Michael L. Galloway

Validity and Reliability of the Robotic Objective Structured Assessment of Technical Skills

OBJECTIVE: Objective Structured Assessments of Technical Skills have been developed to measure the skill of surgical trainees. Our aim was to develop an Objective Structured Assessments of Technical Skills specifically for trainees learning robotic surgery. METHODS: This is a multiinstitutional study conducted in eight academic training programs. We created an assessment form to evaluate robotic surgical skill through five inanimate exercises. Gynecology, general surgery, and urology residents, Fellows, and faculty completed five robotic exercises on a standard training model. Study sessions were recorded and randomly assigned to three blinded judges who scored performance using the assessment form. Construct validity was evaluated by comparing scores between participants with different levels of surgical experience; interrater and intrarater reliability were also assessed. RESULTS: We evaluated 83 residents, nine Fellows, and 13 faculty totaling 105 participants; 88 (84%) were from gynecology. Our assessment form demonstrated construct validity with faculty and Fellows performing significantly better than residents (mean scores 89±8 faculty, 74±17 Fellows, 59±22 residents; P<.01). In addition, participants with more robotic console experience scored significantly higher than those with fewer prior console surgeries (P<.01). Robotic Objective Structured Assessments of Technical Skills demonstrated good interrater reliability across all five drills (mean Cronbachs &agr; 0.79±0.02). Intrarater reliability was also high (mean Spearmans correlation 0.91±0.11). CONCLUSION: We developed a valid and reliable assessment form for robotic surgical skill. When paired with standardized robotic skill drills, this form may be useful to distinguish between levels of trainee performance. LEVEL OF EVIDENCE: II

Contained morcellation using the GelPOINT advance access platforms and 3M Steri-Drape endobag

OBJECTIVE To report a technique that safely allows power and hand morcellation for laparoscopic hysterectomy and myomectomy specimens in a contained fashion in the event of unsuspected uterine sarcoma or leiomyosarcoma. DESIGN Video article introducing a method for enclosed tissue morcellation for laparoscopic specimens. SETTING Hospital of an academic-based practice. PATIENT(S) Two patients underwent laparoscopic hysterectomy: a 57-year-old G7 P5025 female for leiomyoma, anemia, and a history of CIN-3; and a 38-year-old G0P0 female with a 10-year history of pelvic pain and severe dysmenorrhea who failed medical therapy. INTERVENTION(S) A technique using the GelPOINT Platform incision extender system and GelSeal Cap (GSP) Advanced Access Platform and a 50 cm × 50 cm 3M Steri-Drape endobag for enclosed intracorporeal and extracorporeal tissue morcellation of laparoscopic specimens. MAIN OUTCOME MEASURE(S) For training purposes, we used a pelvic simulator and cadaver to describe the step-by-step process and troubleshoot issues to optimize intra- and extracorporeal morcellation. This allowed for easier implementation on the live patient. RESULT(S) Simulation training and the cadaver model provided a learning platform for contained internal power and external hand morcellation, accelerating the learning curve in its application to the live patient. CONCLUSION(S) The GSP and 3M Steri-Drape endobag is an alternative for laparoscopic power or hand morcellation. Using simulation training helped transition this technique to the live patient, allowing for easy and safe removal of tissue specimens and minimizing the potential for tissue seeding and dissemination.

Lichen sclerosus: a 5-year follow-up after topical, subdermal, or combined therapy.

Objective The purpose of our study was to compare clinical data regarding patients with pruritic lichen sclerosus (LS) at moderate or severe stages using 2 different therapies with a 5-year follow-up. Materials and Methods The study was approved by the institutional review board and was presented as a retrospective clinical data review of patients with pruritic biopsy diagnosis LS who underwent therapy at our university private practice from 2002 to 2005. We compared the results of a weekly topical application of high-potency steroid (HPS) with a combined HPS and monthly anesthetic/steroid subdermal injection (ASI). Outcomes were timed to achieve pruritus-free status, the number of symptomatic recurrences, and patient satisfaction with therapy. Results Fifty-four patients were diagnosed with LS between 2002 and 2005. There were 13 patients who had mild-stage, 25 who had moderate-stage, and 16 who had severe-stage LS. Five-year follow-up data on 17 patients with moderate-stage LS and 14 patients with severe-stage LS were obtained. Time to pruritus free was 6 weeks with ASI and 19 weeks with HPS for moderate-stage LS (p = .04) and 9 weeks with ASI and 24 weeks with HPS for severe-stage LS (p = .03). Recurrences were more frequent on HPSfor moderate-stage LS (p = .04) but not significant with HPS for severe-stage LS (p = .15). Only ASI was successful at treating patients with recalcitrant pruritus. Conclusions In our population, patients with symptomatic moderate-stage LS seem to have a more rapid and prolonged response to ASI than to HPS but are less satisfied with the injections.

