2263 Surgical Experience in Patients with Von Willebrand Disease Diagnosis Operated in a Minimally Invasive Gynecological Surgery Unit

Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S98−S231 Study Objective: We present a case study in improving quality metrics with the Kaiser Permanente Minimally Invasive Hysterectomy Initiative to address the high rates of abdominal hysterectomies. Design: Quality Improvement Project. Setting: Route of hysterectomy (abdominal, laparoscopic, vaginal, robotic). Patients or Participants: 31,385 patients who underwent surgical hysterectomy at Kaiser Permanente Northern California between 2008-2015. Interventions: We initiated a four-pronged quality improvement program to increase the rate of minimally invasive hysterectomies, including: 1) Leadership engagement to set goals and achievable targets; 2) Surgeon education and training; 3) Utilization of targeted medical data to track outcomes and drive performance; and 4) Delineation of Obstetrics and Gynecology surgical teams and establishment of criterion-based credentialing. Measurements and Main Results: Total abdominal hysterectomy percentages decreased from 50.5% to 6.9%, and total laparoscopic hysterectomy percentages increased from 21.9% to 61.9%. Robotic hysterectomy percentages only increased from 0.1% to 7.8%, and total vaginal hysterectomy percentages were maintained. Conclusion: Our experience indicates that a quality improvement program to reduce abdominal hysterectomies while improving patient care can be successfully instituted on a large scale with limited reliance on less cost-effective robotic technology. The core aspects of the strategy should be highly incentivized under programs like Medicare Access and CHIP Reauthorization Act (MACRA). Moreover, this model can be used to address other quality issues in gynecologic surgery. It is our hope that the future of gynecologic surgery moves towards such a model that prioritizes optimal patient care. Please note that this abstract includes information that was presented in the paper, “Measuring Quality in Minimally Invasive Gynecologic Surgery: What, How, and Why?” by Abel et. al. in JMIG February 2019. Virtual Poster Session 1: Laparoscopy (9:50 AM — 10:00 AM) 9:50 AM: STATION D 1569 The Efficacy and Safety of Long-Term Management of Uterine Fibroids with Ulipristal Acetate Kim HG,1 Yang J,1 Na YJ2,*. 1Obstetrics and Gynecology, Pusan National University Yangsan Hospital, Yangsan, Korea, Republic of (South); 2 Department of Obstetrics and Gynecology, Pusan National University School of Medicine, Busan, Korea, Republic of (South) *Corresponding author. Study Objective: To investigate the efficacy and safety of four repeated 12-week courses of 5 mg daily ulipristal acetate for intermittent treatment of symptomatic uterine fibroids. Design: A retrospective, single-center observational study. Setting: A university tertiary referral center. Patients or Participants: One hundred seventy-one premenopausal women with symptomatic uterine fibroids. Interventions: Four repeated 12-week treatment courses of daily 5 mg ulipristal acetate. Measurements and Main Results: After four repeated 12-week courses, uterine bleeding was controlled in 93% of the women receiving 5 mg of ulipristal acetate. The rates of amenorrhea were 83% occurring within 9 days in the majority of patients receiving ulipristal acetate. The median changes in total fibroid volume were −17%. Headache and breast tenderness were the most common adverse events associated with ulipristal acetate but did not occur significantly more frequently. Pain showed marked improvements from screening, even during the off-treatment intervals. The safety profile of ulipristal acetate was confirmed, and repeated treatment courses did not increase the occurrence of adverse reactions. There were no significant changes in laboratory parameters during the study. Conclusion: The results of this study demonstrate the efficacy and further support the safety profile of four repeated 12-week courses of 5 mg daily ulipristal acetate for intermittent treatment of symptomatic uterine fibroids.

