A Quantitative System for Technical Assessment and Training of Skills (STATS) for Surgical Performance

Abstracts / Journal of Minimally Invasive Gynecology 23 (2016) S1–S252 Design: This is a retrospective analysis of Medicare claims data for 20122014. Patients undergoing open or Minimally Invasive Surgery (MIS) hysterectomy were identified by ICD-9 and CPT codes. Descriptive analytics were performed to identify the proportion of hysterectomies performed in an outpatient setting. Statistical significance was defined by p-value \= 0.05. Setting: N/A Patients: A total of 55,562, 53,460 and 53,049 patients were included in the analysis for 2012, 2013 and 2014, respectively. Intervention: N/A Measurements and Main Results: In 2014, 2,864 hospitals performed hysterectomies on Medicare patients. 2,367 hospitals performed 30 or fewer procedures in 2014. The top 20% (high volume) and bottom 20% (low volume) of hospitals by volume of hysterectomies were analyzed. In 2014, the 573 high volume hospitals performed 36,093 hysterectomies with 16,828 (47.1%) in the outpatient setting. The 573 low volume hospitals performed 770 hysterectomies with 136 (16.0%) in the outpatient setting (p\.0001). At the high volume hospitals, from 2012-2014, the outpatient procedure (OP) rate increased from 29.4% to 47.1% (p\.0001). The Northeast (20.6% to 40%, p\.0001) and the West (21.4% to 42.4%, p\.0001) had the lowest OP rates though the rate increased during those years. In the Midwest and the South, the OP rate increased from 27.3% to 48.8% (p\.0001) and 37.2% to 51.9% (p\.0001), respectively. At low volume hospitals, the OP rate increased from 8.9% to 16% from 2012-2014 (p=.0001). Conclusion: Higher volume of hysterectomy procedures is associated with a higher likelihood of procedures being performed in an outpatient setting. While there is regional variation in the OP rate at high volume hospitals, both high volume and low hospitals have experienced growth in OP rate for hysterectomies. 118

Open Communications 8 - Laparoscopic Surgeries (2:15 PM - 3:15 PM) 3:08 PM – GROUP B

Laser Angiography with Indocyanine Green (ICG) to Assess Vaginal Cuff Perfusion During Total Laparoscopic Hysterectomy (TLH): A Pilot Study Beran BD,1 Shockley ME,1 Arnolds KD,1 Escobar PF,2 Zimberg SE,1 Sprague ML.1 1Section of Minimally Invasive Gynecology, Cleveland Clinic Florida, Weston, Florida; 2Department of Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas Study Objective: To determine feasibility of using NIR perfusion angiography to assess vaginal cuff vascular perfusion during total laparoscopic hysterectomies. Design: Pilot experimental study. Setting: Academic-affiliated hospital. Patients: Twenty women undergoing TLH for benign disease. Intervention: Following intravenous administration of indocyanine green (ICG), NIR perfusion angiography was employed to capture images of the vaginal cuff before and after closure. Three reviewers analyzed NIR images of vaginal cuffs to determine percent of cuff perimeter with adequate perfusion when open and length of vaginal cuff adequately perfused when closed. Participants underwent 1:1 randomization of energy method used for colpotomy (ultrasonic versus monopolar) and vaginal cuff closure suture (barbed versus non-barbed). Measurements and Main Results: ICG was visible at the vaginal cuff in all participants. Mean time to appearance of ICG in the pelvis after administration was 19.786.75 seconds (meanS.D.) pre-closure, and 25.9922.22 seconds post-closure. With ultrasonic energy, 67.4717.42% (meanS.D.) of open cuff perimeter, and 74.4220.5% of closed cuff length were adequately perfused, while with monopolar energy use, 59.1417.43% of the open cuff perimeter and 66.2815.4% of closed cuff length were adequately perfused. Cuffs closed with barbed suture showed adequate perfusion along 71.4615.14% of the length, while those closed with non-barbed suture showed 68.9420.94% adequate perfusion. When standardized to cervical

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cup circumference, ultrasonic energy required 0.970.21 s/mm (meanS.D.), while monopolar energy required 0.800.31 s/mm (p=0.162). Linear regression showed no association of standardized time of energy activation versus percentage of perimeter of open cuff (R2=0.007) or length of closed cuff (R2=0.005) with adequate perfusion. No complications related to intravenous ICG administration occurred. Conclusion: Intravenous ICG administration and use of NIR perfusion angiography allow evaluation of vascular perfusion at the vaginal cuff during TLH. This technique may inform future prospective studies examining causes for vaginal cuff dehiscence, which is most common following total laparoscopic hysterectomy. 119

Open Communications 9 - Basic Science/Research/ Education (2:15 PM - 3:15 PM) 2:15 PM – GROUP A

