes assessed for the analysis were hip fracture, colorectal cancer, invasive breast cancer, all-cause mortality, CaD global index (composite endpoint of the aforementioned events), coronary heart disease, stroke, cardiovascular death, and total cardiovascular disease.

Menopausal symptoms included hot flashes, night sweats, dizziness, heart racing or skipping beats, tremors, feeling restless or fidgety, feeling tired, difficulty concentrating, forgetfulness, mood swings, vaginal dryness, breast tenderness, headache or migraine, and waking up multiple times at night.

The severity of menopausal symptoms (none; mild; moderate or severe) was measured via a baseline questionnaire.

The investigators found no association between the severity of vasomotor symptoms of hot flashes and night sweats; and any health outcome.

In contrast, the number of menopausal symptoms was significantly associated with risk for stroke: hazard ratio (HR) 1.41 for at least two menopausal symptoms; 95% confidence interval (CI): 1.04 to 1.91, compared to no menopausal symptoms.

For one menopausal symptom, the HR for stroke was 1.19; 95% CI: 0.88 to 1.61, compared to no menopausal symptoms.

The number of menopausal symptoms was also significantly connected to total cardiovascular disease: HR 1.37; 95% CI: 1.20 to 1.56, for at least two menopausal symptoms vs. none.

For one menopausal symptom, the HR for total cardiovascular disease was 1.00; 95% CI: 0.87 to 1.15, compared to no menopausal symptoms.

When stratified by randomization status, CaD did not influence any association evaluated. But the severities of most individual menopausal symptoms, including headaches or migraines, or difficulty concentrating, were linked to a higher total cardiovascular disease risk.

“I was surprised that the severity of vasomotor symptoms was not associated with any health outcome in our analysis,” Dr. Nudy told 

. “In addition, calcium and vitamin D supplementation did not alter any association.”

Because patients with more moderate and severe menopausal symptoms may be likely to see a physician for treatment, “this may be an ideal time to assess their risk of cardiovascular disease,” Dr. Nudy said. “The number or type of moderate or severe menopausal symptoms, but not vasomotor symptoms alone, could be a marker of higher risk for cardiovascular disease.”

Dr. Nudy reports no relevant financial disclosures.

NAMS

A secondary analysis of the Women’s Health Initiative (WHI)-Calcium and Vitamin D (CaD) clinical trial has concluded that vasomotor symptom severity is not linked to any clinical event. 

Vasomotor symptom severity not linked to any clinical event in menopause

Dr. Santoro highlights just some of the content from the scientific program, including cardiovascular disease, the effect of menopause on vasomotor symptoms; genitourinary syndrome of menopause; and hormones of menopause, including a look into FSH as an active driver of menopause.

All presentations have been pre-recorded and now are available for on-demand viewing beginning Sept. 28 through Sept. 21, 2021. Live Q&A sessions will be held from Oct. 5 to Oct. 9. The full program can be found 

Videos

In this video, Senior Editor Angie DeRosa interviews Nanette Santoro, MD, Chair of the 2020 Scientific Program Committee for the Virtual Annual Meeting of the North American Menopause Society (NAMS). 

Highlights from NAMS 2020 Virtual Annual Meeting

This article is based on information presented at the 2020 Virtual Annual Meeting of the North American Menopause Society (NAMS). According to NAMS, all presentations have been pre-recorded and now are available for on-demand viewing beginning Sept. 28 through Sept. 21, 2021. For more information, click 

The findings are independent of sleep risk factors and depressive symptoms.

“I have a longstanding interest in understanding how trauma is related to poor sleep and health,” said first author Karen Jakubowski, PhD, a postdoctoral scholar in psychiatry at the University of Pittsburgh in Pennsylvania. 

“Although some past studies have found that trauma is connected to poor sleep, these studies measured sleep at only one time point. We realized there was a gap in our knowledge of whether trauma is related to poor sleep measured at multiple points over time, particularly in midlife women.”

