- Email: [email protected]
Complications of LASH, TLH and LAVH in Norway
Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S91–S135
S119
The appearance of idiopathic lymphocele is uncommun and can be only speculated to be associated to lymphatic leakage due to a miss diagnosed minor trauma or repetitive effort injury. The management is thought to be similar to those that occur after trauma or surgery. Conclusion: This is an unusual case with a young patient with a unremarkable medical history. The diagnosis of a lymphocele is dificult if there is no history of trauma or pelvic surgery. In this case the diagnosis was done by operative laparoscopy. The patient did well after the surgery. The tratment with this events has to be iqual that with trauma or surgery; draining the lymphocele. 407 Laparoscopic Smoke: Comparative Analysis of Evacuation Methods Ott DE,1 Michal B.2 1Biomedical Engineering, Mercer University, Macon, Georgia; 2Engineering, LEXION Medical, St. Paul, Minnesota Study Objective: Smoke removal during laparoscopic procedures is paramount for vision and to reduce toxic exposure from combustion byproducts for patients and surgeons and staff health and safety. Regulations, studies and recommendations are in place but claims of effectiveness are flawed allowing continued risk and exposure. Designing a useful device meeting patients, science and cost conscious health professionals requirements of dependable efficient smoke removal and port access functionality is a long standing need. The physical structure and design of laparoscopic cannula access with continuous smoke evacuation capability is the focus of this analysis. All laparoscopic cannulas except Synergy are hollow tubes top to bottom. A gas evacuation access port with multiple distal perforations allowing continuous circumferential gas suctioning combining instrument access answers surgical and cost needs simultaneously. It was hypothesized that this configuration would have increased satisfaction clinically and economically. Design: Testing and analysis was done comparing commercially available trocar/cannulas and smoke evacuation devices with LEXION Medical’s VeryClear Port. Evaluations were done for efficiency of smoke evacuation, residual smoke contamination and characteristics of spatial removal. Setting: Research laboratory. Intervention: Laboratory testing and analysis. Measurements and Main Results: Statistically significantly findings (p\0.01) were higher evacuation flow rates (78% improvement), lower pressure drop (70% improvement), radial smoke removal compared to distal only and residual contamination concentration through the VeryClear Port compared to the others. Conclusion: Design architecture of a cannula significantly improves gas removal characteristics related to increased smoke evacuation rate, radial capture, maintenance of pneumoperitoneum, less residual contamination and cost effectiveness which was only accomplished with the VeryClear Port. 408 A Retrospective Cohort Study Evaluating Re-Intervention in Women with Fibroids and Adenomyosis Undergoing Uterine Fibroid Embolization (UFE) Patel NR,1 Samuel S,2 Makai G,2 Garcia M.3 1Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania; 2Department of Obstetrics and Gynecology, Christiana Care Health Systems, Newark, Delaware; 3Deptartment of Radiology/ HVIS, Christiana Care Health Systems, Newark, Delaware Study Objective: To evaluate whether the presence of adenomyosis affects the rate of re-intervention in women who underwent Uterine Fibroid Embolization (UFE) for symptomatic fibroids. Design: Retrospective cohort. Setting: Large tertiary care hospital. Patients: Chart review of 373 women with a UFE between 1/1/2009 through 12/31/2013.
Intervention: All women had a diagnosis of fibroids. Pre-UFE MRI report was assessed for adenomyosis. All patients underwent an elective UFE and were admitted for an overnight stay as observation status. For consistency, all pain medication received was converted to mg of IV Dilaudid. Charts were also reviewed for subsequent surgical re-intervention. Measurements and Main Results: The mean age of both those with concominant fibroids and adenomyosis (group 1, n=70) and fibroids alone (group 2, n=302) was 41 years. There was only a 10% relative difference in the amount of pain medication required immediately following the UFE (group 1: 9.37.8, group 2: 8.45.5, p=0.89) and was not statistically significant (Figure 1). Although there was nearly a 20% higher relative rate of surgical re-intervention in group 1, the groups’ difference was also not statistically significant (group 1: 4.3%, group 2: 3.6% Fisher exact ==.73). The most common reason for surgical reintervention was dysfunctional uterine bleeding followed by pain. Conclusion: Historically, no studies have specifically assessed the incidence of surgical intervention in women undergoing UFE for uterine fibroids in the presence of adenomyosis. This study suggests that the presence of adenomyosis at the time of UFE is not associated with a clinically meaningful increase in the need for medication or the risk of surgical re-intervention. Until such evidence is available, these results suggest that regardless of the presence of adenomyosis, women can undergo successful UFE. A larger, more definitive study is needed to determine if there are clinically meaningful differences.
