Making every birth count: Outcomes of a perinatal mortality audit program.

BACKGROUND: Stillbirth rates have shown little improvement for two decades in Australia. Perinatal mortality audit is key to prevention, but the literature suggests that implementation is suboptimal. AIM: To determine the proportion of perinatal deaths which are associated with contributing factors relating to care in Queensland, Australia. MATERIALS AND METHODS: Retrospective audit of perinatal deaths ≥ 34 weeks gestation by the Health Department in Queensland was undertaken. Cases and demographic information were obtained from the Queensland Perinatal Data Collection. A multidisciplinary panel used the Perinatal Society of Australia and New Zealand (PSANZ) perinatal mortality audit guidelines to classify the cause of death and to identify contributing factors. Contributing factors were classified as 'insignificant', 'possible', or 'significant'. RESULTS: From 1 January to 31 December 2018, 65 deaths (56 stillbirths and nine neonatal deaths) were eligible and audited. Most deaths were classified as unexplained (51.8% of stillbirths). Contributing factors were identified in 46 (71%) deaths: six insignificant (all stillbirths), 20 possibly related to outcome (17 stillbirths), and 20 significantly (16 stillbirths). Areas for practice improvements mainly related to the care for women with risk factors for stillbirth, especially antenatal care. The PSANZ guidelines were applied and enabled a systematic approach. CONCLUSIONS: A high proportion of late gestation perinatal deaths are associated with contributing factors relating to care. Improving antenatal care for women with risk factors for stillbirth is a priority. Perinatal mortality audit is a valuable step in stillbirth prevention and the PSANZ guidelines allow a systematic approach to aid implementation and reporting.

Preoperative evaluation for gynecologic surgery: a guide to judicious, evidence-based testing.

PURPOSE OF REVIEW: Preoperative testing is a routine component of surgical planning, however, the majority of literature agree that laboratory and diagnostic studies are over utilized. We aim to summarize the available literature and provide gynecologists performing elective surgery for benign indications guidance to determine when, in whom, and in what time frame preoperative studies should be collected. RECENT FINDINGS: Current literature supports previous publications indicating routine laboratory and diagnostic testing for elective surgery is unnecessary and continues to be excessive. The frequency of abnormal results is high, whereas the impact on surgical planning and outcomes is negligible. SUMMARY: The preoperative evaluation including thorough history and physical examination should be the cornerstones for eliciting underlying disease, which may alter a surgical strategy. Devising a protocol to direct preoperative testing has been shown to decrease unnecessary tests without compromising prediction of perioperative morbidity/mortality or case cancellation and changes. Avoidance of 'routine preoperative testing' and instead, thoughtful risk stratification of individual patients, should be a goal of providing value-based care.

Vaginal Tissue Extraction Made Easy.

STUDY OBJECTIVE: To demonstrate a new technique to improve vaginal morcellation. DESIGN: This video demonstrates a step-by-step process for morcellation through the vagina in a contained environment (Canadian Task Force Classification III). SETTING: When performing laparoscopic hysterectomy, difficulty arises when the tissue being extracted is larger than the incision made. To avoid extending an abdominal incision, the colpotomy tends to be the favorable location for removal. The difficulty with vaginal morcellation lies in retraction and keeping the specimen at the colpotomy site. INTERVENTION: This 42-year-old gravida 0 female with abnormal uterine bleeding with leiomyoma had completed child-bearing and desired a hysterectomy. She had a 17-week sized uterus with enlarged bulky myomas. Total laparoscopic hysterectomy was performed using three 5-mm ports. After the hysterectomy completed, the specimen was placed in a bag for removal. Morcellation was performed, and the specimen was removed. This video demonstrates a simple technique for containing the specimen using a bag, an Alexis ring, and a stapler, and then removing it vaginally. This approach provides vaginal protection and retraction in a contained system. It also eliminates the need to close the abdominal fascia. CONCLUSION: Morcellation performed through the vagina can be quick and easy using the technique shown in this video. Not only does the technique provide vaginal protection and retraction, but it also contains the specimen to prevent its loss during the morcellation process and to avoid the spread of any unforeseen malignancy. By eliminating the need to close the abdominal fascia, surgical time is reduced, and concerns about hernia formation from extended incisions are allayed.