The investigators used both objective and self-report measures of sleep, “which makes this research even more novel and exciting,” Dr. Jakubowski told 

The ongoing study, which is being conducted at the University of Pittsburgh, consists of a cohort of midlife women, aged 40 to 60 at baseline, who had participated in a previous study on menopausal hot flashes and cardiovascular health from 2012 to 2015.

The women were invited to return to the laboratory 5 years later for a follow-up visit between 2017 and 2020.

Of the 296 women assessed at baseline, 72% were White and 28% Black, with an average age of 54. For the follow-up visit, 166 women were evaluated.

At both baseline and follow-up, women reported adult trauma (Brief Trauma Questionnaire), demographics, depressive symptoms, sleep quality (Pittsburgh Sleep Quality Index [PSQI]) and apnea.

They also provided physical measures of height/weight, as well as a 3-day objective sleep assessment via actigraphy: duration and wake after sleep onset (WASO).

At baseline only, women reported childhood trauma (Child Trauma Questionnaire).

Linking childhood trauma (any/none) and adult trauma (any/none) at baseline with poor sleep (duration <7 hours, WASO ≥31 minutes, PSQI >5) across both baseline and follow-up visits were then assessed.

At baseline, 44% of women reported childhood trauma, compared to 60% who reported adult trauma.

Persistently poor sleep duration, WASO and sleep quality was observed in 61%, 60%, and 33% of women, respectively, at both baseline and follow-up visits.

Childhood trauma was related to persistently poor WASO: odds ratio (OR) 2.32; 95% confidence interval (CI): 1.11 to 4.84 (

Adult trauma also was connected to persistently poor sleep quality: OR 2.13; 95% CI: 1.01 to 4.52 (

However, trauma was unrelated to persistently poor sleep duration.

“We were surprised that trauma was unrelated to women’s sleep duration,” Dr. Jakubowski said. “Our results suggest that trauma history is more connected to disrupted and poor-quality sleep in midlife women, rather than how long women are sleeping.”

To improve sleep quality in this population, Dr. Jakubowski said she believes it is important that women allow themselves time to wind down at night, prior to going to bed. “This may involve doing an activity that they find restful or relaxing, without phones or screens if possible, to help promote the transition from our busy lives to sleep,” she said.

The authors hope that their work inspires further research on the lasting effects of trauma on sleep and health in midlife women, “and aids in the development of future interventions that can tailor and improve sleep in women who have experienced trauma,” Dr. Jakubowski said.

Dr. Jakubowski reports no relevant financial disclosures.

Poor sleep occurs frequently among midlife women, which is significantly linked to childhood and adult trauma, according to a prospective study presented at the 2020 Virtual Annual Meeting of the North American Menopause Society (NAMS).

Trauma’s relation to poor sleep and health in midlife women

Using cannabis for menopause symptom management is common, at least in a sample of midlife women veterans from across California.

The study, which was presented at the 2020 Virtual Annual Meeting of the North American Menopause Society (NAMS), found that among 231 women with a mean age of 55.95 years, 27% reported that they currently or previously used cannabis for managing menopause symptoms, including hot flashes, night sweats, insomnia, and genitourinary symptoms.

An additional 10% of participants expressed interest in using cannabis in the future to manage their menopause symptoms.

Principal investigator Carolyn Gibson, PhD, MPH, a psychologist and health services researcher at the San Francisco Veterans Affairs (VA) Health Care System, said, “These findings come from a larger study I conducted to examine the experience of menopause and menopause-related care among midlife and older women veterans, which is an understudied population that comprises over half of the women we serve in the VA.”

Dr. Gibson was inspired to add questions about cannabis use for menopause symptom management because, over the past several years, popular press articles about its use started appearing regularly in her newsfeed.

“It seems apparent that as cannabis use becomes increasingly mainstream, a growing number of midlife and older women are interested in or using cannabis to help manage menopause symptoms,” Dr. Gibson said. “However, we had no data on actual numbers, or if use is helping or harming women.”

Cross-sectional data were gleaned from the Midlife Women Veterans Health Survey, which was an observational study of women veterans, aged 45 to 64, who were enrolled in VA health care across Northern California. Data were collected between March 2019 and May 2020.

