Kelly N. Wright

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.

Contained tissue extraction using power morcellation: prospective evaluation of leakage parameters

BACKGROUND Safe tissue removal is a challenge for minimally invasive procedures such as myomectomy, supracervical hysterectomy, or total hysterectomy of a large uterine specimen. There is concern regarding disruption or dissemination of tissue during this process, which may be of particular significance in cases of undetected malignancy. Contained tissue extraction techniques have been developed in an effort to mitigate morcellation-related risks. OBJECTIVE The objective of the study was to quantify perioperative outcomes of contained tissue extraction using power morcellation, specifically evaluating parameters of tissue or fluid leakage from within the containment system. STUDY DESIGN This was a study including a multicenter prospective cohort of adult women who underwent minimally invasive hysterectomy or myomectomy using a contained power morcellation technique. Blue dye was applied to the tissue specimen prior to removal to help identify cases of fluid or tissue leakage from within the containment system. RESULTS A total of 76 patients successfully underwent the contained power morcellation protocol. Mean time for the contained morcellation procedure was 30.2 minutes (±22.4). The mean hysterectomy specimen weight was 480.1 g (±359.1), and mean myomectomy specimen weight was 239.1 g (±229.7). The vast majority of patients (73.7%) were discharged home the same day of surgery. Final pathological diagnosis was benign in all cases. Spillage of dye or tissue was noted in 7 cases (9.2%), although containment bags were intact in each of these instances. CONCLUSION Findings are consistent with prior work demonstrating the feasibility of contained tissue extraction; however, further refinement of this technique is warranted.

The Feasibility of Societal Cost Equivalence between Robotic Hysterectomy and Alternate Hysterectomy Methods for Endometrial Cancer

Objectives. We assess whether it is feasible for robotic hysterectomy for endometrial cancer to be less expensive to society than traditional laparoscopic hysterectomy or abdominal hysterectomy. Methods. We performed a retrospective cohort analysis of patient characteristics, operative times, complications, and hospital charges from all (n = 234) endometrial cancer patients who underwent hysterectomy in 2009 at our hospital. Per patient costs of each hysterectomy method were examined from the societal perspective. Sensitivity analysis and Monte Carlo simulation were performed using a cost-minimization model. Results. 40 (17.1%) of hysterectomies for endometrial cancer were robotic, 91 (38.9%), were abdominal, and 103 (44.0%) were laparoscopic. 96.3% of the variation in operative cost between patients was predicted by operative time (R = 0.963, P < 0.01). Mean operative time for robotic hysterectomy was significantly longer than other methods (P < 0.01). Abdominal hysterectomy was consistently the most expensive while the traditional laparoscopic approach was consistently least expensive. The threshold in operative time that makes robotic hysterectomy cost equivalent to the abdominal approach is within the range of our experience. Conclusion. It is feasible for robotic hysterectomy to be less expensive than abdominal hysterectomy, but unlikely for robotic hysterectomy to be less expensive than traditional laparoscopy.

Impact of a robotic simulation program on resident surgical performance

Association between OSATS slope (ie, estimated rate of OSATS change per day from resident level linear regression analysis) shown on Y-vertical axis and total simulation time shown on horizontal X-axis. Solid blue line (Pearson correlation, 0.802; P 1⁄4 .02; estimated slope calculated using: e0.007 þ .0043 * total simulation time) shows fitted least square linear regression line using data from all 8 residents. Pearson correlation was 0.645, P 1⁄4 .01 when resident 3 (red dashed line) was removed from data set. Removal of resident 1 (green dot-dashed line), resulted Q4 in Pearson correlation of 0.966, P 1⁄4 .01.)

Impact of a Fellowship-Trained Minimally Invasive Gynecologic Surgeon on Patient Outcomes

Background and Objectives: As the performance of minimally invasive hysterectomy has increased in the United States, the need to apply outcomes measures has also increased. This study was conducted to determine the impact of a fellowship-trained minimally invasive gynecologic surgery (MIGS) specialist on patient outcomes after laparoscopic hysterectomy (LH) in a gynecology department. Methods: This is a retrospective review of 218 patients who underwent a laparoscopic hysterectomy for benign indications at a suburban academic-affiliated tertiary care hospital with a broad patient base from 2010 to 2014. Results: A total of 218 women underwent conventional laparoscopic hysterectomy by 10 members of a gynecology department: 96 women (44%) by a MIGS specialist and 122 women (56%) by a group of general gynecologists. Operative time was less (119 vs 148 min; P < .001), and patients were more likely to be discharged on the same day (90.6% vs 66.4%; P < .001) for the MIGS specialist compared to other surgeons. More patients of the MIGS specialist had undergone prior laparotomies (42.7% vs 17.2%; P = < .001) and had a greater uterine weight (392 vs 224 g; P < .001). Although the difference was not statistically significant, conversion to laparotomy (0 vs 2 cases; P = .505) and postoperative infection (6 vs 16 cases; P = .095) were lower for the MIGS specialist. Total billing charges were also lower for the MIGS specialist (

Opioid Prescription and Patient Use After Gynecologic Procedures: A Survey of Patients and Providers

9,920 vs

Hemostasis Techniques in Myomectomies

11,406; P < .001). Conclusion: A fellowship-trained MIGS specialist performed laparoscopic hysterectomy in less time on more difficult surgical patients, with a shorter length of stay and lower costs, and no difference in complications compared to other providers in a gynecology department.

