Lauren D. Schiff

The role of simulation and warm-up in minimally invasive gynecologic surgery

Purpose of review The purpose of the review is to update the reader on the current literature and recent studies evaluating the role of simulation and warm-up as part of surgical education and training, and maintenance of surgical skills. Recent findings Laparoscopic and hysteroscopic simulation may improve psychomotor skills, particularly for early-stage learners. However, data are mixed as to whether simulation education is directly transferable to surgical skill. Data are insufficient to determine if simulation can improve clinical outcomes. Similarly, performance of surgical warm-up exercises can improve performance of novice and expert surgeons in a simulated environment, but the extent to which this is transferable to intraoperative performance is unknown. Surgical coaching, however, can facilitate improvements in performance that are directly reflected in operative outcomes. Summary Simulation-based curricula may be a useful adjunct to residency training, whereas warm-up and surgical coaching may allow for maintenance of skill throughout a surgeons career. These experiences may represent a strategy for maintaining quality and value in a lower volume surgical setting.

Quality of Communication in Robotic Surgery and Surgical Outcomes.

Background and Objectives: Robotic surgery has introduced unique challenges to surgical workflow. The association between quality of communication in robotic-assisted laparoscopic surgery and surgical outcomes was evaluated. Methods: After each gynecologic robotic surgery, the team members involved in the surgery completed a survey regarding the quality of communication. A composite quality-of-communication score was developed using principal component analysis. A higher composite quality-of-communication score signified poor communication. Objective parameters, such as operative time and estimated blood loss (EBL), were gathered from the patients medical record and correlated with the composite quality-of-communication scores. Results: Forty robotic cases from March through May 2013 were included. Thirty-two participants including surgeons, circulating nurses, and surgical technicians participated in the study. A higher composite quality-of-communication score was associated with greater EBL (P = .010) and longer operative time (P = .045), after adjustment for body mass index, prior major abdominal surgery, and uterine weight. Specifically, for every 1-SD increase in the perceived lack of communication, there was an additional 51 mL EBL and a 31-min increase in operative time. The most common reasons reported for poor communication in the operating room were noise level (28/36, 78%) and console-to-bedside communication problems (23/36, 64%). Conclusion: Our study demonstrates a significant association between poor intraoperative team communication and worse surgical outcomes in robotic gynecologic surgery. Employing strategies to decrease extraneous room noise, improve console-to-bedside communication and team training may have a positive impact on communication and related surgical outcomes.

Optimizing research in symptomatic uterine fibroids with development of a computable phenotype for use with electronic health records

