Intraoperative Complications and Perioperative and Surgical Outcomes of Single-Port Robotics-Assisted Sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: The objective was to assess intraoperative and postoperative complication rates, along with perioperative and surgical outcomes, following single-port robotics-assisted sacrocolpopexy. METHODS: This retrospective case series included 200 patients who underwent single-port robotics-assisted sacrocolpopexy to treat Pelvic Organ Prolapse Quantification (POPQ) stage 2-4 symptomatic prolapse between April 2020 and August 2023 by a single surgeon. Intraoperative and postoperative complications and perioperative outcomes were evaluated for all the patients, whereas surgical outcomes for 74 patients were assessed at 1-year follow-up. Surgical failure was defined as the presence of any of the following: the presence of vaginal bulging symptoms, any prolapse beyond the hymen, or retreatment for prolapse. RESULTS: During the study period, 200 single-port robotics-assisted sacrocolpopexies were performed. The median age and body mass index were 65.0 years and 24.6 kg/m2 respectively. Most patients had POPQ stage 3 or 4 prolapse and underwent concomitant total hysterectomy. The median total operation time was 212.0 min, and none of the patients required conversion to laparoscopy or laparotomy. The intraoperative cystotomy rate was 2.5%, and one patient had a blood transfusion owing to presacral vessel injury. Postoperative complications of mesh exposure and wound hernia were 0.5% and 2.0% respectively. At 1 year postoperatively, the rate of composite surgical failure was 9.5%, with a 5.4% anatomical recurrence rate. None of the patients experienced apical prolapse recurrence, and one received anterior colporrhaphy for anterior compartment prolapse recurrence. CONCLUSIONS: Single-port robotics-assisted sacrocolpopexy is safe and effective, with low complication rates and favorable perioperative and surgical outcomes.

Arthroscopic Lower Trapezius Tendon Transfer for a Patient with Axillary Nerve Injury and Concomitant Rotator Cuff Tear: A Case Report and Technical Notes.

Introduction: Concomitant nerve injuries with musculoskeletal injuries present a challenging problem. The goals of nerve reconstruction for the shoulder include shoulder abduction and external rotation. When patients fail to achieve acceptable shoulder external rotation and shoulder abduction, tendon transfers such as trapezius transfer offer a reliable option in the subsequent stage. Case Presentation: A 32-year-old male presented with weak external rotation in his left shoulder, after previous axillary nerve reconstruction. He received the ipsilateral lower trapezius transfer with the aim of improving the external rotation. Discussion: The lower trapezius restores a better joint reaction force in both the compressive-distractive and anterior-posterior balancing and provides a centering force through the restoration of the anterior-posterior force couple. Conclusion: We believe that the ipsilateral lower trapezius transfer to the infraspinatus is a good outcome and is effective in improving overall shoulder stability and the shoulder external rotation moment arm or at least maintaining in neutral position with the arm fully adducted in patients with post axillary nerve injuries post unsatisfactory nerve reconstruction to increase the quality of life and activities of daily living.

Same-day Discharge after Robotic Hysterectomy for Benign Conditions: Feasibility and Safety.

STUDY OBJECTIVE: To investigate the feasibility and predictive factors for same-day discharge (SDD) after robotic hysterectomy (RH) for benign indications to optimize patient selection by incorporating preoperative, intraoperative, and postoperative variables. DESIGN: A single-center retrospective cohort study. SETTING: Tertiary academic hospital. PATIENTS: Patients undergoing RH for benign indications. INTERVENTIONS: Patients were designated for SDD by implementing enhanced recovery after surgery protocol. MEASUREMENTS AND MAIN RESULTS: The study included 890 patients who underwent RH for benign indications between the years 2016 and 2021. Of these, 618 (69.4%) were discharged the same day and 272 (30.5%) were admitted for overnight stay. Both groups had similar age (46.4 vs 46.2 years), body mass index (28.3 vs 28.9), and indications for surgery. In multivariable logistic regression, factors that were significant for overnight stay were American Society of Anesthesiologists score 3, Charlson comorbidity index, previous laparotomy, and operative time. Other factors such as surgery start time and preoperative hemoglobin levels were not statistically significant. Postoperative outcomes were comparable for both groups with similar readmission and reoperation rates. CONCLUSION: The likelihood of SDD after RH in this cohort after implementing enhanced recovery after surgery protocol was almost 70%, and most of the predictive factors for overnight stay were nonmodifiable. Importantly, both groups had similar outcomes after surgery.

