A Novel Technique Using Ultrasonic Shears Versus Traditional Methods of Reduction of Bilateral Labia Minora Hypertrophy: A Retrospective Case-Control Study.

INTRODUCTION: To compare the clinical outcomes of bilateral labia minora hypertrophy reduction using ultrasonic shears versus traditional methods. MATERIALS AND METHODS: In this retrospective study, we evaluate the surgical outcomes of 11 women who underwent bilateral labia minora hypertrophy reduction using ultrasonic shears to 14 women who underwent the same procedure using various traditional methods between January 1, 2015 and February 29, 2020 in a single center. The primary outcomes evaluated are total operative time, estimated blood loss, and postoperative pain. Secondary outcomes include postoperative complications and total admission time. The statistical analyses used were exact Wilconxon Rank and Fisher's exact test. RESULTS: 25 total bilateral labiaplasty procedures were included in the analysis. 11 procedures were performed using ultrasonic shears and 14 were performed using traditional methods. The mean reduction operative time for the ultrasonic shears technique when compared with traditional methods was 43.25 minutes (22.82 minutes versus 66.07 minutes, P = .0002). A statistically significant but non-clinically significant difference in estimated blood loss was noted. No statistically significant differences existed with postoperative pain score, total admission time, or postoperative complications. CONCLUSIONS: Ultrasonic shears significantly reduce the time needed for the reduction of bilateral labia minora hypertrophy and therefore should be considered by surgeons as a useful tool in increasing the efficiency of this procedure.

Continuous Hydrogen Sulfide Gas Monitoring using the PortaSens II Portable Gas Leak Detector Model C16 during Laparoscopic or Robotic Surgery Cannot Be Used Intraoperatively to Detect Bowel Injury.

STUDY OBJECTIVE: To determine the feasibility of measuring hydrogen sulfide (H2S) gas in the insufflated abdomen during laparoscopic surgery after transmural bowel injury as a marker of unrecognized bowel injuries. DESIGN: This is a feasibility study performed on swine models during a robotic training course. We aimed to determine baseline H2S levels and subsequent elevations in H2S levels after enterotomy of the large and small intestines. SETTING: University-based robotic training lab. PARTICIPANTS: Three swine participants. INTERVENTIONS: During initial insufflation of the swine abdominal cavity, baseline H2S levels were recorded over 15-second intervals for 10 minutes using the PortaSens II Portable Gas Leak Detector Model C16 (Analytical Technology, Inc., Collegeville, PA). The same values were recorded in separate studies after transmural transection of the small intestine and the large intestine using laparoscopic shears with and without monopolar electrosurgery. MEASUREMENTS AND MAIN RESULTS: Baseline H2S level over the initial 10 minutes of insufflation was 0 parts per million (ppm). The device is calibrated to detect levels of H2S of 0 ppm to 200 ppm. H2S levels after small and large bowel enterotomies without monopolar electrosurgery initially showed a rise to 1 ppm to 2 ppm. However, repeat confirmatory testing failed to show any elevation in H2S levels. H2S levels after small and large bowel enterotomies with monopolar electrosurgery both showed increases to 108 ppm and 74 ppm with a duration of elevation measuring 4 minutes and 4 minutes 15 seconds, respectively. Although our study did show elevations in H2S after transection with monopolar electrosurgery, this was later determined to be the result of cross contamination with carbon monoxide, which was a confounding factor. CONCLUSION: Our study demonstrated that using the methodology and detection methods described, H2S cannot be used to detect unrecognized bowel injury during laparoscopic surgery. Our results were due to cross contamination with other gases created with the use of electrosurgery, and we were unable to reproduce initial testing results, which did show slight rises in H2S levels after enterotomies without monopolar electrosurgery. Further testing of other gases produced by the gastrointestinal tract or the use of alternative detection methods may provide more clinically relevant results.

Establishing Validity for a Vaginal Hysterectomy Simulation Model for Surgical Skills Assessment.

