John Thiel

Outpatient total laparoscopic hysterectomy.

STUDY OBJECTIVE To assess the safety of and patient satisfaction with total laparoscopic hysterectomy as an outpatient procedure. DESIGN Retrospective case study (Canadian Task Force classification III). SETTING Tertiary care hospital. PATIENTS Sixty-six consecutive women. INTERVENTION Outpatient total laparoscopic hysterectomy. MEASUREMENTS AND MAIN RESULTS Of 66 procedures completed, 6 patients (7.5%) required overnight hospitalization, with 4 of them discharged the next day. Seven (11%) minor postoperative complications occurred. One patient required hospitalization to receive intravenous antibiotics and one for drainage of a cuff hematoma. There were three (4.5%) minor intraoperative complications. One woman developed Clostridium difficile diarrhea as well as deep vein thrombosis and pulmonary embolus. Sixty-three women (95%) were satisfied with the procedure and would recommend it to others. CONCLUSION Outpatient total laparoscopic hysterectomy is well tolerated, safe, and cost effective.

Pentoxifylline After Conservative Surgery for Endometriosis: A Randomized, Controlled Trial

STUDY OBJECTIVE To compare outcomes after conservative surgery for endometriosis with and without pentoxifylline and to assess the efficacy of pentoxifylline in preventing recurrence of endometriosis after conservative surgery. DESIGN Parallel-group, randomized, controlled trial (Canadian Task Force classification I). SETTING Tertiary care hospital. PATIENTS Women undergoing conservative surgery for endometriosis. INTERVENTIONS Laparoscopic conservative surgery for endometriosis was completed by a single surgeon (J.A.T.), and all suspected endometriotic lesions were widely excised using monopolar coagulation and scissors. All specimens were submitted to pathology for confirmation of the diagnosis. Randomization to the treatment or control groups was completed preoperatively in the outpatient surgery unit by drawing colored marbles. A preoperative visual analog pain scale (VAS) was completed. After surgery, patients were discharged home with prescriptions for naproxen, hydromorphone, and pentoxifylline. MEASUREMENTS AND MAIN RESULTS Visual analog scale scoring was completed monthly by each patient, and each patient was seen monthly for review and pelvic examination. Analgesic use was recorded daily using an individual medication log. Ongoing treatment choice after completion of the 3-month follow-up was recorded. The relationship between the group receiving pentoxifylline and the control group as well as analysis of the VAS scores at time of surgery and 1, 2, and 3 months postoperatively was determined using a covariate mixed-model ANOVA. Forty-nine patients were enrolled in the trial. One patient became pregnant before surgery, and 1 patients chart was not available for analysis. Of the 47 who underwent conservative surgery for endometriosis, 9 (19%) had no endometriosis noted in the pathology specimens submitted. Two patients withdrew from the trial after surgery, and 2 patients were lost to follow-up after relocating to a different city. Nineteen women completed the 3-month follow-up in the control group, 15 in the group receiving pentoxifylline. The mean age, gravidity, parity, body mass index, previous surgery for endometriosis, menstrual cycle, and preoperative analgesic use did not differ significantly between the control and treatment groups. The time to complete the conservative surgery did not vary between the 2 groups. There were no intraoperative complications: two patients were admitted postoperatively, one for nausea and vomiting, one for pain that resolved 24 hours after admission. The VAS scores did not differ at the time of surgery; and in both the control and the pentoxifylline groups, there was significant improvement at each monthly interval (p <.05). The patients receiving pentoxifylline had significantly better VAS scores at 2 and 3 months after surgery (p <.03). CONCLUSIONS The use of pentoxifylline after conservative surgery for endometriosis resulted in improved VAS scores at 2 and 3 months after the procedure when compared with patients having conservative surgery only. The longer-term use of pentoxifylline after conservative surgery may improve long-term outcomes after surgical treatment for endometriosis.

Cost-Effectiveness Analysis Comparing the Essure Tubal Sterilization Procedure and Laparoscopic Tubal Sterilization

OBJECTIVE To analyze the financial implications of establishing a hysteroscopic sterilization program using the Essure micro-insert tubal sterilization system in an ambulatory clinic. METHODS A retrospective cohort study (Canadian Task Force classification Type II-2), in an ambulatory womens health clinic in a tertiary hospital, of 108 women undergoing Essure coil insertion between 2005 and 2006, and 104 women undergoing laparoscopic tubal sterilization for permanent sterilization between 2001 and 2004. The Essure procedures used a 4 mm single channel operative hysteroscope and conscious sedation (fentanyl and midazolam); the laparoscopic tubal sterilizations were completed under general anaesthesia with a 7 mm laparoscope and either bipolar cautery or Filshie clips. Costs associated with the procedure, follow-up, and management of any complications (including nursing, hospital charges, equipment, and disposables) were tabulated. RESULTS The Essure coils were successfully placed on the first attempt in 103 of 108 women (95%). Three patients required a second attempt to complete placement and two patients required laparoscopic tubal sterilization after an unsuccessful Essure. All 104 laparoscopic tubals were completed on the first attempt with no complications reported. The total cost for the 108 Essure procedures, including follow-up evaluation, was

Assessment of Costs Associated With OutpatientTotal Laparoscopic Hysterectomy

138,996 or

Outcomes in the ultrasound follow-up of the Essure micro-insert: complications and proper placement.

1287 per case. The total cost associated with the 104 laparoscopic tubal sterilization procedures was

Concomitant NovaSure Endometrial Ablation and Essure Tubal Sterilization: A Review of 100 Cases

148,227 or

Oral analgesia vs intravenous conscious sedation during Essure Micro-Insert sterilization procedure: randomized, double-blind, controlled trial.

1398 per case. The incremental cost-effectiveness ratio was

Pre-hysterectomy Assessment of Immediate Tubal Occlusion With the Third-Generation ESSURE Insert (ESS505)

111. CONCLUSIONS The Essure procedure in an ambulatory setting resulted in a statistically significant cost saving of

The effect of menstrual phase and hormonal contraception on successful bilateral placement of the Essure micro-insert tubal coil

111 per sterilization procedure. Carrying out the Essure procedure in an ambulatory setting frees space in the operating room for other types of cases, improving access to care for more patients.

Comparing technical dexterity of sleep-deprived versus intoxicated surgeons.

OBJECTIVE To assess the costs associated with the performance of outpatient total laparoscopic hysterectomy. METHODS This was a retrospective cohort study involving 224 consecutive patients undergoing total laparoscopic hysterectomy (TLH) by a single surgeon in the Regina General Hospital. Outcomes included costs associated with the initial procedure as well as those associated with any intraoperative or postoperative complications. RESULTS The mean age of the patients was 42.7 years. The mean uterine weight was 205 grams (range 69-1163 g), the mean operating time was 79 minutes, and the mean blood loss was 89 cc. The mean postoperative stay in the day surgery unit (DSU) was 354 minutes. Ten patients required admission from the DSU, and nine patients were admitted more than 24 hours after surgery. The total number of admission days was 24, which cost 21,900 US dollars. The total cost of all disposables was 127,373 US dollars and the cost associated with the stays in day surgery was 89,600 US dollars. The total cost for the 224 TLH procedures was 238,573 US dollars, and the average cost per TLH was 1065 US dollars. CONCLUSION Outpatient TLH can be completed safely and with costs that are lower than those incurred by patients having short-stay vaginal hysterectomy in our institution. Outpatient TLH offers the opportunity to save health care costs and a procedure with excellent results.