Shared decision-making in opioid prescribing for minimally invasive hysterectomy: A prospective randomized controlled trial.

OBJECTIVE: To determine the impact of shared decision-making in postsurgical opioid prescribing in women who underwent minimally invasive (MIS) hysterectomy. DESIGN: A randomized controlled trial. SETTING: A single, tertiary care, academic center. PATIENTS AND PARTICIPANTS: From January 2019 through April 2020, 73 women aged 18 years and older who had a planned MIS hysterectomy with the Department of Gynecology were enrolled into the study (36 in the standard arm and 37 in the patient-directed arm). INTERVENTIONS: Participants were assigned either to the standard arm (30 tablets) or patient-directed arm (0-30 tablets) of oxycodone 5 mg. MAIN OUTCOME MEASURES: The primary outcome was the percentage of excess opioid tablets, calculated by the number of unused tablets divided by the number of tablets prescribed. Secondary outcomes included total opioid tablets used, frequency of obtaining additional opioid tablets after discharge, frequency of unscheduled post-operative visits, and patient satisfaction with number of opioid tablets prescribed. RESULTS: Age, race, and body mass index did not differ between groups. Hysterectomies were performed via laparoscopy (16.9 percent), robotic-assisted laparoscopy (38.5 percent), and vaginal routes (44.6 percent). The median (IQR) number of oxycodone prescribed in the patient-directed arm was 15.0 (12.0 and 24.0) tablets. The standard arm had a greater percentage of excess oxycodone tablets 73.6 percent (0.03) than the patient-directed arm 56.3 percent (0.03, p < .01). However, there was no difference in the total number of oxycodone used by patients in the standard (mean 7.9 [0.5] tablets) and patient-directed arms (mean 8.4 [0.5] tablets, p = .50). The mean number of oxycodone used for the entire cohort was 8.1 (0.4) tablets. CONCLUSIONS: Shared decision-making significantly decreased the percent of excess oxycodone tablets but did not decrease the total number of oxycodone tablets used in patients undergoing MIS hysterectomy. Patients used about 22 tablets less than the standard 30 tablets prescribed.

Does a Uterine Manipulator Increase the Distance of the Ureter to the Cervix and/or Vagina? An Anatomical Cadaver Study.

STUDY OBJECTIVE: To determine whether advancing a manipulator increased the distance of the ureter to the cervix and/or vagina. DESIGN: Prospective. SETTING: Academic institution. PATIENTS: A total of 22 intact fresh-frozen female pelvises. INTERVENTIONS: A total of 6 ureteral distances were measured per pelvis. Included were the following measurements on each side: (1) from the lateral cervical wall to the ureter at the intersection with the uterine artery; (2) from the lateral cervical wall to the parametrial ureter; and (3) from the vagina to the ureter at the intersection with the uterine artery. All measurements were obtained with and without advancement of a uterine manipulator. MEASUREMENTS AND MAIN RESULTS: The average distance from the ureter to the cervix and vagina without advancing the manipulator was 2.8 and 3.1 cm, respectively, and the distance from the parametrial ureter to the cervix was 3.3 cm. When the manipulator was advanced, all ureteral distances increased by 0.8, 0.6, and 0.6 cm, respectively, in 12 of the 22 pelvises (55%). Advancing the manipulator did not increase at least 1 of the distances in 10 of the 22 pelvises (45%). The advancement of the manipulator lengthened the 2 shortest ureteral distances of 1 cm noted in 1 pelvis (4.5%) by 0.9 and 0.4 cm. CONCLUSION: The uterine manipulator increased the distance of the ureter to the cervix and vagina for all measurements in 55.5% of the pelvises. The greatest increase was 0.9 cm. The manipulator did not increase at least 1 of the distances in 10 of the 22 pelvises (45.4%).

