Emad Mikhail

National trends of adnexal surgeries at the time of hysterectomy for benign indication, United States, 1998-2011

OBJECTIVE We sought to investigate the most recent national trends of bilateral salpingectomy (BS) and bilateral salpingo-oophorectomy (BSO) at the time of hysterectomy performed for benign indications. STUDY DESIGN We conducted a national cross-sectional analysis of all inpatient discharges for women aged ≥18 years who underwent a hysterectomy for benign indications from 1998 through 2011 using the largest publicly available all-payer inpatient database in the United States. We scanned International Classification of Diseases, Ninth Revision codes for an indication of specific bilateral adnexal surgeries, including BSO and BS. Joinpoint regression was used to characterize and estimate 14-year national trends in performing BSO and BS at the time of hysterectomy for benign indications, overall and in population subgroups. RESULTS During the study period, there were approximately 428,523 inpatient hysterectomy procedures performed annually for benign indications. Of these, >53% had no adnexal surgery performed during the same hospitalization, whereas 43.7% and 1.3% of those discharges had BSO and BS procedures, respectively. The rate of BSO was directly correlated with increasing age for patients <65 years. Conversely, we observed an inverse relationship between BS and patient age, with the BS rate among women aged <25 years twice that of women aged ≥45 years. From 1998 through 2001, there was a 2.2% increase in the rate of BSO per year (95% confidence interval, 0.4-4.0); however, this was followed by a consistent 3.6% (95% confidence interval, -4.0 to -3.3) annual decline in the BSO rate, from 49.7% in 2001 to 33.4% in 2011. National rates of BS among women undergoing hysterectomy for benign indications increased significantly throughout the study period, with an estimated 8% annual increase from 1998 through 2008, followed by a sharp 24% increase annually during the last 4 years of the study period. The BS rate nearly quadrupled in 14 years. CONCLUSION The type of adnexal surgery performed concomitantly with hysterectomy for benign indications has undergone a significant shift since 2001. Significantly more BS and less BSO procedures are being performed among gynecologic surgeons in the United States.

Association between obesity and the trends of routes of hysterectomy performed for benign indications.

OBJECTIVE: To estimate the association between obesity and the recent trends of routes chosen for hysterectomy performed for benign indications in the United States. MATERIALS AND METHODS: Using the American College of Surgeons–National Surgical Quality Improvement Projects database, patients who underwent hysterectomy for benign indications from 2005 to 2011 were identified by International Classification of Diseases, 9th Revision codes and were categorized into total abdominal hysterectomy (TAH), total vaginal hysterectomy (TVH), laparoscopically assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy (TLH). The patients were divided into four subgroups according to body mass index (BMI) (less than 25, 25–29.9, 30–39.9, and 40 or greater). The data were analyzed using Students t test or &khgr;2 and Fishers exact test. RESULTS: A total of 18,810 patients underwent hysterectomy for benign indications during the study period: 9,852 (52.4%) were TAH, 5,146 (27.4%) TVH, 2,296 (12.2%) LAVH, and 1,516 (8.0%) TLH. The rates of TAH increased from 45.7% in patients with ideal body weight to 62% in morbidly obese patients (P<.001). The rate of TVH and LAVH decreased from 32.7% and 13.3% in patients with ideal body weight to 17.1% and 11.7% in morbidly obese patients, respectively (P<.001 and 0.04). The rate of TLH performed was independent of BMI (P=.61). Higher BMI was associated with longer operative time (P<.001) in all routes of hysterectomy. The rates of superficial and deep wound infections were higher with increasing BMI in patients undergoing TAH (P<.001) but not with TVH (P=.26), LAVH (P=1.0), or TLH (P=.48). CONCLUSION: Regarding hysterectomy performed for benign indications, increasing BMI was associated with increased rate of TAH and decreased rate of TVH and LAVH, but not the rate of TLH. Increasing BMI was associated with increased operative time for all subgroups and increased surgical site infection in the TAH group. LEVEL OF EVIDENCE: II

The Relationship Between Obesity and Trends of the Routes of Hysterectomy for Benign Indications

