Hye-Chun Hur

Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement.

The Society of Radiologists in Ultrasound convened a panel of specialists from gynecology, radiology, and pathology to arrive at a consensus regarding the management of ovarian and other adnexal cysts imaged sonographically in asymptomatic women. The panel met in Chicago, Ill, on October 27-28, 2009, and drafted this consensus statement. The recommendations in this statement are based on analysis of current literature and common practice strategies, and are thought to represent a reasonable approach to asymptomatic ovarian and other adnexal cysts imaged at ultrasonography.

Vaginal cuff dehiscence after different modes of hysterectomy.

OBJECTIVE: To update the incidence of vaginal cuff dehiscence after different modes of hysterectomy and to describe surgical and patient characteristics of dehiscence complications. METHODS: This was an observational cohort study at a large academic hospital. All women who underwent hysterectomy and dehiscence repair between January 2006 and December 2009 were identified. Data from this study period were analyzed separately and in combination with our preliminary study (January 2000 to December 2005) for a 10-year analysis (January 2000 to December 2009). The primary outcome was incidence of vaginal cuff dehiscence after total laparoscopic hysterectomy compared with abdominal, vaginal, and laparoscopically assisted vaginal hysterectomy (LAVH). RESULTS: Between 2006 and 2009, the overall incidence of dehiscence was 0.39% (95% confidence interval [CI] 0.21–0.56). The incidence after total laparoscopic hysterectomy was 0.75% (95% CI 0.09–1.4), which was the highest among all modes of hysterectomy (LAVH was 0.46% [95% CI 0.0–1.10]; total abdominal hysterectomy was 0.38% [95% CI 0.16–0.61]; and total vaginal hysterectomy was 0.11%, [95% CI 0.0–0.32]). This incidence was appreciably lower than previously reported (4.93% in 2007 publication, 2.76% readjusted calculation). The 10-year cumulative incidence of dehiscence after all modes of hysterectomy was 0.24% (95% CI 0.15–0.33) and 1.35% (95% CI 0.72–2.3) among total laparoscopic hysterectomies. During the 10-year study period, total laparoscopic hysterectomy-related dehiscence was significantly increased compared with other modes of hysterectomy, with a risk ratio of dehiscence after total laparoscopic hysterectomy of 9.1 (95% CI 4.1–20.3) compared with total abdominal hysterectomy, risk ratio of 17.2 (95% CI 3.9–75.9) compared with total vaginal hysterectomy, and risk ratio of 4.9 (95% CI 1.1–21.5) compared with LAVH. CONCLUSION: Our updated 1.35% incidence of dehiscence after total laparoscopic hysterectomy is much lower than previously reported. LEVEL OF EVIDENCE: II

Management of asymptomatic ovarian and other adnexal cysts imaged at US Society of Radiologists in Ultrasound consensus conference statement.

The Society of Radiologists in Ultrasound (SRU) convened a panel of specialists from gynecology, radiology, and pathology to arrive at a consensus regarding the management of ovarian and other adnexal cysts imaged sonographically in asymptomatic women. The panel met in Chicago, IL, on October 27-28, 2009, and drafted this consensus statement. The recommendations in this statement are based on analysis of current literature and common practice strategies, and are thought to represent a reasonable approach to asymptomatic ovarian and other adnexal cysts imaged at ultrasonography.

Fundamentals of laparoscopic surgery: a surgical skills assessment tool in gynecology.

This analysis suggests that the fundamentals of laparoscopic surgery skills test may be a valuable assessment tool for gynecology residents; however, the cognitive test may need further adaptation for application to gynecologists.

Laparoscopic Management of Hysteroscopic Essure Sterilization Complications: Report of 3 Cases

Hysteroscopic Essure sterilizations offer women and physicians another option for contraception. Overall, the procedure is simple to perform and highly efficacious, and as a result, has gained popularity among practicing gynecologists. Unfortunately, complications occur with any type of surgery. We report 3 cases of hysteroscopic Essure sterilization complications where the Essure microinsert was noted to be misplaced or where patients had persistent postprocedure pain in the setting of appropriately placed microinserts. In all 3 cases, the microinserts were successfully removed laparoscopically.

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 Cronbachs &agr; 0.79±0.02). Intrarater reliability was also high (mean Spearmans 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

Developing an Objective Structured Assessment of Technical Skills for Laparoscopic Suturing and Intracorporeal Knot Tying

