Alison Vogell

Contained tissue extraction using power morcellation: prospective evaluation of leakage parameters

BACKGROUND Safe tissue removal is a challenge for minimally invasive procedures such as myomectomy, supracervical hysterectomy, or total hysterectomy of a large uterine specimen. There is concern regarding disruption or dissemination of tissue during this process, which may be of particular significance in cases of undetected malignancy. Contained tissue extraction techniques have been developed in an effort to mitigate morcellation-related risks. OBJECTIVE The objective of the study was to quantify perioperative outcomes of contained tissue extraction using power morcellation, specifically evaluating parameters of tissue or fluid leakage from within the containment system. STUDY DESIGN This was a study including a multicenter prospective cohort of adult women who underwent minimally invasive hysterectomy or myomectomy using a contained power morcellation technique. Blue dye was applied to the tissue specimen prior to removal to help identify cases of fluid or tissue leakage from within the containment system. RESULTS A total of 76 patients successfully underwent the contained power morcellation protocol. Mean time for the contained morcellation procedure was 30.2 minutes (±22.4). The mean hysterectomy specimen weight was 480.1 g (±359.1), and mean myomectomy specimen weight was 239.1 g (±229.7). The vast majority of patients (73.7%) were discharged home the same day of surgery. Final pathological diagnosis was benign in all cases. Spillage of dye or tissue was noted in 7 cases (9.2%), although containment bags were intact in each of these instances. CONCLUSION Findings are consistent with prior work demonstrating the feasibility of contained tissue extraction; however, further refinement of this technique is warranted.

Suture compared with staple skin closure after cesarean delivery: a randomized controlled trial.

OBJECTIVE: To compare the incidence of wound complications between suture and staple skin closure after cesarean delivery. METHODS: This prospective, randomized clinical trial conducted at three hospitals in the United States between 2010 and 2012 included women undergoing cesarean delivery at 23 weeks of gestation or greater through a low-transverse skin incision. Women were randomized to closure of the skin incision with suture or staples after stratifying by body mass index and primary compared with repeat cesarean delivery. The primary outcome was incidence of wound complications, predefined as a composite of infection, hematoma, seroma, separation of 1 cm or longer, or readmission for wound complications. Analysis was according to the intention-to-treat principle; results were stratified by randomization group and adjusted for hospital by including it as a covariate. RESULTS: A total of 746 women were randomized, 370 to suture and 376 to staple closure. The median gestational age was 39 weeks. Fifty-eight women (7.8%) had wound complications—4.9% in the suture group and 10.6% in the staple group (adjusted odds ratio [OR] 0.43, 95% confidence interval [CI] 0.23–0.78); this was largely the result of the decreased incidence of wound separation in the respective groups (1.6% compared with 7.4%; adjusted OR 0.20, 95% CI 0.07–0.51). CONCLUSIONS: Suture closure of the skin incision at cesarean delivery is associated with a 57% decrease in wound complications compared with staple closure. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, www.clinicaltrials.gov, NCT01211600. LEVEL OF EVIDENCE: I

Impact of a robotic simulation program on resident surgical performance

Association between OSATS slope (ie, estimated rate of OSATS change per day from resident level linear regression analysis) shown on Y-vertical axis and total simulation time shown on horizontal X-axis. Solid blue line (Pearson correlation, 0.802; P 1⁄4 .02; estimated slope calculated using: e0.007 þ .0043 * total simulation time) shows fitted least square linear regression line using data from all 8 residents. Pearson correlation was 0.645, P 1⁄4 .01 when resident 3 (red dashed line) was removed from data set. Removal of resident 1 (green dot-dashed line), resulted Q4 in Pearson correlation of 0.966, P 1⁄4 .01.)

Bilateral Bell palsy as a presenting sign of preeclampsia.

BACKGROUND: Bell palsy is a facial nerve neuropathy that is a rare disorder but occurs at higher frequency in pregnancy. Almost 30% of cases are associated with preeclampsia or gestational hypertension. Bilateral Bell palsy occurs in only 0.3%–2.0% of cases of facial paralysis, has a poorer prognosis for recovery, and may be associated with a systemic disorder. CASE: We describe a case of a 24-year-old primigravid woman with a twin gestation at 35 weeks diagnosed initially with bilateral facial palsy and subsequently with preeclampsia. She then developed partial hemolysis, elevated liver enzymes, and low platelet count syndrome, prompting the diagnosis of severe preeclampsia, and was delivered. CONCLUSION: Bilateral facial palsy is a rare entity in pregnancy that may be the first sign of preeclampsia and suggests increased severity of disease, warranting close monitoring.