OBJECTIVE: To use the Messick validity framework for a simulation-based assessment of vaginal hysterectomy skills. METHODS: Video recordings of physicians at different levels of training and experience performing vaginal hysterectomy on a high-fidelity vaginal surgery model were objectively assessed using a modified 10-item Vaginal Surgical Skills Index, a one-item global scale of overall performance, and a pass-fail criterion. Participants included obstetrics and gynecology trainees and faculty from five institutions. Video recordings were independently assessed by expert surgeons blinded to the identities of the study participants. RESULTS: Fifty surgeons (11 faculty, 39 trainees) were assessed. Experience level correlated strongly with both the modified Vaginal Surgical Skills Index and global scale score, with more experienced participants receiving higher scores (Pearson r=0.81, P<.001; Pearson r=0.74, P<.001). Likewise, surgical experience was also moderately correlated with the modified Vaginal Surgical Skills Index and global scale score (Pearson r=0.55, P<.001; Pearson r=0.58, P<.001). The internal consistency of the modified Vaginal Surgical Skills Index was excellent (Cronbach's alpha=0.97). Interrater reliability of the modified Vaginal Surgical Skills Index and global scale score, as measured by the intraclass correlation coefficient, was moderate to good (0.49-0.95; 0.50-0.87). Using the receiver operating characteristic curve and the pass-fail criterion, a modified Vaginal Surgical Skills Index cutoff score of 27 was found to most accurately (area under the curve 0.951, 95% CI 0.917-0.983) differentiate competent from noncompetent surgeons. CONCLUSION: We demonstrated validity evidence for using a high-fidelity vaginal surgery model with the modified Vaginal Surgical Skills Index or global scale score to assess vaginal hysterectomy skills.

Evaluating the Impact of Office Hysteroscopy in a Military Treatment Facility.

INTRODUCTION: Office hysteroscopy has become a cornerstone of modern gynecologic care through the advent of advanced technology and emphasis on an efficient healthcare system. In 2017, Medicare announced an increase in office hysteroscopy reimbursement by 237%, giving an incentive for gynecologists to move from the operating room into the clinic. The U.S. military medical system needs more cost-effective and efficient healthcare, given that the cost of military healthcare increased by 130% between 2000 and 2012 (accounting for 10% or $52 billion of the Department of Defense budget). Within our institution, we have moved to conducting a regularly scheduled outpatient hysteroscopy clinic. Increased healthcare costs, decreased available operating room time, and efforts to boost patient and provider satisfaction drove the change. MATERIALS AND METHODS: After institutional review board approval, we performed a retrospective observational cost-benefit analysis of 235 outpatient and 45 inpatient records that included female military healthcare beneficiaries age 18 or older who had diagnostic or operative hysteroscopy performed in the operating room or office setting from January 2015 to October 2018. We specifically focused on diagnostic hysteroscopy, hysteroscopic biopsy and polypectomy, and hysteroscopic foreign body removal (intrauterine device removal). We then compared admission time, procedure time, reimbursement, and cost for each of the hysteroscopic procedure groups to yield a total cost-benefit value (TCBV). TCBV was defined as cost savings plus difference in reimbursement rate. RESULTS: This study analyzes the costs and benefits of a regularly scheduled hysteroscopy clinic within the U.S. military medical system. We performed a cost-benefit analysis that indicated a substantial difference between clinic and operating room TCBV, total relative value units or reimbursement rates, and total patient care time. We found the average admission time for an inpatient procedure was 6.23 hours compared to our standard 1-hour clinic time. The average success rate for procedure completion in the clinic was 89%. We found the average TCBV for 100 patients (after 11% reoperation rate) to be as high as $64,220, $159,940, and $66,709 for diagnostic hysteroscopy, hysteroscopic biopsy and polypectomy, and hysteroscopic foreign body (intrauterine device) removal, respectively. CONCLUSIONS: Compared to traditional operating room hysteroscopy, we were able to demonstrate reduced costs with increased reimbursement while performing the same scope of care for patients undergoing office hysteroscopy. Decreased total time in performing office hysteroscopy suggests the potential benefit of increased patient and provider satisfaction. Our study indicated substantial incentive for military gynecologists to incorporate office hysteroscopy into their practice given the increased relative value units generated. Our office hysteroscopy protocol is discussed to encourage other military facilities to follow in our footsteps.

The Impact of Robotic-Assisted Technology on Attitudes of Host Nation Individuals Participating in Pacific Partnership 2018: Improving Partnerships Through Technology.

The USNS Mercy (T-AH 19) on Pacific Partnership 2018 was the first mobile, expeditionary platform to utilize the da Vinci Surgical System. Using a de-identified, web-based survey, the impact of this new technology on Pacific Partnership 2018 on the attitudes of host nation surgeons was examined.