Differential expression of nuclear hormone receptors by dendritic cell subsets in human vaginal mucosa and skin.

Nuclear hormone receptors (NHRs) expressed by dendritic cells (DCs), the major immune inducers and regulators, could play important roles in host immunity. Assessment of NHRs expressed by DCs in the vaginal mucosa (VM), in comparison with those expressed by DCs in other tissues, will thus help us understand the immunology of human vagina. This study identified 16 NHR transcripts that are differentially expressed among 8 different antigen-presenting cell (APC) subsets isolated from human VM, skin, and blood. The expression profiles of NHRs were largely tissue specific. VM APCs expressed increased levels of LXRA, RXRA, ESRRA, ESRRAP2, and PPARG, whereas skin and blood APCs expressed increased levels of NURR1, NOR1 and RARA. Of interest, female sex hormone receptors, ESR1 and PGR, were found to be mainly expressed by non-APC cell types in the VM; ESR1 by HLA-DR+CD34+ and PGR by HLA-DR- cells. ERα and PR were expressed by vimentin+ cells in the VM, but not in human skin. ERα, but not PR, was also expressed in CD10+ cells in the lamina propria of VM. In conclusion, NHR expression by APC subsets is tissue- and cell type-specific. Future studies on the roles of individual NHRs expressed by different cell types, including DC subsets, in the human VM are warranted.

Cell type-specific expression of estrogen and progesterone receptors in the human vaginal mucosa.

Female sex hormones affect the immune response in the lower female genital tract. To understand their mechanisms of action, it is essential to define cell types expressing estrogen receptor (ER) and/or progesterone receptor (PR) in the human vaginal mucosa (VM). Here, we report that none of the dendritic cell (DC) subsets in the human VM expressed ERα or PR in situ. However, they were capable of expressing ERα, but not PR, after in vitro culture of the whole VM tissues. Similarly, ERα and/or PR expression by T cells in the VM tissues was also inducible rather than constitutive. In contrast, ERα and/or PR were constitutively expressed in HLA-DR- non-immune cell types (vimentin+, desmin+, or CD10+). These new findings will help us understand the mechanisms of action of female sex hormones in the modulation of immune response in the human VM and lower female genital tract.

Engaging the opioid epidemic head on: Improving proper disposal of unused opioid medications after surgery.

BACKGROUND: Currently, in the United States, there is an epidemic of opioid abuse. While this problem is well known to the public due to significant media and political attention, patients are poorly educated on the proper handling and disposal of unused opioids. Instead, the onus has fallen on the healthcare provider to minimize the number of opioids prescribed. STUDY OBJECTIVE: To improve proper opioid disposal rates after gynecologic surgery by providing educational materials along with a disposal bag. STUDY DESIGN: We performed a prospective study evaluating baseline understanding of medication disposal using a questionnaire given to the patients during their preoperative visit. Subsequently, patients were provided written information on proper disposal of their medications and an activated charcoal medication disposal bag. Study patients completed a survey about disposal of their unused opioids at their last post-operative visit. The success of education and proper disposal of opioid medications were evaluated. RESULTS: Thirty-five patients, average age of 45 (range 20-77), were enrolled, and 31 patients successfully completed both surveys. The surgeries performed included hysterectomy 23 percent (n = 7), laparoscopic excision of endometriosis 32 percent (n = 10), laparoscopic ovarian cystectomy 23 percent (n = 7), prolapse repair 3 percent (n = 1), and midurethral sling procedures 19 percent (n = 6). Chronic pelvic pain was identified in 39 percent (n = 12) of our patient population. Prior to education, 52 percent (n = 16) of patients did not dispose of their opioids. Furthermore, 71 percent (n = 22) of patients stated they had never been educated by a medical provider regarding appropriate disposal. Nineteen percent (n = 6) confirmed they have used an opioid medication prescribed to someone else. Demographic data show 65 percent (n = 20) of these patients had completed a college degree or greater. After education and being given a reliable option for medication disposal with the Deterra® bag, 94 percent (n = 29) of patients properly disposed of their opioids after surgery, demonstrating a 45 percent (p < 0.001) increase in proper disposal. In our study alone, 491 tablets of 5mg oxycodone were properly disposed. The majority of patients, 77 percent (n = 24) used the drug disposal bag, and when queried, stated they would be willing to pay on average $7.70 (range 0-20) per bag. Without education and a simple option for disposal, 422 tablets prescribed may have been subject to inappropriate diversion. CONCLUSION: This study clearly shows that patient education, coupled with a reliable option for opioid disposal, is effective. We strongly encourage other surgical institutions to implement similar practices not only for our surgical patients' safety, but also for the tens of thousands of patients who died of opioid abuse in the last year.

