Impact of timing on wound dressing removal after caesarean delivery: a multicentre, randomised controlled trial.

We compared wound dressing removal at 24 hours versus 48 hours following low-risk caesarean deliveries. This multicentre, randomised, controlled study included patients 18-44 years of age with low-risk term, singleton pregnancies. The randomisation was done weekly. Scheduled caesarean deliveries without labour were included. For comparison, the Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation of deep tissues, Isolation of bacteria, Stay in hospital > 14 days (ASEPSIS) score for wound healing assessment was modified. The absolute scores were obtained based on a one-day reading rather than the five-day reading used in ASEPSIS. Zero ("0") was assigned as a complete healing. Higher scores were associated with more severe disruption of healing. The patients were enrolled between March 2015 and February 2017. The demographics were not statistically different. The wound scoring was similar in the groups at discharge and first-week evaluation. At the six weeks post-surgery, the wound scoring was significantly less in the 48-hour (3.9%) versus the 24-hour group (9%; p = .002). Dressing removal at 48 hours had a lower scoring in the low-risk population with scheduled caesarean deliveries.IMPACT STATEMENTWhat is already known on this subject? Surgical dressings are used to provide suitable conditions to heal caesarean incisions. There has been a limited number of studies on the evaluation of ideal timing on wound dressing removal after a caesarean delivery. These studies concluded there are no increased wound complications with removal at six hours versus 24 hours or within or beyond 48 hours after surgery.What do the results of this study add? The postoperative removal of the wound dressing at 48 hours had a lower wound score at six weeks than the removal at 24 hours for women with uncomplicated scheduled caesarean deliveries.What are the implications of these findings for clinical practice and/or further research? Early discharge after caesarean delivery is becoming more common. Dressing removal at 24 hours versus 48 hours becomes more crucial and needs to be clarified. Besides, high-risk populations, different skin closure techniques, and patients in labour should be addressed separately.

Perioperative, postoperative and anatomical outcomes of robotic sacrocolpopexy.

The study aimed to analyse the anatomical, perioperative and postoperative outcomes of the robotic-assisted sacrocolpopexy (RSCP). After obtaining Institutional Review Board (IRB #19-0167) approval, our retrospective case series included 144 consecutive patients that underwent an RSCP for symptomatic stage II pelvic organ prolapse (POP) or symptomatic/asymptomatic stage III/IV POP. Patient information included operative parameters, perioperative and postoperative complications, readmissions and reoperation. Demographics and baseline characteristics were summarised by frequencies and percentages for categorical variables, and by mean/median, standard deviation, and ranges for continuous variables. In our study, concomitant surgeries with sacrocolpopexy consisted of hysterectomy, Burch colposuspension and midurethral sling. The anatomical success rate was 87.5% and the reoperation rate was 10.4%. The mean follow-up time was 12.5 (±8.7) months. Intraoperative complications 13 (9%) were bowel serosal abrasion, bladder wall injuries, trochar site bleeds, subcutaneous emphysema and a retroperitoneal haematoma. Our results suggest that RSCP is a feasible and safe approach for the treatment of POP with a low complication rate and favourable medium-term outcomes regarding anatomical and symptomatic results.Impact statementWhat is already known on this subject? Pelvic organ prolapse affects more than 25% of women in the United States. Apical and anterior compartment defects are challenging cases and sacrocolpopexy is considered the gold standard treatment option for apical and anterior compartment defects. As technology has advanced, minimally invasive approaches have been popular with their pros.What the results of this study add? We present the highest volume case series in the literature from our tertiary care centre for robotic-assisted sacrocolpopexy (RSCP). Our results suggest that RSCP is a feasible and safe approach for the treatment of POP with a low complication rate and favourable 1-year outcomes regarding anatomical and subjective results.What the implications are of these findings for clinical practice and/or further research? Robotic-assisted sacrocolpopexy has the potential to gain more popularity in the near future based on accumulating data on its feasibility and safety results.