409 Complications of LASH, TLH and LAVH in Norway Putz A, Putz AM. Obstetrics & Gynecology, Vestfold Hospital Trust, Tønsberg, Vestfold, Norway Study Objective: It is very important to indicate the differences in complications of LASH, TLH and LAVH in Norway. Design: The study uses the results of 2013 of the Norwegian Gynecologic Endoscopic Register. Setting: The Norwegian Gynecologic Endoscopic Register is web-based and participation in the register is mandatory for all the gynecologic departments in Norway. All intra- and postoperative complications within four weeks after operation are documented. Patients: Included are all patients in 2013 with a LASH-, TLH- and LAVHprocedure of the Norwegian Gynecologic Endoscopic Register. Measurements and Main Results: Registration of patients includes operation parameters, intraoperative complications, previous surgery, co morbidity, general health parameters and demographic factors. The postoperative complications get registered with a questionnaire or by telephone four weeks after operation. A preliminary result shows regional significant differences in intraoperativ complications. A response rate of registration of postoperative complications over 90%, indicates significant regional differences in postoperative complications too. Intra- and postoperative complications are not only regionally different, further examinations indicate significant differences according to previous surgery, demographic factors, general health factors and co morbidity.
S120
Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S91–S135
Conclusion: LASH, TLH and LAVH are common operations in Norway. Rates of intra- and postoperative complications vary significant. The Norwegian Gynecologic Endoscopic Register is a good tool for analyzing indication, implementation and complications of LASH, TLH and LAVH.
Each participant peformed the tasks in the morning upon arrival to the hospital after sleeping a full night at home and on the next day after finishing a night shift. Measurements and Main Results: We represent the results of this pilot study. Conclusion: We represent the results of this pilot study.
410 A Year’s Worth of Readmissions Following Elective Gynaecological Surgery White C, Johnston K. Obstetrics and Gynaecology, Antrim Area Hospital, Antrim, United Kingdom Study Objective: To calculate the Emergency Readmission Rate (ERA) within 30 days of discharge, following elective gynaecological surgery. Design: A review of ‘gynaecology dashboard’ statistics and a retrospective chart review of emergency readmissions following elective gynaecological surgery over from 01/01/2012 to 12/31/2013. Setting: Gynaecological surgeries carried out in a Health Care Trust in Northern Ireland, providing care for over 460,000 people. Patients: 22 patients were identified using the gynaecology dashboard, as having been readmitted within 30 days following elective surgery, out of a total of 1187 elective gynaecological surgical procedures. Measurements and Main Results: The ERA within 30 days of discharge following an elective gynaecological procedure is 1.9% (22/1187). Most readmissions, 40.9% (9/22) occur following vaginal surgery (including tension free tape procedures and management of vaginal cysts), the most common complication is pelvic collection 18.1% (4/22), 2 drained in theatre. The ERA following a laparotomy is 36.4% (8/22). Complications of wound healing 14% (3/22) and pain 14%(3/22) account for the most common reason for readmission. followed by pelvic collection 9% (2/22). Following laparotomy 9% (2/22) required return to theatre to manage their complication, one for drainage of pelvic collection and the other for wound re-suturing. The ERA following laparoscopy was 22.7% (5/22). 3 had a pelvic collection, one of which was drained via laparotomy. 9% (2/22) had a wound infection following laparoscopy, all managed conservatively. 22.7% (5/22) of patients were readmitted for management of pain with no pathological cause, 3 following laparotomy and 2 following vaginal surgery. Conclusion: The ERA can be used as a marker of service quality. The ERA following an elective gynaecological procedure in our department is low. Use of a laparoscopic approach to surgical procedures may help reduce the ERA.