Expanding the Horizon: Single-port Robotic Vascularized Omentum Lymphatic Transplant.

Vascularized omentum lymphatic transplant is frequently used for the treatment of lymphedema due to demonstrated efficacy, a reduced complication profile, and, in particular, negligible risk of donor site lymphedema. Historically harvested by open laparotomy, more recent techniques involve laparoscopic omental harvest. Although effective and reproducible, laparoscopy may be limited by reduced visualization, minimal tactile feedback, multiple port sites, and imprecise instrumentation. Therefore, we employed the da Vinci Single-Port (SP) surgical robot system for vascularized omentum lymphatic transplant. A 52-year-old man with a 3-year history of progressive left lower extremity swelling and lymphoscintigraphy and magnetic resonance lymphangiogram consistent with lymphedema of unknown etiology underwent vascularized omentum lymphatic transplant to the left groin. A 2.5-cm infraumbilical incision was used for placement of the primary trocar, through which the camera and operating instruments were passed. Following robotic harvest, the omental lymph node flap was transferred to the left groin for microsurgical anastomosis. The procedure was uneventful, and the patient was discharged on postoperative day 1. At 6 weeks, there were no complications. Here, we show for the first time the safety and feasibility of robotic omental lymph node flap harvest for extremity lymphedema using the da Vinci Single-Port robotic system. The benefits of this technology include a minimally-invasive approach that allows for flap dissection and removal through a single 2.5-cm incision. Further investigation is necessary to characterize the indications and limitations of this technique in plastic surgery.

A Case Series of Robot-assisted Rectus Abdominis Flap Harvest for Pelvic Reconstruction: A Single Institution Experience.

STUDY OBJECTIVE: To analyze outcomes and postoperative complications in patients undergoing robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction. DESIGN: Case series. SETTING: Academic setting. PATIENTS: Pelvic reconstruction surgery patients. INTERVENTIONS: The rectus abdominis muscle flap can be used as a flap for pelvic reconstruction, providing a large volume of soft tissue that can be used in the treatment of many comorbid conditions, including genital fistulas, postradiation pelvic exenteration, and abdominoperineal resection defects. Intraperitoneal harvest of the rectus muscle using a robotic approach allows avoidance of laparotomy and subsequent disruption of the anterior rectus sheath, thus preserving the integrity of the abdominal wall. MEASUREMENTS AND MAIN RESULTS: A retrospective analysis of patient demographic and clinical characteristics was performed for all patients who underwent robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction at our institution from October 1, 2016, to October 31, 2018. The postoperative complications analyzed included bowel obstructions, surgical site infections, emergency room visits, and need for readmission. Six patients (4 women and 2 men), with a mean age of 69.2 years (range = 57-79 years) and median follow-up time of 9.2 months (range = 5-12 months), were included. Muscle flap harvest was performed on the right side in 4 patients and on the left in 2 patients. The indications for reconstructive surgery included vesicovaginal fistula, complex pelvic organ prolapse, anterior and posterior exenteration, partial and total vaginectomy, partial vulvectomy, and abdominoperineal resection. Two patients received neoadjuvant chemoradiation. One of the 6 cases was converted to laparotomy; however, this was not owing to the rectus harvest. Three patients experienced no complications after reconstruction; 1 patient reported occasional abdominal pain; 1 patient had intermittent bowel obstruction; and 1 patient developed a pelvic abscess, requiring readmission. All 6 patients achieved satisfactory healing of the pelvic wound after robot-assisted rectus abdominis flap inset. CONCLUSION: Robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction is a reliable means of defect closure, despite the presence of substantial comorbidities and risk factors in this patient cohort. Patient selection and counseling are crucial to optimize surgical outcomes in this complex population.