Outcomes of robotic, laparoscopic, and open hysterectomy for benign conditions in obese patients

OBJECTIVE: To compare outcomes of robotic-assisted (RAH), total laparoscopic hysterectomy (LH), and total abdominal hysterectomy (TAH) for benign conditions in obese patients. MATERIAL AND METHODS: Retrospective cohort (Class II-2) analysis. All obese patients who underwent RAH, LH or TAH for benign conditions by a single surgeon at the University of Texas Medical Branch between January 2009 and December 2011 were identified and their charts reviewed. The patients' characteristics, operative data, and post-operative outcomes were collected and statistically analyzed. RESULTS: A total of 208 patients who underwent RAH (n=51), LH (n=24) or TAH (n=133) were analyzed. There were no significant differences among the groups in demographic characteristics, indications for surgery or pathologic findings. RAH and LH were associated with lower estimated blood loss (EBL) (p<0.001) and shorter length of hospital stay (LOS) (p<0.001) compared with TAH. In addition, RAH and LH had lower intraoperative and early postoperative (≤6 weeks) complications compared with TAH (p=0.002). However, the procedure time was longer in RAH and LH (p<0.001). No significant differences were noted among the groups for late post-operative complications (after 6 weeks) or unscheduled post-operative visits. CONCLUSION: Minimally invasive hysterectomy appears to be safe in obese patients with the advantages of less EBL, fewer intraoperative complications, and shorter LOS.

Robot-Assisted Abdominal Cerclage During Pregnancy.

BACKGROUND AND OBJECTIVES: Cervical insufficiency is a difficult condition to diagnose and can lead to preterm birth, miscarriage, or perinatal infant morbidity and mortality. We conducted this retrospective case study and literature review to evaluate the safety and efficacy of robot-assisted abdominal cerclage during pregnancy. METHODS: We conducted a case series and a systematic review that included patients who underwent robot-assisted abdominal cerclage during pregnancy from January 2010 through March 2016. RESULTS: Six patients met the criteria for the case series. Median age was 34 years (range, 28-37) at the time of the procedure. In 5 cases, the indication for transabdominal cerclage was a failed vaginal cerclage in a previous pregnancy, whereas a scarred and shortened cervix caused by a previous dilatation and curettage-induced cervical laceration was the indication in the remaining case. Median operating time was 159.5 minutes (range, 124-204), and median estimated blood loss was 25 mL (range, 10-25). No surgeries were converted to laparotomies; all patients were discharged on postoperative day 1. The median gestational age at delivery was 37.5 weeks (range, 22-39). Five patients delivered between 36 and 39 weeks. No patients had chorioamnionitis or preterm premature rupture of membranes. One patient went into preterm labor at 22 weeks, and the cerclage was removed via minilaparotomy. Eight articles met the criteria for systematic review. Sixteen patients underwent robot-assisted abdominal cerclage during pregnancy. Median age was 31.5 years (range, 25-37). The major indication in most articles was previous failed transvaginal cerclage. The median gestational ages at time of procedure and delivery were 12 weeks (range, 10-15) and 37 weeks (range, 33-39), respectively. CONCLUSION: Robot-assisted abdominal cerclage is safe and effective during pregnancy.

Overcoming the obstacles of visualization in robotically assisted abdominal cerclage using indocyanine green.

Abdominal cerclage is found to have success rates of 85-95 % with lower incidence of preterm delivery and preterm premature rupture of membranes when compared to the vaginal approach. However, since it is more invasive, its use has been limited to selected cases. Robot-assisted abdominal cerclage is a relatively new minimally invasive technique that gives the opportunity for less invasive procedures when compared to the open technique and, when compared to conventional laparoscopy, has the advantages of 3D visualization and endowristed instrumentation. The distinctive feature of our case is the use of near infrared camera system, which is a relatively new modality in robotics and, to the best of our knowledge, this is the first report in the literature that indocyanine green dye was used to help to visualize vascular anatomy during a robotic cerclage procedure in a pregnant patient.