Opioid Use after Laparoscopic Hysterectomy: Prescriptions, Patient Use, and a Predictive Calculator

STUDY OBJECTIVE To describe opioid distribution and patient use after gynecologic procedures. DESIGN Survey study (Canadian Task Force classification III). SETTING An urban academic tertiary care hospital. SUBJECTS Ninety-six gynecologists in the Boston area, and 147 patients who underwent a benign hysterectomy between January 2015 and April 2016. INTERVENTIONS Survey study of physicians and patients composed of 2 parts: (1) a physician survey on opioid prescribing practices after gynecologic procedures and (2) a patient survey on opioid consumption after hysterectomy. Physicians were contacted via e-mail to participate in an online survey. Eligible patients were contacted via telephone and asked to participate in a telephone survey. MEASUREMENTS AND MAIN RESULTS Fifty-one physicians responded to an online survey and prescribed a mean of 27.1 tablets (range, 5-30) of oxycodone (5 mg) or hydromorphone (2 mg) after abdominal hysterectomy (AH), a mean of 22.6 tablets (range, 5-30) after laparoscopic hysterectomy (LH), and a mean of 16.8 tablets (range 5-30) after vaginal hysterectomy (VH). Physicians prescribed more opioids for AH compared with LH, with a mean difference of 4.5 tablets (standard deviation, 4.7; p < .01), and AH compared with VH, with a mean difference of 6.8 tablets (standard deviation, 5.8; p < .01), which were both statistically significant. In addition, 40.0% of physicians prescribe opioids after a hysteroscopy and 19.2% after a dilation and curettage. Fifty-six patients participated in the telephone survey: 64.6% of patients used less than half of the opioids prescribed and 16.1% used none. For AH, patients reported being prescribed a mean of 25.7 tablets and using a mean of 8.7 tablets (range, 0-60; 33.9% used). For LH or VH, patients reported being prescribed a mean of 24.2 tablets and using a mean of 10.0 tablets (range, 0-30; 41.4% used). Opioid consumption was not significantly different for AH compared with LH or VH (p = .613 for AH to LH, p = .279 for AH to VH). CONCLUSIONS With respect to the physician survey, we conclude there is a wide range of opioid prescription practices and patient opioid consumption after gynecologic surgery. The patient survey revealed that physicians prescribe fewer opioid tablets after a minimally invasive approach to hysterectomy versus open hysterectomy. However, most patients use less than half of prescribed opioids, and a fraction did not use any opioids at all.

Power Versus Hand Morcellation: Impact on Operating Room Efficiency and Cost [8G]

Purpose of ReviewMyomectomy can be associated with significant blood loss, particularly when large and numerous fibroids are removed. Surgeons have incorporated a large number of methods to reduce blood loss, including pre-operative optimization, the use of minimally invasive surgery, and intraoperative techniques. The purpose of this review is to summarize these methods and evaluate the literature supporting those with clinical value.Recent FindingsThe use of minimally invasive surgery has clear benefit in reducing blood loss in myomectomy for appropriately selected patients. Preoperative hormonal treatments reduce myoma size and reduce the complexity of myomectomy. Myometrial vasoconstriction, vessel ligation or compression, and the use of barbed suture decrease blood loss in myomectomy.SummarySurgeons should be aware of the large number of pre-operative and intraoperative measures to reduce blood loss in myomectomy and employ those with proven clinical benefit, particularly in operations that are likely to involve excessive bleeding and the need for transfusion.

Unilateral Human Papillomavirus Infection and Cervical Dysplasia in a Patient With Two Cervices.

Background In the setting of America’s opioid epidemic, judicious postoperative opioid prescribing is important. Gynecologists lack standard guidelines about postoperative opioid prescriptions. Objectives The objectives of the study were to describe opioid prescribing practices by a group of minimally invasive gynecologic surgeons, to measure postoperative opioid use after minimally invasive hysterectomy, and to identify preoperative factors that could predict whether a patient will be a low or high postoperative opioid user. Study Design This was a prospective survey‐based study including 125 women undergoing laparoscopic hysterectomy for benign indications at 2 community teaching hospitals. Patients were preoperatively surveyed about demographics, past medical history, and current and expected pain scores and were screened for anxiety, depression, and pain catastrophizing. At 1 and 2 weeks after surgery, patients were surveyed about their pain and pain medication use. Results Ninety‐eight percent of patients were prescribed an opioid for acute postoperative pain. The median opioid prescription was for 150 morphine milligram equivalents, equivalent to 20 tablets of oxycodone 5 mg, while median patient postoperative use was 37.5 morphine milligram equivalents, equivalent to 5 tablets of oxycodone 5 mg. Ninety percent of patients had leftover opioids at 2 weeks after surgery, and most leftover opioids were stored in an unsecure location. Preoperative factors that were most strongly correlated with postoperative opioid use included a history of chronic pelvic pain or endometriosis, preoperative opioid use, anxiety, depression, pain catastrophizing, preoperative pain score, anticipated postoperative pain score, and anticipated postoperative pain medication needs. A predictive calculator was developed based on these factors to help identify patients who are likely to be a high opioid user (defined as taking greater than 112.5 morphine milligram equivalents) or a low opioid user (defined as taking 37.5 morphine milligram equivalents or less). Conclusion On average, surgeons prescribed 4 times the amount of opioids than was needed for patients undergoing laparoscopic hysterectomy for acute postoperative pain control. Individualizing patients’ opioid prescriptions based on preoperative risk factors could help reduce excess prescription opioids.