Comparing Peer and Faculty Feedback for Asynchronous Laparoscopic Skill Acquisition.

OBJECTIVE: Traditionally, expert surgeons have provided surgical trainees with feedback about their simulation performance, including for asynchronous practice. Unfortunately, innumerable time demands may limit experts' ability to provide feedback. It is unknown whether and how peer feedback is an effective mechanism to help residents acquire laparoscopic skill in an asynchronous setting. As such, we aimed to assess the effect of peer feedback on laparoscopic performance and determine how residents perceive giving and receiving peer feedback. DESIGN: We conducted a convergent mixed methods study. In the quantitative component, we randomized residents to receive feedback on home laparoscopic tasks from peers or faculty. We then held an end-of-curriculum, in-person laparoscopic assessment with members from both groups and compared performance on the in-person assessment between the groups. In the qualitative component, we conducted interviews with resident participants to explore experiences with feedback and performance. Three authors coded and rigorously reviewed interview data using a directed content analysis. SETTING: We performed this study at a single tertiary academic institution: the University of California, San Francisco. PARTICIPANTS: We invited 47 junior residents in general surgery, obstetrics-gynecology, and urology to participate, of whom 37 (79%) participated in the home curriculum and 25 (53%) participated in the end-of-curriculum assessment. RESULTS: Residents in the peer feedback group scored similarly on the final assessment (mean 70.7%; SD 16.1%) as residents in the faculty feedback group (mean 71.8%; SD 11.9%) (p = 0.86). Through qualitative analysis of interviews with 13 residents, we identified key reasons for peer feedback's efficacy: shared mental models, the ability to brainstorm and appreciate new approaches, and a low-stakes learning environment. CONCLUSIONS: We found that peer and faculty feedback led to similar performance in basic laparoscopy and that residents engaged positively with peer feedback, suggesting that peer feedback can be used when residents learn basic laparoscopy.

Repair of Isthmocele Following Embolization of Uterine Arteriovenous Malformation.

OBJECTIVE: To present a case of concurrent uterine arteriovenous malformation (AVM) and isthmocele, treated with ethylene vinyl alcohol copolymer (EVAC) embolization of the AVM followed by robotic isthmocele repair. DESIGN: A stepwise video demonstration with narration. SETTING: A tertiary care academic hospital. Patient is a 37-year-old with one previous cesarean section who presented with persistent heavy vaginal bleeding after a dilation and evacuation procedure. Imaging showed evidence of an isthmocele and an iatrogenic uterine AVM secondary to the dilation and evacuation procedure. Both entities are morbid conditions associated with significant operative blood loss. Embolization of the acquired AVM was first performed to stabilize bleeding. In addition, owing to the extensive uterine defect and history of infertility, surgical repair of the isthmocele was recommended. INTERVENTIONS: A multidisciplinary approach combining interventional radiology and gynecologic surgery expertise, implementing several strategies to minimize blood loss: 1. Image-guided uterine AVM embolization with EVAC [1] 2. Hysteroscopic identification of isthmocele and residual EVAC in the cavity, with fluorescence transillumination to clearly delineate isthmocele borders 3. Robot-assisted laparoscopic approach for bladder flap creation, as well as retroperitoneal space dissection to skeletonize uterine arteries 4. Transient occlusion of uterine arteries using vascular clamps to minimize operative blood loss given the isthmocele size and its proximity to the left uterine artery 5. Resection of the isthmocele and removal of residual intracavitary EVAC 6. Multilayer, bidirectional hysterotomy closure and vascular clamp removal to restore uterine blood supply CONCLUSIONS: Successful multidisciplinary treatment of concurrent uterine AVM and isthmocele. Cesarean delivery at 36 to 37 weeks' gestational age was recommended for future deliveries.

Alternatives to excisional therapy: a clinical review of our current options to conservatively manage symptomatic leiomyomas.

