Sara R.C. Driessen

Case-Mix Variables and Predictors for Outcomes of Laparoscopic Hysterectomy: A Systematic Review

The assessment of surgical quality is complex, and an adequate case-mix correction is missing in currently applied quality indicators. The purpose of this study is to give an overview of all studies mentioning statistically significant associations between patient characteristics and surgical outcomes for laparoscopic hysterectomy (LH). Additionally, we identified a set of potential case-mix characteristics for LH. This systematic review was conducted according to the Meta-Analysis of Observational Studies in Epidemiology guidelines. We searched PubMed and EMBASE from January 1, 2000 to August 1, 2015. All articles describing statistically significant associations between patient characteristics and adverse outcomes of LH for benign indications were included. Primary outcomes were blood loss, operative time, conversion, and complications. The methodologic quality of the included studies was assessed using the Newcastle-Ottawa Quality Assessment Scale. The included articles were summed per predictor and surgical outcome. Three sets of case-mix characteristics were determined, stratified by different levels of evidence. Eighty-five of 1549 identified studies were considered eligible. Uterine weight and body mass index (BMI) were the most mentioned predictors (described, respectively, 83 and 45 times) in high quality studies. For longer operative time and higher blood loss, uterine weight ≥ 250 to 300 g and ≥500 g and BMI ≥ 30 kg/m(2) dominated as predictors. Previous operations, adhesions, and higher age were also considered as predictors for longer operative time. For complications and conversions, the patient characteristics varied widely, and uterine weight, BMI, previous operations, adhesions, and age predominated. Studies of high methodologic quality indicated uterine weight and BMI as relevant case-mix characteristics for all surgical outcomes. For future development of quality indicators of LH and to compare surgical outcomes adequately, a case-mix correction is suggested for at least uterine weight and BMI. A potential case-mix correction for adhesions and previous operations can be considered. For both surgeons and patients it is valuable to be aware of potential factors predicting adverse outcomes and to anticipate this. Finally, to benchmark clinical outcomes at an international level, it is of the utmost importance to introduce uniform outcome definitions.

Training of Hysteroscopic Skills in Residency Program: The Dutch Experience

STUDY OBJECTIVE To evaluate whether hysteroscopy training in the Dutch gynecological residency program is judged as sufficient in daily practice, by assessment of the opinion on hysteroscopy training and current performance of hysteroscopic procedures. In addition, the extent of progress in comparison with that of the residency program of a decade ago is reviewed. DESIGN Survey (Canadian Task Force Classification III). PARTICIPANTS Postgraduate years 5 and 6 residents in obstetrics and gynecology and gynecologists who finished residency within 2008 to 2013 in the Netherlands. INTERVENTION Subjects received an online survey regarding performance and training of hysteroscopy, self-perceived competence, and hysteroscopic skills acquirement. RESULTS Response rate was 65% of the residents and 73% of the gynecologists. Most residents felt adequately prepared for basic hysteroscopic procedures (86.7%), but significantly less share this opinion for advanced procedures (64.5%) (p < 0.01). In comparison with their peers in 2003, the current residents demonstrated a 10% higher appreciation of the training curriculum. However, their self-perceived competence did not increase, except for diagnostic hysteroscopy. Regarding daily practice, not only do more gynecologists perform advanced procedures nowadays but also their competence level received higher scores in comparison with gynecologists in 2003. Lack of simulation training was indicated to be the most important factor during residency that could be enhanced for optimal acquirement of hysteroscopic skills. CONCLUSION Implementation of hysteroscopic procedures taught during residency training in the Netherlands has improved since 2003 and is judged as sufficient for basic procedures. The skills of surgical educators have progressed toward a level in which gynecologists feel competent to teach and supervise advanced hysteroscopic procedures. Even though the residency preparation for hysteroscopy is more highly appreciated than a decade ago, this study indicated that simulation training might serve as an additional method to improve hysteroscopic skills acquisition. Future research is needed to determine the value of simulation training in hysteroscopy.

Assessing basic "physiology" of the morcellation process and tissue spread: a time-action analysis.

STUDY OBJECTIVE To assess the basic morcellation process in laparoscopic supracervical hysterectomy (LSH). Proper understanding of this process may help enhance future efficacy of morcellation regarding the prevention of tissue scatter. DESIGN Time-action analysis was performed based on video imaging of the procedures (Canadian Task Force classification II-2). SETTING Procedures were performed at Leiden University Medical Centre and St Lucas Andreas Hospital, Amsterdam, the Netherlands. PATIENTS Women undergoing LSH for benign conditions. INTERVENTIONS Power morcellation of uterine tissue. MEASUREMENTS AND MAIN RESULTS The morcellation process was divided into 4 stages: tissue manipulation, tissue cutting, tissue depositing, and cleaning. Stages were timed, and perioperative data were gathered. Data were analyzed as a whole and after subdivision into 3 groups according to uterine weight: <350 g, 350 to 750 g, and >750 g. A cutoff point was found at a uterine weight of 350 g, after which an increase in uterine weight did not affect the cleaning stage. The tissue strip cutting time was used as a measure for tissue strip length. With progression of the morcellation process, the tissue strip cutting time decreases. The majority of cutting time is of short duration (i.e., 60% of the cutting lasts 5 seconds or less), and these occur later on in the morcellation process. CONCLUSION With the current power morcellators, the amount of tissue spread peaks and is independent of uterine weight after a certain cutoff point (in this study 350 g). There is a relative inefficiency in the rotational mechanism because mostly small tissue strips are created. These small tissue strips occur increasingly later on in the procedure. Because small tissue strips are inherently more prone to scatter by the rotational mechanism of the morcellator, the risk of tissue spread is highest at the end of the morcellation procedure. This means that LSH and laparoscopic hysterectomy procedures may be at higher risk for tissue scatter than total laparoscopic hysterectomy. Finally, engineers should evaluate how to create only large tissue strips or assess alternatives to the rotational mechanism.

