Miya Yamamoto

Laparoscopic 5-mm trocar site herniation and literature review.

This report concludes that there is no evidence to recommend routine closure of 5-mm trocar incisions; the choice should be left to the discretion of the individual surgeon.

Same-Day Discharge After Laparoscopic Hysterectomy

OBJECTIVE: To estimate readmission rates and emergency care use by patients discharged home the same day after laparoscopic hysterectomy. METHODS: This was a retrospective case series of patients discharged home the same-day after total or supracervical laparoscopic hysterectomy in a managed care setting. Chart reviews were performed for outcomes of interest which included readmission rates, emergency visits, and surgical and demographic characteristics. The two hysterectomy groups were compared using &khgr;2 tests for categorical variables and t tests or Wilcoxon rank-sum tests for continuously measured variables. RESULTS: One-thousand fifteen laparoscopic hysterectomies were performed during the 3-year study period. Fifty-two percent (n=527) of the patients were discharged home the same-day; of those, 46% (n=240) had total laparoscopic hysterectomies and 54% (n=287) had supracervical. Cumulative readmission rates were 0.6%, 3.6%, and 4.0% at 48 hours, 3 months, and 12 months, respectively. The most common readmission diagnoses included abdominal incision infection, cuff dehiscence, and vaginal bleeding. Less than 4% of patients presented for emergency care within 48 or 72 hours, most commonly for nausea or vomiting, pain, and urinary retention. Median uterine weight was 155 g, median blood loss was 70 mL, and median surgical time was 150 minutes. There was no difference in readmission rates or emergency visits for the total compared with the supracervical laparoscopic hysterectomy group. CONCLUSION: Same-day discharge after laparoscopic hysterectomy is associated with low readmission rates and minimal emergency visits in the immediate postoperative period. Same-day discharge may be a safe option for healthy patients undergoing uncomplicated laparoscopic hysterectomy. LEVEL OF EVIDENCE: III

Risk of Preterm Delivery in Non-Diabetic Women with Polycystic Ovarian Syndrome

Objective:To examine the risk and etiology of preterm delivery in women with polycystic ovary syndrome (PCOS).Study Design:Retrospective cohort study comparing preterm delivery rate among non-diabetic PCOS and non-PCOS women with singleton pregnancy. Multivariable logistic regression was used to identify predictors of preterm delivery among PCOS women.Result:Among 908 PCOS women with singleton pregnancy, 12.9% delivered preterm compared with 7.4% among non-PCOS women (P<0.01). Causes of preterm delivery among PCOS women included preterm labor (41%), cervical insufficiency (11%), hypertensive complications (20%), preterm premature rupture of membranes (15%), fetal–placental concerns (9%) and intrauterine fetal demise (5%). Maternal age, race/ethnicity and nulliparity were significant predictors of preterm delivery in PCOS, whereas body mass index and fertility medications were not.Conclusion:A higher proportion of PCOS women delivered preterm (12.9%) compared with non-PCOS women, with the majority of cases due to spontaneous preterm birth. Future studies should explore etiologies and strategies to improve pregnancy outcomes in PCOS.

Prevalence of cervical insufficiency in polycystic ovarian syndrome

BACKGROUND Pregnant women with polycystic ovarian syndrome (PCOS) experience a greater rate of adverse obstetrical outcomes compared with non-PCOS women. We examined the prevalence and incidence of cervical insufficiency (CI) in a community cohort of pregnant women with and without PCOS. METHODS A retrospective cohort study was conducted within a large integrated health care delivery system among non-diabetic PCOS women with second or third trimester delivery during 2002-2005 (singleton or twin gestation). PCOS was defined by Rotterdam criteria. A non-PCOS comparison group matched for delivery year and hospital facility was used to estimate the background rate of CI. Women were designated as having new CI diagnosed in the index pregnancy (based on cervical dilation and/or cervical shortening) and prior CI based on prior diagnosis of CI with prophylactic cerclage placed in the subsequent pregnancy. RESULTS We identified 999 PCOS women, of whom 29 (2.9%) had CI. There were 18 patients with new CI and 11 with prior CI having prophylactic cerclage placement; four CI patients had twin gestation. In contrast, only five (0.5%) non-PCOS women had CI: two with new CI and three with prior CI. The proportion of newly diagnosed incident CI (1.8 versus 0.2%) or prevalent CI (2.9 versus 0.5%) was significantly greater for PCOS compared with non-PCOS pregnant women (both P < 0.01). Among PCOS women, CI prevalence was particularly high among South Asians (7.8%) and Blacks (17.5%) compared with Whites (1%) and significantly associated with gonadotropin use (including in vitro fertilization). Overall, the PCOS status was associated with an increased odds of prevalent CI pregnancy (adjusted odds ratio 4.8, 95% confidence interval 1.5-15.4), even after adjusting for maternal age, nulliparity, race/ethnicity, body mass index and fertility treatment. CONCLUSION In this large and ethnically diverse PCOS cohort, we found that CI occurred with a higher than expected frequency in PCOS women, particularly among South Asian and Black women. PCOS women with CI were also more likely to have received gonadotropin therapy. Future studies should examine whether natural and hormone-altered PCOS is a risk factor for CI, the role of race/ethnicity, fertility drugs and consideration for heightened mid-trimester surveillance in higher risk subgroups of pregnant women with PCOS.