INTRODUCTION: The objective of this study was to determine if obesity has an effect on the recent trends of routes chosen for hysterectomy for benign indications. Patients with elevated body mass index (BMI) experience a higher risk for perioperative morbidity and are expected to benefit from minimally invasive surgical approaches. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, patients who underwent hysterectomy for benign indications from 2005 to 2011 were identified by International Classification of Diseases, 9th Revision codes and were categorized into total abdominal hysterectomy (TAH), total vaginal hysterectomy (TVH), laparoscopically assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy (TLH) using Current Procedural Terminology codes. Patients were divided into four groups according to BMI (BMI less than 25 kg/m2, BMI 25–29.9 kg/m2, BMI 30–39.9 kg/m2, and BMI 40 kg/m2 or greater). The data were analyzed using tests for trend, Wilcoxon rank, and Fishers exact tests. RESULTS: A total of 18,810 patients underwent hysterectomy for benign indications: 9,852 (52.38%) TAH, 5,146 (27.36%) TVH, 2,296 (12.21%) LAVH, and 1,516 (8.06%) TLH. The TAH rates increase as BMI increases (P<.001). The TVH rates decreases as BMI increases (P<.001). The LAVH rates decrease as well as BMI increases (P=.04). There was no significant difference in TLH rates (P=.61). The BMI increase was associated with an in increase in operative time (P<.001) in all groups. Wound infection rates were higher as the BMI increases in TAH (P<.001) but not in TVH (P=.26), LAVH (P=1), or TLH (P=.48). CONCLUSION: As the BMI increases, the rate of TAH increases and the rates of TVH and LAVH decrease. Elevated BMI increases operative time in all subgroups and wound infection in the TAH group.

Association Between Obesity and Perioperative Morbidity in Open Versus Laparoscopic Sacrocolpopexy

Objectives The aim of this study was to compare differences in 30-day perioperative morbidity and mortality for women undergoing open sacrocolpopexy (OSCP) versus laparoscopic sacrocolpopexy (LSCP) across all body mass index (BMI) groups and between patients of ideal versus elevated BMI (includes overweight, obese, and morbidly obese). Materials and Methods Data for this retrospective review were obtained from the American College of Surgeons-National Surgical Quality Improvement Project database using current procedural terminology. All women older than 18 years who underwent an OSCP or LSCP from 2005 to 2013 were included. Patients were divided into 4 BMI (weight [kg]/[height (m)]2) subgroups: (1) less than 25, (2) 25 to 29.9, (3) 30 to 39.9, and (4) 40 or greater. The data were analyzed using Student t or &khgr;2 test and Fisher exact test. Results A total of 4894 women underwent an OSCP or LSCP. Shorter operative times were observed with OSCP (P < 0.05) in all BMI groups except morbidly obese patients. Compared with patients of ideal body weight, overweight and obese patients had significantly longer operation times during LSCP (P < 0.05), a difference that was not observed during OSCP. For all BMI subgroups, the length of hospital stay was significantly shorter for LSCP (1 [1–1]) versus OSCP (2 [2–3]) (P < 0.05). Statistically significant increases in the rate of superficial surgical site infections were observed in OSCP in patients of both ideal and overweight BMIs (P < 0.05). Conclusions Obesity increases the operative time during LSCP. For patients in all BMI groups, LSCP offers the benefit of shorter hospital stays when compared with OSCP.

Association between Fellowship Training, Surgical Volume, and Laparoscopic Suturing Techniques among Members of the American Association of Gynecologic Laparoscopists

Study Objective. To compare surgical volume and techniques including laparoscopic suturing among members of the American Association of Gynecologic Laparoscopists (AAGL) according to fellowship training status. Design. A web-based survey was designed using Qualtrics and sent to AAGL members. Results. Minimally invasive gynecologic surgery (FMIGS) trained surgeons were more likely to perform more than 8 major conventional laparoscopic cases per month (63% versus 38%, P < 0.001, OR [95% CI] = 2.78 [1.54–5.06]) and were more likely to perform laparoscopic suturing during these cases (32% versus 16%, P < 0.004, OR [95% CI] = 2.44 [1.25–4.71]). The non-fellowship trained (NFT) surgeons in private practice were less likely to perform over 8 conventional laparoscopic cases (34% versus 51%, P = 0.03, OR [95% CI] = 0.50 [0.25–0.99]) and laparoscopic suturing during these cases (13% versus 27%, P = 0.01, OR [95% CI] = 0.39 [0.17–0.92]) compared to NFT surgeons in academic practice. Conclusion. The surgical volume and utilization of laparoscopic suturing of FMIGS trained surgeons are significantly increased compared to NFT surgeons. Academic practice setting had a positive impact on surgical volume of NFT surgeons but not on FMIGS trained surgeons.

