Tarek Toubia

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.

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.

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.