Same-Day Discharge After Minimally Invasive Myomectomy.

OBJECTIVE: To estimate readmission rates of patients discharged home the same day after a minimally invasive myomectomy. METHODS: This is a retrospective case series of patients who underwent minimally invasive myomectomy and were discharged the same day, which examines the feasibility and safety by rates of readmission within Kaiser Permanente Northern California. Chart review was performed for outcomes of interest including readmission rates, emergency department, and urgent clinic visits within 48 hours, 7 days, and up to 3 months along with surgical and demographic characteristics. RESULTS: Of the 403 minimally invasive myomectomies performed during the study period, 88% (N=356) of patients were discharged home the same day. No readmissions required reoperation or were life-threatening. Two patients (0.6%) were readmitted within 48 hours for postoperative fever. A cumulative total of five patients (1.4%) were readmitted within 3 months. Urgent care and emergency department visits occurred in zero and seven patients (2.0%) within 48 hours of discharge, most commonly for pain and urinary retention. Median leiomyoma weight was 204 g, median body mass index was 26, median blood loss was 75 mL, and median surgical time was 157 minutes. CONCLUSION: Same-day discharge after minimally invasive myomectomy was found to have a low readmission rate and low health care utilization in the immediate postoperative period. Same-day discharge appears to be a safe option for healthy patients after undergoing an uncomplicated minimally invasive myomectomy.

Chronic Abdominal Pain of Gynecologic Causes: Diagnosis and Treatment

Chronic abdomino-pelvic pain or chronic pelvic pain (CPP) is estimated to affect 4 % of women, decreasing quality of life and work productivity, with healthcare costs of more than two billion dollars per year in the United States. Diagnosis of the etiology is difficult as symptoms can be vague and often the patient has several sources for her pain. Non-gynecologic disorders are associated with higher prevalence rates than gynecologic disorders and include: Irritable bowel syndrome (IBS), interstitial cystitis/painful bladder syndrome (IC/PBS), abdominal/pelvic myofascial pain, and neuralgias (discussed in other chapters of this book). Gynecologic disorders include: endometriosis, prior pelvic inflammatory disease, leiomyomata, adenomyosis, tuberculous salpingitis, ovarian remnant syndrome, ovarian retention syndrome, and pelvic congestion syndrome. Dysmenorrhea (pain with the menstrual cycle) and dyspareunia (pain with sexual intercourse) are also common symptoms. Other non-gynecologic disorders, such as depression, fibromyalgia, migraines, low back pain, or a history of physical/sexual abuse, should be evaluated and addressed. Patients with CPP often have been to multiple doctors and had numerous interventions without any improvement of pain or even a diagnosis. A patient–physician relationship based on empathy and trust, along with patient education and setting realistic goals (including pain decrease with improvement of daily functioning), is extremely important.

Predictive Clinical Factors to Distinguish Uterine Sarcoma From Benign Uterine Pathology in Hysterectomy Cases [6Q]

INTRODUCTION: Preoperative diagnosis of occult uterine sarcomas has proven to be challenging in presumed benign hysterectomy cases. We aim to discern clinical features that could identify a potential uterine sarcoma. METHODS: We conducted a case-control study of women diagnosed with occult (no preoperative suspicion) and presumed (known or suspected) uterine sarcoma and compared these groups to age- and race-matched controls (1:2 ratio) of women undergoing hysterectomy for leiomyoma or abnormal uterine bleeding 2006–2013 in Kaiser Permanente in California. Conditional logistic regression analyses were used to identify potential preoperative clinical factors associated with uterine sarcoma (any sarcoma, presumed sarcoma, occult sarcoma) with the threshold of significance set at P less than .05. RESULTS: Of 273 total uterine sarcoma cases identified, 118 (43.2%) were occult. Risk factors predictive of any malignancy in comparison to the control (P less than .05) included documented uterine size increase (OR 4.1 any; 3.7 presumed; 8.7 occult), pelvic pain requiring narcotic medications (OR 5.6 any; 5.9 presumed; 22.1 occult), and history of transfusion within 3 months of hysterectomy (OR 4.7 any; 7.2 presumed; 11.6 occult). Other factors such as uterine weight, postmenopausal bleeding, pelvic pain requiring hospitalization or ER admission, prior hormonal therapy or previous uterine artery embolization were not found to be significantly different between groups. CONCLUSION: Our large case cohort identifies potential characteristics of occult and presumed uterine sarcomas in comparison to benign hysterectomy patients. These results may be useful for developing a nomogram to predict uterine sarcoma in the preoperative setting.