411
Poster Session: Education
Do Night Shifts Affect Young Surgeons’ Motor and Cognitive Capacities? A Pilot Study Brandes-Klein O, Pal-Ohana H, Segev E, Hod Y, Stein N, Rofe G, Paz M, Kaufman Y, Lissak A. Department of Obstetrics and Gynecology and Simulation Center for Multidisciplinary Advanced Research and Teaching in Endoscopy (S.M.A.R.T.E), Carmel – Lady Davis Medical Center, Haifa, Israel Study Objective: There is an ongoing debate on whether sleep deprivation impairs psychomotor and other professional skills and enhances serious medical errors in medical staff (1,2,3). Current data on how sleep deprivation influences medical staff’s surgical and psychomotor skills performances is inconclusive (4,5,6,7,8). Every medical intern is expected during his training years to perform on 24 hour shifts. In this prospective pilot study we checked the medical staff of the department of obstetrics and gynecology at the Carmel Lady Davis medical center in Haifa, Israel, for their motor and cognitive skills before and after a night shift for a period of two months. Design: Materials and methods: The medical staff participating in the study included interns, and young specialists up to three years after finishing their internship. All participants were checked before and after a night shift, for total time, accuracy, and other factors in performing basic laparoscopic skills on a virtual reality LapMentor (simbionix)( ) and also for degree of fatigue using objective and subjective tests (VAS-F and DSST).
412 TTT – A Systematic Management Model for Development of Minimally Invasive Surgery Gomes-da-Silveira GG, Cidade PR, Dibi R. Advanced Laparoscopic Surgery Center, Santa Casa Hospital, Porto Alegre, Rio Grande do Sul, Brazil Study Objective: To provide a fully development of minimally invasive surgery, with managerial tools of participatory and systemic vision. Design: Now, we have to think about corporate customers, institutions, instead of individual surgeons. This is because the proposal here is not to teach only the surgical technique, as in conventional courses. Our goal will be to change the culture of the institutions, forwarding them toward minimally invasive surgery. For this we will provide, in addition to surgical training, management support, tools like project for deployment of infrastructure and development of people. Following the principle of the 3 Ts (training, tools, team). Setting: The development of 3 Ts in MIS, through the PDCA system, is unheard of! However, virtually all studies on laparoscopic surgery deployment in services and institutions cite as barriers: technical training, institutional support and team. Patients: Business Unit: Hospital direction Units management Doctors Nursing team Engineering technicians Reception, scheduling Patients Committees of Business Unit: check indicators, promote improvements, get new goals Agents: representat. Intervention: Create, around a MIS development, a Business Unit, with participative management system and teams focused on continuous improvement indicators, through the PDCA method. PDCA: Plan, Do, Check, Action P: the project design D: the project applied C: indicators assessment A: promote improvements, new goals, (new plans ). Measurements and Main Results: Indicators Length of stay, number of surgeries (% MIS), infection rate, turnover beds Billing surgical unit, opme Surgical time Instrumental use CME Time/optimization service (continuous improvement) Systemic vision Patient satisfaction, QoL, returns to work and daily activities. Conclusion: In conclusion, we have , first, to put this management system knowledge togheter with the technical courses of MIS. The next step will be to provide management tools and training to introduce the PDCA system in institutions / hospitals. 413 Fundamentals in Minimally Invasive Gynecolgic Surgery - A Fourth Year Medical Student Elective Lang TG,1 Shiber L-DJ,1 Biscette SM,1 Shwayder J,2 Pasic R,1 Lutz E,2 Hudgens J.2 1Ob/Gyn - Minimally Invasive Gynecologic Surgery, University of Louisville, Louisville, Kentucky; 2Ob/Gyn, University of Mississippi, Jackson, Mississippi
S119
