Advances in gynecologic simulation: implementation, validity, and new resources.

PURPOSE OF REVIEW: Simulation plays an integral role in gynecological surgical training that will continue and grow in the future. It aims to supplement surgical training as residents are experiencing decreased surgical volumes. It has also been recognized as a means for assessing a trainee's capabilities to the point of being incorporated into the board certification process. This review will highlight the recent updates in research and resources available for gynecologic surgery simulation. RECENT FINDINGS: The literature reviewed demonstrated that, across the board, participants in simulation find it beneficial. A variety of low-fidelity and high-fidelity models, virtual reality programs, and artificial intelligence technology have been developed recently. As the field advances, researchers have started to investigate methods to increased engagement and provide feedback without the need for direct observation, the logical next step considerations to maximize the impact and availability of simulation. SUMMARY: Gynecologic surgery training programs must stay abreast of the wide variety of simulation training available. Efforts should continue to be made to investigate the impact of simulation patient outcomes. The academic medicine community has a responsibility to ensure high-quality simulation is available to all surgical trainees to avoid disparities between low-resource and high-resource programs.

A Novel Technique Using Ultrasonic Shears Versus Traditional Methods of Reduction of Bilateral Labia Minora Hypertrophy: A Retrospective Case-Control Study.

INTRODUCTION: To compare the clinical outcomes of bilateral labia minora hypertrophy reduction using ultrasonic shears versus traditional methods. MATERIALS AND METHODS: In this retrospective study, we evaluate the surgical outcomes of 11 women who underwent bilateral labia minora hypertrophy reduction using ultrasonic shears to 14 women who underwent the same procedure using various traditional methods between January 1, 2015 and February 29, 2020 in a single center. The primary outcomes evaluated are total operative time, estimated blood loss, and postoperative pain. Secondary outcomes include postoperative complications and total admission time. The statistical analyses used were exact Wilconxon Rank and Fisher's exact test. RESULTS: 25 total bilateral labiaplasty procedures were included in the analysis. 11 procedures were performed using ultrasonic shears and 14 were performed using traditional methods. The mean reduction operative time for the ultrasonic shears technique when compared with traditional methods was 43.25 minutes (22.82 minutes versus 66.07 minutes, P = .0002). A statistically significant but non-clinically significant difference in estimated blood loss was noted. No statistically significant differences existed with postoperative pain score, total admission time, or postoperative complications. CONCLUSIONS: Ultrasonic shears significantly reduce the time needed for the reduction of bilateral labia minora hypertrophy and therefore should be considered by surgeons as a useful tool in increasing the efficiency of this procedure.

Continuous Hydrogen Sulfide Gas Monitoring using the PortaSens II Portable Gas Leak Detector Model C16 during Laparoscopic or Robotic Surgery Cannot Be Used Intraoperatively to Detect Bowel Injury.

STUDY OBJECTIVE: To determine the feasibility of measuring hydrogen sulfide (H2S) gas in the insufflated abdomen during laparoscopic surgery after transmural bowel injury as a marker of unrecognized bowel injuries. DESIGN: This is a feasibility study performed on swine models during a robotic training course. We aimed to determine baseline H2S levels and subsequent elevations in H2S levels after enterotomy of the large and small intestines. SETTING: University-based robotic training lab. PARTICIPANTS: Three swine participants. INTERVENTIONS: During initial insufflation of the swine abdominal cavity, baseline H2S levels were recorded over 15-second intervals for 10 minutes using the PortaSens II Portable Gas Leak Detector Model C16 (Analytical Technology, Inc., Collegeville, PA). The same values were recorded in separate studies after transmural transection of the small intestine and the large intestine using laparoscopic shears with and without monopolar electrosurgery. MEASUREMENTS AND MAIN RESULTS: Baseline H2S level over the initial 10 minutes of insufflation was 0 parts per million (ppm). The device is calibrated to detect levels of H2S of 0 ppm to 200 ppm. H2S levels after small and large bowel enterotomies without monopolar electrosurgery initially showed a rise to 1 ppm to 2 ppm. However, repeat confirmatory testing failed to show any elevation in H2S levels. H2S levels after small and large bowel enterotomies with monopolar electrosurgery both showed increases to 108 ppm and 74 ppm with a duration of elevation measuring 4 minutes and 4 minutes 15 seconds, respectively. Although our study did show elevations in H2S after transection with monopolar electrosurgery, this was later determined to be the result of cross contamination with carbon monoxide, which was a confounding factor. CONCLUSION: Our study demonstrated that using the methodology and detection methods described, H2S cannot be used to detect unrecognized bowel injury during laparoscopic surgery. Our results were due to cross contamination with other gases created with the use of electrosurgery, and we were unable to reproduce initial testing results, which did show slight rises in H2S levels after enterotomies without monopolar electrosurgery. Further testing of other gases produced by the gastrointestinal tract or the use of alternative detection methods may provide more clinically relevant results.

