Establishing Benchmarks For Minimum Competence With Dry Lab Robotic Surgery Drills.

The Robotic Objective Structured Assessment of Technical Skills (R-OSATS) is a previously validated assessment tool that is used to assess 5 standardized inanimate robotic surgery drills. R-OSATS is used to evaluate performance on surgical drills, with scores of 0 to 20 for each drill. Our objective was to establish the minimum threshold score that denotes competence on these drills. Thus, we performed a standard setting study using data from surgeons and trainees in 8 academic medical centers. Cutoff scores for the minimal level of competence using R-OSATS were established using 2 techniques: the modified Angoff and the contrasting groups methods. For the modified Angoff method, 8 content experts met and, in an iterative process, derived the scores that a minimally competent trainee should receive. After 2 iterative rounds of scoring and discussion with the modified Angoff method, we established a minimum competence score per drill with high agreement (rWG range, 0.92-0.98). There was unanimous consensus that a trainee needs to achieve competence on each independent drill. A second method, the contrasting groups method, was used to verify our results. In this method, we compared R-OSATS scores from "inexperienced" (34 postgraduate year 1 and 2 trainees) with "experienced" (22 faculty and fellow) robotic surgeons. The distributions of scores from both groups were plotted, and a cutoff score for each drill was determined from the intersection of the 2 curves. Using this method, the minimum score for competence would be 14 per drill, which is slightly more stringent but confirms the results obtained from the modified Angoff approach. In conclusion, using 2 well-described standard setting techniques, we have established minimum benchmarks designating trainee competence for 5 dry lab robotic surgery drills.

Pregnancy outcomes following robot-assisted myomectomy.

STUDY QUESTION: What are the characteristics of the pregnancy outcomes in women undergoing robot-assisted laparoscopic myomectomy (RALM) for symptomatic leiomyomata uteri? SUMMARY ANSWER: Despite a high prevalence of women with advanced maternal age, obesity and multiple pregnancy in our cohort, the outcomes are comparable with those reported in the literature for laparoscopic myomectomy. WHAT IS KNOWN ALREADY: Reproductive outcomes after traditional laparoscopic myomectomy are well documented. However, reproductive outcomes following robotic myomectomy are not well studied. This paper describes the pregnancy outcomes for a large cohort of women after robotic myomectomy. STUDY DESIGN, SIZE, DURATION: This is a retrospective cohort of women who became pregnant after robot-assisted myomectomy at three centers. Of the 872 women who underwent robotic myomectomy during the period October 2005-November 2010, 107 subsequently conceived resulting in 127 pregnancies and 92 deliveries through 2011. PARTICIPANTS/MATERIAL, SETTING, METHODS: Women of reproductive age with fibroids who wanted a minimally invasive treatment option and desired uterine preservation were recruited. We conducted a multicentre study with three centers, two in a private practice and one in an academic setting. Pregnancy outcomes and their relationship to myoma characteristics were analyzed. MAIN RESULTS AND ROLE OF CHANCE: Mean ± SD age at myomectomy was 34.8 ± 4.5 years and 57.4% [95% confidence interval (CI) 48.0, 66.3] of women were overweight or obese. The mean number of myomas removed was 3.9 ± 3.2 with a mean size of 7.5 ± 3.0 cm and mean weight of 191.7 ± 144.8 g. Entry of the myoma into the endometrial cavity occurred in 20.6% (95% CI 15.0, 27.7) of patients. The mean time to conception was 12.9 ± 11.5 months. Assisted reproduction techniques were employed in 39.4% (95% CI 32.6, 46.7) of these women. Seven twin pregnancies and two triplet pregnancies occurred, for a multiple pregnancy birth rate of 9.8% (95% CI 5.0, 17.8). Spontaneous abortions occurred in 18.9% (95% CI 13.0, 26.6). Preterm delivery prior to 35 weeks of gestational age occurred in 17.4% (95% CI 10.9, 26.5). One uterine rupture (1.1%; 95% CI 0.3, 4.7) was documented. Pelvic adhesions were discovered in 11.4% (95% CI 7.0, 18.0) of patients delivered by Cesarean section. Higher preterm delivery rates were significantly associated with a greater number of myomas removed and anterior location of the largest incision (compared with all other sites) in logistic regression analyses (P = 0.01). None of the myoma characteristics were related to spontaneous abortion. BIAS, CONFOUNDING AND OTHER REASONS FOR CAUTION: Given the retrospective nature of the data collection, some pregnancies may not have been captured. In addition, owing to the high prevalence of infertility patients in this cohort, the data cannot be used to counsel women who are undergoing RALM about fertility rates after surgery. GENERALIZABILITY TO OTHER POPULATIONS: Prospective studies are needed to determine if the results shown in our cohort are generalizable to all women seeking a minimally invasive option for the conservative treatment of symptomatic fibroids with pregnancy as a desired outcome. STUDY FUNDING/COMPETING INTEREST(S): There was no funding source for this study.