Is Same-Day Discharge After Minimally Invasive Myomectomy a Safe Option? [86]

INTRODUCTION: Increasingly, myomectomies are routinely being completed with minimally invasive technology, either robotically or laparoscopically. Traditionally, many patients stay 1-2 days after this surgery. To date, no studies have evaluated whether patients can be safely discharged the same day after a minimally invasive myomectomy. Our primary objective was to evaluate readmission rates of patients discharged home the same-day following minimally invasive myomectomy. Secondary objectives included postoperative urgent care visits, as well as patient and operative characteristics. METHODS: This was a retrospective case series of patients discharged home the same day after laparoscopic or robotic myomectomy in a managed care setting in 2011-2013. Chart review was performed for outcomes of interest which included readmission rates, emergency department, and urgent clinic visits within 48 hours and 3 months, and surgical and demographic characteristics. RESULTS: Four hundred three minimally invasive myomectomies were performed during the study period. Eighty-eight percent (n=356) of patients were discharged home the same day; of those, 83% (n=297) of myomectomies were performed laparoscopically, and 17% (n=59) were performed robotically. The most common indication for myomectomy was pain (70%) and bleeding (46%). Two patients (0.6%) were readmitted within 48 hours, both from the laparoscopic group. A total of 5 patients (1.4%) were readmitted within 3 months; 4 from the laparoscopic group and 1 from the robotic group. Urgent care visits occurred in 3.9% of patients (n=14). Median myoma weight was 207 g, median body mass index was 26, median blood loss was 50 mL, and median surgical time was 150 minutes. CONCLUSION: Same-day discharge after laparoscopic or robotic myomectomy was found to have a low readmission rate and low health care utilization use in the immediate postoperative period. Same-day discharge appears to be a safe option for healthy patients undergoing minimally invasive myomectomy.

Cyst Removal With Dilute Vasopressin

Salient details of the interventional Acessa Procedure for radiofrequency ablation of symptomatic uterine fibroids are presented. The procedure is unique: ablation is guided by intra-abdominal laparoscopic ultrasound, does not require laparoscopic suturing or subsequent overnight hospital stay, but does require basic laparoscopic and ultrasound skills. Hemostasis is achieved by coagulation of the handpiece track upon withdrawal of the handpiece from the fibroid and uterus. Fibroids 0.7 to 15 cm in diameter have been treated. The patient is a 31 year-old, nulligravida black female who presented with menorrhagia, abdominal fullness and pelvic pressure. Ultrasound detected a 17-cm uterus with multiple intramural and subserosal fibroids, the two largest being 6 cm and 3 cm in greatest diameters. The patient desired outpatient, surgical, and uterine-conserving therapy. She was discharged 5 hours post-procedure with acetaminophencodeine and nonsteroidal anti-inflammatory drugs. The average patient misses a median of 5 workdays.

Laparoscopic Management of a 13 Week Interstitial Ectopic Pregnancy

Introduction: Interstitial pregnancies account for approximately 2% to 4% of all ectopic pregnancies; however, without timely diagnosis and treatment, they are associated with a high rate of morbidity and mortality. The traditional surgical approach has been laparotomy with cornual wedge resection or even hysterectomy. With advances in laparoscopic surgery, new surgical techniques have been reported: cornuostomy incision with removal of pregnancy contents, cornual wedge resection, and combined laparoscopic and hysteroscopic suction removal. However, these laparoscopic techniques have been described mostly in first-trimester interstitial pregnancies with smaller mass sizes. Case Description: We report a case of a successfully treated interstitial pregnancy of a 35-year-old woman in her second trimester with a mass diameter of 8 cm via laparoscopic cornual wedge resection. The surgery had minimal blood loss, aided by myometrial injection of dilute vasopressin, systematic electrocautery ligation, and continuous barbed suture closure of the remaining myometrium and serosa. The patient had an uneventful postoperative course and has recovered fully. Discussion: With advances in laparoscopic techniques, laparoscopy has become a viable surgical treatment of interstitial pregnancy. However, few case descriptions of successful laparoscopic management of pregnancies that have progressed into the second trimester exist. This is due to several factors: the rarity of these pregnancies to progress past the first trimester without uterine rupture, the size of second-trimester pregnancies, and the technical difficulty encountered with such large resections. In our case report, we share our successful experience of laparoscopic management of an 8-cm-diameter interstitial pregnancy at 13 weeks’ gestation.