Barbara S. Levy

Randomized trial of suture versus Electrosurgical bipolar vessel sealing in vaginal hysterectomy

OBJECTIVE To compare blood loss and procedure time of vaginal hysterectomy using an electrosurgical bipolar vessel sealer versus using sutures. METHODS Sixty patients scheduled for vaginal hysterectomy in a single surgical practice were randomized to either electrosurgical bipolar vessel sealer or sutures as the hemostasis technique. Procedure time was defined as time from initial mucosal injection to closure of the vaginal cuff with satisfactory hemostasis. Blood loss was estimated by the anesthesia service. Statistical methodology included the Student t and Wilcoxon rank-sum tests, and all comparisons were two tailed, with P < .05 considered significant. RESULTS Use of an electrosurgical bipolar vessel sealer resulted in shorter procedure times: The mean procedure time in the electrosurgical bipolar vessel sealer arm was 39.1 minutes (range 22–93) versus 53.6 minutes (range 37–160) for the suture arm (P = .003). Mean estimated blood loss was also statistically less with electrosurgical bipolar vessel sealer: 68.9 mL (range 20–200) versus 126.7 mL (range 25–600) for the suture arm (P = .005). Complication rate and length of stay did not differ by hemostasis technique. Seventy-eight percent of all cases were outpatient. CONCLUSION Electrosurgical bipolar vessel sealer is an effective alternative to sutures in vaginal hysterectomy, resulting in significantly reduced operative time and blood loss.

Laparoscopic-assisted vaginal hysterectomy: American Association of Gynecologic Laparoscopists' 2000 membership survey.

A questionnaire was mailed to all members of the AAGL to determine the current performance of laparoscopic-assisted vaginal hysterectomy (LAVH), and to assess the relative frequencies of techniques and complications. Answers of the 1092 members who responded were entered into a database computer program and analyzed. The analysis revealed 14,911 LAVHs performed by 767 members. Complication rates appeared to be in the same range as those reported for vaginal hysterectomy and total abdominal hysterectomy. Inferior epigastric injury was the most common complication. Physicians showed a shift in their practices away from abdominal hysterectomy after they learned LAVH.

Hysteroscopic Sterilization: 10-Year Retrospective Analysis of Worldwide Pregnancy Reports

STUDY OBJECTIVE To identify factors that might contribute to pregnancies reported after hysteroscopic sterilization worldwide. DESIGN Retrospective review of commercial data compiled from the MAUDE database, medical literature, and manufacturer reports received during commercial distribution of hysteroscopic sterilization micro-inserts from 2001 through 2010 (Canadian Taskforce classification III descriptive study). MEASUREMENTS AND MAIN RESULTS From 2001 through 2010, 497 305 hysteroscopic sterilization kits were distributed worldwide, and 748 pregnancies were reported, i.e., 0.15% of the estimated user population based on the number of distributed kits. The data were sufficient to enable analysis of 508 pregnancies for potential contributing factors and showed most to be associated with patient or physician noncompliance (n = 264) or misinterpreted confirmation tests (n = 212). Conceptions deemed to have occurred within 2 weeks of the procedure and therefore too early for detection were identified in 32 cases. CONCLUSION Although there are limitations to the dataset and the study design is retrospective, it represents the largest body of cumulative hysteroscopic sterilization data available to date. Of the 748 pregnancies reported, it is apparent that some might have been prevented with greater patient and clinician attention to interim contraceptive use and counseling and with more rigorous evaluation and informed interpretation of the procedure confirmation tests. Although the estimated pregnancy rate based on such a dataset is likely an underestimation, it does suggest that the evaluable field performance of hysteroscopic sterilization micro-inserts is consistent with the labeled age-adjusted effectiveness of 99.74% at 5 years.

Outpatient vaginal hysterectomy: optimizing perioperative management for same-day discharge.