Minimally Invasive Adnexal Mass Extraction: Considerations and Techniques (With Videos).

Adnexal masses are a common indication for surgery in the United States. This article reviews the clinical features that may suggest an underlying malignancy, including ultrasound and biomarkers. The decision regarding how to remove an adnexal mass involves consideration of several factors, including body habitus, intra-abdominal anatomy, concomitant procedures planned, characteristics of the adnexal mass, and concern for underlying malignancy. Minimally invasive techniques for removal of adnexal masses are discussed in detail, with a review of the risk of an unexpected underlying malignancy.

Robotic Single-Site Endometriosis Resection Using Firefly Technology.

STUDY OBJECTIVE: To demonstrate the feasibility of robotic single-site resection of advanced endometriosis using new technology. DESIGN: We show a video that demonstrates our technique for accomplishing single-site laparoscopic resection of advanced endometriosis. The video is a step-by-step explanation of robotic single-site resection of endometriosis nodules overlying the ureter and rectum. BACKGROUND: Laparoscopic surgery has been shown to effectively improve pain and fertility in women with endometriosis [1]. Compared with traditional multiport laparoscopy, single-incision laparoscopy is associated with similar incidence rates of blood loss, conversion to open laparotomy, and wound complications, but it has superior cosmetic outcomes and high patient satisfaction [2-5]. Furthermore, robotic single-incision laparoscopy combined with robotic Firefly technology potentially increases the removal of invisible endometriosis. Without complete resection of endometriosis, patients are less likely to achieve full pain relief postoperatively. SETTING: University hospital. PATIENT: A 36 year old G1P1 female was referred for chronic pelvic pain. She described her pain as hip pain, pain with walking, dyspareunia, dyschezia and right anterior abdominal wall pain. INTERVENTION: To improve detection of endometriosis, we injected the patient with indocyanine green (ICG), a fluorescent dye with widespread medical applications in identifying increased vascularity of tissues. We then visualized the tissues with robotic Firefly technology, a fluorescence-detection tool built into the da Vinci SI Surgical Systems (Intuitive Surgical, Inc, Sunnyvale, CA). MAIN RESULTS: Because endometriosis lesions are associated with a high degree of neovascularization, the ICG turned the endometriosis tissues dark green, thereby enabling us to detect endometriosis that would not have been seen as readily with conventional single-site laparoscopy. This video demonstrates our technique for successfully accomplishing a single-site laparoscopic resection of advanced endometriosis, including ureterolysis, adhesiolysis, peritoneal stripping, and a rectal nodule excision. CONCLUSIONS: We found that Firefly technology and ICG facilitated identification of endometriosis in single-site robotic surgery. We were able to successfully perform single-site laparoscopic resection of advanced endometriosis nodules overlying the ureter and rectum with complete resolution of pelvic pain symptoms and excellent cosmetic results.

Hand-Assisted Laparoscopic Hysterectomy for Large Uteri.

STUDY OBJECTIVE: To determine whether laparoscopic hand-assisted hysterectomy for a large uterus had different surgical outcomes compared with traditional open hysterectomy. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Academic tertiary care hospital. PATIENTS: Women who had undergone laparoscopic hand-assisted hysterectomy for a large uterus were included as the hand-assist group. The control group comprised patients with similar final specimen weight (>1 kg), characteristics (body mass index, age), and surgical history, who underwent open hysterectomy for a large uterus. INTERVENTION: Laparoscopic hysterectomy using a hand-assist port for laparoscopic portion of the case. RESULTS: The 2 groups were similar in terms of specimen weight (median, 1765.5 g for hand-assist vs 1215.50 g for controls; p = .29). In univariate analysis, the median operating time was longer in the hand-assist group compared with controls (241.5 minutes vs 185.0 minutes; p = .002), whereas median length of stay was shorter in the hand-assist group (1.0 day vs 3.0 days; p < .0001). These differences remained significant after adjustment for potential confounders in multivariable analysis (p < .05). There was no difference in estimated blood loss (p > .05) between the 2 groups, although the change in hemoglobin was less in the hand-assist group compared with controls in multivariable analysis (adjusted mean.74 vs. 1.8; p = .04). Complications were divided into intraoperative complications (transfusion, consultation, bowel injury, bladder injury, ureter injury, and other), hospital postoperative complications (reoperation, transfusion, slow return of bowel function, ileus, poor pain control, fever of unknown origin, venous thromboembolism, pneumonia, and neuropathy), and complications after discharge (readmission, wound infection). The 2 groups had a similar low rate of complications (p > .05). CONCLUSION: Laparoscopic hand-assist hysterectomy is a feasible alternative to open hysterectomy in patients with a large uterus.

