J.I. Einarsson

Trendelenburg Position in Gynecologic Robotic-Assisted Surgery

OBJECTIVE To estimate the necessity of routine patient positioning in steep Trendelenburg in robotic-assisted gynecologic surgery performed for benign indications. DESIGN Descriptive study (Canadian Task Force classification II-2). SETTING University-affiliated community hospital. PATIENTS Twenty women undergoing robotic-assisted gynecologic surgery for benign indications. INTERVENTION Robotic-assisted total hysterectomy, supracervical hysterectomy, myomectomy, and sacrocolpopexy. MEASUREMENTS AND MAIN RESULTS Demographic data and perioperative variables were recorded including age, body mass index, procedure type, console time, perioperative complications, estimated blood loss, hospital length of stay, and degree of Trendelenburg position. The degree of Trendelenburg position was measured at the end of each procedure using an electronic level. The surgeons were blinded to the degree of Trendelenburg used. All procedures were performed successfully without conversion to laparotomy. All patients were discharged to home within 24 hours. No perioperative complications were noted. The mean (SD; 95% CI) Trendelenburg position used in this cohort was 16.4 (4.1; 14.4-18.3) degrees. Patient body mass index was 28.5 (5.3; 26.1-31.1). Median console time was 87.5 (27-112) minutes. CONCLUSION Robotic-assisted benign gynecologic surgery can be effectively performed without use of the steep Trendelenburg position. The practice of routine adherence to steep Trendelenburg positioning in benign gynecologic robotic surgery should be questioned.

Inhibition of HIV transmission in human cervicovaginal explants and humanized mice using CD4 aptamer-siRNA chimeras.

The continued spread of the HIV epidemic underscores the need to interrupt transmission. One attractive strategy is a topical vaginal microbicide. Sexual transmission of herpes simplex virus type 2 (HSV-2) in mice can be inhibited by intravaginal siRNA application. To overcome the challenges of knocking down gene expression in immune cells susceptible to HIV infection, we used chimeric RNAs composed of an aptamer fused to an siRNA for targeted gene knockdown in cells bearing an aptamer-binding receptor. Here, we showed that CD4 aptamer-siRNA chimeras (CD4-AsiCs) specifically suppress gene expression in CD4⁺ T cells and macrophages in vitro, in polarized cervicovaginal tissue explants, and in the female genital tract of humanized mice. CD4-AsiCs do not activate lymphocytes or stimulate innate immunity. CD4-AsiCs that knock down HIV genes and/or CCR5 inhibited HIV infection in vitro and in tissue explants. When applied intravaginally to humanized mice, CD4-AsiCs protected against HIV vaginal transmission. Thus, CD4-AsiCs could be used as the active ingredient of a microbicide to prevent HIV sexual transmission.

Risk factors for uterine rupture after laparoscopic myomectomy

Case reports for uterine rupture subsequent to laparoscopic myomectomy were reviewed to determine whether common causal factors could be identified. Published cases were identified via electronic searches of PubMed, Google Scholar, and hand searches of references, and unpublished cases were obtained via E-mail queries to the AAGL membership and AAGL Listserve participants. Nineteen cases of uterine rupture after laparoscopic myomectomy were identified. The removed myomas ranged in size from 1 through 11 cm (mean, 4.5 cm). Only 3 cases involved multilayered closure of uterine defects. Electrosurgery was used for hemostasis in all but 2 cases. No plausible contributing factor could be found in one case [corrected]. It seems reasonable for surgeons to adhere to techniques developed for abdominal myomectomy including limited use of electrosurgery and multilayered closure of the myometrium. Nevertheless, individual wound healing characteristics may predispose to uterine rupture.

Contained power morcellation within an insufflated isolation bag.

