Paul Tyan

Systematic Review of Transabdominal Cerclage Placed via Laparoscopy for the Prevention of Preterm Birth.

Preterm birth is the leading cause of neonatal mortality and morbidity. Multiple interventions are available to minimize this occurrence; however, despite current recommendations including medical management, cervical length screening, and transvaginal cerclage, a substantial number of women still experience preterm birth. For those patients, experts recommend transabdominal cerclage (TAC). In this systematic review, we compared 26 studies (1116 patients) of TAC placed via laparotomy (TAC-lap) and 15 studies (728 patients) of TAC placed via laparoscopy (TAC-lsc). There was no significant difference in overall neonatal survival between the TAC-lsc and TAC-lap groups (89.9% vs 90.8%, respectively; p = .80). When T1 losses were excluded, the neonatal survival rate was significantly higher for the TAC-lsc group (96.5% vs 90.1%; p < .01). In terms of obstetrical outcomes, the TAC-lsc group had a higher rate of deliveries at gestational age (GA) > 34 weeks (82.9% vs 76%; p < .01) and a lower rate of deliveries at GA 23.0 to 33.6 weeks (6.8% vs 14.8%; p < .01). The TAC-lsc group also had fewer T2 losses (3.2% vs 7.8%; p < .01). TAC-lsc offers all the benefits of minimally invasive surgery with better obstetrical outcomes compared with TAC-lap.

Multidisciplinary Resection of Deeply Infiltrative Endometriosis

STUDY OBJECTIVE To describe a multidisciplinary approach for the resection of deeply infiltrative endometriosis using the robotic platform. DESIGN A technical video showing a step-by-step approach for the resection of deeply infiltrative endometriosis (Canadian Task Force classification level III). Institutional review board approval was not required for this study. SETTING There is considerable involvement of the bowel and bladder with deeply infiltrative endometriosis [1-3]. The need for operative procedures involving multiple organs while performing a complete resection is common. The benefits of minimally invasive surgery for a gynecologic pathology have been documented in numerous studies. Patients had fewer medical and surgical complications postoperatively, better cosmesis, and better quality of life [4-6]. We believe that deeply infiltrative endometriosis does not preclude patients from having a minimally invasive resection procedure. In this video, we describe how the robotic platform was used for a seamless transition between surgical specialties including gynecology, colorectal, and urology to ensure complete resection of endometriosis lesions involving multiple organs. PATIENT A 47-year-old woman with a 4-year history of severe pelvic pain, dysuria, dyspareunia, dyschezia, and dysmenorrhea failing multiple medical therapies presented to our clinic to discuss surgical options. After thorough counseling, the decision was made to proceed with definitive surgical management. Postoperatively, the patient was admitted for 2 days of postoperative inpatient care. After meeting all immediate postoperative milestones, she was discharged with an indwelling Foley catheter and instructed to follow up in the clinic with all 3 surgical specialties. At the 1-week interval, she was seen by the urology team; her indwelling catheter was removed after a cystoscopy was performed documenting adequate healing. Two weeks postoperatively, the patient was seen by the gynecology and colorectal teams and was noted to be healing adequately from the procedure. Her six-week visit was also unremarkable. She continued to follow up with the gynecology team for her yearly well-woman examinations and has been symptom free for 2 years after the surgery. She takes norethindrone daily to minimize recurrence. INTERVENTIONS Preoperative pelvic magnetic resonance imaging (MRI) showed bladder endometriosis and extensive rectovaginal endometriosis. We describe the multidisciplinary approach used for surgery and the procedures performed by each specialty. The urology team performed a cystoscopy preoperatively to assess for full-thickness erosions and the location of those lesions in that event. The urology team also reviewed the magnetic resonance images with the radiology team, and the endometriosis lesions were suspected to be close to the bladder trigone, keeping in mind that this finding could be overestimated given that the bladder was deflated at the time the imaging was obtained. Accordingly, at the time of surgery, the decision was made to proceed with cystoscopy and the placement of ureteral stents as a prophylactic measure. An intentional cystotomy and resection of the bladder section involved with endometriosis were performed followed by watertight closure. The trigone area of the bladder was not involved, and ureteral reimplantation was not needed in this case. The gynecology team operated second and performed an extensive dissection of the retroperitoneal space with the development of the pararectal and paravesical spaces. They also ligated the uterine artery at its origin followed by dissection of the uterovesical space, effectively reflecting the bladder off of the lower uterine segment. At this point, they proceeded with a total hysterectomy, and the specimen was removed from the pelvis through the vaginal cuff. Preoperatively, the colorectal surgeon ordered a colonoscopy to determine if full-thickness erosions were present and reviewed the magnetic resonance images with the radiology team. Based on the MRI and colonoscopy, all patients are counseled and consented for the possibility of a low anterior resection and loop ileostomy to protect the anastomosis. Based on the understanding that colorectal and gynecologic surgeries have a different approach when dissecting the pararectal space at our institution, a discussion between the 2 teams is initiated at the multidisciplinary session for surgery planning. In the case we present, the colorectal surgeon opted for the removal of the uterus before his dissection was initiated given that he dissects this space presacrally and not retroperitoneally like the gynecology counterpart. He would also benefit from the extra space for dissection with the uterus out of the pelvis. The colorectal part of the case was initiated by mobilization of the rectum and dissecting the obliterated rectovaginal space. The presacral space was then opened followed by mobilization of the rectosigmoid from its attachment. The case was concluded with full transection and reanastomosis of the rectum section involved with endometriosis. The specimen was also removed from the pelvis through the vaginal cuff. MEASUREMENTS AND MAIN RESULTS Complete resection of deeply infiltrative endometriosis spanning beyond the scope of 1 surgical specialty. No immediate intraoperative, perioperative, or long-term complications from surgery. Complete resolution of endometriosis symptoms. CONCLUSION We encourage collaborative care for planning and performing comprehensive and safe resection of deeply infiltrative endometriosis.

