The impact of surgeon volume on perioperative outcomes in hysterectomy.

BACKGROUND AND OBJECTIVES: To estimate the effect of surgeon volume on key perioperative outcomes after all modes of hysterectomy. METHODS: We performed a review of 1914 hysterectomies performed at a large, academic tertiary-care hospital. Women who underwent abdominal, laparoscopic, vaginal, or robotic hysterectomy for benign non-obstetric indications in 2006, 2009, and 2010 were included. RESULTS: Gynecologic surgeons were categorized according their average annual hysterectomy case volume: low volume (<11 cases per year), intermediate volume (11-50 cases per year), and high-volume (>51 cases per year). Taking all modes of hysterectomy together, surgeries performed by high-volume surgeons required a shorter operative time (155.11 minutes vs 199.19 -203.35 minutes, P<.001) and resulted in less estimated blood loss compared with low- and intermediate-volume surgeons (161.09 mL vs 205.58 -237.96 mL, P<.001). The 3 surgical volume groups did not differ from each other significantly in the conversion to laparotomy, readmission rate, or incidence of intraoperative or postoperative complications. These findings were maintained when subgroup analyses were performed by type of hysterectomy, with few exceptions. In the subgroup of vaginal hysterectomies by intermediate-volume surgeons, there were slightly more postoperative complications. There were fewer intraoperative complications in laparoscopic/robotic hysterectomies performed by high-volume surgeons, though not statistically significant. CONCLUSIONS: Hysterectomies performed by high-volume surgeons at our institution during the 3-year study period were associated with shorter operative times and less estimated blood loss.

[Summary of the practice guideline 'Heavy menstrual bleeding']. / Samenvatting richtlijn 'Hevig menstrueel bloedverlies'.

A new multidisciplinary practice guideline on heavy menstrual bleeding (HMB) has recently been published. HMB may occur with or without structural abnormalities. The pictorial blood loss assessment chart (PBAC) is the best method for estimating the amount of blood loss and for distinguishing between heavy and normal blood loss. Haemoglobin levels should be determined at least once. Transvaginal ultrasound is the preferred imaging technique. Saline or gel infusion sonography should be used in cases where ultrasound results are suspect for intracavitary abnormalities. A hysteroscopy should only be performed if sonography results are inconclusive. The very first treatment of choice should be placement of a hormone-impregnated intrauterine system. For HMB without structural abnormalities, endometrial ablation is an alternative to hysterectomy, whereby second-generation ablation techniques are preferred to first-generation techniques. For HMB with uterine fibroids, uterine artery embolisation is a good alternative to hysterectomy. For HMB with submucosal fibroids, hysteroscopic resection of the fibroids is recommended.

Preconceptional laparoscopic abdominal cerclage: a multicenter cohort study.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of laparoscopic abdominal cerclage placement in the prevention of recurrent preterm birth. STUDY DESIGN: We conducted a multicenter cohort study with retrospective Dutch (32 patients) and Boston (34 patients) cohorts who had undergone preconceptional laparoscopic abdominal cerclage placement. Eligible patients had at least 1 second/third trimester fetal loss or delivered at <34 weeks of gestation because of cervical insufficiency and/or a short or absent cervix. Primary outcome was delivery of an infant at ≥ 34 weeks of gestation with neonatal survival. Secondary outcome measures included surgical and pregnancy outcomes and patients' satisfaction (Dutch cohort). RESULTS: Surgical outcomes of 66 patients were excellent, with 3 minor complications. After preconceptional laparoscopic abdominal cerclage, 35 pregnancies were evaluated. Twenty-five patients (71.4%) delivered at ≥ 34 weeks of gestation; 3 patients (8.6%) experienced a second-trimester fetal loss. The total fetal survival rate was 90.0%. CONCLUSION: Preconceptional laparoscopic abdominal cerclage shows encouraging and favorable perinatal outcomes in patients with a poor obstetric history.

Case report: a novel method for uterine-sparing hysteropexy.

OBJECTIVE: The objective of this study was to describe a technique for uterine-sparing hysteropexy. CASE REPORT: A 50-year-old multiparous woman with pelvic organ prolapse underwent laparoscopic sacrohysteropexy utilizing polypropylene mesh with good clinical result. CONCLUSIONS: Placement of mesh arms medial to the uterine vessels during a laparoscopic sacrohysteropexy can be facilitated by using blunt needles to introduce the mesh arms.