Opioid Use after Laparoscopic Hysterectomy: Prescriptions, Patient Use, and a Predictive Calculator

Background In the setting of America’s opioid epidemic, judicious postoperative opioid prescribing is important. Gynecologists lack standard guidelines about postoperative opioid prescriptions. Objectives The objectives of the study were to describe opioid prescribing practices by a group of minimally invasive gynecologic surgeons, to measure postoperative opioid use after minimally invasive hysterectomy, and to identify preoperative factors that could predict whether a patient will be a low or high postoperative opioid user. Study Design This was a prospective survey‐based study including 125 women undergoing laparoscopic hysterectomy for benign indications at 2 community teaching hospitals. Patients were preoperatively surveyed about demographics, past medical history, and current and expected pain scores and were screened for anxiety, depression, and pain catastrophizing. At 1 and 2 weeks after surgery, patients were surveyed about their pain and pain medication use. Results Ninety‐eight percent of patients were prescribed an opioid for acute postoperative pain. The median opioid prescription was for 150 morphine milligram equivalents, equivalent to 20 tablets of oxycodone 5 mg, while median patient postoperative use was 37.5 morphine milligram equivalents, equivalent to 5 tablets of oxycodone 5 mg. Ninety percent of patients had leftover opioids at 2 weeks after surgery, and most leftover opioids were stored in an unsecure location. Preoperative factors that were most strongly correlated with postoperative opioid use included a history of chronic pelvic pain or endometriosis, preoperative opioid use, anxiety, depression, pain catastrophizing, preoperative pain score, anticipated postoperative pain score, and anticipated postoperative pain medication needs. A predictive calculator was developed based on these factors to help identify patients who are likely to be a high opioid user (defined as taking greater than 112.5 morphine milligram equivalents) or a low opioid user (defined as taking 37.5 morphine milligram equivalents or less). Conclusion On average, surgeons prescribed 4 times the amount of opioids than was needed for patients undergoing laparoscopic hysterectomy for acute postoperative pain control. Individualizing patients’ opioid prescriptions based on preoperative risk factors could help reduce excess prescription opioids.

Novel Imaging Technologies In Laparoscopic Gynecologic Surgery: A Systematic Review

Novel imaging technologies continued to be introduced into the operative setting. In particular, novel image-enhanced laparoscopic techniques are being explored for use in gynecologic operations. This systematic review describes these technologies in four relevant areas of gynecologic surgery. The PubMed database was searched for human, English-language studies, and the reference lists of retrieved articles were reviewed. An analysis of pooled data from 34 studies that met inclusion criteria was performed. The results suggest that image-enhanced technology may be useful in several common gynecologic procedures. Autoand drug-enhanced fluorescence laparoscopy allow for increased detection of nonpigmented endometriotic lesions. Using these technologies for peritoneal staging of ovarian malignancy is of uncertain benefit. Drug-enhanced fluorescence laparoscopy for sentinel lymph node (SLN) detection in patients with uterine or cervical malignancy is feasible, showing a high rate of SLN detection, but a low sensitivity of identifying metastases. Finally, their use in intra-operative visualization of the ureter is promising. The majority of available data was from feasibility studies with limited sample sizes. Nevertheless, the results described in this systematic review support the expectation that these upcoming image-enhanced laparoscopy techniques will play a more important role in the future care of gynecologic patients. [DOI: 10.1115/1.4038360]

Power Versus Hand Morcellation: Impact on Operating Room Efficiency and Cost [8G]

INTRODUCTION: When the FDA warned against laparoscopic power morcellators in the majority of women undergoing laparoscopic hysterectomy for fibroids, there was a shift from power morcellation to contained hand morcellation among minimally invasive surgeons. METHODS: This retrospective cohort study compares all laparoscopic hysterectomies performed at an academic suburban tertiary care center by power morcellation before the FDA warning to a hand morcellation protocol developed after the FDA warning. RESULTS: From 2010–2015, 84 cases of laparoscopic hysterectomies requiring morcellation were identified. Of these, 46 involved power morcellation while 35 underwent hand morcellation. The two groups were overall similar in BMI (28.9 vs 29.4, P=.7), prior laparoscopy (28% vs 17%, P=.3) or laparotomy (39% vs 23% P=.12) removal of cervix (56% vs 69%; P=.2), use of robot (8.7% versus 8.6%, P=1) or uterine weight (550 g vs 455 g, P=.98). The hand morcellation group had an average operating room time of 178 min compared to power morcellation, which took 155 min, P<.001. Both groups had rare complications or unscheduled visits. To account for other factors influencing operating room time, a multivariable linear regression model was created. In this model hand morcellation was a significant independent predictor of increase in OR time by 42 min (95% CI = 18–66, P<.001). CONCLUSION: Hand morcellation significantly increases OR time and further work should focus on improving efficiency of this procedure.