Cannabis use was more frequently reported among women reporting hot flashes (67% vs. 50% for non-users; 

But there were no differences observed for other menopause symptoms between the two groups.

“I was expecting some women to report cannabis use for menopause symptom management, but was a little surprised to see a rate approaching 30%,” Dr. Gibson said. “This is in comparison to 19% of women in the sample who reported menopausal hormone therapy use.”

Dr. Gibson also expected to find some differences, such as cannabis use for menopause symptoms being more common among women who were younger or less engaged in VA care, but this was not the case.

The study did not address frequency of use and/or potency of the cannabis.

“Patients may not always disclose cannabis use, especially in the VA health care system, where cannabis is considered illegal under federal guidelines, regardless of state laws,” Dr. Gibson said. “Nonetheless, providers should be aware that their perimenopausal and postmenopausal patients may be using cannabis to manage their menopause symptoms.”

There is much to be learned about the potential benefits and harms of cannabis use, particularly related to menopause and aging, she said. “However, existing evidence raises concerns about its impact on cognition, cardiovascular health and mental health,” she said.

Future areas of research include who is using cannabis for menopause symptom management, what type of cannabis products they are using, what symptoms they are targeting and whether cannabis is actually effective.

“We also need to know whether our numbers would look the same outside of Northern California, and how typical patterns of use impact health and functioning among perimenopausal and postmenopausal women,” Dr. Gibson said.

Dr. Gibson reports no relevant financial disclosures.

This article is based on information presented at the 2020 Virtual Annual Meeting of the North American Menopause Society (NAMS). According to NAMS, all presentations have been pre-recorded and now are available for on-demand viewing beginning Sept. 28 through Sept. 21, 2021.

Cannabis for managing menopause symptoms

Markers of mitochondrial function in perimenopausal and postmenopausal women correlate to numerous measures of cognitive performance, according to a study presented at the 2020 Virtual Annual Meeting of the North American Menopause Society (NAMS).

These measures are verbal learning, verbal memory, organizational strategies that support verbal learning and memory, verbal fluency and spatial ability.

“Evidence, largely from animal studies, suggests there is a change in mitochondrial function from the premenopause to the perimenopause, and the change is a deleterious one resulting in brain dysfunction,” said co-principal investigator Pauline Maki, PhD, a professor of psychiatry, psychology and ob/gyn at the University of Illinois at Chicago. “This change in mitochondrial function would indicate a critical change in the way that the brain generates and uses energy as women age.”

Dr. Maki and her colleagues were inspired by a 2017 study in 

 that identified a mitochondrial biomarker (an Alzheimer’s bioenergetic phenotype) in the brain and periphery of perimenopausal and postmenopausal women. “We wanted to expand the range of mitochondrial biomarkers in the human work,” Dr. Maki told 

The current MsBrain study enrolled 110 perimenopausal and postmenopausal women living in and around Pittsburgh (mean age 58.56, 77.3% White) who were assessed over the past 3 years.

The women completed a cognitive test battery, including tests of verbal learning and memory, spatial reasoning, working memory, verbal recall and global cognition.

Extracellular flux analysis was used to obtain measures of nonmitochondrial oxygen consumption, baseline respiratory rate, maximal respiratory capacity, basal glycolytic rate, proton leak, mitochondrial oxidation production, and adenosine triphosphate (ATP)-linked respiration in circulating platelets.

“We discovered a range of mitochondrial biomarkers significantly related to cognitive function in cognitively normal postmenopausal women,” Dr. Maki said. “Many of the biomarkers were related to the ability of women to use helpful strategies when learning new material.”

Higher non-mitochondrial oxygen consumption, baseline respiratory rate, maximal respiratory capacity, basal glycolytic rate, proton leak, ATP-linked respiration in circulating platelets and mitochondrial oxidant production were each associated with better performance on a range of cognitive test scores: verbal learning (

 < 0.01); organizational strategies to enhance learning (

 < 0.05); California Verbal Learning Test (CVLT) short delay (

Dr. Maki said one way to learn new material is rote or simple memorization. “But the other involves deep processing of the material,” she said. “Mitochondrial markers were notably related to the extent to which women used the more helpful of the two strategies, which is related to function of the prefrontal cortex.”