The Flipped Ovary Sign in Ovarian Torsion.

The diagnosis of ovarian torsion is challenging and relies mostly on morphologic findings. Occasionally, women or children with acute pelvic pain who have undergone an initial ultrasound (US) evaluation with results interpreted as negative for ovarian torsion will return with recurrent or increasing pain, prompting an US reevaluation. The flipped ovary sign refers to a demonstrable change in the orientation of the ovary on follow-up US examinations, recognized by changing positions of ovarian landmarks established by follicles, cysts, or masses. This sign is valuable for identifying ovarian torsion in these patients, even in the absence of classic morphologic or Doppler features of ovarian torsion.

Impact of Uterine Sliding Sign in Routine United States Ultrasound Practice.

OBJECTIVES: The study aim was to evaluate the diagnostic performance of the uterine sliding sign in predicting deeply infiltrating endometriosis in the setting of non-physician sonographers performing but not interpreting the maneuver. The impact of uterine sliding sign has not been previously demonstrated in this practice setting. METHODS: Physicians' remote interpretations of transvaginal ultrasound examinations in 2016, before uterine sliding sign, were compared to examinations in 2019 after addition of uterine sliding sign to determine the diagnostic rates. Surgical and histopathological results were reviewed to determine sensitivity and specificity of the respective exam techniques. RESULTS: Two hundred eighty-five transvaginal ultrasounds were performed in 2016 and 390 sliding sign ultrasounds in 2019. The number of deeply infiltrating endometriosis cases identified increased significantly from 2% to 6% during the study period (chi-square, Fisher's exact test p = .012). The sensitivity and specificity of routine pelvic sonography for detecting deeply infiltrating endometriosis improved from 36%/94% to 68%/98%. CONCLUSIONS: Uterine sliding sign videos should be included in the standard sonographic protocol for patients presenting with chronic pelvic pain, endometriosis history, or sonographic evidence of endometriosis in the setting of physicians interpreting sonographic images obtained by non-physicians.

Robotic LESS and Reduced-Port Hysterectomy Using the da Vinci SP Surgical System: A Single-Institution Case Series.

STUDY OBJECTIVE: To present a series of robotic laparoendoscopic single-site surgery (LESS) and reduced-port hysterectomy cases and discuss the surgical technique required for successful use on this new platform. DESIGN: Retrospective case series. SETTING: Academic medical center. PATIENTS: All patients undergoing robotic LESS or reduced-port hysterectomy with the SP1098 da Vinci SP Surgical System (Intuitive Surgical, Sunnyvale, CA) from December 2019 to March 2020. INTERVENTIONS: Robotic LESS or reduced-port hysterectomy. MEASUREMENTS AND MAIN RESULTS: A total of 8 cases of hysterectomy were performed successfully. Four cases included concomitant resection of endometriosis. Five cases required placement of an additional port. The average uterine weight was 136.1 g ± 61.5 g (range 87-246). The average estimated blood loss was 37.5 mL ± 27 mL (range 20-100). The average operative time was 86.5 minutes ± 27.1 minutes (range 60-132). The time required for vaginal cuff closure was available for patients 5 to 8, and ranged from 10 minutes to 13 minutes. All patients had same-day discharge. There were no conversions to alternative surgical modality, complications, or readmissions. CONCLUSION: Our preliminary experience with the SP1098 da Vinci SP Surgical System demonstrated the technical feasibility and safety of this surgical modality for gynecologic surgery. Additional studies examining postoperative outcomes and prospective studies comparing this modality with traditional robotic surgery are indicated.