First Described Case of Group B Streptococcus Pelvic Abscess in a Patient with No Medical Comorbidities

Background. Group B Streptococcus is an organism that commonly infects a wide range of hosts including infants in the first week of life, pregnant women, and older age adults as well as adults with underlying medical comorbidities. Case. Large pelvic abscess in a nonpregnant patient found to be caused by Group B Streptococcus was treated successfully with IR guided drainage and antibiotics. Conclusion. Though rare, GBS can still be a cause of invasive infection even in individuals who are nonpregnant and have no underlying comorbidities. Empiric antibiotic coverage for this organism should be kept in mind when treating an abscess.

Correction to: Two-port robotic hysterectomy: a novel approach

The objective of the study was to demonstrate a novel technique for two-port robotic hysterectomy with a particular focus on the challenging portions of the procedure. The study is designed as a technical video, showing step-by-step a two-port robotic hysterectomy approach.

Two-port robotic hysterectomy: a novel approach

The objective of the study was to demonstrate a novel technique for two-port robotic hysterectomy with a particular focus on the challenging portions of the procedure. The study is designed as a technical video, showing step-by-step a two-port robotic hysterectomy approach (Canadian Task Force classification level III). IRB approval was not required for this study. The benefits of minimally invasive surgery for gynecological pathology have been clearly documented in multiple studies. Patients had fewer medical and surgical complications postoperatively, better cosmesis and quality of life. Most gynecological surgeons require 3–5 ports for the standard gynecological procedure. Even though the minimally invasive multiport system provides an excellent safety profile, multiple incisions are associated with a greater risk for morbidity including infection, pain, and hernia. In the past decade, various new methods have emerged to minimize the number of ports used in gynecological surgery. The interventions employed were a two-port robotic hysterectomy, using a camera port plus one robotic arm, with a focus on salpingectomy and cuff closure. We describe a transvaginal and a transabdominal approach for salpingectomy and a novel method for cuff closure. The transvaginal and transabdominal techniques for salpingectomy for two-port robotic-assisted hysterectomy provide excellent tension and exposure for a safe procedure without the need for an extra port. We also describe a transvaginal technique to place the vaginal cuff on tension during closure. With the necessary set of skills on a carefully chosen patient, two-port robotic-assisted total laparoscopic hysterectomy is a feasible procedure.

Predictors of Overnight Admission after Minimally Invasive Hysterectomy in the Expert Setting