The investigators were surprised by the number of associations found between mitochondrial markers and cognition at midlife. “Our results are encouraging,” Dr. Maki said.

The cross-sectional study, however, was unable to address whether these are causal connections. “Although the findings might be related to menopause, we cannot state that, because the women in our study were postmenopausal,” she said. “We also do not know if these same relationships might also exist in men of similar ages.”

Study outcomes in general indicate that the mitochondria, which control energy production in the brain, are associated with cognitive function. “This is a new mechanism that can be targeted in future longitudinal studies to examine changes in mitochondria markers and changes in cognition through the menopause transition,” Dr. Maki said.

Dr. Maki has been a paid consultant to Pfizer, Abbvie and Balchem.

This article is based on information presented at the 2020 virtual annual meeting of the North American Menopause Society (NAMS). According to NAMS, all presentations have been pre-recorded and now are available for on-demand viewing beginning Sept. 28 through Sept. 21, 2021. 

Cognition decline after menopause transition

The meeting will include the latest information on menopause and midlife women’s health with a focus on reaching new heights in menopause care.

Registration will open on September 28 and fees vary. Participants will be provided with 12-month access to the Plenary Symposia, special lectures, Menopause 101 course, Pre-Meeting Symposium, Live Q&A sessions, a Virtual Exhibit Hall, abstract presentations, a Poster Session, and Product Theater.

For those already registered for the in-person meeting, NAMS will automatically refund the registration fees paid. See 

for additional details and updates on this year’s NAMS Annual Meeting.

The North American Menopause Society (NAMS) has announced its decision to host the 2020 Annual Meeting virtually from September 30 to October 3.

NAMS 2020 Virtual Annual Meeting

A series of presentations at the 43rd AAGL Global Congress on Minimally Invasive Gynecological Surgery explored the challenges of diagnosing and treating chronic pelvic pain. Erin Teeter Carey, MD, of the Center for Pelvic Pain and Sexual Health at University at Kansas Medical Center in Overland Park gave a presentation entitled "A Systematic Approach to the Evaluation of Chronic Pelvic Pain."

Chronic pelvic pain is not only debilitating but also frustrating for patients and practitioners. When evaluating patients with chronic pain, OB/GYNs need to consider the physical sources of pain as well as the psychosocial issues that go hand-in-hand with pelvic pain.

In her presentation, Carey reviewed:
- The definition of chronic pelvic pain (CPP).
- How pertinent history and physical exam findings relate to the etiology of the pain.
- The process to evaluate and manage chronic pelvic pain.
- How to understand the psychosocial issues associated with chronic pelvic pain.

Chronic pain is described by ACOG as pain in the lumbosacral back, abdomen (below the umbilicus), or the pelvis that lasts 6 months or longer and results in disability or in a patient's seeking out medical care. The condition is common, may be accompanied by dysmenorrhea or dyspareunia, and could affect as many as 38 of every 1000 women.

Dr Carey explains that practitioners shouldn't expect all chronic pain to result from one particular diagnosis but instead to treat the pain as a diagnosis in and of itself. OB/GYNs should also assess the entire person, considering any unique history, biopsychosocial situations, and the possibility of pain being from several contributors.

Further, Dr Carey points out that evaluating chronic pain is time consuming and may require help from prior physicians, as well as any reports from previous surgery or hospitalizations. The mnemonic "OPQRST-ASPN," if you can remember it, can be helpful in taking a history:

ssociated Symptoms (gastrointestinal, genitourinary)
- 

Listen to the patient, but also ask deeper questions. Ask the patient to describe the pain, including what it feels like (is it pulling, cramping, stabbing), how intense it is (daily, cyclic, or are there pain-free times), whether there are any triggers (such as food, stress, or sex), and what time of day it is present. If the pain was treated in the past surgically or medically, determine if any treatments were helpful. Query about involvement of other organ systems and whether there are bowel or bladder symptoms, headaches, or head and neck pain. Physical history should include medical, surgical, family, social, psychiatric, sleep, and sexual history.