Laparoscopic Single-Site Myomectomy of 11-cm Intramural Myoma.

STUDY OBJECTIVE: To demonstrate the feasibility of laparoscopic single-incision myomectomy using new technology. DESIGN: A step-by-step video demonstrating our technique for accomplishing a laparoscopic single-site myomectomy of a large intramural myoma. SETTING: Single institution. INTERVENTIONS: Single-incision laparoscopic surgery (SILS) has been shown to have similar outcomes to multiport laparoscopy but with superior cosmetic results [1,2] but has traditionally been associated with an increased learning curve, primarily because of poor ergonomics and instrument collisions, lack of triangulation, and, until recently, inadequate instrumentation. MEASUREMENTS AND MAIN RESULTS: We present a case of laparoscopic single-site myomectomy of an 11-cm intramural myoma. This video was exempt from institutional review board review at our institution. SILS has traditionally been associated with poor ergonomics; however, we found that the articulating Enseal G2 Articulating Tissue Sealer (Ethicon Endo-Surgery, Blue Ash, OH) enables completion of complex surgical procedures not traditionally associated with single-site laparoscopy. This video demonstrates our technique to successfully accomplish a single-site laparoscopic myomectomy including the importance of vertical closure with V-Loc (Covidien, New Haven, CT) at the surgical site. CONCLUSION: We found that the articulating Enseal enables a single-incision laparoscopic myomectomy to be performed with only minimal modifications on multiport surgery techniques. We were able to successfully perform a myomectomy on an 11-cm intramural myoma with excellent cosmetic results.

Outcomes of robotic sacrocolpopexy using barbed delayed absorbable sutures.

STUDY OBJECTIVE: To evaluate 1-year outcomes of robotic sacrocolpopexy (RSC) for pelvic organ prolapse using barbed delayed absorbable sutures. DESIGN: Retrospective cohort study (Class II-3). SETTINGS: University-based hospital in Southeast Texas. PATIENTS: Patients with symptomatic apical pelvic organ prolapse who underwent RSC using barbed delayed absorbable sutures between January 2011 and August 2012. Patients were examined postoperatively at least twice (after 6 weeks and 1 year). INTERVENTIONS: RSC procedure. MEASUREMENTS AND MAIN RESULTS: The study included a total of 20 patients, of them 15 had grades 3 or 4 whereas 5 had grade 2 apical defects according to the Baden-Walker classification system. Fourteen patients (70%) underwent concomitant hysterectomy while 9 (45%) underwent concomitant anti-incontinence surgery. Mesh suturing times were 46.9 ± 12.6 and 20.5 ± 9.3 minutes in the first 10 versus the last 10 cases, respectively (p < .001). The mean follow-up duration was 17.3 months (range, 12-24 months). There were no recurrences of apical defects or mesh/suture exposure/erosion. However, 1 patient developed a grade 2 cystocele, and another developed new-onset urinary incontinence, both after 1 year. A third patient's urine leakage did not improve postoperatively. Lastly, a fourth patient developed port site incisional hernia and underwent repair 5 months later. CONCLUSION: Our study suggests that barbed delayed absorbable sutures are safe and effective in RCS procedures over 1 year. Larger, comparative, and randomized trials are recommended for definitive conclusions.

Trocar site hernia on an 8-mm port following robotic-assisted hysterectomy.