OBJECTIVE To develop a teaching and assessment tool for laparoscopic suturing and intracorporeal knot tying. DESIGN AND SETTING We designed an Objective Structured Assessment of Technical Skills (OSATS) tool that includes a procedure-specific checklist (PSC) and global rating scale (GRS) to assess laparoscopic suturing and intracorporeal knot-tying performance. Obstetrics and Gynecology residents at our institution were videotaped while performing a laparoscopic suturing and intracorporeal knot-tying task at a surgical simulation workshop. A total of 2 expert reviewers assessed resident performance using the OSATS tool during live performance and 1 month later using the videotaped recordings. OSATS scores were analyzed using the Wilcoxon rank-sum test. Data are presented as median scores (interquartile range [IQR]). Intrarater and interrater reliabilities were assessed using a Spearman correlation and are presented as an r correlation coefficient and p value. An r ≥ 0.8 was considered as a high correlation. After testing, we received feedback from residents and faculty to improve the OSATS tool as part of an iterative design process. PARTICIPANTS In all, 14 of 21 residents (66.7%) completed the study, with 9 junior residents and 5 senior residents. RESULTS Junior residents had a lower score on the PSC than senior residents did; however, this was not statistically significant (median = 6.0 [IQR: 4.0-10.0] and median = 13.0 [IQR: 10.0-13.0]; p = 0.09). There was excellent intrarater reliability with our OSATS tool (for PSC component, r = 0.88 for Rater 1 and 0.93 for Rater 2, both p < 0.0001; for GRS component, r = 0.85 for Rater 1 and 0.88 for Rater 2, both p ≤ 0.0002). The PSC also has high interrater reliability during live evaluation (r = 0.92; p < 0.0001), and during the videotape scoring with r = 0.77 (p = 0.001). CONCLUSIONS Our OSATS tool may be a useful assessment and teaching tool for laparoscopic suturing and intracorporeal knot-tying skills. Overall, good intrarater reliability was demonstrated, suggesting that this tool may be useful for longitudinal assessment of surgical skills.

Dilute versus concentrated vasopressin administration during laparoscopic myomectomy: a randomised controlled trial

To determine if higher‐volume, fixed‐dose administration of vasopressin further reduces blood loss at the time of minimally invasive myomectomy.

Fibroid morcellation: a shared clinical decision tool for mode of hysterectomy

OBJECTIVE To compare risks and benefits of laparoscopic hysterectomy with morcellation versus abdominal hysterectomy without morcellation for large fibroids. STUDY DESIGN We developed a shared clinical decision tool to communicate risks and benefits of laparoscopic versus abdominal hysterectomy to patients with large fibroids as mandated by the FDA. The decision tool was designed to serve as a framework for providers to counsel patients about mode of hysterectomy to facilitate shared decision-making between patient and provider. Risks and benefits were estimated from the literature, including surgical complications (venous thromboembolism, small bowel obstruction, adhesions, hernia, surgical site infections, and transfusions), uterine sarcoma risks, and quality-of-life endpoints. The shared clinical decision tool was applied to a hypothetical population of 20,000 patients with large uterine fibroids, of which 10,000 underwent laparoscopic hysterectomies and 10,000 had abdominal hysterectomies. RESULTS Abdominal hysterectomy would result in 50.1% more adhesions, 10.7% more hernias, 4.8% more surgical site infections, 2.8% more bowel obstructions, and 2% more venous thromboembolisms compared to laparoscopic hysterectomy. Abdominal hysterectomy would also result in longer hospital stays (2 days), slower return to work (13.6 days), greater postoperative day 3 narcotic requirements (48%), and lower SF-36 quality-of-life scores (50.4 points lower). 0.28% of fibroid hysterectomy patients would have unsuspected uterine sarcomas. Among these patients, laparoscopic hysterectomy with morcellation would have a 27% reduction in 5-year overall survival rates and a 28.8 month shorter recurrence-free survival period. CONCLUSION Some evidence suggests laparoscopic hysterectomy with morcellation may result in increased risk of cancer dissemination with worse survival outcomes among uterine sarcoma patients compared to abdominal hysterectomy without morcellation, however, the current data is limited and the exact risks associated specifically with electromechanical morcellation are not conclusive. Data also supports abdominal hysterectomy would lead to a net detriment in other outcomes, with greater risks of venous thromboembolism, obstruction, hernia, adhesions, infection, and blood loss compared to laparoscopic hysterectomy. This shared clinical decision tool may aid the patient and physician in determining an optimal mode of hysterectomy for large uterine fibroids while taking account of risks and benefits as mandated by the FDA.

Impact of Cystectomy on Ovarian Reserve: Review of the Literature

Ovarian cysts are common in the reproductive age. Pathologic cysts such as endometriomas and dermoids often require surgical intervention if symptomatic. Laparoscopic cystectomy is the first-line treatment for these cysts and is associated with better pain control and less recurrence than drainage or cyst ablation procedures. There has been an emerging concern about the effect of ovarian cystectomy on ovarian reserve with some evidence of short-term and long-term reduction in ovarian reserve. Certain cyst characteristics (endometrioma pathology, large cyst size, bilateral presentation) are associated with a greater decline in ovarian reserve after cystectomy. The impact of surgery on ovarian reserve can be minimized by selecting the appropriate surgery for the patient, careful tissue handling, and limited use of electrosurgery. Patients should be counseled on the risks of surgery on reproductive potential, and the management plan should be individualized to the patients symptoms and reproductive goals.