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Hysterectomy in Obesity and How Route of Surgery Impacts Outcomes for Benign Disease
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Abstracts / Journal of Minimally Invasive Gynecology 23 (2016) S1–S252
Design: Observational retrospective study on patients with endometriomas by detecting other associated sonographic signs of pelvic endometriosis such as adhesions, tubal pathology, adenomyosis and DIE. Setting: University hospitals. Patients: Symtomatic patients who underwent a transvaginal sonography (TVS) and showed an ovarian cyst with typical appearance of endometrioma were included in this study. Patients with previous pelvic surgery and without symptoms were excluded. Intervention: Mapping of endometriosis by TVS and laparoscopic treatment when indicated for endometriomas and other pelvic endometriosis. Measurements and Main Results: 226 symptomatic patients % 40 years with at least an ovarian endometrioma with a diameter of R 20 mm were included in this study. Mean age was 32.9 4.9 yrs, mean endometriomas diameter was 35.5 16.5mm, Bilateral endometriomas were observed in 32 patients (14%). Of the 226 patients 41(18%) showed posterior rectal DIE and 92 (41%) a thickening of at least one uterosacral lignament (USL). 138 patients (61%) showed adhesions and 82 (36%) had myometrial signs of adenomyosis. Only 21 (9%) had a single isolated ovarian lesion with a mobile ovary and without any other ultrasound signs of pelvic endometriomas. Conclusion: Ovarian endometrioma is a marker for pelvic endometriosis and is rarely isolated. A high percentage of USL involvement has been observed. In a clinical context when there is an ovarian endometrioma an accurate TVS should investigate the extent of the disease to check for other endometriotic lesions in order to choose the most appropriate management to treat patient’s pain and infertility not only considering the presence of ovarian lesions. 71
Open Communications 3 - Basic Science/Research/ Education (11:00 AM - 12:00 PM) 11:00 AM – GROUP A
Hysterectomy in Obesity and How Route of Surgery Impacts Outcomes for Benign Disease Henderson SD,1 Borodulin O,1 Gerkin RD,2 Mourad J.1 1Obstetrics & Gynecology, Banner - University Medical Center Phoenix, Phoenix, Arizona; 2Graduate Medical Education, Banner - University Medical Center Phoenix, Phoenix, Arizona Study Objective: To determine outcomes of hysterectomy for benign disease in the obese patient. Design: Retrospective chart review. Setting: Academic teaching hospital. Patients: Patients undergoing hysterectomies for benign disease between between January 2013 and August 2015 with Body Mass Index (BMI) R 30 kg/m2. Measurements and Main Results: A total of 124 patients with a BMI R 30 kg/m2 underwent hysterectomy for benign disease during the study period, 96 via a minimally invasive surgical (MIS) procedure (roboticassisted laparoscopy, laparoscopy or vaginal hysterectomy) and 28 via an open abdominal hysterectomy. Nine of the MIS hysterectomies were converted to open hysterectomies due to difficulties with laparoscopic entry or visualization. Demographics did not differ in regards to age, race or BMI between the two groups. Obese patients who underwent MIS hysterectomy were more likely to have decreased operative time (p\0.001), decreased estimated blood loss (p\0.001), decreased admission rate (p=0.01) and decreased length of hospital stay (p\0.001) compared to patients who underwent open hysterectomy. Patients with large uterine size (uterine weight >250g) were less likely to undergo a MIS procedure (24.1% vs. 54.1%, p=0.002), as were patients with a BMI >40 kg/m2 (46.0% vs. 67.6%, p=0.032). On regression analysis, uterine weight was found to be predictive of increased operative time (p=0.002) and increased estimated blood loss (p=0.014), independent of BMI or route of surgery.
