The Effect of Vertical Versus Horizontal Vaginal Cuff Closure on Vaginal Length After Laparoscopic Hysterectomy.

STUDY OBJECTIVE: To determine whether vertical versus horizontal closure of the vaginal cuff during laparoscopic hysterectomy has an effect on postoperative vaginal length and pelvic organ prolapse. DESIGN: A prospective randomized controlled trial. Subjects were randomly assigned to vertical or horizontal vaginal cuff closure at the time of total laparoscopic hysterectomy. Pelvic organ prolapse quantization (POP-Q) tests were performed before surgery, 2 to 4 weeks after surgery, and 3 to 4 months after surgery (Canadian Task Force classification I). SETTING: An academic university-affiliated community hospital. PATIENTS: Patients undergoing laparoscopic or robotic-assisted laparoscopic total hysterectomy for benign or malignant disease, excluding those undergoing radical hysterectomy or concomitant pelvic floor procedure. INTERVENTIONS: Subjects were randomized into the vertical or horizontal vaginal cuff closure group. Total hysterectomy was completed with traditional laparoscopic techniques or with robotic assistance. A colpotomy ring was used in each subject. Vaginal cuff closure was performed with barbed suture in a running fashion according to the group assignment. MEASUREMENTS AND MAIN RESULTS: A total of 43 subjects were enrolled and randomized. One patient was excluded because the vaginal cuff was closed vaginally, 1 cancelled surgery, and 1 was completed without a uterine manipulator. The mean change in vaginal length was -0.89 cm (standard deviation [SD] = 1.03) in the horizontal group and -0.86 cm (SD = 1.19) in the vertical group (p = .57). POP-Q evaluation revealed no differences between groups and an overall trend toward improved POP-Q measurements. The average duration of vaginal cuff closure did not differ (p = .45), and there were no intraoperative complications related to vaginal cuff closure. CONCLUSION: Horizontal and vertical laparoscopic closure of the vaginal cuff after laparoscopic hysterectomy results in similar changes in vaginal length and other POP-Q scores.

"Pause" for Resident Education in the Operating Room.

Objective: To determine if asking residents to discuss their specific learning objectives with the attending physician prior to beginning a surgical case would improve the educational experience in the operating room. Study Design: This was a prospective nonrandomized cohort study utilizing a self-administered questionnaire. Prior to the intervention, residents and attendings were asked to fill out surveys evaluating the educational experience in the operating room. Subsequently, attending physicians were instructed to ask residents at the beginning of the surgery, "What are your goals for this surgical case?" During this intervention period, the same anonymous survey was filled out. Preintervention and postintervention answers were compared by t test and Fisher's exact test. Results: A total of 49 preintervention and 47 postintervention resident-attending survey pairs were collected. After implementation of the intervention, 100% of residents reported having surgical goals for the procedure as compared to 45% prior to the intervention (p<0.0001). Additionally, during the intervention residents reported they were better able to maximize learning opportunities and were more satisfied with their participation in the case. Attending physicians were more likely to be aware of resident learning objectives after the intervention. Conclusion: We propose the routine addition of an educational pause to the surgical time out.

Robotic-assisted Abdominal Cerclage Placement During Pregnancy and Its Challenges.

