Tatiana Catanzarite

Venous thromboembolism in reconstructive pelvic surgery

OBJECTIVE We sought to determine the incidence and risk factors for venous thromboembolism (VTE) in women undergoing reconstructive pelvic surgery (RPS). STUDY DESIGN Using the American College of Surgeons National Surgical Quality Improvement Program registry, we identified patients who underwent RPS from 2006 through 2010 based on Current Procedural Terminology codes. We defined 2 cohorts: women with any RPS performed, with concomitant surgery from other specialties allowed (RPS + other), and women whose only procedure was RPS. VTE was defined as deep vein thrombosis or pulmonary embolism diagnosed within 30 days of surgery. Demographic characteristics, comorbidities, and operative characteristics were extracted from the database. Variables were analyzed using χ(2) tests and Student t tests for categorical and continuous variables. We performed a multiple logistic regression to control for confounding variables. RESULTS In all, 20,687 women underwent RPS + other, with 69 cases of VTE for a rate of 0.3%. Multivariate analysis demonstrated predictors for postoperative VTE including inpatient hospital status (odds ratio [OR], 7.69; P < .001), higher American Society of Anesthesiology Physical Status classification (OR, 2.70; P < .001), and emergency intervention (OR, 3.65; P = .008). When women undergoing only RPS were analyzed, there were 14 cases of VTE, with an incidence of 0.1% and the only specific predictor for postoperative VTE was length of stay (P < .037). CONCLUSION The incidence of VTE following RPS is very low, but it is increased in women undergoing concomitant surgeries. Patients undergoing inpatient surgery with higher American Society of Anesthesiology Physical Status classifications and requiring emergency intervention were at highest risk for VTE.

Risk Factors for Unscheduled 30-day Readmission after Benign Hysterectomy

Objectives Readmission rates after hysterectomy have been reported, but specific risk factors for readmission have not been fully delineated. We aimed to determine risk factors for and implications of 30-day unscheduled readmission after benign hysterectomy using data from the American College of Surgeons National Surgical Quality Improvement Program. Methods We identified benign hysterectomy procedures recorded at all participating National Surgical Quality Improvement Program institutions between 2011 and 2012. Outcomes of interest were 30-day unscheduled readmission rates, variables associated with readmission, and complication and mortality rates associated with readmission. Bivariate analyses were performed using Pearson &khgr;2 and independent t tests for categorical and continuous variables, respectively. Multivariable regression analysis was performed to identify factors independently associated with readmission. Results In total, 21,228 hysterectomies were identified during the study period. Thirty-day readmission rates were 3.8% for abdominal hysterectomy, 2.7% for laparoscopic hysterectomy, 2.9% for laparoscopic-assisted vaginal hysterectomy, and 3.0% for vaginal hysterectomy. Readmission was associated with increased perioperative complications (49.2% vs 6.1%, P < 0.001), return to the operating room (26.3% vs 0.6%, P < 0.001), and mortality (0.3% vs 0.01%, P < 0.001). The most common complications in patients requiring readmission were surgical site infections (28.4%), sepsis (12.8%), urinary tract infection (9.7%), and blood transfusion (6.7%). Variables that were independently associated with 30-day readmission after multivariable regression analysis included younger age (odds ratio [OR] 0.98/year, P < 0.001), smoking (OR 1.28, P = 0.01), diabetes mellitus (OR 1.47, P = 0.008), dyspnea (OR 1.48, P = 0.04), bleeding disorders (OR 1.82, P = 0.04), American Society of Anesthesiologists class ≥3 (OR 1.32, P = 0.009), prior surgery within 30 days (OR 3.60, P = 0.04), longer operative time (OR 1.20 per hour of operative time, P < 0.001), inpatient status (OR 1.36, P = 0.001), and longer length of hospital stay (OR 1.04/day, P < 0.001). Conclusions Using a large national database, we identified several patient-related and procedural risk factors for unscheduled 30-day readmission after hysterectomy. Readmission was associated with significantly higher rates of complications, a return to the operating room, and a 30-fold increase in mortality. Our findings reinforce the importance of patient selection and optimization of comorbidities before hysterectomy. Future research should aim to further delineate differential risks of readmission by surgical route as well as modifiable risk factors for readmission.

The Effect of Operative Time on Perioperative Morbidity After Laparoscopic Hysterectomy

INTRODUCTION: We aimed to determine the effect of operative time on the risk of perioperative morbidity after laparoscopic hysterectomy. METHODS: Deidentified data from the National Surgical Quality Improvement Program Database were reviewed for patients undergoing total or subtotal laparoscopic hysterectomy from 2006 to 2011. Robotic and traditional laparoscopy data were pooled. Primary outcomes were 30-day complication rates in relation to operative time. Demographics, comorbidities, and complications were compared using bivariate and multivariate regression analysis. RESULTS: Nine thousand sixty-four women underwent laparoscopic hysterectomy during the study period. Medical, surgical, and overall complications increased significantly with increasing operative time (Fig. 1). On bivariate analysis, operative times over 240 minutes were associated with significant increases in composite morbidity (13.3% compared with 4.7%, P<.001), surgical complications (4.1% compared with 1.6%, P<.001), medical complications (10.7% compared with 3.3%, P<.001), and reoperation (2.6% compared with 1.2%, P=.013) as well as venous thromboembolis, urinary tract infection, and blood transfusion. These associations remained statistically significant on multivariate analysis. For each additional 10 minutes of operative time, the odds of overall, medical, and surgical complications increased by 5.1%, 6.2%, and 4.1%, respectively, and the odds of reoperation, venous thromboembolism, urinary tract infection, and transfusion increased by 5.1%, 6.2%, 4.1%, and 8.3%, respectively. Fig. 1. Rates of overall, surgical, and medical complications and reoperation stratified by 60-minute intervals of surgical duration. CONCLUSIONS: We demonstrated a direct, independent correlation between increased operative time during laparoscopic hysterectomy and perioperative morbidity. Operating time exceeding 4 hours was associated with a nearly threefold increase in overall complications. Patients considering laparoscopic hysterectomy who are at risk for excessive operating time may benefit from an alternative surgical approach.