The increasing use of laparoscopy has resulted in added complications specific to the laparoscopic approach, such as trocar site hernia (TSH), which is an uncommon but well-recognized problem for both regular laparoscopic and robotic-assisted laparoscopic procedures. We describe an extremely rare case of TSH at an 8-mm port site occurring a relatively short time after surgery in a 53-year-old patient undergoing robotic-assisted laparoscopic hysterectomy for benign reasons. Additionally, this report attempts to explain the possible etiological factors relating to TSH following robotic-assisted surgery. According to our case report, a defect in the 8-mm port that may lead to hernia is one possible explanation, and closure of the 8-mm trocar sites' fascia may be a safer approach during robotic-assisted surgery. Additional reports are needed to accurately determine the frequency of occurrence and importance of this complication.

Intraocular pressure and steep Trendelenburg during minimally invasive gynecologic surgery: is there a risk?

STUDY OBJECTIVE: Steep Trendelenburg position is frequently used during gynecologic minimally invasive surgery (MIS). However, little attention has been given to the potential impact of this nonphysiologic positioning on patients, specifically intraocular pressure (IOP). The purpose of our study was to evaluate IOP changes during laparoscopic or robotic hysterectomy conducted in the steep Trendelenburg position. DESIGN: Prospective cohort study (Canadian Task Force classification II-2). SETTING: John Sealy Hospital at the University of Texas Medical Branch, Galveston, TX. PATIENTS: Female patients with no history of ocular pathology who underwent elective robotic or laparoscopic hysterectomy. INTERVENTIONS: The anesthesia protocol was standardized for all study patients. IOP and mean arterial pressure (MAP) were obtained before anesthesia, after general anesthesia and intubation were achieved, after 1 hour of steep Trendelenburg positioning, after 2 hours of steep Trendelenburg positioning, and after the patient was returned to the supine position. Ocular perfusion pressure (OPP) was calculated using the following equation: OPP = MAP - IOP. MAIN RESULTS: A total of 10 patients were included in this prospective study. A significant increase in IOP from baseline was observed after 1 hour and 2 hours of steep Trendelenburg positioning (p = .005 and .002, respectively). There was a statistically significant trend of increasing the IOP from baseline to the second hour of steep Trendelenburg positioning (p < .001). The IOP remained significantly elevated once the patient was returned to the supine position when compared with the baseline IOP (p = .006). OPP significantly decreased from baseline after 2 hours of steep Trendelenburg positioning (p = .03). CONCLUSIONS: IOP increases significantly when patients are placed in the steep Trendelenburg position. Although further studies are needed to better characterize this process, given the aging population of our MIS patients in whom risk for glaucoma is significant, preoperative ocular health assessment should be considered in certain cases.

Robotic-assisted, ultrasound-guided abdominal cerclage during pregnancy: overcoming minimally invasive surgery limitations?

Herein, we report robotic abdominal cerclage placement under ultrasound guidance. The da Vinci Si system (Intuitive Surgical, Sunnyvale, CA) allows a simultaneous display of the operative field and transvaginal ultrasound images. Additionally, the vaginal ultrasound probe assisted in the manipulation of the uterus to improve visualization without placing excessive pressure on the gravid uterus. Ultrasound guidance improves needle placement accuracy and reduces potential for injuries.

Cardiovascular disease in women: how nurses can promote awareness and prevention.

Cardiovascular disease (CVD) is the leading cause of death of women in the U.S. and Canada. Experts estimate that one in two U.S. women will die of heart disease or stroke compared with one in 25 women who will die of breast cancer. Risk factors for CVD include hypertension, high cholesterol, obesity and sedentary lifestyle.

Resident strategies for making a life in a nursing home: a qualitative study.

