Reducing patient's perception of postoperative vaginal bleeding after laparoscopic hysterectomy via independent closure of the vaginal cuff angles (RCT).

STUDY OBJECTIVE: Determine if independently suturing the vaginal cuff angles in addition to running barbed suture has an effect on patients' perception of postoperative bleeding after laparoscopic hysterectomy. DESIGN: Randomized controlled trial. SETTING: University-based medical center. PATIENTS: Females ages 18-60 undergoing laparoscopic hysterectomy. INTERVENTIONS: Patients were randomly assigned to either cuff closure via single layer of barbed suture (control) vs adding figure-of-eight stitches at each angle (intervention). A survey was given between 10 and 25 days after surgery inquiring about bleeding and dyspareunia. A second survey was given between postoperative days 90-114. Chart review was performed to record emergency room visits, complications, infections, and reoperations during the first 90 postoperative days. RESULTS: n = 117 patients were analyzed. 62 (control) and 55 (intervention). Groups were similar in terms of age (42.92 v 44.29p =.35), BMI (33.79 v 34.06p =.85), diabetes (5.26 % (3/55) v 15.09 % (8/53) p =.08) p =.97). Bleeding was decreased in intervention arm (24.19 % (15/62) v 9.09 % (5/55) p =.03). Median (IQR) pelvic pain score was similar (2.0 (0-5.0) v 2.0 (0-4.0) p =.26). Median total operative time (IQR) (129 min (102, 166) v 139 min (120, 163) p =.39) and median EBL (IQR) (50 mL (30-75) vs 50 mL (20-75) p =.43) were similar. Cuff closure in seconds (IQR) was higher in intervention group (373 sec (323, 518) v 571 sec (520, 715) p <.01). 8/60 control patients visited the ED (13.33 %) v 7/54 (12.96 %) p =.95. Readmissions (1.67 % (1/60) v 1.85 % (1/55) p = 1), re-operations (0 % (0/60) v 1.85 % (1/55) p =.47) and postoperative infections (5.0 % (3/60) v 1.85 % (1/54) p =.62) were similar. Secondary survey showed no significant difference in bleeding (15.38 % (4/26) v 4.35 % (1/23) p =.35) and SF-36 results were similar. CONCLUSION: Independently suturing the vaginal cuff angles reduces patients' perception of vaginal bleeding in the early postoperative period. Incidence of complications, reoperations, and long-term quality of life are similar.

Liposomal Bupivacaine Injection for Analgesia During Minimally Invasive Supracervical Hysterectomy.

Objective: To evaluate the efficacy of intracervical injection of liposomal bupivacaine for postoperative pain control among women undergoing minimally invasive supracervical hysterectomy. Methods: A randomized double-blinded placebo-controlled trial of intracervical injection of combination liposomal bupivacaine and bupivacaine for postoperative pain among patients undergoing laparoscopic and robotic supracervical hysterectomy. Patients were enrolled between October 1, 2018 and April 30, 2019. The primary outcome was pain at 12 hours postoperatively using a numeric rating scale from zero to 10. Pain scores were also recorded pre-operatively, immediately postoperatively, at 12, 24, and 48 hours postoperatively. The secondary outcome was the number of patients who required opioid analgesic medications up to 48 hours postoperatively. Results: Sixty participants were randomized into the control (n = 30) and intervention (n = 30) groups. Pain scores were 1 and 1.75 (p = 0.89) immediately postoperatively, 3 and 3.5 (p = 0.85) at 12 hours, 3.5 and 5 (p = 0.22) at 24 hours, and 2.75 and 4 (p = 0.18) at 48 hours for the control and intervention groups, respectively. Within the first 24 hours, 10 patients in the control and 14 patients in the intervention group used narcotics (p = 0.37). From the 24 to 48 hours window, 6 and 8 patients in the control and intervention groups used narcotics (p = 0.74), respectively. Conclusion: There was no statistically significant difference in pain scores between patients receiving combination liposomal bupivacaine and bupivacaine intracervical block and those receiving placebo in the first 48 hours after surgery. There was no difference in analgesic use between the two study groups.