Barriers to Referral to Fellowship-trained Minimally Invasive Gynecologic Surgery Subspecialists.

STUDY OBJECTIVE: To determine patterns and barriers for referral to fellowship-trained minimally invasive gynecologic surgeons. DESIGN: Questionnaire. SETTING: United States and its territories and Canada. PARTICIPANTS: Actively practicing general obstetrician/gynecologists (OB/GYNs). INTERVENTIONS: Internet-based survey. MEASUREMENTS AND MAIN RESULTS: Of 157 respondents, 144 (91.7%) general OB/GYNs were included. Subspecialty fellowship training resulted in the exclusion of 13 (8.3%) respondents. A total of 86 respondents (59.7%) considered referral to fellowship-trained minimally invasive gynecologic surgery (MIGS) subspecialists. The top 3 cited reasons for nonreferral were adequate residency training (n = 84, 58.3%), preference for continuity of care (n = 48, 33.3%), and preference for referral to other subspecialists (n = 46, 31.9%). The top 3 cited reasons for referral to MIGS subspecialists were complex pathology (n = 92, 63.9%), complex medical and/or surgical history (n = 76, 52.8%), and out of scope of practice (n = 53, 36.8%). If providers required intraoperative assistance, respondents consulted an OB/GYN colleague with comparable training (n = 50, 34.7%), gynecologic oncologist (n = 48, 33.3%), or non-OB/GYN surgical subspecialist (n = 33, 22.9%). Factors that were not associated with the decision to refer to MIGS subspecialists included years in practice (p = .13), additional training experiences beyond residency (p = .45), and number of hysterectomies performed by laparotomy (p = .69). Self-reported high-volume surgeons (p <.01) were less likely to refer. In contrast, providers who self-reported as low-volume surgeons (p = .02) and were aware of MIGS subspecialists in the community (p <.01) were more likely to consider referral. Respondents reported using a laparoscopic approach to hysterectomy most frequently (n = 79, 54.9%). In contrast, 36.8% preferred the laparoscopic route for themselves or their partner, whereas 48.6% preferred the vaginal approach. CONCLUSION: Most of the general OB/GYNs would consider referral to fellowship-trained MIGS subspecialists. Providers who reported adequate residency training and those who preferred continuity of care or referral to other surgical subspecialists were less likely to refer to MIGS subspecialists.

Nerve-sparing in Gynecology.

OBJECTIVE: To demonstrate identification and dissection of the pelvic autonomic nerves in gynecologic surgery. DESIGN: Identification on the right and left pelvic pelvises, dissection and preservation of the inferior hypogastric plexus in deep endometriosis, and dissection and preservation of the pelvic autonomic nerves in radical hysterectomy. SETTING: Academic center. INTERVENTIONS: Robotic excision of the pelvic peritoneum, excision of deep endometriosis in the uterosacral ligaments, and radical hysterectomy. CONCLUSION: Pelvic autonomic nerves are easy to identify with the magnification provided with an endoscopic camera. They should be dissected and preserved whenever possible because of their important function.

Nerve-sparing in Gynecologic Surgery: A Perspective.

