2015 Award Winning Abstracts & Videos

2015 Award Oral Winning Abstracts & Videos Presentations WEDNESDAY, NOVEMBER 19, 2014

an aborting myoma. This was Stage II at presentation and has required

treatment. second wason occult found at the time of Gyneprolapse Listed below are the winning abstracts and videos for the 44thfurther AAGL GlobalTheCongress Minimally Invasive 1 Plenary 1 - Laparoscopy surgery and would have been considered Stage Ia1 if not morcellated. She cology.(11:00 All of these awards will be presented during the General Session on Tuesday, November 17, 2015 at 7:45am AM - 11:09 AM) has not had any other treatment and remains without evidence of to 9:05am, except for the Robert B. Hunt award, which will berecurrence presented during thesurgery. JMIG Breakfast. They also will 2 years after the Morcellated Uterine Pathology in 815 Consecutive Conclusion: The majority of the cases in this series (99.75%) were benign. be presented at their regularly scheduled times. Patients at a Single Academic Institution Ascher-Walsh CJ, Rosen L, Perera E, Robbins A, Sekhon L, Barr R, Mamik M. Obstetrics, Gynecology and Reproductive Sciences, Icahn School of Medicine at Mt. Sinai, New York, New York

Golden Hysteroscope Award Best onToHysteroscopy Study Paper Objective: assess the risk of

abnormal uterine pathology in patients undergoing laparoscopic supracervical hysterectomy or laparoscopic myomectomy 14 (7:45 AM - 8:00 with AM)specimen power morcellation. Design: Retrospective chart review. Setting: University Hospital. Metroplasty With the CombinaAccuracy of Hysteroscopic Patients: consecutive laparoscopic supracervical hysterectomies tion of Pre825 Surgical Three-Dimensional Ultrasonography andor myomectomies from 6/06 through A 7/13 performed by the alaparoscopic Novel Graduated Intrauterine Palpator: Randomized same surgeon. Controlled Trial 1Intervention: Laparoscopic 2 laparoscopic Di Spiezio Sardo A, 1Zizolfi B,supracervical Bettocchi S, 3hysterectomy Exacoustos C,or1Nocera C, 1myomectomy 1 with specimen 1 removed by power morcellation. Means and Nazzaro G, Nappi C. Unit of Obstetrics and Gynecology, University standard deviations calculated withofSPSS software of Federico II, Naples, Italy; 2Unit Obstetrics andpackage. Gynecology, Measurements and Main Results: 394 cases wereUniversity laparoscopic Department of Biomedical Sciences and Human Oncology, supracervical hysterectomies and of 431 cases were “Aldo Moro,” Bari, Italy; 3University “Tor Vergata,” Rome,laparoscopic Italy myomectomies.

Study Objective: To assess whether the use of a novel graduated intrauterDemographics ine palpator can improve the accuracy of hysteroscopic metroplasty introMeancriteria Age Mean Parity Mean BMI ducing objective intraoperative (SD) study (SD) (SD) Design: Prospective randomized Setting: University Federico II Hysteroscopic clinic Lapx myomectomy, 40.45 (11.95) 0.22 (0.58) 24.67 (5.36) Patients: n=431 90 women with uterine septum diagnosed with 3D-transvaginal ultrasound randomized T (metroLapx SCH,(3D-TVS) n=394 were47.61 (7.84) into two 1.55groups: (1.62) Group27.70 (6.49) plasty with intrauterine palpator) (n = 45) and Group C (metroplasty without intrauterine palpator) (n =45). Majority of theambulatory cases in both groups were simple myomas in sethe Intervention: hysteroscopic metroplasty under (52.8% conscious laparoscopic hysterectomy group and 73.3% in the dation using a supracervical 5mm hysteroscope and miniaturized 5Fr instruments: (a) laparoscopic myomectomy groupof ) 3/4 of the septum; b) blunt scissors to bipolar electrode for the removal Of the 825 consecutive morcellated specimen, there were no sarcomas. 16 refine the base of the septum; c) intrauterine palpator to measure the porspecimens showed some nuclear atypia but did not not have the combined tion of the removed septum (only Group T). 3D TVS and second-look hysatypia, necrosis and mitosis to meet criteria for a STUMP tumor. 2 teroscopy were used to identify the number of complete (residual septum (0.25%) endometrial carcinomas were found. One was misdiagnosed as < 5 mm), suboptimal (residual septum 5-10 mm) or incomplete resections (residual septum > 10 mm). In Group T, the metroplasty was stopped when Pathology the intrauterine palpator showed that the resected septum corresponded to Lapx the presurgical ultrasonographic measures in order to obtainLapx a fundal notch myomectomy of 1.0 cm. In Group C, the metroplasty was interrupted onceSCH the tubal Total ostia were clearly visible on the same line and/or hemorrhage from small myoMyoma 316 208 524 metrial vessels of the fundus was observed. Adenomyosis 5 26 31 Measurements and Main Results: No differences were observed in baseMyoma + Adenomyosis 4 96 100 line characteristics between the two groups. The proportion of patients with Myoma with degeneration 95 31 126 complete septum resection was significantly higher in group T (71.5% vs. Myoma with degeneration + 0 7 7 41%, chi-squared p= .006; RR 1.684 95% CI 1.116-2.506 adenomyosis Normal 0 18 18 Atypical endometrial hyperplasia 0 1 1 Endometrial carcinoma 0 2 2 Atypical myoma 11 5 16 1553-4650/$ - see front matter  2014 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2014.08.016