PURPOSE OF REVIEW: This article provides a clinical review of the alternatives to traditional excisional surgical therapies for uterine leiomyomas, such as myomectomy or hysterectomy. RECENT FINDINGS: In this review, currently available hormonal medications will be briefly discussed. Then, nonhormonal medical therapy will be addressed with respect to mechanism of action, safety, and efficacy. Finally, the risk-benefit profile of nonexcisional procedures for management of leiomyomas will be addressed. SUMMARY: This provides an update on the information available for more conservative options for symptomatic leiomyoma management.

Systematic Review of Topical Hemostatic Agent Use in Minimally Invasive Gynecologic Surgery.

BACKGROUND AND OBJECTIVES: To perform a systematic review of articles evaluating hemostatic effectiveness and peri-operative outcomes when topical hemostatic agents (HA) are used in minimally invasive gynecologic surgeries (MIGS) for benign conditions. METHODS: Studies published through March 31, 2017 were retrieved through PubMed, EMBASE, Cochrane, and ClinicalTrials.gov to identify all eligible studies. No studies were excluded based on publish date. All comparative studies or case series with >10 participants reporting use of at least one topical HA in MIGS for benign conditions were included as long as full-text articles were available and written in English. Studies were excluded if surgery was done for malignancy or completed via an open approach. Articles that included multiple surgical subspecialties were excluded if data related to MIGS was unable to be isolated. Evaluation for eligibility and data extraction was performed by three independent reviewers. Quality of evidence was also assessed by each reviewer. RESULTS: From 132 articles, a total of 8 studies were included in this systematic review. We found that use of fibrin sealant decreased time to hemostasis, postoperative hemoglobin drop, and estimated blood loss (EBL) compared with bipolar energy and reduced the overall operative time in laparoscopic myomectomy. When fibrin sealant use at time of myomectomy was compared to bipolar energy there was no significant difference in the rate of postoperative complications. Furthermore, there was less of a decrease in anti-Mullerian hormone (AMH) level when a thrombin-gelatin matrix was used compared to bipolar energy on ovarian tissue. CONCLUSION: Application of topical HA in MIGS can reduce operative time, blood loss, and ameliorate damage to ovarian function. However, more data needs to be gathered for use of HA during different types of gynecologic procedures (adnexal surgery, myomectomy, and hysterectomy) to provide better quality evidence to guide their use.

Minimally Invasive Hysterectomy for Uteri Greater Than One Kilogram.

BACKGROUND AND OBJECTIVES: To assess the feasibility and safety of minimally invasive hysterectomy for uteri >1 kg. METHODS: Clinical and surgical characteristics were collected for patients in an academic tertiary care hospital. Included were patients who underwent minimally invasive hysterectomy by 1 of 3 fellowship-trained gynecologists from January 1, 2009, to July 1, 2015 and subsequently had confirmed uterine weights of 1 kg or greater on pathology report. Both robotic and conventional laparoscopic procedures were included. RESULTS: During the study period, 95 patients underwent minimally invasive hysterectomy with confirmed uterine weight over 1 kg. Eighty-eight percent were performed with conventional laparoscopy and 12.6% with robot-assisted laparoscopy. The median weight (range) was 1326 g (range, 1000-4800). The median estimated blood loss was 200 mL (range, 50-2000), and median operating time was 191 minutes (range, 75-478). Five cases were converted to laparotomy (5.2%). Four cases were converted secondary to hemorrhage and one secondary to extensive adhesions. There were no conversions after 2011. Intraoperative transfusion was given in 6.3% of cases and postoperative transfusion in 6.3% of cases. However, after 2013, the rate of intraoperative transfusion decreased to 1.0% and postoperative transfusion to 2.1%. Of the 95 cases, there were no cases with malignancy. CONCLUSIONS: This provides the largest case series of hysterectomy over 1 kg completed by a minimally invasive approach. Our complication rate improved with experience and was comparable to other studies of minimally invasive hysterectomy for large uteri. When performed by experienced surgeons, minimally invasive hysterectomy for uteri >1 kg can be considered feasible and safe.

Magnetic resonance imaging correlation to intraoperative findings of deeply infiltrative endometriosis.