Assessment of minimally invasive surgical skills of pre-medical students: What can we learn from future learners?

OBJECTIVE: Knowledge of baseline laparoscopic and robotic surgical skills of future learners is essential to develop teaching strategies that best fit them. The objectives of this study are to determine baseline laparoscopic and robotic skills of high school and college students and compare them to those of current obstetrics and gynecology residents. MATERIAL AND METHODS: A cross-sectional (Class II-2) pilot study. Laparoscopic and robotic surgical skills of college and high (secondary) school students were evaluated using simulators and compared to those of obstetrics and gynecology residents. In addition, questionnaire data were collected regarding video game playing and computer use. RESULTS: A total of 17 students, both high school (n=9) and college (n=8), in addition to 11 residents, completed the study. Overall, students performed comparably to the residents in simple exercises (p>.05). However, students took significantly longer time to complete complex exercises (p=.001). Finally, students played video games significantly more than residents (p<.001). CONCLUSION: Future learners may have a different background skill set. This difference may be related to improved hand-eye coordination, possibly due to playing video games. The results of this pilot study should spur more research into surgical teaching strategies.

A financial analysis of operating room charges for robot-assisted gynaecologic surgery: Efficiency strategies in the operating room for reducing the costs.

OBJECTIVE: To analyse the steps taking place in the operating room (OR) before the console time starts in robot-assisted gynaecologic surgery and to identify potential ways to decrease non-operative time in the OR. MATERIAL AND METHODS: Thirteen consecutive robotic cases for benign gynaecologic disease at the Department of Obstetrics and Gynecology at University of Texas Medical Branch (UTMB) were retrospectively reviewed. The collected data included the specific terms 'Anaesthesia Done' (step 1), 'Drape Done' (step 2), and 'Trocar In' (step 3), all of which refer to the time before the actual surgery began and OR charges were evaluated as level 3, 4, and 5 for open abdominal/vaginal hysterectomy, laparoscopic hysterectomy, and robot-assisted hysterectomy, respectively. RESULTS: The cost of the OR for 0-30 minutes and each additional 30 minutes were $3,693 and $1,488, $4,961 and $2,426, $5,513 and $2,756 in level 3, 4, and 5 surgeries, respectively. The median time for step 1 was 12.1 min (5.25-23.3), for step 2 was 19 (4.59-44) min, and for step 3 was 25.3 (16.45-45) min. The total median time until the actual operation began was 54.58 min (40-100). The total cost was $6948.7 when the charge was calculated according to level 4 and $7771.1 when the charge was calculated according to level 5. CONCLUSION: Robot-assisted surgery is already 'cost-expensive' in the preparation stage of a surgical procedure during anaesthesia induction and draping of the patient because of charging levels. Every effort should be made to shorten the time and reduce the number of instruments used without compromising care. (J Turk Ger Gynecol Assoc 2014; 15: 25-9).

Balloon tamponade for the management of postpartum uterine hemorrhage.

OBJECTIVE: To evaluate the use of the Bakri balloon in postpartum hemorrhage (PPH) resistant to medical treatment. METHODS: The Bakri balloon was applied to 45 women with PPH after failure of initial management. Bilateral internal iliac artery ligation (BIIAL) and hysterectomy were performed if necessary. RESULTS: The Bakri balloon was applied in 45 women; an additional BIIAL was required in nine women. The mean inflation volume of the Bakri balloon was 571±264 mL (range: 240-1300 mL). Hemostasis was achieved in 34 (75.5%) women with the Bakri balloon alone, and in six women with an additional BIIAL. The Bakri balloon was effective with additional procedures overall in 40 of 45 (88.8%) women. In 34 women with uterine atony, the Bakri balloon was successful alone in 27 (79.4%) and with an additional BIIAL in 30 (88.2%) women. An inflation volume of >500 mL was necessary in 18 women with uterine atony. CONCLUSION: The Bakri balloon may be performed as a first line of treatment for PPH resistant to uterotonic agents, and can be used not only in tertiary centers but also in limited-resource centers. The inflation volume of the Bakri balloon should be adjusted according to the type of PPH; a volume exceeding 500 mL may be necessary in uterine atony.

