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Retroperitoneal Ureteral and Uterine Artery Identification During Robotic Hysterectomy: Learning Curve and Determinants of Improvement During Fellowship Training
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Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
Study Objective: To determine if pre-operative warm-up by surgical trainees, with instructor feedback, compared to either warm-up or feedback alone, improves surgical efficiency, precision and quality. Design: Randomized controlled trial with three arms. Setting: Academic tertiary care hospital. Patients: Obstetrics and Gynecology trainees were randomized using stratified block randomization based on surgical skill assessed by use of a laparoscopic virtual reality simulator (scored as a percent ranging from 0-100). Intervention: Participants were randomized to either warm-up on the virtual reality simulator with instructor feedback (WF), warm-up alone (W), or feedback alone (F). Trainees then completed a laparoscopic salpingectomy in the operating room. Measurements and Main Results: Two blinded independent assessors evaluated video recordings of the surgeries using a validated assessment tool and the average score was used (maximum score 45). Eighteen trainees completed the study, six in each arm. The mean baseline score on the simulator was similar in each group (67.7% for W, 69.8% for F and 66.7% for WF). The mean score in the WF group was the highest (28.9 (SD 8.9)) compared to the W group (19.7 (SD 11.1)) and the F group (22.17 (SD 8.2)). After four participants who received intra-operative feedback were excluded to minimize bias, a non-parametric regression analysis was used to compare the primary outcome (the average score on the assessment tool) between groups. The WF group (n = 5) was compared to the W and F groups combined (n = 9). Controlling for baseline score, participants in the WF group scored significantly higher compared to W or F alone (p = 0.048). The inter-rater correlation between the video reviewers was 0.87 (95% CI 0.70-0.95) using the Intraclass correlation coefficient. Conclusion: This study suggests that a pre-operative surgical warm-up with instructor feedback can improve operative performance compared to either a warm-up or feedback alone.
49 Robot-Assisted Laparoscopic Myomectomy: A Comparison of Techniques Sanderson DJ, Ghomi A. Obstetrics and Gynecology, Sisters of Charity Hospital, Buffalo, New York Study Objective: To determine the difference in perioperative variables between a 3-arm technique and a 4-arm technique for robot-assisted laparoscopic myomectomy. Design: Retrospective cohort study (Canadian Task Force classification II-2). Setting: Academic affiliated community hospital. Patients: Patients who underwent consecutive robot-assisted laparoscopic myomectomy between 2009 and 2014. Intervention: Robot-assisted laparoscopic myomectomy. Measurements and Main Results: A total of 101 robot-assisted laparoscopic myomectomies were identified and grouped based upon a 4-arm technique and a 3-arm technique. 60 patients were grouped in the 4-arm technique group and 41 patients in the 3-arm technique group. Patient demographics including age, body mass index, gravidy, parity, surgical history, and American Society of Anesthesiologists (ASA) classification were found to be similar between both groups. Data were analyzed using a student t-test with confidence interval of 95%. Z-test was used to determine probability with p\0.05 considered to be statistically significant. Operative time was 90 minutes shorter in the
4-arm technique group compared to the 3-arm technique (CI -115 to -65, p\0.01). Estimated blood loss (112 ml versus 166 ml, p=0.26), number of fibroids removed (2.68 versus 2.73, p=0.48), fibroid weight (203.15 g versus 174.63 g, p=0.65), morphine equivalents administered postoperatively (5.46 versus 6.27, p=0.34), pain score at discharge from post-anesthesia care unit (2.58 versus 2.67, p=0.46), and length of stay (0.13 days versus 0.26 days, p=0.25) were similar. Single independent variable regression modeling shows that use of the 4th robotic arm accounts for 37% of the variation in mean operative time (p\0.01). Conclusion: The use of a 4-arm robot-assisted laparoscopic myomectomy technique is associated with a significantly shorter operative time when compared to the 3-arm technique, with all other perioperative variables being similar.