STUDY OBJECTIVE To identify predictors of overnight admission after laparoscopic and robot-assisted hysterectomy to improve preoperative counseling and patient optimization. DESIGN A single-center retrospective cohort study (Canadian Task Force classification III). SETTING Academic university hospital. PATIENTS Patients undergoing straight-stick laparoscopic and robot-assisted hysterectomy by fellowship-trained minimally invasive gynecologic surgeons for benign indications INTERVENTIONS: Straight-stick laparoscopic and robot-assisted hysterectomy. MEASUREMENTS AND MAIN RESULTS Data from 396 consecutive minimally invasive hysterectomy procedures were collected for analysis. Three hundred twelve patients (79%) were discharged the same day, and 84 (21%) were admitted for at least 1 night. Data from the 2 groups were compared. Overnight stay compared with same-day discharge was associated with older age (47.3 vs 43.4 years, p < .001), lower preoperation hematocrit (35.8% vs 37.3%, p = .035), history of prior laparotomy (31% vs 14.1%, p = .003), prolonged operative time (190.5 vs 115.2 minutes, p < .001), estimated blood loss (244.6 vs 104.1 mL, p < .001), lysis of adhesion (27.4% vs 13.5%), and intraoperative organ injury (17% vs 3%, p = .005). Logistic regression analysis, adjusting for all included variables as confounders, showed that hematocrit increments of 5% were protective against any overnight stay (odds ratio, .622; p = .015), and a 30-minute increase in operative time increased the odds of an overnight stay by 1.6 (p < .001). History of a laparotomy remained a significant predictive factor for an overnight stay (odds ratio, 3.2; p = .006). Later surgery end time, in 60-minute increments, increased the odds of an overnight stay by 1.2 (p < .01). CONCLUSION Perioperative factors such as age, hematocrit, surgery time, and surgical history as well as intraoperative factors such as prolonged operative time are predictive of overnight hospital stay.

Technique for Tissue Containment and Extraction in the Complex Minimally Invasive Myomectomy Setting

STUDY OBJECTIVE To achieve tissue containment and extraction for numerous and large myomas in the complex minimally invasive difficult myomectomy setting via a surgical tutorial including technical pointers and suggestions DESIGN: A step-by-step explanation of the .surgery using video (instructive video) (Canadian Task Force classification III). Institutional review board approval was not required for this study. SETTING George Washington University Hospital, Washington, DC. PATIENTS Multiple patients with a high number or large size of leiomyomata. INTERVENTIONS Four reproducible techniques that enable the minimally invasive gynecologic surgeon to perform complex tissue containment and extraction: MEASUREMENTS AND MAIN RESULTS: One of the main challenges encountered with minimally invasive myomectomy procedures includes myoma containment and extraction. Given the potential risks for leiomyomatosis and the spread of leiomyosarcoma, the Food and Drug Administration banned electromechanical morcellation device usage [1]. After implementation of the ban and fueled by the increasing size and number of myomas removed through minimally invasive techniques, tissue containment and extraction are becoming increasingly challenging. This shift is partly reflected by the number of complications attributable to surgeon experience [2,3]. With the increase in the number of myomas removed during a minimally invasive myomectomy, the risk of myoma retention in the abdominal cavity is amplified. Also, the increase in the myoma size removed through minimally invasive surgery renders tissue extraction through contained, extracorporeal, manual morcellation more challenging [2-5]. Inefficiencies in tissue containment and extraction could potentially be hazardous to the patients safety and detrimental to the operating room efficiency, and the AAGL Practice Report on tissue extraction emphasizes that the use of specimen retrieval pouches should be investigated further [2-6]. Patients underwent uncomplicated complex minimally invasive myomectomy. CONCLUSION Mastering these reproducible techniques maximizes patient safety and operating room efficiency during minimally invasive myomectomy procedures.

Determining the Effect of External Stressors on Laparoscopic Skills and Performance Between Obstetrics and Gynecology Residents

STUDY OBJECTIVE To evaluate the effect of stress on laparoscopic skills between obstetrics and gynecology residents. DESIGN Observational prospective cohort study. DESIGN CLASSIFICATION Prospective cohort. SETTING Urban teaching university hospital. PARTICIPANTS (PATIENTS) Thirty-one obstetrics and gynecology residents, postgraduate years 1 to 4. INTERVENTION We assessed 4 basic laparoscopic skills at 2 sessions. The first session was the baseline; 6 months later the same skills were assessed under audiovisual stressors. We compared the effect of stress on accuracy and efficiency between the 2 sessions. MEASUREMENTS AND MAIN RESULTS A linear model was used to analyze time. Under stress, residents were more efficient in 3 of the 4 modules. Ring transfer (hand-eye coordination and bimanual dexterity), p = 0.0304. Ring of fire (bimanual dexterity and measure of depth perception), p = 0.0024 and dissection glove (respect of delicate tissue planes), p = 0.0002. Poisson regression was used to analyze the total number of penalties. Residents were more likely to acquire penalties under stress. Ring transfer, p = 0.0184 and cobra (hand-to-hand coordination), p = 0.0487 yielded a statistically significant increase in penalties in the presence of stressors. Dissection glove p = 0.0605 yielded a nonsignificant increase in penalties. CONCLUSION Our work confirmed that while under stress residents were more efficient, this translated into their ability to complete tasks faster in all the tested skills. Efficiency, however, came at the expense of accuracy.