Outpatient robotic hysterectomy: clinical outcomes and financial analysis of initial experience.

BACKGROUND: Robotic surgery is associated with several advantages but also high costs. This study evaluates clinical outcomes and financial feasibility of outpatient robotic hysterectomy. METHODS: Retrospective cohort study (Class II-2) of patients who underwent robotic hysterectomy for benign conditions by the same surgeon (M.A.B.) at the University of Texas Medical Branch, Galveston, TX, USA, during November 2010-February 2013. The study only included cases considered appropriate for outpatient management. Clinical outcomes and costs for patients discharged the same day (outpatients) were compared to those electively admitted (hospitalized). RESULTS: Twenty-nine cases (14 outpatient and 15 hospitalized) were analysed. Demographic, pre-, peri- and postoperative characteristics and payer types were not different among the groups (p > 0.05). Outpatient hysterectomy was associated with $4968 hospital savings (p < 0.001), $410 payer savings (p = 0.775) and $4558 improvement in net profit/loss (p = 0.01). CONCLUSIONS: In well-selected patients, adopting a well-designed programme, outpatient robotic hysterectomy seems to be safe and financially feasible.

Outcomes of robotic sacrocolpopexy using barbed delayed absorbable sutures.

STUDY OBJECTIVE: To evaluate 1-year outcomes of robotic sacrocolpopexy (RSC) for pelvic organ prolapse using barbed delayed absorbable sutures. DESIGN: Retrospective cohort study (Class II-3). SETTINGS: University-based hospital in Southeast Texas. PATIENTS: Patients with symptomatic apical pelvic organ prolapse who underwent RSC using barbed delayed absorbable sutures between January 2011 and August 2012. Patients were examined postoperatively at least twice (after 6 weeks and 1 year). INTERVENTIONS: RSC procedure. MEASUREMENTS AND MAIN RESULTS: The study included a total of 20 patients, of them 15 had grades 3 or 4 whereas 5 had grade 2 apical defects according to the Baden-Walker classification system. Fourteen patients (70%) underwent concomitant hysterectomy while 9 (45%) underwent concomitant anti-incontinence surgery. Mesh suturing times were 46.9 ± 12.6 and 20.5 ± 9.3 minutes in the first 10 versus the last 10 cases, respectively (p < .001). The mean follow-up duration was 17.3 months (range, 12-24 months). There were no recurrences of apical defects or mesh/suture exposure/erosion. However, 1 patient developed a grade 2 cystocele, and another developed new-onset urinary incontinence, both after 1 year. A third patient's urine leakage did not improve postoperatively. Lastly, a fourth patient developed port site incisional hernia and underwent repair 5 months later. CONCLUSION: Our study suggests that barbed delayed absorbable sutures are safe and effective in RCS procedures over 1 year. Larger, comparative, and randomized trials are recommended for definitive conclusions.

Trocar site hernia on an 8-mm port following robotic-assisted hysterectomy.

The increasing use of laparoscopy has resulted in added complications specific to the laparoscopic approach, such as trocar site hernia (TSH), which is an uncommon but well-recognized problem for both regular laparoscopic and robotic-assisted laparoscopic procedures. We describe an extremely rare case of TSH at an 8-mm port site occurring a relatively short time after surgery in a 53-year-old patient undergoing robotic-assisted laparoscopic hysterectomy for benign reasons. Additionally, this report attempts to explain the possible etiological factors relating to TSH following robotic-assisted surgery. According to our case report, a defect in the 8-mm port that may lead to hernia is one possible explanation, and closure of the 8-mm trocar sites' fascia may be a safer approach during robotic-assisted surgery. Additional reports are needed to accurately determine the frequency of occurrence and importance of this complication.

Economic impact of blood transfusions: balancing cost and benefits.