S99 Virtual Poster Session 1: Laparoscopy (9:50 AM — 10:00 AM) 9:50 AM: STATION E 1612 Comparison of Short Term Outcomes after Laparoscopic Salpingostomy Versus Salpingectomy for the Surgical Management of Ectopic Pregnancy Bouchelion AC,1,* Sheyn D,2 Billow M1. 1OB/GYN, University Hospitals Cleveland Medical Center, Cleveland, OH; 2University Hospitals Cleveland Medical Center/MetroHealth Medical Center, Cleveland, OH *Corresponding author. Study Objective: To investigate the differences in complication rates between laparoscopic salpingostomy and salpingectomy. Design: Propensity score matched retrospective cohort study. Setting: American College of Surgeons National Surgical Quality Improvement Program database. Patients or Participants: Women with surgical management of ectopic pregnancy between 2010-2017. Interventions: Laparoscopic salpingectomy and salpingostomy. Measurements and Main Results: Of 8,092 ectopic pregnancies, 989 were treated with laparoscopic salpingostomies and matched to laparoscopic salpingectomies at a ratio of 1:2 using propensity scores for the likelihood of undergoing salpingostomy. Propensity scores were calculated using preoperative demographic and clinical characteristics. After matching, no significant differences exist between salpingostomy and salpingectomy in preoperative hematocrit (36.1+/-4.4% vs 35.8+/-4.7%, p=0.91), transfusion rate (1.9% vs 2.0%, p=0.19), age (29.8+/-5.7yrs vs 30.1 +/-5.7yrs, p=0.31), and comorbidities (5.8% vs 4.7%). Mean operating times between salpingostomy and salpingectomy showed no difference, (60.7+/-27.2min vs 58.9+/-36.4 min, p=0.78) or conversion to laparotomy (0.2% vs 0.06%, p=0.99). Wound contamination was higher with salpingectomies (3.4% vs 0.02%). The composite complication rate was 10.1%. Postoperative transfusions (6.5% vs 5.8%, p=0.003), reoperation (2.0% vs 0.5%, p<0.001), and readmissions (1.9% vs 0.8%, p=0.005), were more common in the salpingostomy group. There was no difference in infectious, cardiovascular and pulmonary morbidity between groups. After logistic regression, there was a slightly increased risk of complications with salpingostomies compared to salpingectomies (aOR=1.63, 95%CI: 1.36-1.95). Preoperative transfusion was the most significant risk factor of postoperative complications (aOR:8.67, 95%CI:6.32-11.91), followed by American Society of Anesthesiology class ≥3 (aOR:2.75, 95%CI:2.233.37), preoperative WBC ≥10.0 cells/mL (aOR: 2.51, 95%CI:2.13-2.96), and wound class ≥ 3 (aOR:2.54, 95%CI:1.04-6.19). Conclusion: Laparoscopic salpingostomy is associated with higher risk of complications compared to laparoscopic salpingectomy when treating ectopic pregnancies; though the magnitude of this effect is small given the cohort size. This should be considered when counseling patients on salpingectomy versus salpingostomy. Virtual Poster Session 1: Laparoscopy (9:50 AM — 10:00 AM) 9:50 AM: STATION F 2263 Surgical Experience in Patients with Von Willebrand Disease Diagnosis Operated in a Minimally Invasive Gynecological Surgery Unit Guarin CB,* Villegas-Echeverri JD, Lopez JD, Lopez JD, Arturo V. Risaralda, Clınica Comfamiliar, Pereira, Colombia *Corresponding author. Study Objective: To describe the post-surgical outcome in patients with a history of von Willebrand’s disease undergoing minimally invasive surgery. Design: Case reports, a review of the medical records of the patients who underwent gynecological surgery in the period from 2013 to 2017, reporting the intra and post operative complications.

S100

Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S98−S231

Setting: N/A. Patients or Participants: To describe the post-surgical outcome in patients with a history of von Willebrand’s disease undergoing minimally invasive surgery. Interventions: N/A. Measurements and Main Results: Intra and postoperative complications of patients with von Willebrand’s disease, reoperation, need for laparoconversion, hospital stay, surgical time and bleeding. Conclusion: All surgeries were elective and a plan was prepared for the treatment of hemostasis for each patient. During this period, 6 stories of patients with Vwd undergoing surgical procedures were found, there was no registry of complications, there were no deaths or major hemorrhages and there was no need for laparoconversion. The results of this report indicate that surgery can be performed safely by providing adequate and timely haemostasis before and after the procedure.

Cope AG,1,* Wetzstein MM,2 Mara KC,3 Warner NS,4 Burnett TL1. 1 Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN; 2 Obstetrics and Gynecology, Mayo Clinic, Rochester, MN; 3Department of Health Sciences Research, Mayo Clinic, Rochester, MN; 4Anesthesiology, Mayo Clinic, Rochester, MN *Corresponding author.