The appearance of idiopathic lymphocele is uncommun and can be only speculated to be associated to lymphatic leakage due to a miss diagnosed minor trauma or repetitive effort injury. The management is thought to be similar to those that occur after trauma or surgery. Conclusion: This is an unusual case with a young patient with a unremarkable medical history. The diagnosis of a lymphocele is dificult if there is no history of trauma or pelvic surgery. In this case the diagnosis was done by operative laparoscopy. The patient did well after the surgery. The tratment with this events has to be iqual that with trauma or surgery; draining the lymphocele. 407 Laparoscopic Smoke: Comparative Analysis of Evacuation Methods Ott DE,1 Michal B.2 1Biomedical Engineering, Mercer University, Macon, Georgia; 2Engineering, LEXION Medical, St. Paul, Minnesota Study Objective: Smoke removal during laparoscopic procedures is paramount for vision and to reduce toxic exposure from combustion byproducts for patients and surgeons and staff health and safety. Regulations, studies and recommendations are in place but claims of effectiveness are flawed allowing continued risk and exposure. Designing a useful device meeting patients, science and cost conscious health professionals requirements of dependable efficient smoke removal and port access functionality is a long standing need. The physical structure and design of laparoscopic cannula access with continuous smoke evacuation capability is the focus of this analysis. All laparoscopic cannulas except Synergy are hollow tubes top to bottom. A gas evacuation access port with multiple distal perforations allowing continuous circumferential gas suctioning combining instrument access answers surgical and cost needs simultaneously. It was hypothesized that this configuration would have increased satisfaction clinically and economically. Design: Testing and analysis was done comparing commercially available trocar/cannulas and smoke evacuation devices with LEXION Medical’s VeryClear Port. Evaluations were done for efficiency of smoke evacuation, residual smoke contamination and characteristics of spatial removal. Setting: Research laboratory. Intervention: Laboratory testing and analysis. Measurements and Main Results: Statistically significantly findings (p\0.01) were higher evacuation flow rates (78% improvement), lower pressure drop (70% improvement), radial smoke removal compared to distal only and residual contamination concentration through the VeryClear Port compared to the others. Conclusion: Design architecture of a cannula significantly improves gas removal characteristics related to increased smoke evacuation rate, radial capture, maintenance of pneumoperitoneum, less residual contamination and cost effectiveness which was only accomplished with the VeryClear Port. 408 A Retrospective Cohort Study Evaluating Re-Intervention in Women with Fibroids and Adenomyosis Undergoing Uterine Fibroid Embolization (UFE) Patel NR,1 Samuel S,2 Makai G,2 Garcia M.3 1Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania; 2Department of Obstetrics and Gynecology, Christiana Care Health Systems, Newark, Delaware; 3Deptartment of Radiology/ HVIS, Christiana Care Health Systems, Newark, Delaware Study Objective: To evaluate whether the presence of adenomyosis affects the rate of re-intervention in women who underwent Uterine Fibroid Embolization (UFE) for symptomatic fibroids. Design: Retrospective cohort. Setting: Large tertiary care hospital. Patients: Chart review of 373 women with a UFE between 1/1/2009 through 12/31/2013.
Intervention: All women had a diagnosis of fibroids. Pre-UFE MRI report was assessed for adenomyosis. All patients underwent an elective UFE and were admitted for an overnight stay as observation status. For consistency, all pain medication received was converted to mg of IV Dilaudid. Charts were also reviewed for subsequent surgical re-intervention. Measurements and Main Results: The mean age of both those with concominant fibroids and adenomyosis (group 1, n=70) and fibroids alone (group 2, n=302) was 41 years. There was only a 10% relative difference in the amount of pain medication required immediately following the UFE (group 1: 9.37.8, group 2: 8.45.5, p=0.89) and was not statistically significant (Figure 1). Although there was nearly a 20% higher relative rate of surgical re-intervention in group 1, the groups’ difference was also not statistically significant (group 1: 4.3%, group 2: 3.6% Fisher exact ==.73). The most common reason for surgical reintervention was dysfunctional uterine bleeding followed by pain. Conclusion: Historically, no studies have specifically assessed the incidence of surgical intervention in women undergoing UFE for uterine fibroids in the presence of adenomyosis. This study suggests that the presence of adenomyosis at the time of UFE is not associated with a clinically meaningful increase in the need for medication or the risk of surgical re-intervention. Until such evidence is available, these results suggest that regardless of the presence of adenomyosis, women can undergo successful UFE. A larger, more definitive study is needed to determine if there are clinically meaningful differences.