Gynecologic Surgeons’ Perspectives on Risk Factors and Prophylaxis of Trocar Site Hernias: A National Survey [22Q]

INTRODUCTION:Although trocar site hernias (TSH) occur in only 1.5-1.8% of all laparoscopic procedures, TSHs can represent serious postoperative complications. The purpose of this study was to survey gynecologic surgeons who are active members of the Society of Laparoendoscopic Surgeons (SLS) in orde

Abdominal Hysterectomy for Obese Patients

Obesity is becoming a challenging health problem worldwide and in the United States, where national estimates indicate that 35.5 % of the adult population is obese. Hysterectomy is one of the most frequently performed surgical procedures in the United States. More than half of the hysterectomy procedures in the United States are performed through laparotomy incisions. It is expected that this proportion is even higher in developing countries. Multiple research studies have shown an increased risk of perioperative morbidity for obese patient undergoing abdominal hysterectomy. If minimally invasive approach is not feasible for whatever reason, appropriate perioperative care should be employed to improve outcomes for obese women undergoing abdominal hysterectomy.

Association between Obesity, Surgical Route, and Perioperative Outcomes in Patients with Uterine Cancer

Objective To study temporal trends of hysterectomy routes performed for uterine cancer and their associations with body mass index (BMI) and perioperative morbidity. Methods A retrospective review of the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) 2005-2013 databases was conducted. All patients who were 18 years old and older with a diagnosis of uterine cancer and underwent hysterectomy were identified using ICD-9-CM and CPT codes. Surgical route was classified into four groups: total abdominal hysterectomy (TAH), total vaginal hysterectomy (TVH), laparoscopic assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy (TLH) including both conventional and robotically assisted. Patients were then stratified according to BMI. Results 7199 records were included in the study. TLH was the most commonly performed route of hysterectomy regardless of BMI, with proportions of 50.9%, 48.9%, 50.4%, and 51.2% in ideal, overweight, obese, and morbidly obese patients, respectively. The median operative time for TAH was 2.2 hours compared to 2.7 hours for TLH (p < 0.01). The median length of stay for TAH was 3 days compared to 1 day for TLH (p < 0.01). The percentage of patients with an adverse outcome (composite indicator including transfusion, deep venous thrombosis, and infection) was 17.1 versus 3.7 for TAH and TLH, respectively (p < 0.01). Conclusion During the last decade, TLH has been increasingly performed in women with uterine cancer. The increased adoption of TLH was seen in all BMI subgroups.

National rates, trends and determinants of inpatient surgical management of tubal ectopic pregnancy in the United States, 1998–2011

To describe the frequency and temporal trends of inpatient hospitalization for tubal ectopic pregnancy as well as patients’ characteristics, determinants and the current national trends in surgical management of ectopic pregnancy.

Demonstration of a box-stitch technique for laparoscopic uterosacral ligament suspension

AimWe demonstrate a novel box stitch technique of laparoscopic post-hysterectomy uterosacral ligament suspension for apical prolapse in restorative pelvic reconstructive surgery.Material and methodsWe present a case of a 58yo female with symptomatic stage III pelvic organ prolapse with a history of a total abdominal hysterectomy 30 years prior. She strongly desired the usage of no synthetic or biologic mesh for her restorative surgical repair. This video provides a step-by-step guide on how to perform a laparoscopic box stitch as a technique for uterosacral ligament suspension as an apical native tissue option for patients with the need for post hysterectomy apical prolapse.ConclusionThis video demonstrates a novel box-stitch technique of laparoscopic post-hysterectomy uterosacral ligament suspension as a native tissue option for minimally invasive reconstructive surgery. The procedure is a reasonable option to address apical prolapse in patients who do not desire or who are unable to have synthetic or biologic mesh placed for restorative reconstructive prolapse surgery.