OBJECTIVE: To provide a perspective on nerve-sparing (NS) surgery in gynecology. DATA SOURCES: Literature review, English language. METHODS OF STUDY SELECTION: Systematic reviews and meta-analyses studies were selected for review for oncology; comparative studies were selected for endometriosis, and 1 comparative and 1 prospective study were chosen for sacrocolpopexy. TABULATION, INTEGRATION, AND RESULTS: Two tables summarize the results of systematic reviews and meta-analyses in oncology. Oncology, endometriosis, and urogynecology sections. Primary benefit of NS technique is decreased bladder dysfunction, and, to a lesser degree, vaginal and rectal dysfunc. CONCLUSION: NS is preferable to conventional surgery for benign and malignant conditions to reduce postoperative bladder, rectal, and vaginal dysfunction.

Robotic Harvest of a Rectus Abdominis Muscle Flap After Abdominoperineal Resection.

INTRODUCTION: As multidisciplinary treatment modalities for rectal cancer continue to evolve, neoadjuvant chemoradiation then surgical resection is a common approach. Robotic-assisted abdominoperineal resection is becoming more prevalent in part because of better visualization and instrument mobility within the pelvis. After abdominoperineal resection, postoperative perineal wound complications remain a significant risk. Pelvic reconstruction lowers this risk, and a pedicled rectus abdominis muscle flap is frequently used to achieve this. Traditional flap harvest requires laparotomy, resulting in violation of both rectus sheaths and a large midline scar. Robotic harvest of the rectus abdominis muscle for pelvic reconstruction after abdominoperineal resection is a novel approach with foreseeable benefits. TECHNIQUE: After completion of abdominoperineal resection, 2 additional trocars are inserted in the lateral abdomen, and the robot is reoriented toward the posterior abdominal wall. The peritoneum and posterior rectus sheath are incised, and dissection is carried superiorly and inferiorly in a sagittal plane to reveal the rectus abdominis muscle. The muscle body is separated from the anterior rectus sheath. Once the inferior epigastric artery is identified, the superior pole of the muscle is transected. Continued lateral dissection ensures flap mobility for placement within the pelvis. After obtaining proper reach, the robot is undocked, and the flap is sutured in place through the perineal defect. RESULTS: After trocar placement and robot repositioning, both the colorectal and plastic surgeons trade places at the console. Robotic flap harvest precludes the need for laparotomy. The anterior rectus sheath remains unviolated and the patient avoids an additional midline scar. The aforementioned benefits of robot-assisted abdominoperineal resection, namely increased visualization and maneuverability, were also found applicable when robotically harvesting this flap. CONCLUSIONS: This technique exemplifies an additional minimally invasive technique for patients pursuing abdominoperineal resection. With knowledge of this novel approach, surgeons can better tailor their operations to benefit the patient.

Perioperative Outcomes of Total Vaginal Hysterectomy in Women with Prior Cesarean Delivery.

STUDY OBJECTIVE: To compare the incidence of perioperative complications of total vaginal hysterectomy (TVH) in women with and without a prior cesarean section (CS). DESIGN: Retrospective cohort. SETTING: Tertiary care academic institution. PATIENTS: A total of 742 women who underwent TVH over a 5-year period. INTERVENTIONS: TVH. MEASUREMENTS AND MAIN RESULTS: Prior CS did not increase the overall rate of Clavien-Dindo grades 2 to 3 complications (p =.20). The incidence of cystotomy (2.2% CS vs 1.1% no CS, p =.29), ureteral injury (1.1% vs 0.2%, p =.23), proctotomy (1.1% vs 0.2%, p =.23), postoperative bleeding (1.1% vs 0.6%, p =.47), or reoperation (0.0% vs 0.3%, p = 1.00) was not increased from having a prior CS. Prior CS increased blood transfusion (5.6% vs 0.6%, p <.05) but did not increase conversion to laparotomy (2.2% vs 0.6%, p =.15), length of hospitalization (11.2% vs 14.1% discharge on the same day, 66.3% vs 63.6% discharge on postoperative day 1, and 22.5% vs 22.4% discharge on or after postoperative day 2, p =.76), or 30-day readmission rates (1.1% vs 3.5%, p =.34). CONCLUSION: In patients who underwent TVH, a prior CS increased postoperative blood transfusion but did not increase the risk for overall perioperative complications.