Review of Sterilization Techniques and Clinical Updates.

Sterilization is the most common form of contraception used worldwide and is highly effective in preventing unintended pregnancy. Each of the available sterilization methods has unique advantages and disadvantages that influence the choice of approach for each individual patient. Salpingectomy for sterilization has become more popular in recent years, with mounting evidence suggesting a protective effect against ovarian cancers originating in the fallopian tube. At the same time, Essure hysteroscopic sterilization has come under scrutiny because of increasing reports of possible adverse effects associated with its use. Here we review clinical updates in sterilization techniques, with a focus on salpingectomy and Essure hysteroscopic sterilization.

Comparison of two simulation systems to support robotic-assisted surgical training: a pilot study (Swine model).

OBJECTIVE: To compare the efficacy of simulation-based training between the Mimic dV- Trainer and traditional dry lab da Vinci robot training. DESIGN: A prospective randomized study analyzing the performance of 20 robotics-naive participants. Participants were enrolled in an online da Vinci Intuitive Surgical didactic training module, followed by training in use of the da Vinci standard surgical robot. Spatial ability tests were performed as well. Participants were randomly assigned to 1 of 2 training conditions: performance of 3 Fundamentals of Laparoscopic Surgery dry lab tasks using the da Vinci or performance of 4 dV-Trainer tasks. Participants in both groups performed all tasks to empirically establish proficiency criterion. Participants then performed the transfer task, a cystotomy closure using the daVinci robot on a live animal (swine) model. The performance of robotic tasks was blindly assessed by a panel of experienced surgeons using objective tracking data and using the validated Global Evaluative Assessment of Robotic Surgery (GEARS), a structured assessment tool. RESULTS: No statistically significant difference in surgeon performance was found between the 2 training conditions, dV-Trainer and da Vinci robot. Analysis of a 95% confidence interval for the difference in means (-0.803 to 0.543) indicated that the 2 methods are unlikely to differ to an extent that would be clinically meaningful. CONCLUSION: Based on the results of this study, a curriculum on the dV- Trainer was shown to be comparable to traditional da Vinci robot training. Therefore, we have identified that training on a virtual reality system may be an alternative to live animal training for future robotic surgeons.

Magnification effects on distance estimation during robotic suturing.

We aimed to understand the impact of magnification on distance estimation during robotic suturing. Twenty subjects estimated the lengths of various sutures externally, in plain sight, to validate their ability to measure distances. They then robotically repaired a 3-cm cystotomy, suturing 10 mm above and below the incision and 10 mm on either side of the incision. The bladder was removed and distances measured. A total of 20 surgeons were analyzed: 7 residents, 8 fellows, and 5 staff. Specialties comprised four urologists, eight general gynecologists, two urogynecologists, three gynecologic oncologists, and three reproductive endocrinologists. The mean estimation for external suture length was not significant at 10 mm: mean = 9.6 (±3.2) mm (p = 0.59). When comparing these data sets, the externally visualized 10-mm suture versus the suture-to-suture and the suture-to-incision distances were both significantly different (p = 0.002 and p < 0.001, respectively). The mean distance between each suture was 6.5 (±1.8) mm, which was significantly different from the 10-mm goal (p < 0.001, 95 % confidence interval (CI) [-4.4,-2.6]). The mean distance from the suture to the incision was 4.1 (±1.0) mm, which was also statistically significantly different from the goal (p < 0.001, 95 % CI [-6.3,-5.4]). Surgical experience was negatively associated with suture-to-incision distance (r s = -0.53, p = 0.016). Inter-suture distance was also negatively associated with experience (r s = -0.30, p = 0.22), though not statistically significant. In vivo distances are significantly underestimated during robotic suture placement. Interestingly, the most experienced surgeons had the worst distance estimation from the incision to the suture.

Obstetric simulation for medical student, resident, and fellow education.

Simulation for training new providers is no longer the wave of the future, but the reality of the present. It provides significant activation and allows for both the integration of concepts with actual application and the ability to practice a wide range of procedural skills at an earlier stage of training than would otherwise be possible. It is also an optimal method to sharpen teamwork and communication skills that are critical to patient safety. These concepts are especially relevant in the field of obstetrics, where even routine deliveries may become life-threatening emergencies and the health of the mother and child are dependent on correct and timely interventions and teamwork. Almost all of the skills needed, even for advanced invasive procedures, in obstetrics can be taught with currently available simulators. In this report we will discuss the use of medical simulation for training obstetric providers from medical school through subspecialty level training.