Background Women with symptomatic uterine fibroids can report a myriad of symptoms, including pain, bleeding, infertility, and psychosocial sequelae. Optimizing fibroid research requires the ability to enroll populations of women with image‐confirmed symptomatic uterine fibroids. Objective Our objective was to develop an electronic health record–based algorithm to identify women with symptomatic uterine fibroids for a comparative effectiveness study of medical or surgical treatments on quality‐of‐life measures. Using an iterative process and text‐mining techniques, an effective computable phenotype algorithm, composed of demographics, and clinical and laboratory characteristics, was developed with reasonable performance. Such algorithms provide a feasible, efficient way to identify populations of women with symptomatic uterine fibroids for the conduct of large traditional or pragmatic trials and observational comparative effectiveness studies. Symptomatic uterine fibroids, due to menorrhagia, pelvic pain, bulk symptoms, or infertility, are a source of substantial morbidity for reproductive‐age women. Comparing Treatment Options for Uterine Fibroids is a multisite registry study to compare the effectiveness of hormonal or surgical fibroid treatments on women’s perceptions of their quality of life. Electronic health record–based algorithms are able to identify large numbers of women with fibroids, but additional work is needed to develop electronic health record algorithms that can identify women with symptomatic fibroids to optimize fibroid research. We sought to develop an efficient electronic health record–based algorithm that can identify women with symptomatic uterine fibroids in a large health care system for recruitment into large‐scale observational and interventional research in fibroid management. Study Design We developed and assessed the accuracy of 3 algorithms to identify patients with symptomatic fibroids using an iterative approach. The data source was the Carolina Data Warehouse for Health, a repository for the health system’s electronic health record data. In addition to International Classification of Diseases, Ninth Revision diagnosis and procedure codes and clinical characteristics, text data–mining software was used to derive information from imaging reports to confirm the presence of uterine fibroids. Results of each algorithm were compared with expert manual review to calculate the positive predictive values for each algorithm. Results Algorithm 1 was composed of the following criteria: (1) age 18‐54 years; (2) either ≥1 International Classification of Diseases, Ninth Revision diagnosis codes for uterine fibroids or mention of fibroids using text‐mined key words in imaging records or documents; and (3) no International Classification of Diseases, Ninth Revision or Current Procedural Terminology codes for hysterectomy and no reported history of hysterectomy. The positive predictive value was 47% (95% confidence interval 39–56%). Algorithm 2 required ≥2 International Classification of Diseases, Ninth Revision diagnosis codes for fibroids and positive text‐mined key words and had a positive predictive value of 65% (95% confidence interval 50–79%). In algorithm 3, further refinements included ≥2 International Classification of Diseases, Ninth Revision diagnosis codes for fibroids on separate outpatient visit dates, the exclusion of women who had a positive pregnancy test within 3 months of their fibroid‐related visit, and exclusion of incidentally detected fibroids during prenatal or emergency department visits. Algorithm 3 achieved a positive predictive value of 76% (95% confidence interval 71–81%). Conclusion An electronic health record–based algorithm is capable of identifying cases of symptomatic uterine fibroids with moderate positive predictive value and may be an efficient approach for large‐scale study recruitment.

Uterine weight and complications after abdominal, laparoscopic, and vaginal hysterectomy

BACKGROUND: Although uterine size has been a previously cited barrier to minimally invasive hysterectomy, experienced gynecologic surgeons have been able to demonstrate that laparoscopic and vaginal hysterectomy is feasible with increasingly large uteri. By demonstrating that minimally invasive hysterectomy continues to have superior outcomes even with increased uterine weights, opportunity exists to meaningfully decrease morbidity, mortality, and cost associated with abdominal hysterectomy. OBJECTIVE: We sought to determine if there is an association between uterine weight and posthysterectomy complications and if differences in that association exist across vaginal, laparoscopic, and abdominal approaches. STUDY DESIGN: We conducted a cohort study of prospectively collected quality improvement data from the American College of Surgeons National Surgical Quality Improvement Program database, composed of patient information and 30‐day postoperative outcomes from >500 hospitals across the United States and targeted data files, which includes additional data on procedure‐specific risk factors and outcomes in >100 of those participating hospitals. We analyzed patients undergoing hysterectomy for benign conditions from 2014 through 2015, identified by Current Procedural Terminology code. We excluded patients who had cancer, surgery by a nongynecology specialty, or missing uterine weight. Patients were compared with respect to 30‐day postoperative complications and uterine weight, stratified by surgical approach. Bivariable tests and multivariable logistic regression were used for analysis. RESULTS: In all, 27,167 patients were analyzed. After adjusting for potential confounders, including medical and surgical variables, women with 500‐g uteri were >30% more likely to have complications compared to women with uteri ≤100 g (adjusted odds ratio, 1.34; 95% confidence interval, 1.17–1.54; P < .0001), women with 750‐g uteri were nearly 60% as likely (adjusted odds ratio, 1.58; 95% confidence interval, 1.37–1.82; P < .0001), and women with uteri ≥1000 g were >80% more likely (adjusted odds ratio, 1.85; 95% confidence interval, 1.55–2.21; P < .0001). The incidence of 30‐day postsurgical complications was nearly double in the abdominal hysterectomy group (15%) compared to the laparoscopic group (8%). Additionally, for each stratum of uterine weight, abdominal hysterectomy had significantly higher odds of any complication compared to laparoscopic hysterectomy, even after adjusting for potential demographic, medical, and surgical confounders. For uteri <250 g, abdominal hysterectomy had twice the odds of any complication, compared to laparoscopic hysterectomy (adjusted odds ratio, 2.05; 95% confidence interval, 1.80–2.33), and among women with uteri between 250–500 g, abdominal hysterectomy was associated with an almost 80% increase in odds of any complication (adjusted odds ratio, 1.76; 95% confidence interval, 1.41–2.19). Even among women with uteri >500 g, abdominal hysterectomy was still associated with a >30% increased odds of any complication, compared to laparoscopic hysterectomy (adjusted odds ratio, 1.35; 95% confidence interval, 1.07–1.71). CONCLUSION: We found that while uterine weight was an independent risk factor for posthysterectomy complications, abdominal hysterectomy had higher odds of any complication, compared to laparoscopic hysterectomy, even for markedly enlarged uteri. Our study suggests that uterine weight alone is not an appropriate indication for abdominal hysterectomy. We also identified that it is safe to perform larger hysterectomies laparoscopically. Patients may benefit from referral to experienced surgeons who are able to offer laparoscopic hysterectomy even for markedly enlarged uteri.