OBJECTIVE: To present tactics for optimizing outpatient vaginal hysterectomy and describe perioperative outcomes in a large consecutive case series. METHODS: This is a descriptive study and review of clinical outcomes in 1,071 patients selected to undergo vaginal hysterectomy for benign indications from 2000 to 2010. The setting is a single-surgeon private practice in a community hospital. Outcome measures include length of hospital stay, estimated blood loss, operative time, uterine weight, and perioperative complications, including hospital readmissions and emergency room visits. RESULTS: One thousand seventy-one of 1,162 cases (92%, 95% confidence interval [CI] 90.5–93.7) were total vaginal hysterectomies, of which 1,029 (96%, 95% CI 94.9–97.3) were discharged the same day after surgery. The median operative time was 34 minutes (range 17–210 minutes), and estimated blood loss was 45 mL (range 5–800 mL). The median patient age was 46 years (range 27–86 years), and median uterine weight was 160 g (range 25–1,380 g). One hundred ninety-three patients (18%, 95% CI 15.8–20.5) were nulliparous and 218 (20%, 95% CI 18–22.9) had prior pelvic surgery. Five patients (0.5%, 95% CI 0.2–1.1) required readmission or emergency room evaluation within the first 30 days. CONCLUSION: Vaginal hysterectomy can be successfully adopted as a same-day discharge procedure. In this population, regardless of previous pelvic surgery or nulliparity, good perioperative outcomes have been achieved. LEVEL OF EVIDENCE: III

National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism.

Obstetric venous thromboembolism is a leading cause of severe maternal morbidity and mortality. Maternal death from thromboembolism is amenable to prevention, and thromboprophylaxis is the most readily implementable means of systematically reducing the maternal death rate. Observational data support the benefit of risk-factor-based prophylaxis in reducing obstetric thromboembolism. This bundle, developed by a multidisciplinary working group and published by the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women’s Health Care, supports routine thromboembolism risk assessment for obstetric patients, with appropriate use of pharmacologic and mechanical thromboprophylaxis. Safety bundles outline critical clinical practices that should be implemented in every maternity unit. The safety bundle is organized into four domains: Readiness, Recognition, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged.

1997 AAGL membership survey: Practice profiles

In 1997 the Board of the AAGL decided to use its surveying capacity to learn more about its membership with respect to current practices, including office procedures, types of patients, drug prescriptions, and fees and reimbursement. A list of such questions was sent to 6058 members in July 1997, and responses were analyzed from October to February 1998. The purpose was to provide information about who and what our membership currently is and how we practice, as well as to inform potential vendors as to the nature of the AAGL membership for their marketing considerations. Information of primary interest to fiscal and commercial purposes will be used by the AAGL for the benefit of its members. Information relevant to dayto-day practice is presented here.

Deficits in recognition of random shapes with changed visual fields

Four random shapes were presented twice to each of 96 Ss under monocular viewing. Two shapes were presented to the left visual field and two to the right. In the test series, including control shapes, Ss experienced significant difficulty in recognizing those shapes which had been changed from one visual field to the other.

Perioperative Pain Management

The clinical anesthesia, general surgery, and gynecology literature addressing the pathophysiology and management strategies for perioperative pain were reviewed. There are few prospective, randomized studies from which to draw meaningful conclusions. Nevertheless, a theoretical construct has been developed which may help the gynecologic surgeon optimizing pain management. The era of managed care and shorter hospital stays has focused physicians and, in particular, surgeons on elements of patient care that can be addressed and improved. Reducing or eliminating postoperative pain without excessive sedation promotes rapid mobilization and return to self-care. Strategies for pain management can be adopted that reduce postoperative ileus and other adverse reactions to analgesics.

Nonsurgical management of chronic pelvic pain

The following article will give you the opportunity to assess your understanding and knowledge of the material and earn continuing medical education (CME) credit. Review articles will be published in many issues of the Journal of the American Association of Gynecologic Laparoscopists. They will be designated as course reading and offer physicians a chance to earn up to 1 CME credit hour per article.

Building a Better Safety Net: Taking the Safety Agenda to Office-Based Womenʼs Health

The recent focus on health care safety is a response to the central ethical tenet of medicine—to do no harm. The delivery of safe hospital care has led to demonstrable reductions in medical errors, adverse events, and patient injuries. These improvements have led to a commensurate reduction of legal risk and the emotional toll on caregivers as well as families. It also has reinvigorated the reason many physicians went into medicine—to make a difference for womens health. The new, voluntary Safety Certification in Outpatient Practice Excellence (SCOPE) for Womens Health program of the American Congress of Obstetricians and Gynecologists is a means to both evaluate and recognize work in a critical but often neglected arena—the outpatient setting. It builds on infrastructure created for safety programs in hospital settings. Strong physician leadership, the development of an office culture committed to safety, communication and teamwork skills, safety programs for office-based surgery, medication safety, and tracking systems are all important for safe treatment of our patients in the office setting. The SCOPE Program defines the necessary safety goals for ambulatory womens health care and provides an educational pathway to reach those goals. SCOPE certification is an achievement recognizing the commitment of physicians and their staff to the health and safety of their patients.