50 Retroperitoneal Ureteral and Uterine Artery Identification During Robotic Hysterectomy: Learning Curve and Determinants of Improvement During Fellowship Training Elkattah R,1 DePasquale S.2 1Obstetrics and Gynecology - Division of Minimally Invasive Gynecology, University of Tennessee College of Medicine - Chattanooga, Chattanooga, Tennessee; 2Obstetrics and Gynecology - Division of Gynecologic Oncology, University of Tennessee College of Medicine - Chattanooga, Chattanooga, Tennessee
Study Objective: To determine the time taken, factors, and the learning curve involved in retroperitoneal identification of the ureter and uterine artery during robotic hysterectomy for a fellow-in-training. Setting: Academic hospital. Patients: Patients undergoing robotic hysterectomy over the course of two rotations (R1 & R2). Intervention: The time required for retroperitoneal identification of the ureter at the pelvic brim (T1) followed by identification of the uterine artery (T2) was recorded for all participants in R1 & R2. Mean times were measured. Failures were identified as T>600s. Statistical significance was set at 0.05 and comparative analysis between T1R1 & T1R2, T2R1 & T2R2, and total times (T1+T2)R1 & (T1+T2)R2 was performed. The effect of age, body mass index (BMI), uterine mass, laterality of dissection, adhesions, and surgical history on dissection times was analyzed. Measurements and Main Results: 42 consecutive retroperitoneal dissections were performed; 21 successes and 1 failure in each rotation. Mean time and standard error measurements were as follows: T1R1 = 273.7 30.4 s compared to T1R2 = 188.2 32.9 s; T2R1 = 129.6 16.4 s compared to T2R2 = 83.3 10.7 s; (T1+T2)R1 = 230.9 23.2 s compared to (T1+T2)R2 = 106.5 10.3 s. Significant shorter dissection times were noted in T2 and in T1+T2 between both rotations. Age, adhesions, surgical history, uterine mass and laterality of dissection had no effect on timings between the two rotations. There was a statistically significant increase in T1 with increasing BMI. The overall dissection time (T1+T2) plateaued by the 15th case. Conclusion: There is significant improvement in dissection times with consecutive surgeries. As BMI increases, the time to identify the ureter increases. Fifteen cases are required for a fellow to become adept at retroperitoneal identification of the ureter and uterine artery in robotic hysterectomy.
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
Study Objective: To determine if pre-operative warm-up by surgical trainees, with instructor feedback, compared to either warm-up or feedback alone, improves surgical efficiency, precision and quality. Design: Randomized controlled trial with three arms. Setting: Academic tertiary care hospital. Patients: Obstetrics and Gynecology trainees were randomized using stratified block randomization based on surgical skill assessed by use of a laparoscopic virtual reality simulator (scored as a percent ranging from 0-100). Intervention: Participants were randomized to either warm-up on the virtual reality simulator with instructor feedback (WF), warm-up alone (W), or feedback alone (F). Trainees then completed a laparoscopic salpingectomy in the operating room. Measurements and Main Results: Two blinded independent assessors evaluated video recordings of the surgeries using a validated assessment tool and the average score was used (maximum score 45). Eighteen trainees completed the study, six in each arm. The mean baseline score on the simulator was similar in each group (67.7% for W, 69.8% for F and 66.7% for WF). The mean score in the WF group was the highest (28.9 (SD 8.9)) compared to the W group (19.7 (SD 11.1)) and the F group (22.17 (SD 8.2)). After four participants who received intra-operative feedback were excluded to minimize bias, a non-parametric regression analysis was used to compare the primary outcome (the average score on the assessment tool) between groups. The WF group (n = 5) was compared to the W and F groups combined (n = 9). Controlling for baseline score, participants in the WF group scored significantly higher compared to W or F alone (p = 0.048). The inter-rater correlation between the video reviewers was 0.87 (95% CI 0.70-0.95) using the Intraclass correlation coefficient. Conclusion: This study suggests that a pre-operative surgical warm-up with instructor feedback can improve operative performance compared to either a warm-up or feedback alone.
