Maria V. Vargas

Use of Intravenous Tranexamic Acid During Myomectomy: A Randomized Double-Blind Placebo Controlled Trial

Study Objective: The aim of this research was to evaluate surgical findings, postoperative features, and complications in a series of 64 cases of benign adnexal. mass that was approached in each case with single incision laparoscopic surgery (SILS). Design: In a tertiary medical center in Brazil, 64 patients with presurgery diagnoses of benign adnexal masses underwent laparoscopic surgery using the SILS technique. Each patient’s adnexal mass was presumed to be benign, based on each patient’s echography features, patient’s age, C-125 level, and menopausal status. Setting: Retrospective study. Patients: 64 patients with presurgery diagnoses of benign adnexal masses Intervention: Single incision laparoscopy. Measurements and Main Results: Hystologic results of all the recruited patients showed benign lesions. Benign cysts (28; 43,8%), solid teratomas (10; 15,6%),and endometriosis (8; 12,5%) were the most prevalent results. There was 1 case of an incisional hernia, the only postoperative complication that required new hospital admission. The average length of stay in the hospital was 22 hours (range: 17–28). Conclusion: SILS is a feasible approach for benign adnexal masses, presenting low rates of postoperative complications and short hospital stays.

Minimally Invasive Hysterectomy for Uteri Greater Than One Kilogram.

Background and Objectives: To assess the feasibility and safety of minimally invasive hysterectomy for uteri >1 kg. Methods: Clinical and surgical characteristics were collected for patients in an academic tertiary care hospital. Included were patients who underwent minimally invasive hysterectomy by 1 of 3 fellowship-trained gynecologists from January 1, 2009, to July 1, 2015 and subsequently had confirmed uterine weights of 1 kg or greater on pathology report. Both robotic and conventional laparoscopic procedures were included. Results: During the study period, 95 patients underwent minimally invasive hysterectomy with confirmed uterine weight over 1 kg. Eighty-eight percent were performed with conventional laparoscopy and 12.6% with robot-assisted laparoscopy. The median weight (range) was 1326 g (range, 1000–4800). The median estimated blood loss was 200 mL (range, 50–2000), and median operating time was 191 minutes (range, 75–478). Five cases were converted to laparotomy (5.2%). Four cases were converted secondary to hemorrhage and one secondary to extensive adhesions. There were no conversions after 2011. Intraoperative transfusion was given in 6.3% of cases and postoperative transfusion in 6.3% of cases. However, after 2013, the rate of intraoperative transfusion decreased to 1.0% and postoperative transfusion to 2.1%. Of the 95 cases, there were no cases with malignancy. Conclusions: This provides the largest case series of hysterectomy over 1 kg completed by a minimally invasive approach. Our complication rate improved with experience and was comparable to other studies of minimally invasive hysterectomy for large uteri. When performed by experienced surgeons, minimally invasive hysterectomy for uteri >1 kg can be considered feasible and safe.

Diagnosis of Deeply Infiltrative Endometriosis: Accuracy of a Specific Magnetic Resonance Imaging Protocol

Objective: To evaluate the accuracy of a specific magnetic resonance imaging (MRI) protocol in diagnosing the extent and location of deeply infiltrative endometriosis (DIE). Methods: A retrospective chart review of women age 20 to 51 years of age who had a preoperative evaluation suspicious for DIE base on: 1) preoperative examination showing a rectovaginal mass or nodularity, non-mobile uterus fixed to rectum, and/or an adnexal mass, 2) severe or cyclic dysuria, dyschezia, and/or dyspareunia, or 3) a history of prior surgery for advanced staged endometriosis. These women subsequently underwent an institution specific endometriosis protocol pelvic MRI. Our MRI endometriosis protocol uses a 1.5T machine which takes images in T2, T1 non- fat saturation, and a fat saturation T1 in axial orientation along all three planes pre and postcontrast. Slices are thinner in the T1 and T2 images using the endometriosis protocol compared to the standard protocol. Intra-operative data were collected for women who underwent surgery for endometriosis. MRI findings were compared with intraoperative findings. Twenty-six women who had high suspicion for DIE on our institution specific MRI and subsequently underwent a laparoscopic surgery by a single minimally invasive gynaecologic surgeon were included in our study. Results: Of the twenty-six women, who met criteria for our study, twenty-one were found to have DIE, two were found to have superficial endometriosis, and there was one case of a tubo-ovarian abscess. Two were found to have other pelvic pathology such as fibroids, cysts, adhesions, and/or fibrosis. For patients with a high preoperative suspicion of DIE, our MRI protocol had a sensitivity of 82%, specificity of 80%, PPV of 95%, NPV of 50%. Conclusions: Our standardized endometriosis MRI protocol predicts the extent of DIE. Benefits of MRI include potential to replace multiple imaging exams, improve preoperative planning, and aid in decision for referral to a specialized surgeon.