Virtual Poster Session 1: Laparoscopy (9:50 AM — 10:00 AM) 9:50 AM: STATION G 2452 Reproductive Outcomes Following use of Barbed Suture During Laparoscopic Myomectomy Dmello M*. Minimally Invasive Gynecologic Surgery, Brigham and Women’s Hospital, Boston, MA *Corresponding author. Study Objective: To review pregnancy outcomes after laparoscopic myomectomy using barbed suture for myometrial closure. Design: A retrospective case series and follow up survey. Setting: A large academic medical center. Patients or Participants: Patients who underwent laparoscopic myomectomy with the use of barbed suture for myometrial closure between 2011- 2016. Interventions: Laparoscopic myomectomy and a survey regarding pregnancy outcomes. Measurements and Main Results: A total of 316 patients underwent laparoscopic myomectomy between 2011 and 2016. The survey response rate was 163/316 (51.5%). 144/316 agreed to participate, while 19/316 declined. Among the 62 (43%) respondents who attempted pregnancy, 49/ 62 (79.0%) became pregnant. Comparing the women that became pregnant and those that failed to achieve pregnancy, the pregnant group was on average younger (33.1 years versus 37.6 years, p =0.0028) and had fewer fibroids removed (2.5 versus 3.8, p=0.0396). There were 75 pregnancies amongst the 49 patients who reported pregnancies, with 60 (80%) spontaneous conceptions and 15 (20%) achieved with reproductive assistance. All patients achieving pregnancy got pregnant within 60 months after laparoscopic myomectomy (mean 19.2 months, range 2 to 60 months). There were 47 (63%) live births, 22 (29%) spontaneous abortions, 4 (5%) pregnancy terminations, 2 (3%) ectopic pregnancies and 2 (3%) ongoing pregnancies. Of the 47 live births, 43 were delivered via cesarean section (91.4%). One patient (2.1%) reported fetal growth restriction, and 4 (8.5%) patients experienced preterm labor. No instances of uterine rupture were noted in this cohort. Regarding subsequent pregnancies, 21 women achieved a second pregnancy post-myomectomy, 66% of which resulted in a live birth. Three women had a third post-myomectomy pregnancy with one resulting in live birth; two subjects achieved a fourth post-myomectomy pregnancy with one resulting in live birth. Conclusion: According to our findings, pregnancy outcomes after laparoscopic myomectomy with barbed suture are comparable to available literature of pregnancy outcome with traditional smooth suture. Virtual Poster Session 1: Laparoscopy (9:50 AM — 10:00 AM) 9:50 AM: STATION H 2938 Abdominal ICE Following Laparoscopic Hysterectomy: A Randomized Controlled Trial

Study Objective: To assess impact of abdominal ice packs on opioid use and pain control following laparoscopic hysterectomy. Design: Randomized controlled trial. Setting: Academic tertiary care medical center. Patients or Participants: One-hundred-forty-two adult women undergoing laparoscopic (either conventional or robotic) hysterectomy were randomized to control (n=69) or intervention (n=73). Exclusion criteria included preoperative opioid use, planned ICU admission or same-day discharge, an incision 34 cm, and regional anesthesia use. Interventions: Subjects in the intervention group had a large ice pack placed directly on the lower abdomen prior to leaving the operating room. The ice pack was maintained continuously for twelve hours post-op, as desired thereafter until discharge, and continued use encouraged after discharge for up to 48 hours. Measurements and Main Results: Total opioids administered postoperatively while inpatient and after dismissal were assessed in morphine metabolic equivalents (MME). Postoperative pain, as well as analgesia acceptability and side effects, were assessed using validated measures, the Brief Pain Inventory (BPI) and Overall Benefit of Analgesia Score (OBAS). Median MME was lower in the intervention group compared to controls from inpatient stay on the floor to completion of opioid use as outpatient (22.5 vs 26.2), but was not statistically significant (p=0.79). There was no significant difference between groups in BPI assessment of postoperative pain severity (p=0.80) or pain interference (p=0.36) or OBAS total score (p=0.88). The majority in the intervention group were very satisfied with ice pack use (n=51, 79.7%) and very likely to recommend to friends or family (n=54, 83.1%). There were no adverse events related to ice pack use. Conclusion: There was no significant difference in postoperative opioid use or pain assessment with ice pack use following laparoscopic hysterectomy. However, the majority of subjects expressed high satisfaction with this intervention and would recommend use to others, suggesting potential desirability as adjunct therapy in postoperative pain control. Virtual Poster Session 1: Laparoscopy (9:50 AM — 10:00 AM) 9:50 AM: STATION I 2570 What’s the Limit of Total Laparoscopic Myomectomy?»In Terms of Intraoperative Conversion» Sakate S*. Obstetrics and Gynecology, Kurashiki Medical Center, Kurashiki, Japan *Corresponding author. Video Objective: To assess what limit to complete surgical procedure of laparoscopic myomectomy (LM), I review surgical outcomes of cases performed LM, laparoscopy-assisted myomectomy (LAM) and abdominal myomectomy (AM), and present the cases converted from LM to LAM. Design: Retrospective cohort study. Setting: Urban general hospital in Japan. Patients: All women who were underwent myomectomy, between 2014 to 2018. Interventions: Medical records were reviewed for baseline characteristics and perioperative outcomes. Measurements and Main Results: First, I present our operative procedure of LM. We have modified diamond trocar placement.After the vasopressin injection into the myometrium of fibroid surface,we make incisions with ultrasonic or electric scalpel and enucleate fibroids. After the suturing of myometrium, we make posterior colpotomy and carry out them transvaginally. If fibroids are too large to be carried out, we perform intracorporal or intravaginal manual morcellation. Second, A total of 1123 patients were