Blood transfusions may be lifesaving, but they inherit their own risks. Risk of transfusion to benefit is a delicate balance. In addition, blood product transfusions purchases are one of the largest line items among the hospital and laboratory charges. In this review, we aimed to discuss the transfusion strategies and share our transfusion protocol as well as the steps for hospitals to build-up a blood management program while all these factors weight in. Moreover, we evaluate the financial burden to the health care system.

Effect of residents' previous laparoscopic surgery experience on initial robotic suturing experience.

Objective. To assess the impact of gynecology residents' previous laparoscopic experience on the learning curve of robotic suturing techniques and the value of initial structured teaching in dry lab prior to surgery. Methods. Thirteen gynecology residents with no previous robotic surgery experience were divided into Group 1, consisting of residents with 2 or fewer laparoscopic experiences, and Group 2, consisting of residents with 3 or more laparoscopic experiences. Group 1 had a dry-laboratory training in suturing prior to their initial experience in the operating room. Results. For all residents, it took on average 382 ± 159 seconds for laparoscopic suturing and 326 ± 196 seconds for robotic suturing (P = 0.12). Residents in Group 1 had a lower mean suture time than residents in Group 2 for laparoscopic suturing (P = 0.009). The residents in Group 2, however, had a lower mean suture time on the robot compared to Group 1 (P = 0.5). Conclusion. Residents with previous laparoscopic suturing experience may gain more from a robotic surgery experience than those with limited laparoscopic surgery experience. In addition, dry lab training is more efficient than hands-on training in the initial phase of teaching for both laparoscopic and robotic suturing skills.

Primary tracheal adenocystic carcinoma and tracheal tumors during pregnancy.

Cancer complicates approximately 0.1% of all pregnancies. Primary tracheal carcinoma is one of very rarely seen tumors and the rate of its being seen makes up approximately % 0.2 of all tumors of respiratory tract. The patient, 28 years old, who has 28-weeks-pregnant, was diagnosed with primary tracheal adenocystic carcinoma. Patient was made operation as thoracotomy and tracheal tumor was removed at the 28(th) week of pregnancy. Patient was delivered with sectio abdominale at the 39(th) week of pregnancy. Primary tracheal adenocystic carcinoma is very rarely seen tumors and it is the first tracheal ACC with pregnancy case in literature to have been detected and surgically treated during pregnancy. We discussed primary tracheal adenocystic carcinoma and tracheal tumors during pregnancy with literature.

Comparison of Perioperative Outcomes of Total Laparoscopic and Robotically Assisted Hysterectomy for Benign Pathology during Introduction of a Robotic Program.

Study Objective. Prospectively compare outcomes of robotically assisted and laparoscopic hysterectomy in the process of implementing a new robotic program. Design. Prospectively comparative observational nonrandomized study. Design Classification. II-1. Setting. Tertiary caregiver university hospital. Patients. Data collected consecutively 24 months, 34 patients underwent laparoscopic hysterectomy, 25 patients underwent robotic hysterectomy, and 11 patients underwent vaginal hysterectomy at our institution. Interventions. Outcomes of robotically assisted, laparoscopic, and vaginal complex hysterectomies performed by a single surgeon for noncancerous indications. Measurements and Main Results. Operative times were 208.3 ± 59.01 minutes for laparoscopic, 286.2 ± 82.87 minutes for robotic, and 163.5 ± 61.89 minutes for vaginal (P < .0001). Estimated blood loss for patients undergoing laparoscopic surgery was 242.7 ± 211.37 cc, 137.4 ± 107.50 cc for robotic surgery, and 243.2 ± 127.52 cc for vaginal surgery (P = 0.05). The mean length of stay ranged from 1.8 to 2.3 days for the 3 methods. Association was significant for uterine weight (P = 0.0043) among surgery methods. Conclusion. Robotically assisted hysterectomy is feasible with low morbidity, a shorter hospital stay, and less blood loss. This suggests that robotic assistance facilitates a minimally invasive approach for patients with larger uterine size even during implementing a new robotic program.