Elective robotic hysterectomy for placenta accreta spectrum in the second trimester: Case report.

BACKGROUND: A scheduled pre-viable hysterectomy is a treatment option for women with early diagnosed placenta accreta spectrum who do not wish future fertility. A minimally invasive hysterectomy with pregnancy in situ for placenta accreta spectrum has not been previously reported. CASE: A patient with evidence of placenta accreta spectrum on prenatal imaging underwent an elective robot-assisted laparoscopic hysterectomy at 16 weeks of gestation. The procedure was uncomplicated and she was discharged on postoperative day 1. Pathology was consistent with placenta percreta. CONCLUSION: Robot-assisted laparoscopic hysterectomy with pregnancy in situ is feasible in a patient with placenta accreta spectrum in the second trimester. TEACHING POINTS: 1. Early diagnosis of placenta accreta spectrum is important for surgical planning and management. 2. We present a technique for minimally invasive hysterectomy in a patient with placenta accreta spectrum diagnosed before viability.

Simulation-Based Education to Train Learners to "Speak Up" in the Clinical Environment: Results of a Randomized Trial.

INTRODUCTION: Assertiveness is essential for communication and/or speaking up. We performed a randomized trial to assess the effectiveness of assertiveness/advocacy/CUS/two-challenge rule (AACT) simulation-based education for labor and delivery, as well as postpartum nurses. We aimed to determine whether this training would improve labor and delivery and postpartum nurses speaking up in the clinical setting. METHODS: We conducted a randomized controlled trial among nurses on labor and delivery and postpartum units. During the intervention, participants were trained on abnormal vital signs, underwent a baseline assertiveness self-assessment, and were block-randomized (by work location: labor and delivery or postpartum) to either simulation-based AACT (intervention) or I-PASS [Illness Severity, Patient Summary, Action List, Situational Awareness and Contingency Planning, Synthesis by Receiver hand-off tool education] (control) simulation-based education. The outcome part of the study consisted of an in situ simulated clinical encounter during which each individual learner's assertive behaviors were assessed as they found out about a patient's abnormal vital signs. Two raters, different from those that participated in the intervention part of the experiment, and who were blinded to whether the learner was in the control or intervention arm, scored participants. The learner (Registered Nurse) was not aware that this was an in situ simulation and perceived this as a real clinical encounter. The degree to which the learners spoke up was measured using a validated scale (Pian-Smith). RESULTS: Seventy nurses completed the study. There were 34 learners in the intervention and 36 in the control groups. Among those in the intervention group, there were 18 labor and delivery (LDI) nurses and 16 postpartum (PPI) nurses. Among the control group, there were 14 labor and delivery (LDC) nurses and 22 postpartum (PPC) nurses. Using a five-point Pian-Smith scale, we demonstrated that there was no difference in the likelihood of speaking up between the overall intervention and control groups (2.00 ± 1.00 and 1.65 ± 0.82, P = 0.10). Among controls, the likelihood of speaking up was higher for labor and delivery nurses than for postpartum nurses (P < 0.006). There was a significant interaction (P = 0.02) between treatment group and work location. Although the control and intervention groups from labor and delivery showed similar higher levels of speaking up (2.29 ± 0.89 and 2.06 ± 0.95, respectively, P = 0.49), postpartum nurses in the intervention arm were more likely to speak up than were postpartum nurses in the control arm (1.97 ± 1.07 vs. 1.25 ± 0.43, P = 0.007). CONCLUSIONS: Although there was no difference in speaking up scores between intervention and control groups overall, simulation-based AACT training among postpartum nurses was associated with a statistically significant increase in the likelihood of speaking up during a challenging simulated clinical encounter. The degree of change makes the clinical significance uncertain. There was no statistically significant difference in the likelihood of speaking up among labor and delivery nurses.