Simulation Based Robotics Training to Test Skill Acquisition and Retention

Study Objective: Laparoscopic management of ectopic pregnancy is a common procedure encountered during Obstetrics and Gynecology (ObGyn) residency training. Although a limited number of commercial products exist to aid simulation in teaching laparoscopic salpingostomy and salpingectomy, these models are either incomplete (ex. partial tube only) or quite expensive, thus limiting application. Our goal was to develop a low fidelity uterine model with simulated ectopic pregnancy that could be used by Ob-Gyn residents when performing simulation for laparoscopic treatment of ectopic pregnancy. Design: Pilot design of a novel low fidelity uterine model with simulated ectopic pregnancy for use in laparoscopic simulation. Setting: The model is manipulated with traditional laparoscopic instruments within a standard laparoscopic task trainer. Patients: Ob-Gyn residents at a single academic center used the created model when performing simulation for laparoscopic salpingostomy and salpingectomy. Intervention: A low fidelity uterine model with simulated ectopic pregnancy was constructed using common items. A plastic maraca functioned as the uterus with attached uterine manipulator. A plastic whoosh ball placed inside a small balloon served as the ectopic pregnancy; this was placed inside a larger balloon and attached to the maraca to simulate fallopian tube with ectopic pregnancy. Additional balloons were added for ovaries and press and seal was used as peritoneum.

Matching Trends for the Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS) Since Participation in the National Residency Match Program (NRMP)

OBJECTIVE To evaluate the level of interest in the fellowship in minimally invasive gynecologic surgery (FMIGS) using data from the National Residency Match Program (NRMP) over the past 5 years. DESIGN Retrospective report (Canadian Task Force classification II-2). SETTING Publicly reported data from the NRMP. PARTICIPANTS Applicants using the NRMP to match into fellowship training. INTERVENTIONS Reporting matching trends for the gynecologic surgical subspecialty programs starting in 2014, when the FMIGS programs began participating in the NRMP. MEASUREMENTS AND MAIN RESULTS From 2014 to 2018, the number of FMIGS positions increased from 28 to 38. Over the 5 application cycles, the FMIGS programs had the highest ratio of applicants to positions overall (range, 1.7-2.0 for FMIGS) of the surgical gynecologic subspecialty programs analyzed (Gynecologic Oncology, Female Pelvic Medicine and Reconstructive Surgery, and Reproductive Endocrinology and Infertility). CONCLUSIONS Since the FMIGS programs began participating in the NRMP in 2014, the FMIGS match has been highly competitive as a gynecologic surgical subspecialty, suggesting a high level of interest from residency graduates. This may reflect growing recognition that there is a body of knowledge unique to minimally invasive gynecologic surgeons.

The Robotic-Assisted Treatment of Endometriosis: A Colorectal Surgical Perspective

Endometriosis is a common benign gynecologic condition defined as the presence of uterine lining, or endometrium, outside of the uterine cavity. Implants create a proinflammatory environment secondary to the production of cytokines, prostaglandins, and metalloproteinases. The inflammation present in endometriosis lesions leads to scar tissue formation and adhesions between pelvic organs. Severe dysmenorrhea, chronic pelvic pain, and infertility are the most common symptoms of women diagnosed with endometriosis. Symptoms can be debilitating affecting work productivity and quality of life.