Effect of validated skills simulation on operating room performance in obstetrics and gynecology residents: a randomized controlled trial.

OBJECTIVES: To estimate whether training on previously validated laparoscopic skill stations translates into improved technical performance in the operating room. METHODS: We performed a multicenter, randomized, controlled trial evaluating the performance of a laparoscopic bilateral midsegment salpingectomy. Residents were randomized to either traditional teaching (no simulation) or faculty-directed sessions in a simulation laboratory. A sample size of at least 44 lower-level residents (postgraduate year [PGY] 1 or 2) and 66 upper-level (PGY 3 or 4) were necessary to demonstrate a 50% improvement in performance assuming an α error of 0.05 and ß error of 0.20 for each group independently. The primary outcomes were the final total normalized simulation score and the operating room performance score. Paired t test and Wilcoxon rank-sum tests were used to evaluate the differences within and between cohorts. Our final model involved a multiple linear regression analysis for the main effects of a priori--specified variables. RESULTS: We enrolled 116 residents from eight centers across the United States. There was no statistically significant difference in baseline simulation or operative performances. Although both groups demonstrated improvement with time, the trained group improved significantly higher normalized simulation scores (378 ± 54 compared with 264 ± 86; P<.01) and higher levels of competence on the simulated tasks (96.2% compared with 61.1%; P<.01). The simulation group also had higher objective structured assessment of technical skills scores in the operating room (27.5 compared with 30.0; P=.03). CONCLUSION: We found that proficiency-based simulation offers additional benefit to traditional education for all levels of residents. The use of easily accessible, low-fidelity tasks should be incorporated into formal laparoscopic training.

Survey of robotic surgery training in obstetrics and gynecology residency.

To examine the status of resident training in robotic surgery in obstetrics and gynecology programs in the United States, an online survey was emailed to residency program directors of 247 accredited programs identified through the Accreditation Council for Graduate Medical Education website. Eighty-three of 247 program directors responded, representing a 34% response rate. Robotic surgical systems for gynecologic procedures were used at 65 (78%) institutions. Robotic surgery training was part of residency curriculum at 48 (58%) residency programs. Half of respondents were undecided on training effectiveness. Most program directors believed the role of robotic surgery would increase and play a more integral role in gynecologic surgery. Robotic surgery was widely reported in residency training hospitals with limited availability of effective resident training. Robotic surgery training in obstetrics and gynecology residency needs further assessment and may benefit from a structured curriculum.

Simulation training improves resident performance in operative hysteroscopic resection techniques.

OBJECTIVE: The purpose of this study was to determine whether a simulated training scenario improved resident performance in operative hysteroscopic resection. STUDY DESIGN: An interventional cohort study evaluated the ability of a hysteroscopic simulation model to improve resident performance in hysteroscopy. Residents were evaluated on operative hysteroscopy before training and at 1 and 6 months after training. Two physician graders, who were blinded to training status, evaluated the residents' performances. Statistical analyses included the chi2 and the t test, as appropriate. RESULTS: Hysteroscopic simulation training was associated with a reduction in operative times (11.8 minutes vs 7.4 minutes; P < .001) and resection times (4.3 minutes vs 2.4 minutes; P < .007) 1 month after training. At 6 months, total operative times were greater compared with those measured at 1 month, but resection times differed minimally. The total number of questions regarding hysteroscopic knowledge that were answered correctly increased from 15 to 26 (P < .001). CONCLUSION: Training that used a simulation hysteroscopic model improved resident performance.

Use of end-to-end anastomotic sizer with occlusion balloon to prevent loss of pneumoperitoneum in robotic vesicovaginal fistula repair.

Maintaining the pneumoperitoneum in robotic-assisted surgery can be difficult when vaginal integrity is compromised, such as in vesicovaginal fistula. We report an approach using an anastomotic sizer modified with an occlusion balloon for manipulation of the vaginal apex and maintenance of the pneumoperitoneum for robotic-assisted vesicovaginal fistula repair.

Anatomic comparison of two transobturator tape procedures.