49 Robot-Assisted Laparoscopic Myomectomy: A Comparison of Techniques Sanderson DJ, Ghomi A. Obstetrics and Gynecology, Sisters of Charity Hospital, Buffalo, New York Study Objective: To determine the difference in perioperative variables between a 3-arm technique and a 4-arm technique for robot-assisted laparoscopic myomectomy. Design: Retrospective cohort study (Canadian Task Force classification II-2). Setting: Academic affiliated community hospital. Patients: Patients who underwent consecutive robot-assisted laparoscopic myomectomy between 2009 and 2014. Intervention: Robot-assisted laparoscopic myomectomy. Measurements and Main Results: A total of 101 robot-assisted laparoscopic myomectomies were identified and grouped based upon a 4-arm technique and a 3-arm technique. 60 patients were grouped in the 4-arm technique group and 41 patients in the 3-arm technique group. Patient demographics including age, body mass index, gravidy, parity, surgical history, and American Society of Anesthesiologists (ASA) classification were found to be similar between both groups. Data were analyzed using a student t-test with confidence interval of 95%. Z-test was used to determine probability with p\0.05 considered to be statistically significant. Operative time was 90 minutes shorter in the
4-arm technique group compared to the 3-arm technique (CI -115 to -65, p\0.01). Estimated blood loss (112 ml versus 166 ml, p=0.26), number of fibroids removed (2.68 versus 2.73, p=0.48), fibroid weight (203.15 g versus 174.63 g, p=0.65), morphine equivalents administered postoperatively (5.46 versus 6.27, p=0.34), pain score at discharge from post-anesthesia care unit (2.58 versus 2.67, p=0.46), and length of stay (0.13 days versus 0.26 days, p=0.25) were similar. Single independent variable regression modeling shows that use of the 4th robotic arm accounts for 37% of the variation in mean operative time (p\0.01). Conclusion: The use of a 4-arm robot-assisted laparoscopic myomectomy technique is associated with a significantly shorter operative time when compared to the 3-arm technique, with all other perioperative variables being similar.
50 Retroperitoneal Ureteral and Uterine Artery Identification During Robotic Hysterectomy: Learning Curve and Determinants of Improvement During Fellowship Training Elkattah R,1 DePasquale S.2 1Obstetrics and Gynecology - Division of Minimally Invasive Gynecology, University of Tennessee College of Medicine - Chattanooga, Chattanooga, Tennessee; 2Obstetrics and Gynecology - Division of Gynecologic Oncology, University of Tennessee College of Medicine - Chattanooga, Chattanooga, Tennessee
Study Objective: To determine the time taken, factors, and the learning curve involved in retroperitoneal identification of the ureter and uterine artery during robotic hysterectomy for a fellow-in-training. Setting: Academic hospital. Patients: Patients undergoing robotic hysterectomy over the course of two rotations (R1 & R2). Intervention: The time required for retroperitoneal identification of the ureter at the pelvic brim (T1) followed by identification of the uterine artery (T2) was recorded for all participants in R1 & R2. Mean times were measured. Failures were identified as T>600s. Statistical significance was set at 0.05 and comparative analysis between T1R1 & T1R2, T2R1 & T2R2, and total times (T1+T2)R1 & (T1+T2)R2 was performed. The effect of age, body mass index (BMI), uterine mass, laterality of dissection, adhesions, and surgical history on dissection times was analyzed. Measurements and Main Results: 42 consecutive retroperitoneal dissections were performed; 21 successes and 1 failure in each rotation. Mean time and standard error measurements were as follows: T1R1 = 273.7 30.4 s compared to T1R2 = 188.2 32.9 s; T2R1 = 129.6 16.4 s compared to T2R2 = 83.3 10.7 s; (T1+T2)R1 = 230.9 23.2 s compared to (T1+T2)R2 = 106.5 10.3 s. Significant shorter dissection times were noted in T2 and in T1+T2 between both rotations. Age, adhesions, surgical history, uterine mass and laterality of dissection had no effect on timings between the two rotations. There was a statistically significant increase in T1 with increasing BMI. The overall dissection time (T1+T2) plateaued by the 15th case. Conclusion: There is significant improvement in dissection times with consecutive surgeries. As BMI increases, the time to identify the ureter increases. Fifteen cases are required for a fellow to become adept at retroperitoneal identification of the ureter and uterine artery in robotic hysterectomy.