AIM: To identify strategies that older adults use to adapt to live in long-term care. BACKGROUND: The use of long-term care services has risen and this trend is expected to continue as the population reaches old age. Moving into a long-term care setting has been documented internationally as an overwhelming life change for many older adults. It has been observed that residents adjust differently over time, but the basis for these differences needs further exploration. DESIGN: A qualitative design using grounded theory method was employed. METHODS: A total of in-depth interviews were conducted in October 2008-February 2009 with a sample of 21 participants. Participants ranged in age from 65-93 years, 81% women and 19% men; mainly Caucasian with one African American and one Hispanic. Length of stay ranged from 3 days to over 9 years living in long-term care so that all stages of adjustment were included in the study. Ground theory method was used to analyse the data. FINDINGS: The results of this study yielded 21 facilitative strategies. The core category identified was personal resiliency, which served as the underpinning for the strategies used by the participants. Strategies were identified in making the decision to move into long-term care and in day-to-day living. CONCLUSION: Understanding the strategies that facilitate residents to make a successful transition to long-term care life will assist nurses to intervene in ways that are supportive. The strategies identified in this study may be used to develop interventions for residents that are having difficulty living in long-term care. Further exploration of how resiliency has an impact on strategies used by residents is clinically relevant, but further research is needed.

Effect of residents' previous laparoscopic surgery experience on initial robotic suturing experience.

Objective. To assess the impact of gynecology residents' previous laparoscopic experience on the learning curve of robotic suturing techniques and the value of initial structured teaching in dry lab prior to surgery. Methods. Thirteen gynecology residents with no previous robotic surgery experience were divided into Group 1, consisting of residents with 2 or fewer laparoscopic experiences, and Group 2, consisting of residents with 3 or more laparoscopic experiences. Group 1 had a dry-laboratory training in suturing prior to their initial experience in the operating room. Results. For all residents, it took on average 382 ± 159 seconds for laparoscopic suturing and 326 ± 196 seconds for robotic suturing (P = 0.12). Residents in Group 1 had a lower mean suture time than residents in Group 2 for laparoscopic suturing (P = 0.009). The residents in Group 2, however, had a lower mean suture time on the robot compared to Group 1 (P = 0.5). Conclusion. Residents with previous laparoscopic suturing experience may gain more from a robotic surgery experience than those with limited laparoscopic surgery experience. In addition, dry lab training is more efficient than hands-on training in the initial phase of teaching for both laparoscopic and robotic suturing skills.

Robotic-assisted Roux-en-Y gastric bypass performed in a community hospital setting: the future of bariatric surgery?

INTRODUCTION: Since receiving Food and Drug Administration approval in 2000, surgery utilizing a robot has been successfully performed in numerous procedures including gastric bypass. However, despite the proven safety profile, reported lower complication rates, and technical benefits of robotic surgery, only a few centers in the USA have consistently applied this technology to bariatric surgery. In addition, there are limited studies with relatively small sample sizes comparing robotic-assisted Roux-en-Y gastric bypass (RRYGB) with laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: Through a retrospective analysis of our database, we compared outcomes of RRYGB versus LRYGB in the treatment of morbid obesity. All patients who underwent RRYGB and LRYGB through the Comprehensive Weight Management Program of the Queen's Medical Center (Honolulu, HI) from January 2007 to December 2009 were included. Outcomes data included weight loss, operative times, and hospital length of stay. All complications were reported. RESULTS: 105 patients who underwent RRYGB were compared with 195 patients who received LRYGB. Excess weight loss, estimated blood loss, and length of hospital stay were similar in both groups. There were no mortalities in either group. The RRYGB group experienced a 9.5% complication rate versus 9.7% in LRYGB patients. Operative time was the only statistically significant difference, being approximately 17 min in favor of LRYGB. However, there was a steady decrease in RRYGB operative time with increasing experience. CONCLUSION: Our study demonstrates a favorable safety profile with nearly equivalent outcomes and some previously unidentified qualitative benefits of the RRYGB approach to bariatric surgery in a community setting. These results are despite our early experience with the robotic surgery platform and confirm noninferiority of RRYGB versus LRYGB. While the RRYGB operative time was longer than LRYGB, the demonstrated decrease in operative time commensurate with increase in operative experience holds tremendous promise for the future.

Stress-hyperresponsive WKY rats demonstrate depressed dorsal raphe neuronal excitability and dysregulated CRF-mediated responses.