Minimally Invasive Hysterectomy for Uteri Greater Than 1 Kilogram [16Q]

INTRODUCTION: To assess the feasibility and safety of minimally invasive hysterectomy for uteri greater than 1 kilogram. METHODS: Between January 2009 and July 2015, a retrospective chart review was completed at our hospital for laparoscopic hysterectomy done for uteri weighing greater than one kilogram. RESULTS: From 2009 to 2015, 95 patients underwent minimally invasive hysterectomy with confirmed uterine weight over 1 kg. Eighty-eight percent were performed with traditional laparoscopy and 12% with robotic-assisted laparoscopy. The mean (SD) uterine weight was 1564 grams (637.5), the mean (SD) estimated blood loss was 334 mL (385.8), and mean (SD) operating time was 203 min (73.7). Five cases were converted to laparotomy (5.2%). Four cases converted secondary to hemorrhage and one converted due to extensive adhesive disease and inability to safely access the uterine artery. There were no conversions after 2011. In one case, damage to the serosa of the sigmoid colon during adhesiolysis was noted and repaired laparoscopically. Intra-operative transfusion was given in 8.4% of cases and post-operative transfusion in 5.2% of cases. However, after 2013, the rate of intra-operative transfusion decreased to 1.0% and post-operative transfusion to 2.1%. Of the 95 cases there were no cases of malignancy. CONCLUSION: To our knowledge, this provides the largest case series of hysterectomies over 1 kg completed by a minimally invasive approach. Our complication rate improved with experience and was comparable to other studies of laparoscopic hysterectomy for large uteri. When performed by experienced surgeons, minimally invasive hysterectomy for uteri greater than 1 kg can be considered feasible and safe.

Feasibility, Safety, and Prediction of Complications for Complex Minimally Invasive Myomectomy [12J]

INTRODUCTION: The purpose of this study is to assess perioperative outcomes and predict complications for complex minimally invasive myomectomy. METHODS: This is a retrospective cohort study of women undergoing a minimally invasive surgical (MIS) approach to myomectomy by three fellowship-trained surgeons from April 2011 to December 2014. RESULTS: The cohort included 221 patients, of which 47.5% had laparoscopic myomectomy and 52.5% had a robotic myomectomy. The mean (SD) specimen weight in grams, dominant myoma diameter in centimeters, and number of myomata removed were 408.1 (384.9), 9.6 (5.1), and 4.5 (4.1), respectively. The total complication rate was 10.4%. The rate of hemorrhage was 8.6% and the rate of transfusion was 4.1%. These accounted for most complications. Women with complications had larger dominant myoma diameter (mean [SD] in cm 15.2 [6.4] versus 9.5 [4.49], P=.002), and greater number of myomata removed (mean [SD] 6.7 [6.3] versus 4.3 [3.7], P=.031). A logistic regression model combining both diameter of dominant myoma and number of myomata removed reliably predicted complications while minimizing false positives. CONCLUSION: Our cohort had higher specimen weights, larger dominant myoma diameter, and number of myomata removed in comparison to other reports of MIS myomectomy. Complication rates remained equivalent and hemorrhage and transfusion were the most prevalent. A combination of diameter of dominant myoma and number of myomata removed predicted complications while minimizing false positives. Both factors can be easily defined prior to surgery and can be potentially used to guide referral patterns, pre-operative counseling, and the implementation of preventative measures.

Simulation Based Robotics Training to Test Skill Acquisition and Retention [4B]

INTRODUCTION: Simulation-based training may be important to teach and maintain robotic operative skills. The objective of this study is to investigate the learning curve among novice learners and to determine how fast simulation skills decay over time. METHODS: 31 medical students were trained with the daVinci Skills Simulator® in 4 exercises thought to simulate skills necessary in gynecologic robotic surgery. Each exercise was completed until proficient (an overall score of at least 91%) or a maximum of 10 times each. Participants were then randomized into 4 groups and returned for a follow-up session after a 1-, 3-, 5-, or 7-week interval to re-achieve competency and/or complete the same 4 exercises a maximum of 10 times each. RESULTS: Main outcomes measured were total simulation time (TST) to achieve proficiency or complete a task 10 times at baseline and follow-up sessions. Participants were divided into two groups: those able (high performers; n=13) and those unable (low performers; n=18) to reach proficiency of 91% within 10 trials at baseline testing. TST improved for all participants over the study period, however low performers had the greatest reduction in TST in camera targeting (P=.03) and match-board (P=.03) tasks. Participants in the 5-week interval group showed the greatest improvement in TST. CONCLUSION: Learners who start with lower skills at baseline may benefit the most from robotic simulation to improve operative skills. Skills obtained by robotic simulation were best maintained up to a 5-week period. Simulation training may be necessary to maintain robotics proficiency over time.