Impact of the Recorded Audio and Video Feedback on Simulated Surgical Performance: A Randomized Controlled Trial.

INTRODUCTION: Simulation and coaching have become increasingly important in laparoscopic skills acquisition. This study was designed to evaluate if access to the recorded audio and video feedback after a single proctored session improves the acquisition of laparoscopic suturing skills in obstetrics and gynecology (OB/GYN) residents. METHODS: Twenty OB/GYN residents received a single face-to-face coaching session on a laparoscopic vaginal cuff closure model. The session was recorded and residents were randomized to access either the video-only or the audio and video recording of the proctored session. The primary outcome measure was comparison of Global Operative Assessment of Laparoscopic Skills plus Vaginal Cuff Metrics (GOALS+) scores of the vaginal cuff closure prior to and following the proctored session. RESULTS: Only 30% of residents accessed the recorded sessions with junior residents most likely to access the recording. Baseline GOALS+ scores were significantly higher in senior residents (mean 21.7, SD 3.9) as compared to junior residents (mean 14.7, SD 3.2) (p<.001). While all learners' GOALS+ scores significantly improved after proctoring the intervention (p<.001), the senior residents continued to have significantly higher GOALS+ scores at the final assessment (mean 28.3, SD 4.2, p=.01) when compared to their junior residents (mean 24.0, SD 3.1). CONCLUSION: Due to the low uptake of the review of recorded proctored sessions among OB/GYN residents across skill and year levels, we were unable to assess the effect of recorded audio and video feedback on resident performance. However, the intervention of a single proctored session of simulated laparoscopic vaginal cuff closure significantly improved resident performance as assessed with GOALS+ scores.

Two-Layer Compared With One-Layer Vaginal Cuff Closure at the Time of Total Laparoscopic Hysterectomy to Reduce Complications.

OBJECTIVE: To explore whether two-layer laparoscopic vaginal cuff closure at the time of laparoscopic hysterectomy is associated with a lower rate of postoperative complications compared with a standard one-layer cuff closure. METHODS: A retrospective cohort study of total laparoscopic hysterectomies performed by fellowship-trained minimally invasive gynecologic surgeons between 2011 and 2017 was performed. Surgeons sutured the vaginal cuff laparoscopically, either in a two- or one-layer closure. The primary outcome was a composite of total postoperative complications, including all medical and surgical complications within 30 days and vaginal cuff complications within 180 days. Factors known to influence laparoscopic vaginal cuff complications including age, postmenopausal status, body mass index, tobacco use, and immunosuppressant medications were examined and controlled for, while surgeon skill, colpotomy technique, and suture material remained standardized. We conducted statistical analyses including χ2, Fisher exact test, logistic regression, and post hoc power calculations. RESULTS: Of the 2,973 women who underwent total laparoscopic hysterectomies, 40.8% (n=1,213) of vaginal cuffs were closed with a two-layer closure and 59.2% (n=1,760) with a one-layer technique. Two-layer vaginal cuff closure was associated with decreased numbers of total postoperative complications (3.5% vs 5.7%; P<.01). The primary difference stemmed from lower vaginal cuff complications within 180 days (0.9% vs 2.6%; P<.01); no differences in 30-day medical and surgical postoperative complications were observed between the two groups (2.6% vs 3.1%; P=.77). No patients in the two-layer vaginal cuff closure cohort experienced a vaginal cuff dehiscence or mucosal separation compared with 1.0% in the one-layer group (P<.01). Compared with a one-layer closure, a two-layer closure was protective from postoperative complications (adjusted odds ratio 0.38, 95% CI 0.19-0.74). CONCLUSION: Although postoperative complications with laparoscopic hysterectomies are rare, two-layer laparoscopic vaginal cuff closure is associated with lower total postoperative complications compared with a one-layer closure. The difference was primary driven by cuff complications.

Abdominal wall endometriosis: an update in diagnosis, perioperative considerations and management.

PURPOSE OF REVIEW: Abdominal wall endometriosis (AWE) is rare with limited evidence guiding diagnosis and treatment. The purpose of this review is to provide an update of the diagnosis, perioperative considerations, and treatment of AWE. RECENT FINDINGS: Recent studies further characterize presenting symptoms and locations of AWE. Prior abdominal surgery remains the greatest risk factor for the development of AWE. Newer evidence suggests that increasing BMI may also be a risk factor. Ultrasound is first-line imaging for diagnosis. Magnetic resonance image is preferred for surgical planning for deep or extensive lesions. Laparotomy with wide local excision is considered standard treatment for AWE with great success. Novel techniques in minimally invasive surgery have been described as effective for the treatment of AWE. A multidisciplinary surgical approach is often warranted for successful excision and reapproximation of skin and/or fascial defects. Noninvasive therapies including ultrasonic ablation or cryotherapy are also emerging as promising treatment strategies in select patients. SUMMARY: Recent studies provide further evidence to guide diagnosis through physical exam and imaging as well as pretreatment planning. Treatment options for AWE are rapidly expanding with novel approaches in minimally invasive and noninvasive therapies now available.

