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Randomized Comparison of Veress Needle Intraperitoneal Placement (VIP) at Caudaly Displaced Umbilicus Versus Left Upper Quadrant (LUQ) During Laparoscopic Entry
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Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
therapies were administered in conjunction with dilation, including topical estriol cream, anxiolytics (oral and inhaled), local anaesthetic gels and oral analgesia. Following discharge, women continued dilator treatment at home and were reviewed fortnightly. Measurements and Main Results: 68 women with a median age at start of treatment of 18 years (range: 13-36) were admitted for a mean of 3 days with a median of 10 dilation sessions (range 2-15). 48/68 (70.6%) women used adjuvants in different combinations: estriol cream 29/64 (45%), 50:50 nitrous oxide and oxygen 44/67 (66%), diazepam 8/62 (13%), lidocaine ointment 26/62 (42%), paracetamol 35/66 (53%), and naproxen 2/55 (4%). 20/68 (30%) women did not use adjuvants during treatment. Median vaginal length pre-treatment was 3.5cm (range: 0-7.5) and 8cm (range: 3-12) post-intensive treatment. Median vaginal width pre-treatment was 2cm (range: 0-3.5) and 3.5cm (range: 2-4) post-intensive treatment. Median increase for both groups in length during intensive treatment was 4cm (range: 0-7). At discharge, 42/56 (75%) of patients had an anatomical neovagina of 7cm or greater length and 29/30 (97%) were satisfied with sexual intercourse by the end of treatment. Conclusion: Vaginal dilation delivered by intensive treatment with adjuvants in a multi-disciplinary context is an effective first-line treatment for women with MRKH and should be considered before exploring surgical options. 266
Open Communications 22 - Laparoscopy (3:20 PM - 5:00 PM)
Randomized Comparison of Veress Needle Intraperitoneal Placement (VIP) at Caudaly Displaced Umbilicus Versus Left Upper Quadrant (LUQ) During Laparoscopic Entry Vilos AG, Vilos GA, Abu Rafea B, Oraif A, Abduljabar H. Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Schulich School of Medicine and Dentistry, Western Univeristy, London, Ontario, Canada Study Objective: To compare feasibility, safety and number of attempts of Veress intraperitoneal placement (VIP) between a modified umbilical and LUQ technique during laparoscopic entry. Design: REB approved, prospective, patient-blinded randomized control trial occurring between January-December 2014. Setting: University affiliated teaching hospital. Patients: 283 women agreed to participate after informed consent were randomized into umbilical (146) versus LUQ (137) VIP. Intervention: All patients were placed in a horizontal position, with appropriate stirrups, and had endotracheal anesthesia with muscle relaxants during surgery. For umbilical entry, the skin below the umbilicus was grasped with both hands of the assistant and pulled caudally and upwards to maximal displacement. A 1 cm vertical infraumbilical incision was made and the Veress was inserted at 90 degrees to the umbilicus. LUQ entry was performed as previously described. Up to 3 consecutive attempts were allowed before conversion. VIP was achieved in all patients in 4 or less attempts and all procedures were supervised by senior author (GAV). Measurements and Main Results: Outcomes included attempts, conversions to alternate site/entry and complications. Exclusion criteria included midline laparotomy and known/suspected abdominal wall adhesions. The two groups were comparable except for weight (LUQ 76.9+/-16.9 kg, umbilicus 72.4+/-16.5 kg, p=0.024) and BMI (LUQ 28.7+/-6.8, umbilicus 27.1+/-6.1 kg/m2, p=0.037). Successful VIP, determined by initial intraperitoneal pressure \9mmHg, for 1st, 2nd, and 3rd attempt was for umbilical (82.8%, 7.6%, 2.8%) and LUQ (90.5%, 8.0%, 0.75%), respectively (Cochran-Armitage Trend test 0.003). Conversion from umbilicus to LUQ and LUQ to umbilicus occurred in 10(6.9%) and 1(0.75%) case, respectively (x2 = 0.025). VIP occurred in all patients. There was one minor vessel injury in each group (0.7%).
Pre-peritoneal insufflation occurred in umbilical 5(3.4%) and LUQ 4(2.9%) cases (NS). Conclusion: VIP was satisfactory with both methods but LUQ placement was associated with fewer attempts and lower conversions to alternative sites.
