Determining a Learning Curve for Contained Hand Tissue Extraction: Perioperative Outcomes and Operative Time.

STUDY OBJECTIVE: To compare the operative time of contained hand tissue extraction with power morcellation and to quantify the learning curve required to develop this skill. DESIGN: A retrospective cohort study (Canadian Task Force classification II-3). SETTING: Lahey Hospital and Medical Center, a suburban academic tertiary care center serving a broad base of patients. PATIENTS: Eighty-eight women undergoing laparoscopic hysterectomy requiring morcellation or tissue extraction from 2012 through 2015. INTERVENTIONS: Power morcellation before the institution's ban on power morcellation and contained hand tissue extraction instituted in a response to the ban. MEASUREMENTS AND MAIN RESULTS: Data were collected to compare the operative time and perioperative outcomes of morcellation before discontinuation of the power morcellator and after adaptation of a contained hand tissue extraction protocol. The data were then used to determine a learning curve for the new procedure. Eighty-eight consecutive cases of laparoscopic hysterectomy requiring morcellation were identified during the study duration, with 46 patients undergoing power morcellation and 42 undergoing hand tissue extraction. The 2 groups were similar overall in body mass index (28.9 vs 29.5, p = .70), prior laparoscopy (28% vs 21%, p = .46) or laparotomy (39% vs 21%, p = .07), removal of the cervix (56% vs 86%, p < .01), and uterine weight (581 vs 628 g, p = .56). The hand tissue extraction group had an average operating room time of 170 minutes compared with 154 minutes (p = .08) for the power morcellation group. The 2 surgeons performed 32 and 10 hand tissue extractions, respectively, with a decrease in 0.7 and 3 minutes per case, respectively, over the course of 7 months (p = .3 and .6, respectively). CONCLUSION: Contained hand tissue extraction was similar to power morcellation in the total operative time. The learning curve of surgeons performing contained hand tissue extraction showed a nonsignificant trend toward improvement in the operative time with an increasing number of cases.

Case Report: Vessel Injury During Suprapubic Catheter Placement and the Importance of Patient Positioning in Obese Patients.

Obesity is a well-known risk factor for increased perioperative morbidity. As surgeons see higher volumes of obese patients, it is important to recognize how an elevated body mass index can impact even the most basic surgical steps, such as patient positioning. This case report describes an iatrogenic injury to the external iliac artery in a morbidly obese patient caused by an abdominal trocar during suprapubic catheter insertion secondary to malrotation of the bony pelvis. It highlights the importance of recognizing the impact of obesity on patient positioning.

Impact of a Fellowship-Trained Minimally Invasive Gynecologic Surgeon on Patient Outcomes.

BACKGROUND AND OBJECTIVES: As the performance of minimally invasive hysterectomy has increased in the United States, the need to apply outcomes measures has also increased. This study was conducted to determine the impact of a fellowship-trained minimally invasive gynecologic surgery (MIGS) specialist on patient outcomes after laparoscopic hysterectomy (LH) in a gynecology department. METHODS: This is a retrospective review of 218 patients who underwent a laparoscopic hysterectomy for benign indications at a suburban academic-affiliated tertiary care hospital with a broad patient base from 2010 to 2014. RESULTS: A total of 218 women underwent conventional laparoscopic hysterectomy by 10 members of a gynecology department: 96 women (44%) by a MIGS specialist and 122 women (56%) by a group of general gynecologists. Operative time was less (119 vs 148 min; P < .001), and patients were more likely to be discharged on the same day (90.6% vs 66.4%; P < .001) for the MIGS specialist compared to other surgeons. More patients of the MIGS specialist had undergone prior laparotomies (42.7% vs 17.2%; P = < .001) and had a greater uterine weight (392 vs 224 g; P < .001). Although the difference was not statistically significant, conversion to laparotomy (0 vs 2 cases; P = .505) and postoperative infection (6 vs 16 cases; P = .095) were lower for the MIGS specialist. Total billing charges were also lower for the MIGS specialist ($9,920 vs $11,406; P < .001). CONCLUSION: A fellowship-trained MIGS specialist performed laparoscopic hysterectomy in less time on more difficult surgical patients, with a shorter length of stay and lower costs, and no difference in complications compared to other providers in a gynecology department.

Unilateral Human Papillomavirus Infection and Cervical Dysplasia in a Patient With Two Cervices.

BACKGROUND: In a uterine didelphys with two cervices, cervical screening may not reveal the same abnormalities. CASE: We present a patient with a uterine didelphys with two cervices in a single vagina after resection of a longitudinal vaginal septum at age 12. She presented with abnormal Pap test results with the right and left cervices discordant from each other. Despite both cervices sharing stroma in the midline, her right cervix was negative for human papillomavirus (HPV) and dysplasia, while her left cervix was HPV positive with high-grade cervical dysplasia on an excisional specimen. CONCLUSION: Uterine didelphys with shared bilateral cervices will not necessarily share the same HPV status or have concordant dysplasia.

Nephrogenic adenoma in a urethral diverticulum.

Nephrogenic adenoma (NA) is a rare finding that represents metaplasia of the urothelium. We present a case of a 46-year-old woman who presented with a symptomatic anterior vaginal wall cyst that was found to be an NA within a urethral diverticulum. Although this remains an infrequently reported entity in the literature, prevalence has been shown to be higher in consecutive case series than what may be presumed by the rarity of case reports in clinical literature. Nephrogenic adenoma within a urethral diverticulum may represent an under-recognized entity which needs to be carefully distinguished from clear cell adenocarcinoma occurring within urethral diverticula. We discuss salient clinical features of NA occurring within a urethral diverticulum and describe a review of literature of published cases to date.