Robotic-assisted surgery for the community gynecologist: can it be adopted?

The American College of Obstetricians and Gynecologists and the American Association of Gynecologic Laparoscopists confirm advantages of conventional minimally invasive surgery over laparotomy for benign gynecological procedures; however, adoption remains low for the general gynecologist. A systematic search for gynecology publications was performed using Medline and Scopus. Available data on adoption rates and perioperative outcomes for hysterectomy, myomectomy, sacrocolpopexy, and endometriosis were reviewed. Robotic assistance may provide an improved rate of minimally invasive surgery adoption with equivalent perioperative outcomes to that of conventional techniques. Accessibility and cost remain controversial. Formal training programs are being created to address these issues.

Fertility and Symptom Relief following Robot-Assisted Laparoscopic Myomectomy.

Objective. To examine success of robot-assisted laparoscopic myomectomy (RALM) measured by sustained symptom relief and fertility. Methods. This is a retrospective survey of 426 women who underwent RALM for fibroids, symptom relief, or infertility at three practice sites across the US. We examined rates of symptom recurrence and pregnancy and factors associated with these outcomes. Results. Overall, 70% of women reported being symptom-free, with 62.9% free of symptoms after three years. At >3 years, 66.7% of women who underwent surgery to treat infertility and 80% who were also symptom-free reported achieving pregnancy. Factors independently associated with symptom recurrence included greater time after surgery, preoperative dyspareunia, multiple fibroid surgeries, smoking after surgery, and preexisting diabetes. Factors positively correlated with achieving pregnancy included desiring pregnancy, prior pregnancy, greater time since surgery, and Caucasian race. Factors negatively correlated with pregnancy were advanced age and symptom recurrence. Conclusions. This paper, the first to examine symptom recurrence after RALM, demonstrates both short- and long-term effectiveness in providing symptom relief. Furthermore, RALM may have the potential to improve the chance of conception, even in a population at high risk of subfertility, with greater benefits among those who remain symptom-free. These findings require prospective validation.

The impact of different surgical modalities for hysterectomy on satisfaction and patient reported outcomes.

BACKGROUND: There is an ongoing debate regarding the cost-benefit of different surgical modalities for hysterectomy. Studies have relied primarily on evaluation of clinical outcomes and medical expenses. Thus, a paucity of information on patient-reported outcomes including satisfaction, recovery, and recommendations exists. OBJECTIVE: The objective of this study was to identify differences in patient satisfaction and recommendations by approach to a hysterectomy. METHODS: We recruited a large, geographically diverse group of women who were members of an online hysterectomy support community. US women who had undergone a benign hysterectomy formed this retrospective study cohort. Self-reported characteristics and experiences were compared by surgical modality using chi-square tests. Outcomes over time were assessed with the Jonkheere-Terpstra trend test. Logistic regression identified independent predictors of patient satisfaction and recommendations. RESULTS: There were 6262 women who met the study criteria; 41.74% (2614/6262) underwent an abdominal hysterectomy, 10.64% (666/6262) were vaginal, 27.42% (1717/6262) laparoscopic, 18.94% (1186/6262) robotic, and 1.26% (79/6262) single-incision laparoscopic. Most women were at least college educated (56.37%, 3530/6262), and identified as white, non-Hispanic (83.17%, 5208/6262). Abdominal hysterectomy rates decreased from 68.2% (152/223) to 24.4% (75/307), and minimally invasive surgeries increased from 31.8% (71/223) to 75.6% (232/307) between 2001 or prior years and 2013 (P<.001 all trends). Trends in overall patient satisfaction and recommendations showed significant improvement over time (P<.001).There were differences across the surgical modalities in all patient-reported experiences (ie, satisfaction, time to walking, driving and working, and whether patients would recommend or use the same technique again; P<.001). Significantly better outcomes were evident among women who had vaginal, laparoscopic, and robotic procedures than among those who had an abdominal procedure. However, robotic surgery was the only approach that was an independent predictor of better patient experience; these patients were more satisfied overall (odds ratio [OR] 1.31, 95% CI 1.13-1.51) and on six other satisfaction measures, and more likely to recommend (OR 1.64, 95% CI 1.39-1.94) and choose the same modality again (OR 2.07, 95% CI 1.67-2.57). Abdominal hysterectomy patients were more dissatisfied with outcomes after surgery and less likely to recommend (OR 0.36, 95% CI 0.31-0.40) or choose the same technique again (OR 0.29, 95% CI 0.25-0.33). Quicker return to normal activities and surgery after 2007 also were independently associated with better overall satisfaction, willingness to recommend, and to choose the same surgery again. CONCLUSIONS: Consistent with other US data, laparoscopic and robotic hysterectomy rates increased over time, with a concomitant decline in abdominal hysterectomy. While inherent shortcomings of this retrospective Web-based study exist, findings show that patient experience was better for each of the major minimally invasive approaches than for abdominal hysterectomy. However, robotic-assisted hysterectomy was the only modality that independently predicted greater satisfaction and willingness to recommend and have the same procedure again.

