Michelle Louie

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.

Hemostasis Techniques in Myomectomies

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.

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.

Hysterectomy for the Transgender Man

Purpose of ReviewOur objective is to summarize the most recent, high-quality data regarding perioperative recommendations for hysterectomy and salpingo-oophorectomy in transgender and gender nonconforming individuals.Recent FindingsMany transgender men desire hysterectomy and salpingo-oophorectomy for gender affirmation, cancer-risk reduction, pelvic pain, or abnormal uterine bleeding. Gender-confirming hysterectomy is safe, effective, and highly beneficial for well-counseled patients. Preoperative considerations include optimizing the office environment, preoperative testing specific to patients with long-term testosterone use, counseling specific to transgender men, consideration of World Professional Association for Transgender Health criteria, and coordination of a multi-disciplinary team. Minimally invasive approaches, including vaginal, laparoscopic, and robotic-assisted hysterectomy, are the standard of care for cisgender women and transgender men given lower complication rates, better post-operative outcomes, and greater cosmetic satisfaction. Concurrent appendectomy, mastectomy, vaginectomy, and urethral reconstruction may be performed at the time of hysterectomy; phalloplasty and metoidioplasty are generally performed as subsequent procedures. Same-day discharge following hysterectomy is safe and has been shown to improve post-operative outcomes. We recommend follow-up with the patient’s mental health professional and endocrinologist in addition to routine surgical follow-up. Long-term satisfaction after genital surgery appears to be high and regret is low.SummaryMore robust and up to date research is needed to improve guidelines and perioperative care for transgender individuals. Available data suggests that hysterectomy and salpingo-oophorectomy for transgender men is safe, is not associated with any additional risks compared to cisgender women, and is associated with an improved quality of life.

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.

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.