OBJECTIVE: To describe a technique for contained power morcellation within an insufflated isolation bag at the time of uterine specimen removal during minimally invasive gynecologic procedures. METHODS: Over the study period of January 2013 to April 2014, 73 patients underwent morcellation of the uterus or myomas within an insufflated isolation bag at the time of minimally invasive hysterectomy or myomectomy. This technique involves placing the specimen into a large plastic bag within the abdomen, exteriorizing the opening of the bag, insufflating the bag within the peritoneal cavity, and then using a power morcellator within the bag to remove the specimen in a contained fashion. Procedures were performed at four institutions and included multiport laparoscopy, single-site laparoscopy, multiport robot-assisted laparoscopy, or single-site robot-assisted laparoscopy. Demographic and perioperative characteristics were collected for the cases. RESULTS: Surgical specimen morcellation within an insufflated isolation bag was successfully used in all cases. The median operative time was 114 minutes (range 32–380 minutes), median estimated blood loss was 50 mL (range 10–500 mL), and the median specimen weight was 257 g (range 53–1,481 g). There were no complications related to the contained morcellation technique nor was there visual evidence of tissue dissemination outside of the isolation bag. CONCLUSION: Morcellation within an insufflated isolation bag is a feasible technique. Methods for morcellating uterine tissue in a contained manner may provide an option to minimize the risks of open power morcellation while preserving the benefits of minimally invasive surgery. LEVEL OF EVIDENCE: II

A randomized trial comparing conventional and robotically assisted total laparoscopic hysterectomy

OBJECTIVE The purpose of this study was to compare operative time and intra- and postoperative complications between total laparoscopic hysterectomy and robotic-assisted total laparoscopic hysterectomy. STUDY DESIGN This study was a blinded, prospective randomized controlled trial conducted at 2 institutions. Subjects consisted of women who planned laparoscopic hysterectomy for benign indications. Preoperative randomization to total laparoscopic hysterectomy or robotic-assisted total laparoscopic hysterectomy was stratified by surgeon and uterine size (> or ≤12 weeks). Validated questionnaires, activity assessment scales, and visual analogue scales were administered at baseline and during follow-up evaluation. RESULTS Sixty-two women gave consent and were enrolled and randomly assigned; 53 women underwent surgery (laparoscopic, 27 women; robot-assisted, 26 women). There were no demographic differences between groups. Compared with laparoscopic hysterectomy, total case time (skin incision to skin closure) was significantly longer in the robot-assisted group (mean difference, +77 minutes; 95% confidence interval, 33-121; P < .001] as was total operating room time (entry into operating room to exit; mean difference, +72 minutes; 95% confidence interval, 14-130; P = .016). Mean docking time was 6 ± 4 minutes. There were no significant differences between groups in estimated blood loss, pre- and postoperative hematocrit change, and length of stay. There were very few complications, with no difference in individual complication types or total complications between groups. Postoperative pain and return to daily activities were no different between groups. CONCLUSION Although laparoscopic and robotic-assisted hysterectomies are safe approaches to hysterectomy, robotic-assisted hysterectomy requires a significantly longer operative time.

The Use of Bidirectional Barbed Suture in Laparoscopic Myomectomy and Total Laparoscopic Hysterectomy

Bidirectional barbed suture is a new design that incorporates tiny barbs spaced evenly along the length of the suture cut facing in opposite directions from the midpoint. Unlike the smooth-textured traditional suture, the bidirectional barbs on this new product introduce a new paradigm in which wound tension is evenly distributed across the length of the suture line rather than at the knotted end. No knots are required with bidirectional barbed suture. We present a small case series with bidirectional barbed suture to close myometrial defects in laparoscopic myomectomies and vaginal cuffs in total laparoscopic hysterectomies. On the basis of our early experience, we are optimistic that this new suture material is a potentially valuable tool for gynecologic surgeons.