STUDY OBJECTIVE: To demonstrate a surgical video of 2 cases, in which the steps of robotic-assisted abdominal cerclage placement were delineated in one and a uterine vessel injury was repaired in the other. DESIGN: Step-by-step explanation of the technique using a surgical video (Canadian Task Force classification III). SETTING: The procedures were performed at a teaching hospital. The first patient was a 25-year-old gravida 4 para 0, with a history of cervical incompetence, who was 13 weeks pregnant at the time of surgery. She had failed McDonald cerclage and was referred for abdominal cerclage placement. The second patient was a 32-year-old gravida 6 para 0 who was 15 weeks pregnant. She had a history of 3 second-trimester miscarriages with painless cervical dilation and had failed McDonald cerclage during her previous pregnancy. Both patients were taken to the operating room for robotic-assisted abdominal cerclage placement early in the second trimester. INTERVENTIONS: Robotic-assisted abdominal cerclage placement was performed with ultrasound guidance. The procedure was begun with formation of the bladder flap [1]. An avascular space between the ascending and descending branches of uterine artery, at the level of the cervicoisthmic junction, was subsequently developed. The Mersilene tape was passed through this space in a posterior-to-anterior direction and pulled taut until it was laid flat along the posterior uterine wall. Six knots were then placed with the Mersilene tape on the anterior aspect of the uterus. The free ends of the tape were trimmed and approximated with a nonabsorbable suture to prevent knot slippage. The vesicouterine reflection was then reapproximated, and correct cerclage placement was confirmed with transvaginal ultrasound. In the second case, an incidental uterine vessel injury occurred during development of the avascular space. Hemostasis was attained immediately by clamping the vessel with the fenestrated graspers. Permanent hemostasis required application of the vascular clips, proximally and distally on the lacerated arterial site. CONCLUSION: A robotic approach was chosen for our patients requiring transabdominal cerclage placement during pregnancy, in an attempt to decrease the surgical morbidity associated with laparotomy [2,3]. Despite the challenges introduced by the enlarged gravid uterus, both procedures were successfully completed, and the patients delivered at term via cesarean section.

The effects of a brief mindfulness-based intervention on pain perceptions in patients with chronic pelvic pain: A case series.

INTRODUCTION: Chronic pelvic pain affects 15-20% of women, and patients frequently do not find relief with first-line therapies. Mindfulness-based meditation programs are effective in improving outcomes for patients with chronic pain conditions, but limited data exists for patients with chronic pelvic pain. We describe the effect of a brief mindfulness-based program, incorporated into pelvic-floor physical therapy visits, on perceived pain in patients with chronic pelvic pain. CASE SERIES: Patients being treated for pelvic pain participated in this 8-week program. Pelvic-floor physical therapists delivered a brief mindfulness-based exercise during routine physical therapy visits. Patients reported pain scores and pain catastrophizing scores at the beginning and end of the program. Ten patients completed the program. Paired-samples t-tests showed that pain catastrophizing significantly decreased from baseline to 8 weeks in patients who completed the mindfulness training and increased among patients who withdrew. CONCLUSION: Mindfulness-based exercises may be a useful complementary therapy for the treatment of chronic pelvic pain.

Transvaginal morcellation.

BACKGROUND AND OBJECTIVES: Transvaginal uterine morcellation has been described in the literature for more than a century. Despite an extensive body of literature documenting its safety and feasibility, concerns about morcellating occult malignant entities have raised questions regarding this technique. In this study, we looked at a single teaching institution's experience with transvaginal morcellation for leiomyomatous uteri. In addition, we reviewed the published literature for outcomes associated with transvaginal morcellation techniques. METHODS: This study was a retrospective case series. Charts of women who underwent total laparoscopic hysterectomy, robot-assisted laparoscopic hysterectomy, and laparoscopic-assisted vaginal hysterectomy for leiomyoma from July 1, 2011, through December 31, 2013, were reviewed. Cases were included if transvaginal morcellation was performed. Morcellation was performed by bringing the uterus into the vagina and by performing a wedge resection technique to reduce the volume of the specimen. Baseline demographics and intra- and postoperative outcomes were abstracted from the charts. A PubMed search from January 1, 1970 to October 31, 2014 was performed to review the literature regarding transvaginal morcellation. RESULTS: Sixty-four women who underwent laparoscopy for leiomyomatous uteri with transvaginal morcellation were identified from July 1, 2011 through December 31, 2013. Mean operative time was 210 minutes (SD 75.5; range, 93-420). The mean blood loss was 153 mL (SD 165; range, 25-1000). The mean uterine size was 608 g (SD 367; range, 106-1834). There were no surgical complications directly attributed to morcellation. The literature search yielded 22 articles describing outcomes after transvaginal morcellation, with a total of 1953 morcellated specimens. CONCLUSIONS: Transvaginal uterine morcellation appears to be a safe alternative to laparotomy for the removal of large uterine specimens in select patients.