267 Direct Supply Cost Per Case (DSCPC) of Minimally Invasive Hysterectomy Mattingly PJ, Naumann RW, Bosse PM. Carolinas HealthCare System, Charlotte, North Carolina Study Objective: To determine the DSCPC of a total hysterectomy performed by various routes. Design: Retrospective cohort study. Setting: Two academic affiliated community hospitals. Patients: Patients undergoing a total hysterectomy by vaginal (TVH), laparoscopic (TLH), single incision laparoscopic (SILS) or robot-assisted laparoscopic (RLH) route for one year starting 4/1/14. Patients who had additional surgical procedures at the time of total hysterectomy were excluded. Intervention: not applicable. Measurements and Main Results: A total of 780 total hysterectomies were identified (TVH=55, TLH=431, SILS=32 RLH=192,). The DSCPC was defined as the average cost of disposable OR equipment for each surgeon for a given procedure. The time of the procedure was defined as total time that the patient was in the operating room. The average DSCPC for a TVH was $506 and the average OR time was 139 minutes. Use of a bipolar device increased the cost of TVH from $239 to $1,243. The use of a bipolar device was associated with a longer OR time but this may have been due to case selection. The average DSCPC for a TLH was $1,530 and the average OR time was 187 minutes. A trend was noted between higher DSCPC and longer OR times for private physicians with R 10 cases/year (p 0.09, R2=0.4). The average DSCPC for a SILS hysterectomy was $2,239 and the average OR time was 142 minutes. The average DSCPC for a RLH was $2,024 and the average OR time was 211 minutes. Conclusion: The average DSCPC may be related to surgeon experience. OR costs for hysterectomy were the highest when performed by SILS route. The average DSCPC of a RLH was approximately $500 more than the average DSCPC of a TLH. TVH had the lowest DSCPC but when a bipolar device was utilized the DSCPC was higher than TLH.
268 An Efficient Technique to Manually Morcellate Very Large Uteri Within an Enclosed Endoscopic Bag: Our Five-Year Experience Serur E, Brown K, Zambrano N, Clemetson E, Lakhi N. Obstetrics and Gynecology, Section of Gynecologic Oncology, Richmond University Medical Center, Staten Island, New York Study Objective: To describe a safe and efficient technique to manually morcellate large uteri within an endoscopic bag at the time of laparoscopic hysterectomy. Design: Retrospective review of all consecutive hysterectomies with uterine weight >500g performed by a single surgeon(ES) from January 2010December 2014. Cases in which the uterus was manually morecellated within an endoscopic bag by either an abdominal or vaginal rout at the time of laparoscopic hysterectomy were included. Setting: Community-Hospital.
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
therapies were administered in conjunction with dilation, including topical estriol cream, anxiolytics (oral and inhaled), local anaesthetic gels and oral analgesia. Following discharge, women continued dilator treatment at home and were reviewed fortnightly. Measurements and Main Results: 68 women with a median age at start of treatment of 18 years (range: 13-36) were admitted for a mean of 3 days with a median of 10 dilation sessions (range 2-15). 48/68 (70.6%) women used adjuvants in different combinations: estriol cream 29/64 (45%), 50:50 nitrous oxide and oxygen 44/67 (66%), diazepam 8/62 (13%), lidocaine ointment 26/62 (42%), paracetamol 35/66 (53%), and naproxen 2/55 (4%). 20/68 (30%) women did not use adjuvants during treatment. Median vaginal length pre-treatment was 3.5cm (range: 0-7.5) and 8cm (range: 3-12) post-intensive treatment. Median vaginal width pre-treatment was 2cm (range: 0-3.5) and 3.5cm (range: 2-4) post-intensive treatment. Median increase for both groups in length during intensive treatment was 4cm (range: 0-7). At discharge, 42/56 (75%) of patients had an anatomical neovagina of 7cm or greater length and 29/30 (97%) were satisfied with sexual intercourse by the end of treatment. Conclusion: Vaginal dilation delivered by intensive treatment with adjuvants in a multi-disciplinary context is an effective first-line treatment for women with MRKH and should be considered before exploring surgical options. 266
Open Communications 22 - Laparoscopy (3:20 PM - 5:00 PM)