Validity and reliability of the robotic Objective Structured Assessment of Technical Skills.

OBJECTIVE: Objective Structured Assessments of Technical Skills have been developed to measure the skill of surgical trainees. Our aim was to develop an Objective Structured Assessments of Technical Skills specifically for trainees learning robotic surgery. METHODS: This is a multiinstitutional study conducted in eight academic training programs. We created an assessment form to evaluate robotic surgical skill through five inanimate exercises. Gynecology, general surgery, and urology residents, Fellows, and faculty completed five robotic exercises on a standard training model. Study sessions were recorded and randomly assigned to three blinded judges who scored performance using the assessment form. Construct validity was evaluated by comparing scores between participants with different levels of surgical experience; interrater and intrarater reliability were also assessed. RESULTS: We evaluated 83 residents, nine Fellows, and 13 faculty totaling 105 participants; 88 (84%) were from gynecology. Our assessment form demonstrated construct validity with faculty and Fellows performing significantly better than residents (mean scores 89±8 faculty, 74±17 Fellows, 59±22 residents; P<.01). In addition, participants with more robotic console experience scored significantly higher than those with fewer prior console surgeries (P<.01). Robotic Objective Structured Assessments of Technical Skills demonstrated good interrater reliability across all five drills (mean Cronbach's α 0.79±0.02). Intrarater reliability was also high (mean Spearman's correlation 0.91±0.11). CONCLUSION: We developed a valid and reliable assessment form for robotic surgical skill. When paired with standardized robotic skill drills, this form may be useful to distinguish between levels of trainee performance. LEVEL OF EVIDENCE: II.

Robotically assisted hysterectomy in patients with large uteri: outcomes in five community practices.

OBJECTIVE: To examine outcomes of robotically assisted laparoscopic hysterectomy in patients with benign conditions involving high uterine weight and complex pathology. METHODS: A multicenter study was undertaken in five community practice settings across the United States. All patients who had minimally invasive laparoscopic hysterectomy with robotic assistance March 2006 through July 2009 and uterine weights of at least 250 g were included. Retrospective chart review identified outcomes including skin-to-skin operative time, conversion to an exploratory laparotomy, blood loss, complications, and hospital duration of stay. The effect of uterine weight on skin-to-skin time and blood loss also was examined. RESULTS: Data were analyzed for 256 patients with uteri weighing 250 to 3,020 g (median 453 g). Most patients were obese or had a history of pelvic or abdominal surgery. Median operative time was 145 minutes. Duration of surgery in patients with uteri 500 g or greater was significantly longer than in patients with uteri less than 500 g (167 compared with 126 minutes, P<.001). Median estimated blood loss also was greater in women with uteri weighing 500 g or more (100 compared with 50 mL, P<.001). Multivariable linear regression analysis confirmed the independent effect of uterine weight on operative time and blood loss. Median duration of hospital stay was 1 day. The conversion rate was 1.6%, the minor complication rate was 1.6%, and major complications occurred in 2.0% of patients. CONCLUSION: Women with large uteri may successfully undergo robotically assisted hysterectomy with low morbidity, low blood loss, and minimal risk of conversion to laparotomy. Results were reproducible among general gynecologists from geographically diverse community settings.

Robotic-assisted gynaecological surgery-establishing training criteria; minimizing operative time and blood loss.

BACKGROUND: The objective was an evaluation of operative time and estimated blood loss (EBL) as a function of experience in gynaecological robotic surgery. METHOD: A retrospective analysis of 40 consecutive cases (approximately one case/week) over a 1 year period using the da Vinci) robotic system was performed, using data from two institutions, Newark Beth Israel Medical Center and Hackensack University Medical Center. Information was obtained from a single surgeon. Among the 40 cases there were 17 hysterectomies and 23 myomectomies. Each patient met the criteria of benign disease. In each institution, a da Vinci) system using three instrument arms and a camera arm was employed for every operation. RESULTS: Tests of differences in means were performed to compare the two groups. In group I (cases 1-20) the mean uterine volume was 863.0 cc and was similar to Group II (cases 21-40) at 632.6 cc. There was no significant difference between the groups when comparing blood loss; means were 86 cc for group I and 62.5 cc for group II. Operative time between groups, however, showed a significant difference (mean of 211.8 min for group 1 compared to 151 min for group 2; p < 0.05) and console time demonstrated a similar trend (mean for group 1 was 159.8 min compared to 90.8 min for group 2; p < 0.05). There were no conversions to laparotomy. Body mass index (BMI) and prior abdominal surgery were not significantly different. Multivariate regressions on operative time and EBL were performed, controlling for uterine weight and volume. The effect of experience on operative time was significant and negative; the coefficient on EBL was not significant. CONCLUSION: This study demonstrates statistical improvement in operative time after the first 20 cases for a single surgeon. This information could be used to establish criteria for training surgeons.