Carey explains that multiple diagnoses and providers at the outset of treatment can result in fragmented care. The start of treatment typically starts with centrally acting medication, lifestyle changes, and physical therapy. The outcome when pelvic pain is managed with surgery remains unclear, but treatment should begin with an evaluation of multiple organ systems. Chronic pelvic pain requires a multidisciplinary approach and is costly to diagnose and treat, but appropriate and timely interventions can lead to effective management and a restoration of quality of life.

Erin Teeter Carey, MD, MSCR. Didactic: No Pain, No Gain. A Systematic Approach to the Evaluation of Chronic Pelvic Pain. 43rd AAGL Global Congress on Minimally Invasive Gynecology. ANAT-702. Available in: 

http://mobile.aagl.org/api/v1/modules/documents/files/pelv609.pdf

AAGL

Chronic pelvic pain is costly to diagnose and treat, but appropriate and timely interventions can lead to a restoration of quality of life.

Evaluating Chronic Pelvic Pain

Is knowledge about retroperitoneal anatomy the Achilles' heel of gynecologic surgeons? No matter the specialty, the core skills for any surgeon include knowledge of the applicable anatomy and the ability to safely expose that anatomy. These basic skills are necessary for surgeons to reveal anatomy without having an effect on either the structure or the function of the organs involved.

In a series of presentations at the 43rd AAGL Global Congress on Minimally Invasive Gynecological Surgery in November 2014, Jaime B. Long, MD, Chief of Urogynecology at Reading Health System in West Reading, PA, discussed several techniques aimed to bridge the knowledge gap and instruct gynecologic surgeons in proper surgical techniques.

The three objectives of Long's presentation were to teach the attendees to:

1. Use dissection techniques to expose anatomy safely.

2. Understand the purpose of dissection maneuvers.

In her talk, Long points out that good technique can empower a surgeon faced with a complex scenario, cut down on complications, and result in faster surgeries. Without technical skill, surgeons can't expect favorable outcomes for their patients. Students who understand and apply good techniques during their procedures should be able to progress into competent surgeons.

The 6 techniques included in Long's presentation include millimeter by millimeter, grasp and tent, push and spread, traction-counter-traction, gentle wiping/teasing, hydrodissection, and skeletonizing. The "millimeter by millimeter" approach allows for the correct orientation and direction of dissection, ongoing evaluation of instruments and techniques, safe exploration of the anatomy, and limiting the potential of injury.

With the "grasp and tent" procedure, surgeons can move the peritoneum or other tissues away from the vital organs before making an incision. Visualization is improved because the tissue contained in the grasp is thinned. In "push and spread," which might also sometimes be called "poke and open," tissue is thinned out even more, releasing scarring.

"Traction-counter-traction" can be done with assistance from a surgical team member and is used to gently pull tissues. The field of dissection is better visualized because this technique thins visceral connection tissues. "Gentle wiping/teasing" is applied slowly, millimeter by millimeter. This technique thins tissues, clears blood, and can help reveal tissue planes. Long advises against using blunt or quick strokes, which could lead to damage.

Hydrodissection, the process of injecting sterile fluid to tent and thin out connective tissues can open potential spaces and is helpful in vaginal dissection. In laparoscopy, CO

 gas might also be used instead of fluid to dissect open spaces. To separate adhesions, clean connective tissue, or for broad ligament dissection, skeletonizing is used. This technique is done by gently brushing the tissue with an open pair of scissors or a fine cutting instrument.

Long also suggests that students start with easy dissections and progress to difficult ones; remain flexible; act quickly on warning signs of bleeding; perform techniques the same way each time they're used; and make use of lighting, retraction, and hemostasis to better visualize the surgical field.

Source: Jaime B. Long, MD. Didactic (Live Cadaveric Demo): Fulfill Your Destiny as a MIG Surgeon, You Must. The Way of the Jedi Master, Surgical Anatomy, It Is. The Art and Practice of Expert Surgical Dissection. 43rd AAGL Global Congress on Minimally Invasive Gynecology. ANAT-702. 

These tips for implementing good technique in laparoscopic surgeries can help reduce complications and result in faster surgeries.

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