Randomized Comparison of Veress Needle Intraperitoneal Placement (VIP) at Caudaly Displaced Umbilicus Versus Left Upper Quadrant (LUQ) During Laparoscopic Entry Vilos AG, Vilos GA, Abu Rafea B, Oraif A, Abduljabar H. Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Schulich School of Medicine and Dentistry, Western Univeristy, London, Ontario, Canada Study Objective: To compare feasibility, safety and number of attempts of Veress intraperitoneal placement (VIP) between a modified umbilical and LUQ technique during laparoscopic entry. Design: REB approved, prospective, patient-blinded randomized control trial occurring between January-December 2014. Setting: University affiliated teaching hospital. Patients: 283 women agreed to participate after informed consent were randomized into umbilical (146) versus LUQ (137) VIP. Intervention: All patients were placed in a horizontal position, with appropriate stirrups, and had endotracheal anesthesia with muscle relaxants during surgery. For umbilical entry, the skin below the umbilicus was grasped with both hands of the assistant and pulled caudally and upwards to maximal displacement. A 1 cm vertical infraumbilical incision was made and the Veress was inserted at 90 degrees to the umbilicus. LUQ entry was performed as previously described. Up to 3 consecutive attempts were allowed before conversion. VIP was achieved in all patients in 4 or less attempts and all procedures were supervised by senior author (GAV). Measurements and Main Results: Outcomes included attempts, conversions to alternate site/entry and complications. Exclusion criteria included midline laparotomy and known/suspected abdominal wall adhesions. The two groups were comparable except for weight (LUQ 76.9+/-16.9 kg, umbilicus 72.4+/-16.5 kg, p=0.024) and BMI (LUQ 28.7+/-6.8, umbilicus 27.1+/-6.1 kg/m2, p=0.037). Successful VIP, determined by initial intraperitoneal pressure \9mmHg, for 1st, 2nd, and 3rd attempt was for umbilical (82.8%, 7.6%, 2.8%) and LUQ (90.5%, 8.0%, 0.75%), respectively (Cochran-Armitage Trend test 0.003). Conversion from umbilicus to LUQ and LUQ to umbilicus occurred in 10(6.9%) and 1(0.75%) case, respectively (x2 = 0.025). VIP occurred in all patients. There was one minor vessel injury in each group (0.7%).
Pre-peritoneal insufflation occurred in umbilical 5(3.4%) and LUQ 4(2.9%) cases (NS). Conclusion: VIP was satisfactory with both methods but LUQ placement was associated with fewer attempts and lower conversions to alternative sites.
267 Direct Supply Cost Per Case (DSCPC) of Minimally Invasive Hysterectomy Mattingly PJ, Naumann RW, Bosse PM. Carolinas HealthCare System, Charlotte, North Carolina Study Objective: To determine the DSCPC of a total hysterectomy performed by various routes. Design: Retrospective cohort study. Setting: Two academic affiliated community hospitals. Patients: Patients undergoing a total hysterectomy by vaginal (TVH), laparoscopic (TLH), single incision laparoscopic (SILS) or robot-assisted laparoscopic (RLH) route for one year starting 4/1/14. Patients who had additional surgical procedures at the time of total hysterectomy were excluded. Intervention: not applicable. Measurements and Main Results: A total of 780 total hysterectomies were identified (TVH=55, TLH=431, SILS=32 RLH=192,). The DSCPC was defined as the average cost of disposable OR equipment for each surgeon for a given procedure. The time of the procedure was defined as total time that the patient was in the operating room. The average DSCPC for a TVH was $506 and the average OR time was 139 minutes. Use of a bipolar device increased the cost of TVH from $239 to $1,243. The use of a bipolar device was associated with a longer OR time but this may have been due to case selection. The average DSCPC for a TLH was $1,530 and the average OR time was 187 minutes. A trend was noted between higher DSCPC and longer OR times for private physicians with R 10 cases/year (p 0.09, R2=0.4). The average DSCPC for a SILS hysterectomy was $2,239 and the average OR time was 142 minutes. The average DSCPC for a RLH was $2,024 and the average OR time was 211 minutes. Conclusion: The average DSCPC may be related to surgeon experience. OR costs for hysterectomy were the highest when performed by SILS route. The average DSCPC of a RLH was approximately $500 more than the average DSCPC of a TLH. TVH had the lowest DSCPC but when a bipolar device was utilized the DSCPC was higher than TLH.
268 An Efficient Technique to Manually Morcellate Very Large Uteri Within an Enclosed Endoscopic Bag: Our Five-Year Experience Serur E, Brown K, Zambrano N, Clemetson E, Lakhi N. Obstetrics and Gynecology, Section of Gynecologic Oncology, Richmond University Medical Center, Staten Island, New York Study Objective: To describe a safe and efficient technique to manually morcellate large uteri within an endoscopic bag at the time of laparoscopic hysterectomy. Design: Retrospective review of all consecutive hysterectomies with uterine weight >500g performed by a single surgeon(ES) from January 2010December 2014. Cases in which the uterus was manually morecellated within an endoscopic bag by either an abdominal or vaginal rout at the time of laparoscopic hysterectomy were included. Setting: Community-Hospital.