Same-day discharge after minimal invasive hysterectomy: Applications for improved value of care.

OBJECTIVE: Hysterectomy is one of the most common surgical procedures. Same-day discharge (SDD) is increasingly utilized for minimally invasive hysterectomies, but its uptake varies across healthcare systems and surgical specialties. An evidence-based initiative was developed to aid in the incorporation of SDD into the practice of minimally invasive hysterectomy (MIH) in the UPMC Health System. The objective of this study was to identify trends of SDD utilization across various gynecologic specialties at UPMC, as well as evaluate the impact of SDD on length of stay (LOS) and complications after the implementation of SDD initiative. STUDY DESIGN: We retrospectively identified 5554 patients who underwent MIH between 2014 and 2017 and were eligible for SDD, as determined by physicians and authorized by patients' insurance plans. Multivariable logistic regression models evaluated the trend of SDD utilization among four specialty types (general gynecologists, urogynecologists, specialized minimally invasive surgeons, and oncologists) and trends in complications. Multivariable logistic and linear regression models were applied to compare complications and LOS between patients with SDD vs. those with overnight admissions. RESULTS: SDD utilization increased from 28.55% to 74.99% during the study period. SDD significantly increased over the study period for all specialty types, with urogynecologists having the highest uptake from 3.9% in 2014 to 95.8% in 2017 (p<.01). After adjusting for year, specialty types, MIH procedure type, and total case time, SDD utilization was associated with shorter mean LOS (p<.01); such that mean LOS was 764.43 min (95% CI: 735.46-793.40) for SDD patients and 2041.84 min (95% CI: 2015.99-2067.70) for patients with overnight admissions. SDD was also associated with 42% lower odds (95% CI: 0.37-0.93, p=.02) of complications compared with patients with overnight admissions. CONCLUSION: Same-day discharge uptake increased over years and was associated with lower odds of complications and decreased length of stay. More studies are needed to explore same-day discharge process to improve patient outcomes, patient satisfaction, and value of care.

Risk-reducing Bilateral Salpingo-oophorectomy: Assessing the Incidence of Occult Ovarian Cancer and Surgeon Adherence to Recommended Practices.

STUDY OBJECTIVE: This study aimed to determine the incidence of ovarian cancer diagnosed at the time of risk-reducing bilateral salpingo-oophorectomy in a large cohort of patients with a BRCA mutation. In addition, we aimed to determine the adherence to the recommended practices for performing a risk-reducing bilateral salpingo-oophorectomy as described by the American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncology. We sought to determine if adherence differed by the type of training (i.e., gynecologic oncologists vs benign gynecologists). DESIGN: Descriptive, retrospective analysis. SETTING: Academic medical center. PATIENTS: Two hundred sixty-nine patients with a known BRCA mutation. INTERVENTIONS: Prophylactic risk-reducing bilateral salpingo-oophorectomy performed either by a gynecologic oncologist or a benign gynecologist between July 2007 and September 2018. MEASUREMENTS AND MAIN RESULTS: Among 269 patients who underwent risk-reducing bilateral salpingo-oophorectomies, 220 procedures were performed by gynecologic oncologists, and 49 were performed by benign gynecologists. Washings were not performed in 5% of the procedures performed by gynecologic oncologists and 37% of the procedures performed by benign gynecologists (p <.001). Complete serial sectioning of the adnexa was not performed in 12% of the procedures performed by oncologists, and 13% of the procedures performed by benign gynecologists (p = .714). There were 8 cases (2.9%) of tubal or ovarian cancer diagnosed within this cohort. Of these cases, only 3 (1.1%) were diagnosed at the time of surgery and met the criteria for conversion to a staging procedure. CONCLUSION: Because the incidence of ovarian cancer diagnosis at the time of risk-reducing bilateral salpingo-oophorectomy is low and is often not diagnosed at the time of surgery owing to the presence of only microscopic disease, it may not be necessary for gynecologic oncologists to exclusively perform these procedures. However, this study also revealed that when this procedure is performed by benign gynecologic surgeons, some of the recommended practices are not routinely followed. If general gynecologic surgeons are to routinely perform risk-reducing bilateral salpingo-oophorectomies, it is important to promote better adherence to these practices.

Postoperative Bladder Filling After Outpatient Laparoscopic Hysterectomy and Time to Discharge: A Randomized Controlled Trial.