Proficiency for Advanced Laparoscopic Procedures in Gynecologic Residency Program: Do all Residents Need to be Trained?

OBJECTIVES To assess the current state of laparoscopic gynecologic surgery in the Dutch residency program, the level of competence among graduated residents, and whether they still perform these procedures. Furthermore, their current attitudes toward the implementation of minimally invasive surgery into residency training were assessed. DESIGN An online survey (Canadian Task Force Classification III) regarding the level of competence, performance, training, and interest for gynecologic laparoscopic procedures. PARTICIPANTS/SETTING Gynecologists who finished residency training between 2008 and 2013 in the Netherlands. RESULTS Response rate was 73% (171/235). The scores for all basic and intermediate laparoscopic procedures performed immediately after residency showed the highest competence level (median 5, of scale 1-5). The competence level for advanced laparoscopic procedures was less at 3, indicating that the graduated residents are not able to perform these procedures without supervision. Overall, 56% of the gynecologists no longer perform any level 3 advanced procedures, and 86% do not perform level 4 advanced procedures. Gynecologists who still perform the inquired laparoscopic procedures scored a significantly higher competence level immediately after residency training for most of procedures compared with the gynecologists who do not perform these procedures. CONCLUSION Residents are sufficiently trained for basic and intermediate laparoscopic procedures during residency training. However, they are not sufficiently equipped to perform advanced laparoscopic procedures without supervision. We should consider training advanced procedures especially to a selected group of residents because most gynecologists do not perform these procedures after residency. The learning curve for advanced procedures continues to rise after finishing residency for those who keep on performing these procedures, therefore an additional fellowship is recommended for this group.

Measuring surgical safety during minimally invasive surgical procedures: a validation study

BackgroundDuring the implementation of new interventions (i.e., surgical devices and technologies) in the operating room, surgical safety might be compromised. Current safety measures are insufficient in detecting safety hazards during this process. The aim of the study was to observe whether surgical teams are capable of measuring surgical safety, especially with regard to the introduction of new interventions.MethodsA Surgical Safety Questionnaire was developed that had to be filled out directly postoperative by three surgical team members. A potential safety concern was defined as at least one answer between (strongly) disagree and indifferent. The validity of the questionnaire was assessed by comparison with the results from video analysis. Two different observers annotated the presence and effect of surgical flow disturbances during 40 laparoscopic hysterectomies performed between November 2010 and April 2012.ResultsThe surgeon reported a potential safety concern in 16% (85/520 questions). With respect to the scrub nurse and anesthesiologist, this was both 9% (46/520). With respect to the preparation, functioning, and ease of use of the devices in 37.5–47.5% (15–19/40 procedures) a potential safety concern was reported by one or more team members. During procedures after which a potential safety concern was reported, surgical flow disturbances lasted a higher percentage of the procedure duration [9.3 ± 6.2 vs. 2.9 ± 3.7% (mean ± SD), p < .001]. After procedures during which a new instrument or device was used, more potential safety concerns were reported (51.2 vs. 23.1%, p < .001).ConclusionsPotential safety concerns were especially reported during procedures in which a relatively high percentage of the duration consisted of surgical flow disturbances and during procedures in which a new instrument or device was used. The Surgical Safety Questionnaire can act as a validated tool to evaluate and maintain surgical safety during minimally invasive procedures, especially during the introduction of a new intervention.

Gamification to Engage Clinicians in Registering Data: A Randomized Trial

OBJECTIVE To determine the effect of additional gamification elements in a web-based registry system in terms of engagement and involvement to register outcome data, and to determine if gamification elements have any effect on clinical outcomes. METHODS Randomized controlled trial for gynecologists to register their performed laparoscopic hysterectomies (LH) in an online application. Gynecologists were randomized for two types of registries. Both groups received access to the online application; after registering a procedure, direct individual feedback on surgical outcomes was provided by showing three proficiency graphs. In the intervention group, additionally gamification elements were shown. These gamification elements consisted of points and achievements that could be earned and insight in monthly collective scores. All gamification elements were based on positive enforcement. RESULTS A total of 71 gynecologists were randomized and entered a total of 1833 LH procedures. No significant difference was found between the groups in terms of engagement and involvement on a 5-point Likert scale, respectively 2.34±0.87 versus 2.56±1.05 and 3.63±0.57 versus 3.33±1.03 for the intervention versus the control group (p>0.05). The intervention group showed longer operative time than the control group (108±42 vs. 101±34 minutes, p=0.04), no other differences were found in terms of surgical outcomes. CONCLUSIONS The addition of gamification elements in a registry system did not enhance the engagement and involvement of clinicians to register their clinical data. Based on our results, we advise that registry systems for clinical data should be as simple as possible with the focus on the main goal of the registry.