Assessment of Reliability Between Live versus Recorded Evaluation of Cystoscopic Skills McKinney SA, Li J, King LP, Lefevre R, Haviland MJ, Hur H-C. Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts Study Objective: To determine if there is a difference between unblinded live observation versus recorded assessment of cystoscopic skills using validated cystoscopy OSATS and GRS checklists. Design: Prospective cohort study. Setting: Academic tertiary care medical center. Patients: All Ob/Gyn residents from Beth Israel Deaconess Medical Center were invited to participate. Intervention: Ob/Gyn residents underwent a cystoscopy workshop with a didactic lecture and simulation skills component that used a wet-bladder model. Residents were videotaped during the simulation skills component. A 2-part validated cystoscopy assessment tool that includes an Objective Structured Assessment of Technical Skills (OSATS) checklist and Global Rating Scale (GRS) checklist was used to assess resident cystoscopy skills unblinded during their live performance. Residents were scored again with the same assessment tool in a blinded fashion using the recordings. Measurements and Main Results: A total of 19 (82.6%) Ob/Gyn residents participated in the workshop. Half (47.4%) of participants had performed >31 cystoscopies prior to the workshop. The median (interquartile range) OSATS score from live observation was 43.0 (39.0-46.0) and from recorded assessment was 43.0 (38.0-45.0). Median scores on the GRS were 24.0 (20.0-28.0) from live observation and 25 (19.0-27.0) from recordings. Spearman correlation coefficients were calculated to compare scores from live observation and recordings. Live and recorded scores were perfectly correlated with respect to the overall pass threshold (r=1.0, p\0.0001). There was also a statistically significant correlation between live and recorded scores for the OSATS (r=0.54, p=0.02) and GRS (r=0.69, p=0.001) checklists. The correlation was stronger for GRS scores than OSATS scores. Conclusion: There was perfect correlation for passing rates between direct observation and recorded assessment of cystoscopic skills using the OSATS and GRS assessment tools. Therefore, recorded assessment using OSATS and GRS checklists may offer an alternative option for objective blinded evaluation of cystoscopy skills without requiring live observation. 120

Open Communications 9 - Basic Science/Research/ Education (2:15 PM - 3:15 PM) 2:22 PM – GROUP A

A Quantitative System for Technical Assessment and Training of Skills (STATS) for Surgical Performance Srinivasan S,1 Krovi V,2 Singhal P,1 Misra S.3 1Department of Minimally Invasive Gynecology, Millard Fillmore Suburban Hospital, Williamsville, New York; 2Department of Mechanical & Aerospace Engineering, State University of New York at Buffalo, Buffalo, New York; 3Department of

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Abstracts / Journal of Minimally Invasive Gynecology 23 (2016) S1–S252

Obstetrics and Gynecology, State University of New York at Buffalo, Buffalo, New York Study Objective: Utilize micro motion analysis on segmented surgical elements or subtasks (therbligs) and statistically analyze the data for specific individualized patterns to identify rate limiting step in a complex process such as surgery and to assess the skill and performance level of a surgeon in a simulated environment. Design: A prospective observational study. Setting: Academic affiliated community hospital. Patients: In the pilot study six robotic surgeons with varying levels of expertise were asked to perform standard simulator tasks on the da Vinci simulator repeatedly. In the second phase which is currently underway, 20 gynecology residents are included as participants. Intervention: Three dimensional (3D) video recordings from the simulator are studied using automated motion analysis. The complex task is decomposed into sub tasks such as cut and grasp that could be individually examined called therbligs. Measurements and Main Results: Preliminary results from the pilot study indicate that overall time based characteristics show only marginal discrimination between experts and novice surgeons. When this is broken down into therbligs, significant discrimination is possible. Based on the 3D trajectories obtained from videos, decision tree type classification algorithm is established to conduct studies for automated recognition of the therbligs. Comparison will be done between each therblig and each resident using sub task completion time, with the aim of identifying the most crucial step objectively and automatedly. Also, the repeatability and sustainability of residents with varying levels of experience will be analyzed and compared to benchmark values set by an expert surgeon to serve as a measure of expertise. Conclusion: Skill assessment through automated motion analysis of sub segments of a complex surgical task is a novel method to measure the expertise of surgeons. Further expansive validation studies are underway with the ultimate aim of overcoming the shortcomings of current system of metrics and contributing to the overall improvement of surgical training. 121

Open Communications 9 - Basic Science/Research/ Education (2:15 PM - 3:15 PM) 2:29 PM – GROUP A