OBJECTIVE: To determine whether backfilling the bladder postoperatively will reduce time to discharge in patients undergoing outpatient laparoscopic hysterectomy. METHODS: In a single-blind, randomized, controlled trial among women undergoing outpatient laparoscopic hysterectomy, patients were randomly assigned to a backfill-assisted void trial or a trial of spontaneous voiding. The primary outcome was time to discharge assessed by length of time spent in the postanesthesia care unit. Secondary outcomes included time to first spontaneous void, urinary retention rates, and postoperative complications within 8 weeks. We estimated that 152 patients (76/group) would provide greater than 80% power to identify a 30-minute difference in the primary outcome with a SD of 56 minutes and a two-sided α of 0.05. RESULTS: Between June 2017 to May 2018, 202 women were screened, 162 women were randomized, and results were analyzed for 153 women. Seventy-five patients (group A) who had a backfill-assisted voiding trial and 78 patients (group B) who had a spontaneous voiding trial were included in the analysis. The mean time to discharge was 273.4 minutes for group A vs 283.2 minutes for group B, which was not found to be significant (P=.45). The mean time to first spontaneous void was 181.1 minutes in group A vs 206.0 minutes in group B. There was a statistically significant reduction of 24.9 minutes in time to first spontaneous void with patients randomized to the backfill group (P=.04). Five of 75 patients (6.7%) in group A and 10 of 78 patients (12.8%) in group B developed urinary retention postoperatively and required recatheterization before discharge, which was also not significant (P=.20). CONCLUSION: Bladder filling before removing the Foley catheter is a simple procedure shown to reduce time to first spontaneous void, but not time to discharge in patients undergoing outpatient laparoscopic hysterectomy. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03126162.

Intravenous acetaminophen vs saline in perioperative analgesia with laparoscopic hysterectomy.

BACKGROUND: Opioids are effective for the treatment of postoperative pain but can cause nausea and are associated with dependency with long-term use. Nonopioid medications such as acetaminophen offer the promise of decreasing these nondesirable effects while still providing patient comfort. OBJECTIVE: The purpose of this study was to compare intravenous acetaminophen with placebo and to evaluate postoperative pain control and opioid usage after laparoscopic hysterectomy. STUDY DESIGN: We conducted a prospective double-blind randomized study with 183 patients who were assigned randomly (1:1) to receive acetaminophen or placebo (Canadian Task Force Design Classification I). Patients received either 1000 mg of acetaminophen (n=91) or a placebo of saline solution (n=92) at the time of induction of anesthesia and a repeat dose 6 hours later. Both groups self-reported pain and nausea levels preoperatively and at 2, 4, 6, 12, and 24 hours after extubation with the use of a visual analog scale with a score of 0 for no pain to 10 for highest level of pain. Patients self-reported pain, nausea, and postoperative oral opiates that were taken after discharge. All opiates were converted to milligram equivalents of oral morphine for standardization. RESULTS: There were no significant differences in generalized abdominal pain at any time point postoperatively that included 2 hours (placebo 3.6±2.5 vs acetaminophen 4.4±2.5; P=.07) and up to 24 hours (placebo 3.3±2.4 vs acetaminophen 3.6±2.5; P=.28). Similar results were observed for nausea scores. There were no differences in opioid consumption at any time point including intraoperatively (placebo 4.4±3.9 vs acetaminophen 3.3±4.0; P=.06), post anesthesia care unit (placebo 10.5±10.3 vs acetaminophen 9.7±10.3; P=.59), and up to 24 hours after surgery (placebo 1.4±2.0 vs acetaminophen 1.6±2.1; P=.61). There were no differences in demographics or surgical data between groups. CONCLUSION: There was no difference between acetaminophen and placebo groups in postoperative pain, satisfaction scores, or opioid requirements. Given the relatively high cost ($23.20 per dose in our study), lack of benefit, and available oral alternatives, our results do not support routine use during hysterectomy.

Use of Uterine Characteristics to Improve Fertility-Sparing Diagnosis of Adenomyosis.

Objective: To describe patient demographics, determine accuracy of clinical diagnosis, and evaluate reliability of laparoscopic uterine characteristics in the diagnosis of adenomyosis. Materials and Methods: Enrollment included 117 patients undergoing laparoscopic hysterectomy for benign indications. Intraoperatively, the attending surgeon predicted uterine weight; evaluated the presence of fibroids; and commented on the uterus' shape, color, and consistency while probing it with a blunt instrument. A prediction was also made about whether final pathology would reveal adenomyosis. Standardized video recordings were obtained at the start of the case. Each video was viewed retrospectively twice by three expert surgeons in a blinded fashion. Uterine characteristics were reported again with a prediction of whether or not there would be a pathologic diagnosis of adenomyosis. These data were used to calculate inter-and intrarater reliability of diagnosis. Results: Women with adenomyosis were more likely to complain of midline pain as opposed to lateral or diffuse pain (p = 0.048) with no difference in the timing of the pain (p = 0.404), compared to patients without adenomyosis. Uterine tenderness on examination was not an accurate predictor of adenomyosis (p = 0.566). Preoperative diagnosis of adenomyosis by clinicians was poor, with an accuracy rate of 51.7%. None of the intraoperative uterine characteristics were significant for predicting adenomyosis on final pathology, nor was any combination of the features (p = 0.546). Retrospective video reviews failed to reveal any uterine characteristics that generated consistent inter- or intrarater reliability (Krippendorff's α < 0.7) in making the diagnosis of adenomyosis. Conclusions: Clinical and video diagnosis of adenomyosis have low accuracy with no uterine characteristics consistently or reliably predicting adenomyosis on final pathology. (J GYNECOL SURG 34:183).