OBJECTIVE: Both outside-in and inside-out methods are available for transobturator tape placement. Our objective was to compare these methods regarding proximity of the tape to the obturator canal and ischiopubic ramus. METHODS: Using seven fresh frozen cadavers, transobturator tapes were placed using the inside-out (TVT-Obturator System, Gynecare, Ethicon Inc, Somerville, NJ) and outside-in (Monarc, American Medical Systems, Minnetonka, MN) methods bilaterally in each cadaver. We dissected to the level of the obturator membrane and measured the distance from the closest aspect of the obturator canal and ischiopubic ramus to each tape. RESULTS: Transobturator tapes placed by using the inside-out technique were significantly closer to the obturator canal than with the outside-in method (mean distances: 1.3+/-0.44 cm compared with 2.3+/-0.41 cm, respectively, P<.001); the greater proximity of the inside-out method was noted in all dissections. Tapes placed with the inside-out method were also farther from the ischiopubic ramus than those placed with the outside-in approach (mean distances: 0.39+/-0.44 cm compared with 0.04+/-0.13 cm, respectively, P=.008). When distances between the tapes relative to the obturator canal were further analyzed according to left or right side, the difference between methods was maintained. Additionally, the distances were consistently farther from the obturator canal on the left side than on the right side regardless of transobturator tape approach. CONCLUSION: The outside-in technique results in the mesh being placed farther from the obturator canal and closer to the ischiopubic ramus, theoretically reducing the risk of neurovascular injury. LEVEL OF EVIDENCE: II.

Laparoscopic appendectomy: a series of cases utilizing laparosonic coagulating shears as compared to endo-GIA and endoshears.

OBJECTIVE: To report a series of laparoscopic appendectomies utilizing laparosonic coagulating shears (LCS) (harmonic scalpel). STUDY DESIGN: We conducted a retrospective chart underwent laparoscopic appendectomy at Walter Reed Army Medical Center between January 1, 1996, and December 31, 2001. Procedures were included if only 1 instrument was utilized for transection of the appendix: endoshears, endo-GIA (Tyco U.S. Surgical, Norwalk, Connecticut) or LCS. Procedures on ruptured appendixes and emergency procedures were excluded. Outcome variables of interest included operative time, estimated blood loss, length of hospital stay and complications. RESULTS: Mean estimated blood loss, mean operative times and hospital stay were consistent with those of other techniques of laparoscopic appendectomy. LCS was used more frequently for appendectomy performed at the time of another procedure than were endo-GIA and endoshears. There were no complications in the harmonic scalpel laparoscopic appendectomy series. CONCLUSION: This series demonstrates that laparoscopic appendectomy with LCS has low morbidity and is as efficacious as other methods of laparoscopic appendectomy.

Conservative management of spontaneous uterine perforation associated with placenta accreta: a case report.

BACKGROUND: Placenta accreta occurring in an unscarred uterus is exceedingly rare. Previous cases of spontaneous uterine perforation associated with placenta accreta were treated with hysterectomy. CASE: A nulliparous woman was clinically diagnosed with placenta accreta when spontaneous vaginal delivery was complicated by postpartum hemorrhage and a retained placenta. Magnetic resonance imaging subsequently revealed focal areas of placenta accreta. Acute-onset abdominal pain and cul-de-sac fluid prompted diagnostic laparoscopy, which revealed a spontaneous uterine perforation in the right posterior-lateral aspect of the uterus. This area was oversewn, and the patient received 2 weeks of postoperative antibiotics because of Enterococcus faecalis bacteremia. CONCLUSION: Spontaneous uterine perforation associated with placenta accreta can be managed conservatively.

Laparoscopic exposure in obese high-risk patients with mechanical displacement of the abdominal wall.

BACKGROUND: Patients with morbid obesity or pulmonary disease are at a higher risk for complications during advanced laparoscopic procedures. Higher intraperitoneal carbon dioxide pressures required to elevate the pannus can negatively impact hemodynamic and respiratory parameters. CASES: We describe a technique that uses a combination of a mechanical retractor and a Foley catheter inserted midway between the umbilicus and the pubic symphysis that assists in elevating the anterior abdominal wall. In 3 cases this technique allowed for a low-pressure pneumoperitoneum during advanced laparoscopic pelvic surgery, which resulted in improved hemodynamic parameters and pulmonary function in these high-risk patients. CONCLUSION: The Foley Lap-Lift facilitated laparoscopy through mechanical abdominal wall elevation and allowed for a lower-pressure pneumoperitoneum. This technique is an addition to traditional operative laparoscopy in select high-risk patients.