Conclusion: Obese patients who underwent hysterectomy for benign disease in a minimally invasive manner had statistically fewer admissions, decreased blood loss, shorter operative time, and decreased length of stay compared to obese patients who underwent open hysterectomy. These findings were independent of uterine weight or BMI, which are significant considerations in surgical planning. 72
Open Communications 3 - Basic Science/Research/ Education (11:00 AM - 12:00 PM) 11:07 AM – GROUP A
Variation in the Gynecologic Aseptic Technique Improves After Standardization and Video-Based Intervention Jorgensen EM, Desai VB, Shook LL, Chatterjee S, Fan L. Obstetrics, Gynecology & Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut Study Objective: Surgical site infections (SSI) are a significant source of postoperative morbidity and mortality; improving aseptic technique will likely decrease rates of SSI. This study aims to assess variation in intraoperative patient preparation for gynecologic cases, and to assess success of a video-based intervention to standardize aseptic technique. Design: We performed a prospective cohort study examining intraoperative patient preparation of gynecologic cases. Housestaff were surveyed on methods used for preparation between July and August 2014. A departmental asceptic protocol was developed, and housestaff and attending surgeons were shown a short video on proper technique. Follow-up surveys of housestaff were performed between January and April 2016. Setting: Tertiary medical center with large academic and community presences. Patients: Benign gynecologic surgical cases were included if both vaginal and abdominal intraoperative preparations were performed. Obstetrics and Gynecology housestaff completed questionnaires collecting date, surgeon, surgery performed, team member completing preparation, sequence of steps, and materials used. Surveys were collected before (n=50) and after (n=52) intervention. Intervention: Gynecologic Services developed a universal standard protocol for intraoperative aseptic technique based on best practice guidelines. A video explaining and demonstrating proper technique for patient preparation was shown at housestaff didactics and departmental grand rounds. Measurements and Main Results: After viewing a video standardizing surgical aseptic technique, surgeons performed every step of surgical preparation correctly and in correct order in 94.2% of cases (49 of 52). Preparation of the vagina prior to the abdomen improved to 100% of cases, from 92%. Insertion of the foley in correct sequence of preparation and draping improved from 64% to 98.1% of cases. When a uterine manipulator was used, placement was the final step in 94.7% of cases, compared to 70% prior to intervention. Patient preparation performed correctly Before intervention After intervention Vaginal prep prior to abdominal 46/50 (92%) Foley placed in correct sequence 32/50 (64%) Uterine manipulator inserted last 30/43 (70%)
52/52 (100%) 51/52 (98.1%) 36/38 (94.7%)
Conclusion: Variation in technique for intraoperative patient preparation decreased after standardization of practice. A short video is a successful way to disseminate knowledge on intraoperative aseptic technique.
Abstracts / Journal of Minimally Invasive Gynecology 23 (2016) S1–S252
Design: Observational retrospective study on patients with endometriomas by detecting other associated sonographic signs of pelvic endometriosis such as adhesions, tubal pathology, adenomyosis and DIE. Setting: University hospitals. Patients: Symtomatic patients who underwent a transvaginal sonography (TVS) and showed an ovarian cyst with typical appearance of endometrioma were included in this study. Patients with previous pelvic surgery and without symptoms were excluded. Intervention: Mapping of endometriosis by TVS and laparoscopic treatment when indicated for endometriomas and other pelvic endometriosis. Measurements and Main Results: 226 symptomatic patients % 40 years with at least an ovarian endometrioma with a diameter of R 20 mm were included in this study. Mean age was 32.9 4.9 yrs, mean endometriomas diameter was 35.5 16.5mm, Bilateral endometriomas were observed in 32 patients (14%). Of the 226 patients 41(18%) showed posterior rectal DIE and 92 (41%) a thickening of at least one uterosacral lignament (USL). 138 patients (61%) showed adhesions and 82 (36%) had myometrial signs of adenomyosis. Only 21 (9%) had a single isolated ovarian lesion with a mobile ovary and without any other ultrasound signs of pelvic endometriomas. Conclusion: Ovarian endometrioma is a marker for pelvic endometriosis and is rarely isolated. A high percentage of USL involvement has been observed. In a clinical context when there is an ovarian endometrioma an accurate TVS should investigate the extent of the disease to check for other endometriotic lesions in order to choose the most appropriate management to treat patient’s pain and infertility not only considering the presence of ovarian lesions. 71
Open Communications 3 - Basic Science/Research/ Education (11:00 AM - 12:00 PM) 11:00 AM – GROUP A
