Katie Propst

Development and validation of a laparoscopic hysterectomy cuff closure simulation model for surgical training

BACKGROUND The number of robotically assisted hysterectomies is increasing, and therefore, the opportunities for trainees to become competent in performing traditional laparoscopic hysterectomy are decreasing. Simulation-based training is ideal for filling this gap in training. OBJECTIVE The objective of the study was to design a surgical model for training in laparoscopic vaginal cuff closure and to present evidence of its validity and reliability as an assessment and training tool. STUDY DESIGN Participants included gynecology staff and trainees at 2 tertiary care centers. Experienced surgeons were also recruited at the combined International Urogynecologic Association and American Urogynecologic Society scientific meeting. Participants included 19 experts and 21 trainees. All participants were recorded using the laparoscopic hysterectomy cuff closure simulation model. The model was constructed using the an advanced uterine manipulation system with a sacrocolopexy tip/vaginal stent, a vaginal cuff constructed from neoprene material and lined with a swimsuit material (nylon and spandex) secured to the vaginal stent with a plastic cable tie. The uterine manipulation system was attached to the fundamentals of laparoscopic surgery laparoscopic training box trainer using a metal bracket. Performance was evaluated using the Global Operative Assessment of Laparoscopic Skills scale. In addition, needle handling, knot tying, and incorporation of epithelial edge were also evaluated. The Student t test was used to compare the scores and the operating times between the groups. Intrarater reliability between the scores by the 2 masked experts was measured using the interclass correlation coefficient. RESULTS Total and annual experience with laparoscopic suturing and specifically vaginal cuff closure varied greatly among the participants. For the construct validity, the participants in the expert group received significantly higher scores in each of the domains of the Global Operative Assessment of Laparoscopic Skills Scale and for each of the 3 added items than did the trainees. The median total Global Operative Assessment of Laparoscopic Skills Scale score (maximum 20) for the experts was 18.8 (range, 11-20), whereas the median total Global Operative Assessment of Laparoscopic Skills Scale score for the trainees was 10 (range, 8-18) (P = .001). The overall score that included the 3 new domains (maximum 35) was 33 (range, 18-35) for the experts and 17.5 (range, 14-31.5) for trainees (P = .001). For the face validity testing, the majority of the study participants (32 [85%]) agreed or strongly agreed that the model is realistic and all participants agreed or strongly agreed that the model appears to be useful for improving technique required for this task. For the interrater reliability, the scores assigned by each observer had an interclass correlation coefficient of 0.8 (95% confidence interval, 0.7-0.93). CONCLUSION This model is easily constructed and has an acceptable cost. We have demonstrated evidence of construct validity. This is a valuable education tool that can serve to improve skills, which are essential to the gynecological surgeon but are often lacking in residency training because of national changes in practice patterns.

Quality Evaluation of Abstracts Presented at the Society of Gynecologic Surgeons Annual Scientific Meeting

STUDY OBJECTIVE To examine the rate of abstract publication from the Society of Gynecologic Surgeons Annual Scientific Meeting (SGSASM), 2004 to 2012. STUDY DESIGN This is a retrospective study in which all abstracts presented at the SGSASM from 2004 to 2012 were reviewed. Information was collected on oral (O), oral poster (OP), and poster (P) presentations. To evaluate for publication, all abstracts were searched for in the US National Library of Medicines PubMed database. Chi-square tests were used to evaluate whether there were differences in distribution of published studies by first author location and affiliation and number of abstract authors. DESIGN CLASSIFICATION Canadian Task Force III. MEASUREMENTS AND MAIN RESULTS In total, 867 abstracts were reviewed, including all O, OP, and P presentations. Video and tips and tricks presentations were excluded. Overall rate of publication for all abstracts from 2004 to 2012 was 55.7%, comprising 82.4% for O presentations, 60.9% for OP presentations, and 41.4% for P presentations. There was no significant difference in location for published abstracts (p = .878), although published abstracts had a significantly greater number of authors (p < .001). Abstracts presented by authors from university programs were more likely to be published (p < .001). For all presentation types, the mean number of citations for published abstracts was different for the 9-year period (O, OP, and P: p < .001), with an overall decline toward the end of the assessment period. CONCLUSION Over a 9-year period (2004-2012), the rate of abstract publication at the SGSASM was 55.7%, which is similar to other academic meetings. The comparability of this publication rate shows that the abstract selection committee is able to select high-quality research with limited information provided in abstract submissions.

