Jamie Kroft

Does surgical "warming up" improve laparoscopic simulator performance?

Introduction The objective of this study was to determine if preoperative warming up by obstetrics and gynecology trainees, using a validated bench model for intracorporeal suturing, improves efficiency, precision, and quality of laparoscopic suturing. Methods A randomized crossover design was used. Fourteen obstetrics and gynecology residents were randomized [3 junior (year 2) and 11 senior (years 3–5) residents]. Participants were randomized to warm-up or no warm-up and then acted as their own controls at least 2 weeks later. Warm-up consisted of the use of a laparoscopic bench model to practice intracorporeal suturing for 15 minutes. All participants performed a prevalidated intracorporeal suturing task (after either warm-up or no warm-up), which was scored based on time, precision, and knot strength. Each participant also completed a questionnaire anonymously to determine if they believed that warming up improved their performance, regardless of the score they received. Results Thirteen participants completed the study. There was no difference in score when warm-up was compared with no warm-up for the group as a whole. When the junior residents were excluded from the analysis, however, analysis of variance showed a significant improvement in score only when a warm-up was completed in the second session (P = 0.022). The questionnaire revealed that 81.8% of participants felt that warming up subjectively improved their ability, independent of their actual score. Conclusions This study demonstrates that a preoperative warm-up, combined with repetition, is beneficial in improving senior obstetrics and gynecology residents’ laparoscopic suturing performance. This demonstrates a novel approach to resident education for teaching advanced laparoscopic skills.

A novel regimen of combination transdermal estrogen and intermittent vaginally administered progesterone for relief of menopausal symptoms.

Objectives. To determine the safety and efficacy of a novel regimen of transdermal estrogen and vaginally administered progesterone for treatment of menopausal symptoms. Study Methods. A retrospective chart review was conducted of menopausal patients aged 46–65, using an oestradiol patch and vaginally administered prometrium for at least 1 year. Available transvaginal ultrasound (TVUS) measurements of endometrial thickness and endometrial biopsy results after at least 1 year of treatment were collated. Symptom relief, bleeding and side effects were reviewed. Results. Forty-one patients were identified, using an estrogen patch ranging from 25 to 100 μg twice weekly and vaginal prometrium either continuously 3–5 days weekly (36 patients), or sequentially 12 days/month (5 patients). Seventeen patients were lost to follow-up or discontinued therapy within 1 year. Only 23.5% (4/17 patients) of patients who had a TVUS after 1 year (or sooner if bleeding occurred) had a thickened endometrial lining on ultrasound (>5 mm), and all of these had normal endometrial biopsies. By 1 year of follow-up, 91.7% of patients were amenorrhoeic. All patients had relief of menopausal symptoms. Conclusions. Vaginal administration of progesterone as part of combined estrogen plus progestin therapy has the potential for decreasing side effects while maintaining endometrial safety and amenorrhoea. Larger prospective trials are warranted.

Unexplained amenorrhea in a patient taking methotrexate for the treatment of rheumatoid arthritis

Background. The cause of secondary amenorrhea in the following case cannot be explained by traditional etiologies. We therefore questioned whether long-term methotrexate treatment played a role as an endometrial inhibitor. Case. A 44-year-old G4P2, with a 5-year history of rheumatoid arthritis, presented with a 2-year history of secondary amenorrhea. The patient took methotrexate since diagnosis. Her FSH, estrogen, prolactin, TSH and T4 levels were normal, her B-HCG was negative, her BMI was 22 and she had no history of Ashermans syndrome. Conclusion. There is no information, based on our search, on whether long-term methotrexate treatment has an effect on the menstrual cycle. This case highlights the need for the elucidation of the effects of long-term methotrexate treatment on the menstrual cycle in patients with rheumatoid arthritis.

Uterine Full Thickness Multifocal Dehiscence Associated With a History of Cho Uterine Compression Sutures

At operation, there was blood in the abdomen, but the lower uterine segment was intact. A single infant was delivered in good condition. The patient had completed childbearing and agreed to undergo hysterectomy. The uterus had multiple areas of full thickness dehiscence anteriorly and posteriorly (Figure 1), with placenta accreta (Figure 2). There have been few reports of pregnancies after use of compression sutures; partial thickness uterine wall necrosis has been described.2

Preoperative Practice Paired With Instructor Feedback May Not Improve Obstetrics-Gynecology Residents' Operative Performance

BACKGROUND There is evidence that preoperative practice prior to surgery can improve trainee performance, but the optimal approach has not been studied. OBJECTIVE We sought to determine if preoperative practice by surgical trainees paired with instructor feedback improved surgical technique, compared to preoperative practice or feedback alone. METHODS We conducted a randomized controlled trial of obstetrics-gynecology trainees, stratified on a simulator-assessed surgical skill. Participants were randomized to preoperative practice on a simulator with instructor feedback (PPF), preoperative practice alone (PP), or feedback alone (F). Trainees then completed a laparoscopic salpingectomy, and the operative performance was evaluated using an assessment tool. RESULTS A total of 18 residents were randomized and completed the study, 6 in each arm. The mean baseline score on the simulator was comparable in each group (67% for PPF, 68% for PP, and 70% for F). While the median score on the assessment tool for laparoscopic salpingectomy in the PPF group was the highest, there was no statistically significant difference in assessment scores for the PPF group (32.75; range, 15-36) compared to the PP group (14.5; range, 10-34) and the F group (21.25; range, 10.5-32). The interrater correlation between the video reviewers was 0.87 (95% confidence interval 0.70-0.95) using the intraclass correlation coefficient. CONCLUSIONS This study suggests that a surgical preoperative practice with instructor feedback may not improve operative technique compared to either preoperative practice or feedback alone.

Déhiscence utérine totale multifocale associée à des antécédents de sutures Cho de compression utérine

U femme de 41 ans (gravida 2, para 1) presentait, a 37 semaines de gestation, des contractions et des douleurs abdominales que le mouvement aggravait. Trois ans auparavant, elle avait subi une cesarienne qui avait donne lieu a une hemorragie postpartum ayant ete prise en charge au moyen d’uterotoniques, de la ligature des arteres uterines et de multiples sutures Cho de compression uterine1 (utilisant du #1 Biosyn).