Comparison of the levonorgestrel‐releasing intrauterine system, hysterectomy, and endometrial ablation for heavy menstrual bleeding in a decision analysis model

A better understanding of the relative risks and benefits of common treatment options for abnormal uterine bleeding (AUB) can help providers and patients to make balanced, evidence‐based decisions.

Cost-effectiveness of treatments for heavy menstrual bleeding

BACKGROUND: Heavy menstrual bleeding affects up to one third of women in the United States, resulting in a reduced quality of life and significant cost to the health care system. Multiple treatment options exist, offering different potential for symptom control at highly variable initial costs, but the relative value of these treatment options is unknown. OBJECTIVE: The objective of the study was to evaluate the relative cost‐effectiveness of 4 treatment options for heavy menstrual bleeding: hysterectomy, resectoscopic endometrial ablation, nonresectoscopic endometrial ablation, and the levonorgestrel‐releasing intrauterine system. STUDY DESIGN: We formulated a decision tree evaluating private payer costs and quality‐adjusted life years over a 5 year time horizon for premenopausal women with heavy menstrual bleeding and no suspected malignancy. For each treatment option, we used probabilities derived from literature review to estimate frequencies of minor complications, major complications, and treatment failure resulting in the need for additional treatments. Treatments were compared in terms of total average costs, quality‐adjusted life years, and incremental cost‐effectiveness ratios. Probabilistic sensitivity analysis was conducted to understand the range of possible outcomes if model inputs were varied. RESULTS: The levonorgestrel‐releasing intrauterine system had superior quality‐of‐life outcomes to hysterectomy with lower costs. In a probabilistic sensitivity analysis, levonorgestrel‐releasing intrauterine system was cost‐effective compared with hysterectomy in the majority of scenarios (90%). Both resectoscopic and nonresectoscopic endometrial ablation were associated with reduced costs compared with hysterectomy but resulted in a lower average quality of life. According to standard willingness‐to‐pay thresholds, resectoscopic endometrial ablation was considered cost effective compared with hysterectomy in 44% of scenarios, and nonresectoscopic endometrial ablation was considered cost effective compared with hysterectomy in 53% of scenarios. CONCLUSION: Comparing all trade‐offs associated with 4 possible treatments of heavy menstrual bleeding, the levonorgestrel‐releasing intrauterine system was superior to both hysterectomy and endometrial ablation in terms of cost and quality of life. Hysterectomy is associated with a superior quality of life and fewer complications than either type of ablation but at a higher cost. For women who are unwilling or unable to choose the levonorgestrel‐releasing intrauterine system as a first‐course treatment for heavy menstrual bleeding, consideration of cost, procedure‐specific complications, and patient preferences can guide the decision between hysterectomy and ablation.