Hysterectomy in Obesity and How Route of Surgery Impacts Outcomes for Benign Disease Henderson SD,1 Borodulin O,1 Gerkin RD,2 Mourad J.1 1Obstetrics & Gynecology, Banner - University Medical Center Phoenix, Phoenix, Arizona; 2Graduate Medical Education, Banner - University Medical Center Phoenix, Phoenix, Arizona Study Objective: To determine outcomes of hysterectomy for benign disease in the obese patient. Design: Retrospective chart review. Setting: Academic teaching hospital. Patients: Patients undergoing hysterectomies for benign disease between between January 2013 and August 2015 with Body Mass Index (BMI) R 30 kg/m2. Measurements and Main Results: A total of 124 patients with a BMI R 30 kg/m2 underwent hysterectomy for benign disease during the study period, 96 via a minimally invasive surgical (MIS) procedure (roboticassisted laparoscopy, laparoscopy or vaginal hysterectomy) and 28 via an open abdominal hysterectomy. Nine of the MIS hysterectomies were converted to open hysterectomies due to difficulties with laparoscopic entry or visualization. Demographics did not differ in regards to age, race or BMI between the two groups. Obese patients who underwent MIS hysterectomy were more likely to have decreased operative time (p\0.001), decreased estimated blood loss (p\0.001), decreased admission rate (p=0.01) and decreased length of hospital stay (p\0.001) compared to patients who underwent open hysterectomy. Patients with large uterine size (uterine weight >250g) were less likely to undergo a MIS procedure (24.1% vs. 54.1%, p=0.002), as were patients with a BMI >40 kg/m2 (46.0% vs. 67.6%, p=0.032). On regression analysis, uterine weight was found to be predictive of increased operative time (p=0.002) and increased estimated blood loss (p=0.014), independent of BMI or route of surgery.
Conclusion: Obese patients who underwent hysterectomy for benign disease in a minimally invasive manner had statistically fewer admissions, decreased blood loss, shorter operative time, and decreased length of stay compared to obese patients who underwent open hysterectomy. These findings were independent of uterine weight or BMI, which are significant considerations in surgical planning. 72
Open Communications 3 - Basic Science/Research/ Education (11:00 AM - 12:00 PM) 11:07 AM – GROUP A
Variation in the Gynecologic Aseptic Technique Improves After Standardization and Video-Based Intervention Jorgensen EM, Desai VB, Shook LL, Chatterjee S, Fan L. Obstetrics, Gynecology & Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut Study Objective: Surgical site infections (SSI) are a significant source of postoperative morbidity and mortality; improving aseptic technique will likely decrease rates of SSI. This study aims to assess variation in intraoperative patient preparation for gynecologic cases, and to assess success of a video-based intervention to standardize aseptic technique. Design: We performed a prospective cohort study examining intraoperative patient preparation of gynecologic cases. Housestaff were surveyed on methods used for preparation between July and August 2014. A departmental asceptic protocol was developed, and housestaff and attending surgeons were shown a short video on proper technique. Follow-up surveys of housestaff were performed between January and April 2016. Setting: Tertiary medical center with large academic and community presences. Patients: Benign gynecologic surgical cases were included if both vaginal and abdominal intraoperative preparations were performed. Obstetrics and Gynecology housestaff completed questionnaires collecting date, surgeon, surgery performed, team member completing preparation, sequence of steps, and materials used. Surveys were collected before (n=50) and after (n=52) intervention. Intervention: Gynecologic Services developed a universal standard protocol for intraoperative aseptic technique based on best practice guidelines. A video explaining and demonstrating proper technique for patient preparation was shown at housestaff didactics and departmental grand rounds. Measurements and Main Results: After viewing a video standardizing surgical aseptic technique, surgeons performed every step of surgical preparation correctly and in correct order in 94.2% of cases (49 of 52). Preparation of the vagina prior to the abdomen improved to 100% of cases, from 92%. Insertion of the foley in correct sequence of preparation and draping improved from 64% to 98.1% of cases. When a uterine manipulator was used, placement was the final step in 94.7% of cases, compared to 70% prior to intervention. Patient preparation performed correctly Before intervention After intervention Vaginal prep prior to abdominal 46/50 (92%) Foley placed in correct sequence 32/50 (64%) Uterine manipulator inserted last 30/43 (70%)
52/52 (100%) 51/52 (98.1%) 36/38 (94.7%)
Conclusion: Variation in technique for intraoperative patient preparation decreased after standardization of practice. A short video is a successful way to disseminate knowledge on intraoperative aseptic technique.