Minimally Invasive Hysterectomies—A Survey on Attitudes and Barriers among Practicing Gynecologists

STUDY OBJECTIVE To explore attitudes and hysterectomy practices among gynecologists in the United States and to identify potential barriers to offering minimally invasive hysterectomies. DESIGN Mixed-mode (online and on-paper) survey of a random sample of 1500 practicing obstetrician-gynecologists. SETTING Nationwide survey in the United States. PARTICIPANTS Nonretired obstetrician-gynecologists identified through a physician list from the American Medical Association. INTERVENTIONS Postal and online survey. MEASUREMENTS & MAIN RESULTS: We received a response from 376 physicians (25.8% response rate). The average age of respondents was 47.9 years, and 87% were generalists. Participants performed on average 4 surgical cases per week and 32 hysterectomies per year, most of which were abdominal hysterectomies. When asked for preferred mode of access for themselves or their spouse, 55.5% chose vaginal hysterectomy (VH), 40.6% chose laparoscopic hysterectomy (LH), and 8% chose abdominal hysterectomy (AH). Younger physicians (<40) and high surgical volume physicians were significantly more likely to chose a laparoscopic approach and identified significantly fewer barriers for performing LH. The main barriers to performing VH were technical difficulty, potential for complications, and caseload of VH. The main barriers for performing LH were training during residency, technical difficulty, personal surgical experience and operating time. The majority of gynecologists wanted to decrease their AH rates and increase their LH rates. The most significant identified contraindications to VH were prior laparotomy, a uterus larger than 12 weeks, narrow introitus, adnexal mass, and minimal uterine descent. CONCLUSIONS While a large majority of gynecologists would prefer a VH or LH for themselves or their spouse, AH remains the most common hysterectomy method in the United States. A generation gap appears to be brewing with younger gynecologist more in favor of the laparoscopic approach. More emphasis should be placed on training gynecologists in performing minimally invasive hysterectomies, given their desire to change their surgical mode of access.

Open Power Morcellation Versus Contained Power Morcellation Within an Insufflated Isolation Bag: Comparison of Perioperative Outcomes

STUDY OBJECTIVE To compare perioperative outcomes, particularly operative time, between uncontained and in-bag power morcellation of uterine tissue at the time of laparoscopic surgery. DESIGN Canadian Task Force classification II-3. SETTING Academic tertiary care hospitals. PATIENTS Women undergoing laparoscopic hysterectomy or myomectomy who required morcellation of uterine tissue for specimen extraction. INTERVENTIONS Outcomes among patients who had in-bag power morcellation were compared with outcomes among patients who had traditional power morcellation. The technique for in-bag morcellation entails placing the specimen into a large containment bag within the abdomen, insufflating the bag within the peritoneal cavity, and then using a power morcellator to remove the specimen from inside the bag. MEASUREMENTS AND MAIN RESULTS The cohort consisted of 85 consecutive patients who underwent surgery with morcellation of uterine tissue. Prospective data collected from 36 patients who underwent in-bag morcellation were compared with retrospective data collected from the immediately preceding 49 patients who had uncontained power morcellation. Baseline demographics were comparable between the 2 groups although women who underwent in-bag morcellation were on average older than the open morcellation group (mean age in years [standard deviation], 49.19 [1.12] vs 44.06 [8.93]; p = .01). The mean operating room time was longer in the in-bag morcellation group (mean time in minutes [standard deviation], 119.0 [55.91] vs 93.13 [44.90]; p = .02). The estimated blood loss, specimen weight, hospital length of stay, and perioperative complication rate did not vary between the 2 groups. Operative times did not vary significantly by surgeon. There were no cases of malignancy or isolation bag disruption. CONCLUSIONS In-bag power morcellation, a tissue extraction technique developed to reduce the risk of tissue dissemination, results in perioperative outcomes comparable with the traditional laparoscopic approach. In this cohort, the mean operative time was prolonged by 26 minutes with in-bag morcellation but may potentially be reduced with further refinement of the technique.

In-Bag Morcellation

In-bag morcellation seems to be a viable alternative to open power morcellation and offers the advantage of minimal to no spillage of tissue or fluids during morcellation. We report our initial experience and technique using this approach.

Costs and outcomes of abdominal, vaginal, laparoscopic and robotic hysterectomies.

Complication rates did not vary significantly among minimally invasive methods of hysterectomy; however, patient costs were significantly influenced by the technique used for hysterectomy.