The incidence of endometrial cancer in this population was 0.25%. Uterine sarcomas are very rare and none were found in the series of 815 consecutive patients undergoing power morcellation. 2

Plenary 1 - Laparoscopy (11:10 AM - 11:15 AM)

Laparoscopic Management of an Advanced Interstitial Pregnancy Ecker AM, Lee TTM. Department of Obstetrics and Gynecology, MageeWomens Hospital of UPMC, Pittsburgh, Pennsylvania Interstitial pregnancy represents only 2-4% of all ectopics but has a mortality rate up to 2.5%. Here we present the case of a 25yo G3/1101 who was incidentally found to Suboptimal in 13 cases (28.5%) group T of andthe 14 have an 11resection week 2was dayachieved interstitial pregnancy. After inresection cases (20%) the in group while incomplete was observed onlysuture in 12 pregnancy, defectC,was closed with a resection 2-0 unidirectional barbed patients in group C (59%). in 3 layers. Conclusion: An accurate presurgical evaluation with 3D-TVS together with the use of a graduate intrauterine palpator facilitates the complete removal of uterine septum, in one surgical step. Mean Pre-op uterine Mean Mass of the Mean Number size in weeks, (SD) specimen in grams (SD) of myomas (SD) 13.56 (3.29) 318.96 (302.57) Golden Laparoscope Award 13.97 Surgical (5.05) Best Video586.12 (1089.03)

3.38 (3.04) NA

376 (8:00 AM - 8:15 AM) Here we describe several tools to minimize blood loss during laparoscopic management of advanced ectopic pregnancy: development of the avascular spaces to allow temporary ligation of all major contributory blood supplies, Extrinsic Ureteral Endometriosis: Tackling the Difficult injection of vasopressin, and judicious use of vessel sealing devices.

Ureterolysis

Ecker AM, Mansuria SM, Lee TTM. Department of Obstetrics and Gynecology, Magee-Womens of UPMC, Pittsburgh, Pennsylvania 3 PlenaryHospital 1 - Laparoscopy (11:16 AM - 11:25 AM) Endometriosis involving the ureter can make ureterolysis extremely chalUnexpected Uterine Sarcoma and Other Gynecologic lenging due to the resultant retroperitoneal fibrosis. There is risk of incomMalignancies Diagnosed after Hysterectomy Performed plete resection and recurrent disease as well as risk of unrecognized or defor Benign Indications layed thermal injury to the ureter from aggressive use of electrosurgery. Here Mahnert N, Morgan D, Johnston C, As-Sanie S. Obstetrics and we will emphasize strategies for management of the difficult ureterolysis in Gynecology, University of Michigan, Ann Arbor, Michigan three patients who presented with pelvic pain and hydronephrosis secondary toStudy endometriosis. principles in performing the difficult ureterolysis Objective:The Tokey define the incidence of unexpected uterine sarcoma include: aggressive maintenance of hemostasis to avoid staining the retroand other gynecologic malignancies among women who underwent peritoneum, ligation of theindications. uterine artery to control bleeding and complete hysterectomy for benign the resection, directed chart bluntreview dissection, preservation of the peri-ureteral Design: Retrospective of a Michigan multi-center prospective sheath andfrom placement J stents December for 4-6wks8th postoperatively. With database Januaryof1stdouble 2012 through 2013. these techniques, difficult ureterolysis can be safely completed. Setting: Cases even were the abstracted from an all-payer quality and safety database maintained by the Michigan Surgical Quality Collaborative (MSQC). MSQC is a statewide group of 52 hospitals that voluntarily report perioperative surgical outcomes. Specially trained, dedicated nurses