Risk factors for trachelectomy following supracervical hysterectomy

We identified risk factors for trachelectomy after supracervical hysterectomy (SCH) due to persistence of symptoms.

Robotic Trachelectomy After Supracervical Hysterectomy for Benign Gynecologic Disease.

Background and Objectives: A renewed interest in the supra cervical approach to hysterectomy has created a cohort of patients with a retained cervix at risk of persistent symptoms requiring a subsequent trachelectomy. The objective of this study was to evaluate the efficacy of robotic trachelectomy after a previous supracervical hysterectomy. Methods: This is a retrospective chart review of women who had robotic trachelectomy after supracervical hysterectomy for benign gynecologic disease from January 2009 through October 2014. Results: Eleven patients underwent robotic trachelectomy for benign conditions during the observed period. Prior supracervical hysterectomy had been performed for pelvic pain (8/11, 73%), abnormal uterine bleeding (7/11, 64%), and dysmenorrhea (5/11, 45%). In 10 of 11 patients, the symptoms leading to robotic trachelectomy were the same as those leading to supracervical hysterectomy. The time from hysterectomy to recurrence of symptoms ranged from 0.5 to 26 months (median, 6), whereas the time interval from previous surgery to robotic trachelectomy ranged from 1 to 57 months (median, 26). Mean age and body mass index at robotic trachelectomy were 42 ± 5.4 years and 32 ± 6.1 kg/m2. Mean length of surgery was 218 ± 88 minutes (range, 100–405). There was 1 major postoperative complication involving bladder perforation and subsequent vesicovaginal fistula (VVF). Endometriosis was seen in 27% of pathologic specimens and cervicitis in another 27%; 45% showed normal tissue histology. In 6 (55%) cases, symptoms leading to trachelectomy resolved completely after surgery, and the other 5 (45%) patients reported a significant improvement. Conclusions: Although trachelectomy can be a challenging surgery, our experience suggests that the robotic approach may be a valuable means of achieving safe and reproducible outcomes.

Considerations for minimally invasive gynecologic surgery in obese patients.

Purpose of review The purpose is to review the key anatomical and physiological changes in obese patients and their effects on preoperative, intraoperative, and postoperative care and to highlight the best practices to safely extend minimally invasive approaches to obese patients and provide optimal surgical outcomes in this high-risk population. Recent findings Minimally invasive surgery is safe, feasible, and cost-effective for obese patients. Obesity is associated with anatomical and physiological changes in almost all organ systems, which necessitates a multimodal approach and an experienced, multidisciplinary team. Preoperative counseling, evaluation, and optimization of medical comorbidities are critical. The optimal minimally invasive approach is primarily determined by the patients anatomy and pathology. Specific intraoperative techniques and modifications exist to maximize surgical exposure and panniculus management. Postoperatively, comprehensive medical management can help prevent common complications in obese patients, including hypoxemia, venous thromboembolism, acute kidney injury, hyperglycemia, and prolonged hospitalization. Summary Given significantly improved patient outcomes, minimally invasive approaches to gynecological surgery should be considered for all obese patients with particular attention given to specific perioperative considerations and appropriate referral to an experienced minimally invasive surgeon.

A Comparative Study of Preoperative Findings and Outcomes in Pre-Menopausal and Post-Menopausal Women With Leiomyosarcoma

A Comparative Study of Preoperative Findings and Outcomes in Pre-Menopausal and Post-Menopausal Women With Leiomyosarcoma Aoun J, Baum S, Buekers T, Schiff L, Theoharis E, Tsafrir Z. Minimally Invasive Gynecologic Surgery, Henry Ford Hospital, West Bloomfield, Michigan; Wayne State University, Wayne State University, Detroit, Michigan; Gynecology Oncology, Henry Ford Hospital, Detroit, Michigan; Minimally Invasive Gynecologic surgery, University of North Carolina, Chapel Hill, North Carolina