Major depression is a debilitating psychiatric disease that may be precipitated by a dysregulation of stress neurocircuitry caused by chronic or severe stress exposure. Moreover, hyperresponsivity to stressors correlates with depressed mood and may contribute to the etiology of major depression. The serotonergic dorsal raphe nucleus (DRN) is an important site in the neurocircuitry underlying behavioral responses to stressors, and is tightly regulated, in part, by a combination of intrinsic cell properties, autoinhibition, and GABAergic synaptic transmission. The stress-related neurotransmitter corticotropin-releasing factor (CRF) modulates DRN neuronal excitability and subsequent 5-HT release in the forebrain. Wistar Kyoto (WKY) rats exhibit exaggerated behavioral responses to stressors, that is, stress hyperresponsivity, and are considered an animal model of depression. To better understand the neurobiological basis of the stress hyperresponsivity, we used a combination of mRNA analysis and whole-cell electrophysiological techniques to measure differences in intrinsic activity and receptor response, in 5-HT- and non-5-HT-containing neurons of the DRN in WKY rats compared with Sprague-Dawley controls. In the WKY rat, there was a decrease in the neuronal excitability of 5-HT neurons coupled with decreased TPH2 production. Additionally, we found that CRF did not increase GABAergic activity in 5-HT neurons as is normally seen in 5-HT neurons of Sprague-Dawley controls. The CRF modulation of 5-HT DRN neurotransmission at the single-cell level is selectively disrupted in the WKY animal model of depression and may be one of the cellular correlates underlying depression.

Storytelling by community-dwelling older adults: perspectives of home care workers.

The purpose of this exploratory, qualitative study was to investigate storytelling by home care clients to their home care workers (HCWs). Specific research questions were: (a) When does storytelling by a care recipient occur during usual care?; (b) How do HCWs engage older clients in storytelling?; (c) How do HCWs respond to the stories told by clients?; and (d) What is the perceived effect of storytelling by older clients on the relationship between the client and the HCW? Two focus groups consisting of 10 HCWs each were conducted. Verbatim transcripts of both focus groups were analyzed using the constant comparative analysis method. Categories and concepts were identified. Characteristics of the HCW and client set the stage for storytelling. The process of storytelling included context, triggers, and temporal aspects. HCWs also shared the content of stories, the impact on their relationship with the client, and the perceived effect on each individual. A visual model depicting the nature of storytelling in association with the care of older clients is presented.

Quality and safety education for nurses clinical evaluation tool.

An efficient evaluation tool is essential when measuring the clinical performance of undergraduate nursing students. It is also important that this evaluation tool accurately assess the critical competencies that students must demonstrate in the clinical setting. The tool should be unambiguous, succinct, and adaptable to a wide variety of clinical experiences and faculty. As part of a curriculum improvement initiative for their baccalaureate nursing program, the nursing faculty teaching in a 4-year undergraduate program identified the need for the development of a new clinical performance evaluation tool for the evaluation of undergraduate nursing students in each clinical placement. The resultant tool more accurately appraised clinical capabilities by focusing on quality and safety in health care, and it permitted the evaluation of critical thinking skills and team communication.

ICU nurses' experiences in providing terminal care.

At least 1 in 5 Americans die while using intensive care service-a number that is expected to increase as society ages. Many of these deaths involve withholding or withdrawing life-sustaining therapies. In these situations, the role of intensive care nurses shifts from providing aggressive care to end-of-life care. While hospice and palliative care nurses typically receive specialized support to cope with death and dying, intensive care nurses usually do not receive this support. Understanding the experiences of intensive care nurses in providing care at the end of life is an important first step to improving terminal care in the intensive care unit (ICU). This phenomenological research study explores the experiences of intensive care nurses who provide terminal care in the ICU. The sample consisted of 18 registered nurses delivering terminal care in an ICU that participated in individual interviews and focus groups. Colaizzi's steps for data analysis were used to identify themes within the context of nursing. Three major themes consisted of (1) barriers to optimal care, (2) internal conflict, and (3) coping. Providing terminal care creates significant personal and professional struggles among ICU nurses.