2015 Award Winning Abstracts & Videos Jerome J. Hoffman Award

IRCAD Award

192

354

Best Abstract by a Resident or Fellow (8:15 AM - 8:30 AM)

Trend of Use of Adhesion Barrier During Hysterectomy or Myomectomy and Its Clinical Impact Closon F, Abenhaim HA, Tulandi T. Obstetrics & Gynecology, Mcgill University, Montreal, Quebec, Canada

Study Objective: To evaluate the use of adhesion barrier in myomectomy or hysterectomy and its clinical impact. Design: Retrospective cohort study (Canadian Task Force classification II-3) Setting: Data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, 2003 to 2011. Patients: We examined the records of women with primary discharge diagnosis of uterine myoma according to the ICD-9. Intervention: Use of adhesion barrier. Measurements and Main Results: The use of adhesion barrier increased threefold between 2003 and 2008 (488 vs. 1508 procedures), and became stable up to 2011. Compared to that in hysterectomy, the use of adhesion barrier in myomectomy was three folds. Of 473,788 women treated by myomectomy or hysterectomy, adhesion barrier was used in only 8,982 cases (2%). The use of adhesion barrier was significantly associated with the rate of ileus after myomectomy 3.2% vs. 2.2% (P<0.0001) or hysterectomy 5.1% vs. 2.5% (P<0.0001). Postoperative fever was also increased in the adhesion barrier group 4.4% vs. 2.9% (P<0.0001) and 2.5% vs. 1.6% (P<0.0001) after myomectomy and hysterectomy respectively. The rate of hematoma after hysterectomy was significantly higher in the adhesion barrier group (0.97% vs. 0.58%; P=0.001), but comparable after myomectomy 0.6% vs. 0.5%.

Conclusion: The use of adhesion barrier in myomectomy or hysterectomy remains very low. Its use appears to be associated with a higher incidence of fever and postoperative ileus.

Excellence in Education (8:30 AM - 8:45 AM)

Laparoscopic Assisted Transversus Abdominis Plane Blocks

Mohling SI, Furr RS. Obstetrics and Gynecology, University of Tennessee College of Medicine-Chattanooga, Chattanooga, Tennessee. This video presentation describes a technique for performing a Transversus Abdominis Plane (TAP) block under laparoscopic guidance. TAP block is a regional anesthetic technique providing analgesia to the parietal peritoneum, skin and muscles of the anterior abdominal wall. In multiple published clinical research studies, TAP blocks have been shown to provide superior analgesia compared to routine IV/PO narcotic pain regimens for postoperative pain. The block is performed by infiltrating anesthetic into the fascial plane, or potential space, between the Transversus abdominis muscle and the Internal Oblique muscle, thereby blocking the anterior divisions of T7-L1 nerves. Over the past decade, TAP blocks have traditionally been performed by an anesthesia team as part of a multimodal approach to postoperative pain control. Research has demonstrated that TAP blocks may be safely and efficaciously performed under laparoscopic guidance by the surgeon who has an understanding of the anatomical landmarks.

2015 Award Winning Abstracts & Videos Jay M. Cooper Award

Best Paper on Minimally Invasive Gynecology by a Fellow 20

(8:45 AM - 9:00 AM)

Standard Versus Robot-Assisted Laparoscopic Hysterectomy: A Prospective Randomized Trial Deimling TA, 1Eldridge JL, 1Riley KA, 2Kunselman AR, 1Harkins GJ. Obstetrics and Gynecology, The Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; 2Public Health Sciences, The Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania

1 1

Study Objective: Determine if robot-assisted hysterectomies were non-inferior to standard laparoscopic hysterectomies with respect to operative time and to determine if short-term surgical outcomes were similar. Design: Prospective Randomized Trial. Setting: University Hospital. Patients: Patients undergoing hysterectomy for benign indications. Intervention: One hundred forty four consenting patients were randomized to either robot-assisted or standard laparoscopic hysterectomy. Randomization occurred on the day of surgery. Operative times, intra-operative, and post-operative complications were recorded for twelve weeks. Measurements and Main Results: A total of 144 patients undergoing hysterectomy were randomized with 72 patients in each arm. Using Fisher’s exact tests and two-sample t-tests as appropriate, there was no evidence of differences between groups with respect to demographics. Thirty-two (44.4%) of the patients had a cesarean section in the standard arm compared to 17 (23.6%) in the robot-assisted arm (p=0.01). Estimated blood loss was not statistically significant between groups. The mean operative time, surgeon incision to surgeon stop, including docking in the robot-assisted group was 73.9 minutes (median=67 minutes) while in the standard laparoscopic group it was 74.9 minutes (median=65.5 minutes) (Figure 1).

A nonparametric, one-sided, bootstrapped bias-corrected and accelerated 95% confidence interval (CI) of the difference in the operative time means was constructed using 10,000 bootstrapped samples as (-∞, 7.3 minutes) (p<0.01). As the upper bound of this 95% CI was less than our a priori non-inferiority margin of 15 minutes, we conclude that robot-assisted hysterectomy is non-inferior to standard laparoscopic hysterectomy with respect to operative time. No differences in complication rates were observed (Table 1).

Table 1: Complications Standard Robot-assisted Laparoscopic Complication n (%) n (%) Any Intra-operative Complication Any Post-operative Complication Re-operate/re-admit Infection Hemorrhage/transfusion Vaginal cuff dehiscence Other

P-value*

2 (2.8) 2 (2.8) 6 (8.3)

0 (0.0) 0 (0.0) 9 (12.5)

0.50 0.50 0.58

2 (2.8) 1 (1.4) 0 (0.0) 2 (2.8) 3 (4.2)

2 (2.8) 1 (1.4) 4 (5.6) 1 (1.4) 4 (5.6)

1.00 1.00 0.12 1.00 1.00

* Fisher’s exact test Conclusion: In the hands of experienced minimally invasive surgeons with expertise in robot-assisted and standard laparoscopic surgery, robot-assisted surgery is non-inferior to standard laparoscopic surgery with respect to operative time during hysterectomy.

Robert B. Hunt Award

Best Paper Published in JMIG (September 2014 – August 2015) (9:00 AM - 9:05 AM)

A Randomized Trial Comparing Vaginal and Laparoscopic Hysterectomy vs Robot-Assisted Hysterectomy Lönnerfors C, Reynisson P, Persson J. Department of Obstetrics and Gynecology, Skane University Hospital and Lund University, Lund, Sweden

Study Objective: To investigate the hospital cost and short-term clinical outcome of traditional minimally invasive hysterectomy vs robot-assisted hysterectomy in women primarily not considered candidates for vaginal surgery. Design: Randomized controlled trial (Canadian Task Force classification I). Setting: University Hospital in Sweden. Patients: One hundred twenty-two women with uterine size ≤16 gestational weeks scheduled to undergo minimally invasive hysterectomy because of benign disease. Interventions: Robot-assisted hysterectomy or traditional vaginal or laparoscopic minimally invasive hysterectomy. Measurements and Main Results: All women underwent surgery as randomized. There were no demographic differences between the 2 groups. Vaginal hysterectomy was possible in 41% in the traditional minimally invasive group, at a mean hospital cost of $4579 compared with $7059 for traditional laparoscopic hysterectomy. This was reflected in a mean hospital cost of $993 more per robotic-assisted hysterectomy than for traditional minimally invasive hysterectomy when the robot was a preexisting investment. This hospital cost increased by $1607 when including investments and cost of maintenance. A per-protocol subanalysis comparing laparoscopy and robotics demonstrated similar hospital cost when the robot was a preexisting investment ($7059 vs $7016). Robotic-assisted hysterectomy was associated with less blood loss and fewer postoperative complications. Conclusion: A similar hospital cost can be attained for laparoscopy and robotics when the robot is a preexisting investment. From the perspective of hospital costs, robotic-assisted hysterectomy is not advantageous for treating benign conditions when a vaginal approach is feasible in a high proportion of patients.