Hysteroscopic morcellator to overcome cervical stenosis

OBJECTIVE To report a step-by-step technique to using a hysteroscopic morcellator to safely gain access into the intrauterine cavity in two patients with severe cervical stenosis and concomitant intrauterine pathology. DESIGN Video article introducing the hysteroscopic morcellator for overcoming severe cervical stenosis. SETTING Academic-based practice. PATIENT(S) A 36-year-old G0 female with primary infertility and uterine polyps and a 34-year-old G0 female with uterine polyps and a difficult trial transfer before undergoing an IVF cycle. In both patients, preoperative saline-infused sonography revealed submucosal filling defects and severe cervical stenosis. INTERVENTION(S) A hysteroscopic technique using the Hologic Myosure to overcome severe cervical stenosis with or without the use of intraoperative ultrasound. MAIN OUTCOME MEASURE(S) Despite using preoperative Cytotec, cervical stenosis was identified. Under direct visualization, a 4-mm Myosure XL blade was placed through a 7.25-mm Myosure XL hysteroscopy. The cutter blade, powered by an electromechanical drive system, enables simultaneous rotation and reciprocation. The blade allows one to shave and remove tissue and is applied to cervical stenosis, allowing safe access into the intrauterine cavity. RESULT(S) The intrauterine hysteroscopic Myosure morcellator allowed for safe and direct entry into the uterine cavity. We have since applied this technique to all patients where cervical stenosis is identified and have minimized potential uterine perforation and false tracks in our patients. CONCLUSION(S) Our technique is an alternative method for overcoming severe cervical stenosis and minimizing potential intraoperative complications.

Expanded carrier screening: a current survey of physician utilization and attitudes

PurposeExpanded carrier screening (ECS) is an available component of preconception and prenatal care. There is complexity around offering, administering, and following-up test results. The goal of this study is to evaluate current physicians’ utilization and attitudes towards ECS in current practice.MethodsThis was a prospective qualitative survey study. A 32-question electronic survey was distributed during a 1-year period to obstetricians-gynecologists who were identified using a Qualtrics listserv database.ResultsWhile more than 90% of physicians offered ethnic-based carrier screening (CS), ECS was offered significantly less (2010, 20.6%, and 2016, 27.1%). Physicians who were not fellowship-trained in reproductive endocrinology and infertility (REI) preferred ethnic-based carrier screening (95.9 vs 16.8%; P < 0.001). REI subspecialists were more likely to offer ECS (80%) compared to 70% of maternal fetal medicine physicians (MFM). Physicians were comfortable discussing negative results (53.6%) compared to positive results (48.4%). Most physicians (56%) believed that ECS should not be offered until the significance of each disease is understood; 52% believed that testing should be restricted to those conditions important to couples; while 26% felt that testing should be done regardless of the clinical significance.ConclusionsDiscussion and application of ECS has increased in clinical practice. However, lack of comfort with counseling and varying beliefs surrounding ECS continue to hinder its utilization. Further education and training programs, and subsequent evaluation are warranted.

Does the Order of Surgical Method of Training Affect Learning and Skill? A Comparison of Laparoscopy and Robotics

Two years later, her twin sister, AMM-2, an 18-year-old G0, presented with a 7 day history of abdominal pain. Gonorrhea was found and treated. CT scan revealed a complex central pelvic mass, 7 x 13.1 x 10.3 cm, containing fat, soft tissue, fluid and areas of calcification. An IUD was in place, she was obese and had a history of anxiety. She underwent uncomplicated laparoscopic left ovarian cystectomy to remove a 15x10 cm smooth-walled mass anterior to the uterus containing a large volume of hair, scalp, and sebaceous material. The right ovary was enlarged consistent with polycystic ovarian syndrome and the clitoris was enlarged to 4 cm in length. Pathologic review confirmed a mature cystic teratoma. Her recovery was uncomplicated. Conclusion: Teratomas are the most common germ cell tumor of the ovary and are frequently encountered in young women. A familial tendency has been reported rarely. Although both of our patients were successfully treated with minimally invasive surgery, previous knowledge of familial association in this case might have led to earlier identification and treatment in AMM-2.

Reducing Emergency Births by Modification in Oxytocin Utilization

Background: The purpose of our study was to explore the correlation between the a mount of oxytocin use and emergency vacuum, forceps, cesarean births and neonatal intensive care unit (NICU) response to fetal distress. In 2004, we restricted the criteria for oxytocin utilization for labor induction and augmentation. Methods: This retrospective study was carried out at a large private university tertiary care hospital- affiliated, and included data from the years 2005 to 2007. We utilized hospital data from vital statistics, labor and delivery, central pharmacy and NICU. Information obtained included maternal characteristics, annual birth data, indication and numbers of emergency vacuum, forceps and cesarean births, oxytocin utilization, and number of NICU responses to fetal distress. Results: The total number of deliveries during the studied period equaled14,184. The oxytocin utilization showed a reduction from 93.3% to 78.9%. The number of patients who did not receive oxytocin during labor increased from 6.7% to 21.1%. The correlation between the reduction of oxytocin utilization with the reduction of emergency cesarean births (10.9% to 5.07%), vacuum briths (9.1% to 8.5%), and forceps birth (4% to 2.3%) including NICU responses to fetal distress (P = 0.0001) revealed a significant statistical difference. The overall cesarean section rate did not indicate a significant increase 29.4% to 29.8% (P = 0.14) nor did the patient’s characteristics differ. Conclusion: In our population, reducing oxytocin appears to strongly correlate with a reduction in the number of emergency vacuum, forceps, cesarean births and NICU responses to fetal distress. doi:10.4021/jcgo5e