Evaluating the Impact of Office Hysteroscopy in a Military Treatment Facility.

INTRODUCTION: Office hysteroscopy has become a cornerstone of modern gynecologic care through the advent of advanced technology and emphasis on an efficient healthcare system. In 2017, Medicare announced an increase in office hysteroscopy reimbursement by 237%, giving an incentive for gynecologists to move from the operating room into the clinic. The U.S. military medical system needs more cost-effective and efficient healthcare, given that the cost of military healthcare increased by 130% between 2000 and 2012 (accounting for 10% or $52 billion of the Department of Defense budget). Within our institution, we have moved to conducting a regularly scheduled outpatient hysteroscopy clinic. Increased healthcare costs, decreased available operating room time, and efforts to boost patient and provider satisfaction drove the change. MATERIALS AND METHODS: After institutional review board approval, we performed a retrospective observational cost-benefit analysis of 235 outpatient and 45 inpatient records that included female military healthcare beneficiaries age 18 or older who had diagnostic or operative hysteroscopy performed in the operating room or office setting from January 2015 to October 2018. We specifically focused on diagnostic hysteroscopy, hysteroscopic biopsy and polypectomy, and hysteroscopic foreign body removal (intrauterine device removal). We then compared admission time, procedure time, reimbursement, and cost for each of the hysteroscopic procedure groups to yield a total cost-benefit value (TCBV). TCBV was defined as cost savings plus difference in reimbursement rate. RESULTS: This study analyzes the costs and benefits of a regularly scheduled hysteroscopy clinic within the U.S. military medical system. We performed a cost-benefit analysis that indicated a substantial difference between clinic and operating room TCBV, total relative value units or reimbursement rates, and total patient care time. We found the average admission time for an inpatient procedure was 6.23 hours compared to our standard 1-hour clinic time. The average success rate for procedure completion in the clinic was 89%. We found the average TCBV for 100 patients (after 11% reoperation rate) to be as high as $64,220, $159,940, and $66,709 for diagnostic hysteroscopy, hysteroscopic biopsy and polypectomy, and hysteroscopic foreign body (intrauterine device) removal, respectively. CONCLUSIONS: Compared to traditional operating room hysteroscopy, we were able to demonstrate reduced costs with increased reimbursement while performing the same scope of care for patients undergoing office hysteroscopy. Decreased total time in performing office hysteroscopy suggests the potential benefit of increased patient and provider satisfaction. Our study indicated substantial incentive for military gynecologists to incorporate office hysteroscopy into their practice given the increased relative value units generated. Our office hysteroscopy protocol is discussed to encourage other military facilities to follow in our footsteps.

Review of Sterilization Techniques and Clinical Updates.

Sterilization is the most common form of contraception used worldwide and is highly effective in preventing unintended pregnancy. Each of the available sterilization methods has unique advantages and disadvantages that influence the choice of approach for each individual patient. Salpingectomy for sterilization has become more popular in recent years, with mounting evidence suggesting a protective effect against ovarian cancers originating in the fallopian tube. At the same time, Essure hysteroscopic sterilization has come under scrutiny because of increasing reports of possible adverse effects associated with its use. Here we review clinical updates in sterilization techniques, with a focus on salpingectomy and Essure hysteroscopic sterilization.

Single-molecule fluorescence imaging of peptide binding to supported lipid bilayers.

Single-molecule fluorescence imaging techniques have been adapted to the quantitative characterization of peptide-binding to lipid bilayers. Peptide-membrane interactions are important in therapeutics, diagnostics, and membrane permeation and for understanding of the structure and function of membrane-bound proteins. Total-internal reflection fluorescence (TIRF) imaging is capable of determining membrane-binding equilibrium constants through the reliable counting of individual peptide molecules in order to report their surface density in the membrane. The residence times of the individual molecules in the membrane can also be determined and the rates of unbinding determined from a histogram of residence times. A combination of the unbinding kinetics and the equilibrium constant allows the binding rate of a peptide to the membrane also to be reported. We apply this method to characterize the lipid membrane affinity of glucagon-like peptide-1 (GLP-1), a 30-residue membrane-active peptide that is involved in glycemic control. Using single-molecule TIRF imaging, we have measured the affiliation of GLP-1 with a supported, phospholipid bilayer and determined its binding equilibrium constant. Two rates of dissociation were observed, suggesting strongly and weakly bound states of the peptide. The rate of membrane association was much slower than diffusion-controlled, indicating a significant kinetic barrier to membrane binding. The data were interpreted using a heterogeneous, surface-reaction model analogous to electron-transfer kinetics at an electrode. To our knowledge, these results are the first example of using single-molecule counting to quantify peptide-lipid bilayer binding equilibria and kinetics.