Evaluation of Positioning Devices for Optimization of Outcomes in Laparoscopic and Robotic-Assisted Gynecologic Surgery

In this review, we evaluate techniques, devices, and equipment for patient positioning and their effect on patient outcomes, such as cephalad slide and neuropathy, in laparoscopic and robotic-assisted gynecologic surgery. We conducted a systematic review by searching MEDLINE, Embase, and Cochrane Library for relevant articles published over a 15-year period. Study selection, data extraction, and quality assessment were performed by 2 reviewers independently. Seven articles, including 3 randomized controlled trials and 4 case series, were included in our analysis. Four studies evaluated cephalad patient slide. In 2 randomized controlled trials (n = 103), the mean slide with various devices (i.e., memory foam, bean bag with shoulder braces, egg crate, and gel pad) ranged from 1.07 ± 1.93 cm to 4.5 ± 4.0 cm. The use of a bean bag with shoulder supports/braces was associated with minimal slide, with a median slide of 0 cm (range, 0-2 cm) in a retrospective series and with mean slide of 1.07 ± 1.93 cm in a randomized controlled trial (vs memory foam). No conclusive effect of body mass index on slide could be identified. Five studies evaluating the incidence of neuropathy found an overall incidence of 0.16% and no differences among slide-preventing devices. The minimal slide described across studies supports the conclusion that any of the currently used devices and techniques for safe patient positioning are within reason. The low overall incidence of neuropathy is also reassuring. Best evidence recommendations cannot be made for a specific device or technique; our findings suggest the importance of strict adherence to the basic tenets of safe patient positioning to minimize slide and prevent nerve injury.

Transdermal Scopolamine and Acute Postoperative Urinary Retention in Pelvic Reconstructive Surgery.

Objective To evaluate the relationship between perioperative use of transdermal scopolamine and the rate of urinary retention after stress urinary incontinence and pelvic organ prolapse procedures in women. Methods This is a retrospective, cohort study; the primary outcome is the rate of acute postoperative urinary retention. Study candidates were adult female patients who underwent pelvic reconstructive surgery at a tertiary care center. Subjects were excluded if preoperative postvoid residual urine volume was greater than 150 mL, preoperative urodynamic testing was not performed, or if a postoperative trial of void was not performed. Subjects were grouped based on preoperative use of transdermal scopolamine. Patients were selected consecutively until 138 subjects per group was reached. Differences in rates of acute postoperative urinary retention were evaluated using a chi-square test. Group demographics were evaluated using t tests and &khgr;2 tests. Results Two hundred seventy-six subjects were included in the analysis, 138 received a transdermal scopolamine patch in the perioperative period and 138 did not. The overall rate of acute postoperative urinary retention was 25.3%. There was no significant difference in the rate of acute postoperative urinary retention between the study groups (scopolamine, 26.8%; no scopolamine, 23.9%; P = 0.580). Demographics of the 2 groups were compared; patients who received scopolamine patch were younger (P = 0.001), received a greater amount of intravenous fluids (P = 0.007), and underwent a greater percentage of incontinence procedures (P = 0.048). Otherwise, there were no differences between the groups. Conclusions Transdermal scopolamine is not a risk factor for acute postoperative urinary retention after pelvic reconstructive procedures.

Bladder septum: an unexpected finding on cystoscopy in a patient with mixed urinary incontinence

A 58-year-old G3, P0 woman presented for management of severe urinary incontinence. She reported urgency as well as stress-provoked symptoms. She voided hourly during the day and had bothersome nocturia. She used adult diapers lined with pads which she changed several times daily. Past surgical history included what the patient called a Bbladder tie^ in 2002 and MarshallMarchetti-Krantz urethropexy in 2004. She reported no relief after either of these procedures. Subsequent urethral bulking procedures were ineffective. She had not benefited from several anticholinergic agents. Pelvic examination revealed no prolapse and a fixed, immobile urethra. Office cystoscopy revealed a 2-cmwide bandlike structure vertically spanning the bladder from the anterior to the posterior wall (Fig. 1). The band appeared epithelialized and vascular, but was without calcification or evidence of exposed mesh. Urodynamics revealed stress urinary incontinence with a Valsalva leak point pressure of 30 cm of water, severe detrusor overactivity, and a reduced cystometric capacity of only 160 ml. The patient underwent cystoscopic resection of the bladder septum using electrocautery with simultaneous rectus fascia pubovaginal sling. Pathologic analysis of the bladder septum revealed fibrosis, without evidence of foreign bodies. Five months postoperatively the stress incontinence symptoms had entirely resolved. Her urgency incontinence, frequency, and nocturia had dramatically improved, and were now responsive to fesoterodine. Though the etiology of the bladder septum was not entirely clear, it was presumably related to Bscarring^ from prior surgical intervention. As pathologic review Fig. 1 Cystoscopic view of bladder septum. The septum vertically spans the bladder from the 12 o’clock to the 6 o’clock position. It is approximately 2 cm in thickness and 5 cm in depth, and is adherent to the anterior and posterior walls of the bladder but not to the dome. An air bubble is seen at the 8 o’clock position in the figure; the trigone is not in view