409 Complications of LASH, TLH and LAVH in Norway Putz A, Putz AM. Obstetrics & Gynecology, Vestfold Hospital Trust, Tønsberg, Vestfold, Norway Study Objective: It is very important to indicate the differences in complications of LASH, TLH and LAVH in Norway. Design: The study uses the results of 2013 of the Norwegian Gynecologic Endoscopic Register. Setting: The Norwegian Gynecologic Endoscopic Register is web-based and participation in the register is mandatory for all the gynecologic departments in Norway. All intra- and postoperative complications within four weeks after operation are documented. Patients: Included are all patients in 2013 with a LASH-, TLH- and LAVHprocedure of the Norwegian Gynecologic Endoscopic Register. Measurements and Main Results: Registration of patients includes operation parameters, intraoperative complications, previous surgery, co morbidity, general health parameters and demographic factors. The postoperative complications get registered with a questionnaire or by telephone four weeks after operation. A preliminary result shows regional significant differences in intraoperativ complications. A response rate of registration of postoperative complications over 90%, indicates significant regional differences in postoperative complications too. Intra- and postoperative complications are not only regionally different, further examinations indicate significant differences according to previous surgery, demographic factors, general health factors and co morbidity.
S120
Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S91–S135
Conclusion: LASH, TLH and LAVH are common operations in Norway. Rates of intra- and postoperative complications vary significant. The Norwegian Gynecologic Endoscopic Register is a good tool for analyzing indication, implementation and complications of LASH, TLH and LAVH.
Each participant peformed the tasks in the morning upon arrival to the hospital after sleeping a full night at home and on the next day after finishing a night shift. Measurements and Main Results: We represent the results of this pilot study. Conclusion: We represent the results of this pilot study.
410 A Year’s Worth of Readmissions Following Elective Gynaecological Surgery White C, Johnston K. Obstetrics and Gynaecology, Antrim Area Hospital, Antrim, United Kingdom Study Objective: To calculate the Emergency Readmission Rate (ERA) within 30 days of discharge, following elective gynaecological surgery. Design: A review of ‘gynaecology dashboard’ statistics and a retrospective chart review of emergency readmissions following elective gynaecological surgery over from 01/01/2012 to 12/31/2013. Setting: Gynaecological surgeries carried out in a Health Care Trust in Northern Ireland, providing care for over 460,000 people. Patients: 22 patients were identified using the gynaecology dashboard, as having been readmitted within 30 days following elective surgery, out of a total of 1187 elective gynaecological surgical procedures. Measurements and Main Results: The ERA within 30 days of discharge following an elective gynaecological procedure is 1.9% (22/1187). Most readmissions, 40.9% (9/22) occur following vaginal surgery (including tension free tape procedures and management of vaginal cysts), the most common complication is pelvic collection 18.1% (4/22), 2 drained in theatre. The ERA following a laparotomy is 36.4% (8/22). Complications of wound healing 14% (3/22) and pain 14%(3/22) account for the most common reason for readmission. followed by pelvic collection 9% (2/22). Following laparotomy 9% (2/22) required return to theatre to manage their complication, one for drainage of pelvic collection and the other for wound re-suturing. The ERA following laparoscopy was 22.7% (5/22). 3 had a pelvic collection, one of which was drained via laparotomy. 9% (2/22) had a wound infection following laparoscopy, all managed conservatively. 22.7% (5/22) of patients were readmitted for management of pain with no pathological cause, 3 following laparotomy and 2 following vaginal surgery. Conclusion: The ERA can be used as a marker of service quality. The ERA following an elective gynaecological procedure in our department is low. Use of a laparoscopic approach to surgical procedures may help reduce the ERA.