OBJECTIVE: To show characteristics of deeply infiltrative endometriosis (DIE) on magnetic resonance imaging (MRI) and how they correlate with intraoperative findings. DESIGN: Overview of still and dynamic MRI images of four different patients with DIE. We then used videos from their surgeries to highlight the appearance of endometriosis corresponding to these images (educational video). SETTING: University hospital. PATIENT(S): Four different patients with DIE were included in this video. These were all women of reproductive age who suffered from debilitating deeply infiltrative endometriosis. These patients had a pelvic MRI performed at our institution and subsequently underwent surgery with one of our minimally invasive gynecologic surgeons. INTERVENTION(S): The MRI endometriosis protocol includes T1-weighted fat and nonfat saturated as well as T2-weighted sequences. Images are taken along all three planes (axial, sagittal, and coronal) before and after contrast. What distinguishes the standard MRI from the endometriosis-protocol MRI is the thickness of the slices taken. For the evaluation of endometriosis, T1 nonfat saturated images are taken in 6-mm slices with no skip sections in between. Then, T1 fat saturated images and T2-weighted images are taken in 5-mm slices with a 1-mm skip section in between slices. The areas that are suspicious for lesions consistent with DIE are corroborated on videos taken during surgery. MAIN OUTCOME MEASURE(S): Value of accurate mapping of lesions with the use of preoperative MRI in surgical planning and complete resection of diseased tissue. RESULT(S): Results from a previously published prospective study by Bazot et al. reported sensitivity, specificity, positive predictive value, and negative predictive value of 90.3%, 91%, 92.1%, and 89%, respectively. Similarly to our institution, that study used a 1.5-T MRI, and the protocol of our institution closely mimicked the technique used in that study. Another prospective study published by Hottat et al. showed sensitivity, specificity, and positive and negative predictive values of MRI predicting intraoperative disease of 96.3%, 100%, 100%, and 93.3% respectively. Those results were gathered with the use of a 3.0-T MRI. The high accuracy in these studies of prediction of deep pelvic endometriosis in specific locations shows that MRI is effective for preoperative planning, as was the case for the four patients in our video. CONCLUSION(S): Preoperative planning for DIE with the use of MRI is integral in surgical planning. Other imaging modalities to diagnose DIE, such as transvaginal ultrasound, endoanal ultrasound, barium enema, cystoscopy, and rectoscopy, have all been used and studied for the evaluation of endometriosis. However, given its accuracy for mapping lesions, MRI could potentially replace multiple types of imaging while offering the best option for preoperative planning. Accurate mapping would result in greater success of resection and allow for multidisciplinary planning if necessary. Furthermore, being able to train the eye to identify lesions on MRI that are consistent with DIE is an asset to the gynecologic surgeon.

Gastric volvulus complication in an infant with undiagnosed congenital diaphragmatic hernia presenting with acute respiratory distress.

INTRODUCTION: Congenital diaphragmatic hernia is an embryologic defect that creates a passage for herniation of abdominal structures into the thoracic cavity. This can lead to a variety of complications, including gastric volvulus that can present acutely with epigastric distention and vomiting. In cases of late-onset congenital diaphragmatic hernia, symptoms may be vague and often necessitate further investigation. CASE: Our patient is a 12-month-old previously healthy female infant who presented to the emergency department with a history of vomiting and acute onset respiratory distress. Her SaO(2) was 94% to 98% on room air, her respiratory rate was in the 80s breaths per minute, and she was noted to have severe retractions. Her chest examination revealed absent breath sounds on the left side. Her abdominal examination was unremarkable. The acute presentation of respiratory distress was initially concerning for a foreign body aspiration, but a chest radiograph demonstrated left-sided opacification and mediastinal shift to the right. The patient required intubation for respiratory decompensation and a subsequent computed tomographic scan showed diaphragmatic hernia with gastric volvulus. CONCLUSIONS: This patient's presentation highlights one of the complications that may occur owing to congenital diaphragmatic hernia. Computed tomographic scan is the confirmatory test for diaphragmatic hernia and, in this case, also uncovered a concomitant gastric volvulus. Treatment includes early resuscitation, a definitive airway, and emergent surgery to prevent ischemic necrosis of the stomach owing to strangulation, gastric perforation, and serious cardiorespiratory decompensation.