The role of appendectomy at the time of laparoscopic surgery for benign gynecologic conditions.

PURPOSE OF REVIEW: The risk-benefit ratio of concurrent appendectomy at the time of gynecologic surgery has long been debated and remains controversial. However, emerging data on the appendix's role in chronic pain syndromes point to a previously unrecognized link between gynecologic disorders and appendicular pathology. In this article, we review the indications for appendectomy at the time of laparoscopic gynecologic surgery for the treatment of endometriosis and chronic pelvic pain. RECENT FINDINGS: The incidence of appendiceal endometriosis is highly variable depending on the patient population selected. Although rare in patients undergoing appendectomy for acute appendicitis, women with endometriosis may experience rates as high as 9.3-39.0%, especially when suffering from deep infiltrative endometriosis. Appendectomy may also significantly reduce pain in women with unexplained chronic pelvic pain. SUMMARY: Despite lack of prospective data, retrospective studies suggest that appendectomy during gynecologic procedures for chronic pelvic pain and severe endometriosis may be beneficial and necessary to fully address the treatment of these complex gynecologic conditions. In these clinical scenarios, the benefits of laparoscopic appendectomy at the time of the primary gynecologic procedure may outweigh the risks and cost, and should be discussed with patients preoperatively.

Racial and Socioeconomic Disparities in Hysterectomy Route for Benign Conditions.

BACKGROUND: The aim of this paper was to explore disparities associated with the route of hysterectomy in the University of Pittsburgh Medical Center (UPMC) health system and to evaluate whether the hysterectomy clinical pathway implementation impacted disparities in the utilization of minimally invasive hysterectomy (MIH). METHODS: We performed a retrospective medical record review of all the patients who have undergone hysterectomy for benign indications at UPMC-affiliated hospitals between fiscal years (FY) 2012 and 2014. RESULTS: A total number of 6373 hysterectomy patient cases were included in this study: 88.7% (5653) were European American (EA), 11.02% (702) were African American (AA), and the remaining 0.28% (18) were of other ethnicities. We found that non-EA, women aged 45-60, traditional Medicaid, and traditional Medicare enrollees were more likely to have a total abdominal hysterectomy (TAH). Residence in higher median income zip code (> $61,000) was associated with 60% lower odds of undergoing TAH. Both FY 2013 and 2014 were associated with significantly lower odds of TAH. Logistic regression results from the model for non-EA patients for FY 2012 and FY 2014 demonstrated that FY and zip code income group were not significant predictors of surgery type in this subgroup. Pathway implementation did not reduce racial disparity in MIH utilization. CONCLUSION: This study demonstrated that there is a significant disparity in MIH utilization, where non-EA and Medicaid/Medicare recipients had higher odds of undergoing TAH. Further research is needed to investigate how care standardization may alleviate healthcare disparities.

Hysterectomy Pathway as the Global Engine of Practice Change: Implications for Value in Care.

INTRODUCTION: In 2012, University of Pittsburgh Medical Center (UPMC) introduced a hysterectomy clinical pathway to reduce the number of total abdominal hysterectomies performed for benign gynecological indications. This study focused on exploring physician and patient factors impacting the utilization of hysterectomy clinical pathways. METHODS: An online survey with 24 questions was implemented to explore physicians' attitudes and perceived barriers toward implementing the pathway. A survey consisting of 27 questions was developed for patients to determine the utility of a pathway-based educational tool for making surgery decisions and to measure satisfaction with the information provided. Descriptive statistics were used to describe survey results, while thematic analysis was performed on verbal feedback submitted by respondents. RESULTS: Physician respondents found the clinical pathway to be practical, beneficial to patients, and up-to-date with the latest evidence-based literature. Key barriers to the use of the pathway that were identified by physicians included perceived waste of time, inappropriateness for some of the patient groups, improper incentive structure, and excessive bureaucracy surrounding the process. Overall, patient respondents were satisfied with the tool and found it to be helpful with the decision-making process of choosing a hysterectomy route. CONCLUSIONS: Physicians and patients found the developed tools to be practical and beneficial. Findings of this study will help to use pathways as a unifying framework to shape future care of patients needing hysterectomy and add value to their care.