411
Poster Session: Education
Do Night Shifts Affect Young Surgeons’ Motor and Cognitive Capacities? A Pilot Study Brandes-Klein O, Pal-Ohana H, Segev E, Hod Y, Stein N, Rofe G, Paz M, Kaufman Y, Lissak A. Department of Obstetrics and Gynecology and Simulation Center for Multidisciplinary Advanced Research and Teaching in Endoscopy (S.M.A.R.T.E), Carmel – Lady Davis Medical Center, Haifa, Israel Study Objective: There is an ongoing debate on whether sleep deprivation impairs psychomotor and other professional skills and enhances serious medical errors in medical staff (1,2,3). Current data on how sleep deprivation influences medical staff’s surgical and psychomotor skills performances is inconclusive (4,5,6,7,8). Every medical intern is expected during his training years to perform on 24 hour shifts. In this prospective pilot study we checked the medical staff of the department of obstetrics and gynecology at the Carmel Lady Davis medical center in Haifa, Israel, for their motor and cognitive skills before and after a night shift for a period of two months. Design: Materials and methods: The medical staff participating in the study included interns, and young specialists up to three years after finishing their internship. All participants were checked before and after a night shift, for total time, accuracy, and other factors in performing basic laparoscopic skills on a virtual reality LapMentor (simbionix)( ) and also for degree of fatigue using objective and subjective tests (VAS-F and DSST).
412 TTT – A Systematic Management Model for Development of Minimally Invasive Surgery Gomes-da-Silveira GG, Cidade PR, Dibi R. Advanced Laparoscopic Surgery Center, Santa Casa Hospital, Porto Alegre, Rio Grande do Sul, Brazil Study Objective: To provide a fully development of minimally invasive surgery, with managerial tools of participatory and systemic vision. Design: Now, we have to think about corporate customers, institutions, instead of individual surgeons. This is because the proposal here is not to teach only the surgical technique, as in conventional courses. Our goal will be to change the culture of the institutions, forwarding them toward minimally invasive surgery. For this we will provide, in addition to surgical training, management support, tools like project for deployment of infrastructure and development of people. Following the principle of the 3 Ts (training, tools, team). Setting: The development of 3 Ts in MIS, through the PDCA system, is unheard of! However, virtually all studies on laparoscopic surgery deployment in services and institutions cite as barriers: technical training, institutional support and team. Patients: Business Unit: Hospital direction Units management Doctors Nursing team Engineering technicians Reception, scheduling Patients Committees of Business Unit: check indicators, promote improvements, get new goals Agents: representat. Intervention: Create, around a MIS development, a Business Unit, with participative management system and teams focused on continuous improvement indicators, through the PDCA method. PDCA: Plan, Do, Check, Action P: the project design D: the project applied C: indicators assessment A: promote improvements, new goals, (new plans ). Measurements and Main Results: Indicators Length of stay, number of surgeries (% MIS), infection rate, turnover beds Billing surgical unit, opme Surgical time Instrumental use CME Time/optimization service (continuous improvement) Systemic vision Patient satisfaction, QoL, returns to work and daily activities. Conclusion: In conclusion, we have , first, to put this management system knowledge togheter with the technical courses of MIS. The next step will be to provide management tools and training to introduce the PDCA system in institutions / hospitals. 413 Fundamentals in Minimally Invasive Gynecolgic Surgery - A Fourth Year Medical Student Elective Lang TG,1 Shiber L-DJ,1 Biscette SM,1 Shwayder J,2 Pasic R,1 Lutz E,2 Hudgens J.2 1Ob/Gyn - Minimally Invasive Gynecologic Surgery, University of Louisville, Louisville, Kentucky; 2Ob/Gyn, University of Mississippi, Jackson, Mississippi