Microsatellite Instability in Endometrial Cancer Leone Roberti Maggiore U, Laraud F, Scala C, Tafi E, Racca A, Venturini PL, Ferrero S. Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), IRCCS AOU San Martino - IST, University of Genoa, Genoa, Ligury, Italy Study Objective: To investigate new evidence in the pathogenesis of type I and type II endometrial cancer for individualized therapies through molecular analysis. Particular attention was paid to the immunohistochemical evaluation of microsatellite instability (MSI). MSI could be evaluated by PCR amplifying microsatellite-specific markers or by the immunohistochemistry (IHC) of MMR (mismatch repair) proteins. Design: Prospective study. Setting: University teaching hospital. Patients: Women operated for endometrial cancer. Intervention: An extended protocol with IHC, including the determination of the MSI (MLH1, PMS2, MSH2 and MSH6) was applied. Histological types were grouped into three subgroups: LGEC (low grade endometrioid carcinoma), HGEC (high grade endometrioid carcinoma), OHEC (other histological types of high-grade endometrial carcinoma). Measurements and Main Results: 114 cases of endometrial cancer were eligible for the study, with a mean ( SD) age of 70.6  12 years. Seventyseven cases were diagnosed as LGEC (67.5%), 8 as HGEC (7.0%) and 29 as OHEC (25,5%). The evaluation of MSI showed loss of contemporary expression of MLH1 / PMS2 in 17 cases and MSH2 / MSH6 in 3 cases. MSI is presented with a frequency of 17.5% of cases. Tumors with MSI showed no peculiar clinicopathological features, however, are

significantly correlated with the endometrioid type, without differences of grade. The comparison between LGEC, HGEC and OHEC outlines a significant distinction between LGEC and OHEC. In OHEC there is a loss of expression of hormone receptors, increase expression of p53. The HGEC is placed in a gray area with intermediate characteristics between the LGEC and OHEC for histopathological and molecular parameters studied. Conclusion: Our study confirms the dualistic model of endometrial cancer: LGEC and OHEC have shown significant differences and they can be considered as completely separate diseases. The MSI valid this opinion because it is relatively frequent in endometrioid carcinomas and not present in non-endometrioid. HGEC constitute a sort of gray area between the two categories. 122

Open Communications 9 - Basic Science/Research/ Education (2:15 PM - 3:15 PM) 2:36 PM – GROUP A

Malignancy Risk Assessment of Endometrial Polyps Through Immune Expression of p53 Protein and PTEN Modotti WP,1 Dias DS,1 Bueloni-Dias FN,1 Modotti CC,2 Rodrigues NP,2 Abr~ao F.1 1Faculdade De Medicina De Botucatu, Rubi~ao Junior, SP, Brazil; 2Faculdade De Medicina De Ribeir~ao Preto, Ribeir~ao Preto, SP, Brazil Study Objective: Assessment of malignancy risk of the endometrial polyps. Design: Cross-sectional, retrospective study. Setting: Botucatu Medical School - January 2010 to December 2014 Patients: 159 polypectomy (US diagnosis of endometrial polyp). Intervention: Immunohistochemical - p53 and PTEN markers (Phosphatase and Tensil Homolog Delete on Chromosome Ten). Groups: group A (120 - polyps without atypia) and group B (39 with atypia). A1 (80) and B1 (21) with negative p53 and positive PTEN; A2 (20) and B2 (11) with positive p53 and positive PTEN; A3 (14) and B3 (4) positive p53 and negative PTEN and A4 (6) and B4 (3) with negative P53 and negative PTEN. Measurements and Main Results: A1 it was found 1 (1.25%) malignant neoplasia. In A2, A3 and A4 were found 6 (15%) with malignant neoplasia (2, 3 and 1 respectively). We found an increased incidence of cancer in groups with at least one of the modified markers (1.25% x 15%, p = 0.0089 and OR 13.94). B1 we found only 1 (4.8%) malignant neoplasia. B2, B3 and B4 was found 7 (38.9%) of malignancy (4, 2 and 1 patients respectively). We found an increased of cancer in groups with at least one of the modified markers (38.9% x 4.8%, p = 0.0025 and OR 12.73). Group B had a higher incidence of cancer than in group A (20.5% x 5.9%; p = 0.011). Negative p53 (110), 3 patients had cancer and 49 positive p53, 11 had neoplasia (p = 0.00006, OR = 7.67). Positive PTEN (132) 8 had malignant and 27 negative PTEN, 7 had malignancy (p = 0.00043; OR = 5.43). Conclusion: Immunohistochemical proved to be a useful to predict the risk of malignant. Additional studies should be expected. Endometrial polyps and abnormal p53 and PTEN may be at increased risk of malignancy. The malignant endometrial were higher in older women and polyps with atypia. 123

Open Communications 9 - Basic Science/Research/ Education (2:15 PM - 3:15 PM) 2:47 PM – GROUP B

Anti-NMDA Receptor Encephalitis: An Underrecognized, Treatable Disease McLatchy JE, Leong M, Greco H, Nimaroff M. Obstetrics and Gynecology, North Shore - Long Island Jewish, Manhasset, New York