Ergonomics in Surgery: A Review

Objective Work-related musculoskeletal disorders (WMSDs) are prevalent among surgeons and may result in practice modification. We aimed to perform a comprehensive review of the English-language literature regarding ergonomic risk, prevalence of WMSDs, and unique ergonomic considerations by route of surgery. Methods Multiple searches were performed of PubMed and University library resources to access English-language publications related to surgeon ergonomics. Combinations of keywords were used for each mode of surgery, including the following: “ergonomics,” “guidelines,” “injury,” “operating room,” “safety,” “surgeon,” and “work-related musculoskeletal disorders.” Each citation was read in detail, and references were reviewed. Results Surgeon WMSDs are prevalent, with rates ranging from 66% to 94% for open surgery, 73% to 100% for conventional laparoscopy, 54% to 87% for vaginal surgery, and 23% to 80% for robotic-assisted surgery. Risk factors for injury in open surgery include use of loupes, headlamps, and microscopes. Unique risks in laparoscopic surgery include table and monitor position, long-shafted instruments, and poor instrument handle design. In vaginal surgery, improper table height and twisted trunk position create injury risk. Although robotic surgery offers some advantages, it remains associated with trunk, wrist, and finger strain. Surgeon WMSDs often result in disability but are under-reported to institutions. Additionally, existing research tools face limitations in the operating room environment. Conclusions Work-related musculoskeletal disorders are prevalent among surgeons but have received little attention owing to under-reporting of injury and logistical constraints of studying surgical ergonomics. Future research must aim to develop objective surgical ergonomics instruments and guidelines and to correlate ergonomics assessments with pain and tissue-level damage in surgeons with WMSDs. Ergonomics training should be developed to protect surgeons from preventable, potentially career-altering injuries.

Ureteral Trauma During Transvaginal Ultrasound-Guided Oocyte Retrieval: A Case Report.

Background Transvaginal ultrasound-guided oocyte retrieval is a safe and well-tolerated procedure. Complications are uncommon and usually limited to vaginal bleeding and pelvic infection. Ureteral injury following oocyte retrieval is exceedingly rare, with only 8 previously reported cases. Case A 34-year-old woman developed gross hematuria 4 hours after transvaginal ultrasound-guided oocyte aspiration. Cystoscopy, laparoscopy, and retrograde pyelography revealed bleeding from the left ureter, no intra-abdominal bleeding, and a patent left urinary collecting system. The ureteral bleeding was successfully managed with placement of a ureteral stent. Conclusion Ureteral trauma during transvaginal-guided oocyte retrieval is a rare complication with a variable clinical presentation. If ureteral injuries are not promptly recognized, significant morbidity may occur. This case demonstrates that early identification of injury and timely intervention result in favorable outcomes.

Operative Time Longer Than 240 Minutes is Predictive of 30-Day Complications After Vaginal Hysterectomy [43].

INTRODUCTION: The relationship between operative time and morbidity is incompletely understood in gynecology. We aimed to evaluate the effect of operative time on 30-day complication rates after vaginal hysterectomy. METHODS: Patients undergoing vaginal hysterectomy for benign indications from 2005 to 2012 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Clinical characteristics and complications were compared for patients with operative time shorter and longer than 240 minutes. Multivariable analysis was performed to determine the independent effect of operative time on complications. RESULTS: A total of 10,311 vaginal hysterectomies were identified. Complications increased significantly as surgical duration increased, with an inflection point at 240 minutes. Characteristics associated with operative time longer than 240 minutes included older age, nonsmoking status, hypertension, chronic obstructive pulmonary disease, higher ASA (American Society of Anesthesiologists) level, higher relative value units average, inpatient status, general anesthesia, and resident physician involvement. Operative time longer than 240 minutes was associated with increased rates of overall complications (15.7% compared with 6.7%, P<.001), medical complications (13.5% compared with 5.6%, P<.001), urinary tract infection (UTI; 8.9% compared with 3.5%, P<.001), blood transfusion (4.3% compared with 1.5%, P<.001), and reoperation (2.9% compared with 1.2%, P=.02), although mortality rates were similar (0% compared with 0.4%, P=.74). After multivariable analysis, longer operative time independently predicted overall complications, medical complications, UTI, and reoperation. CONCLUSION: We demonstrated that operative time longer than 4 hours during vaginal hysterectomy is predictive of 30-day overall complications, medical complications, UTI, and reoperation. Future research should aim to identify modifiable contributors to prolonged operative time.