- Email: [email protected]
Same Day Robotic Hysterectomy: Protocol and Safety and Feasibility Study
S168
Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S133–S181
Patients: 4 patients with heterotopic pregnancy, 3 of which were spontaneous conceptions. Intervention: 3 patients were treated with laparoscopic surgery and one patient underwent open surgery due to hemodynamic instability with a hemoperitoneum of 3.5 L. Measurements and Main Results: One intrauterine pregnancy ended with a first trimester miscarriage. The other 3 pregnancies resulted in live births, 2 at term and one delivered at 30 weeks due to severe pre-eclampsia. Conclusion: The presence of an intrauterine pregnancy may falsely reassure the clinician and a high degree of suspicion is essential to make the diagnosis. High beta hCG levels may give false assurance, early transvaginal scan may not diagnose all cases of ectopic gestation and a haemorrhagic corpus luteum may confuse and delay diagnosis of heterotrophic pregnancy. The detection rates of heterotopic pregnancy with transvaginal scan ranges from 41-84%. Heterotopic pregnancy remains an unusual condition, in spite of its increasing prevalence in recent decades. Most cases are associated with assisted reproductive techniques although spontaneous heterotropic pregnancy appears to be on the increase. Clinical suspicion remains the cornerstone for diagnosis, as there is a failure rate for all the diagnostic tests available. Surgical management is the preferred treatment with laparoscopic salpingectomy preferable to open surgery or conservative surgical techniques. 556 Successful Live Births Following Laparoscopic Repair of Symptomatic Cesarean Section Scar Pregnancy: Two Case Reports Yang G, Lee D, Jeong K. Department of Obstetrics and Gynecology, School of Medicine, Ewha Womans University, Seoul, Korea Study Objective: To assess the efficacy and safety of laparoscopic repair for symptomatic cesarean section scar pregnancy. Design: Two case reports. Setting: Department of Obstetrics and Gynecology of Ewha Womans University Mokdong Hospital. Patients: 27-year-old woman in the seven weeks and two days and 30-yearold woman in the seven weeks and three days of pregnancies with abdominal pain and vaginal bleeding. Intervention: Laparoscopic primary repair after failure of suction curettage. Measurements and Main Results: Cesarean section scar pregnancies with fetal heart beats were diagnosed by transvaginal sonography. At first, suction curettages were tried at b-hCG 105,330 and 68,500mIU/ml, respectively. The first patient underwent the laparoscopic repair of cesarean scar defect because of heavy bleeding after 26 days from suction curettage. The second patient underwent the laparoscopic repair of cesarean scar defect immediately after suction curettage. The defected uterine walls on anterior lower segments and bladder peritoneum were closed using Vicryl #2-0 and #3-0, respectively. After surgery, normal menses resumed in both patients. Two patients all conceived naturally 6 months later and underwent repeated cesarean section at term. These were successful live births although the first patient was treated with uterine artery embolization for postpartum hemorrhage on the tenth day after parturition. Conclusion: Laparoscopic approach of cesarean section scar pregnancy is a useful treatment for subsequent pregnancy to successful live birth. 557 Abstract Withdrawn VIRTUAL POSTER: ROBOTICS 558 Attitudes of Minimally Invasive Reproductive and Gynecologic Surgeons toward Robotic Surgery Bailey AP, Correia KF, Missmer SA, Gargiulo AR. Department of Obstetrics & Gynecology, Brigham and Women’s Hospital and Harvard School of Medicine, Boston, Massachusetts
Study Objective: To identify barriers to the adoption of robotic surgery and how they differ by geography (ACOG Districts) and practice type: Academic (A) versus Private (P). Design: Online survey link emailed June 2012 to all AAGL and ASRM members. Setting: Academic medical center. Patients: 561 actively-practicing post-training gynecologic laparoscopic surgeons (Surgeon) and 138 residents/fellows (response rate 15%). Intervention: Survey completion. Measurements and Main Results: Statistical differences were quantified by chi-square tests. 84%Surgeons had access to a robot with more in A (93%) than P (77%) and less in District VIII (67%) versus the mean for all districts (all p\0.05). 85%Residents/Fellows had robotic training; there was more exposure in Districts IV (96%) and VI (100%) and less in District I (72%) versus the mean for all districts (all p\0.05). 61% Surgeons were credentialed or planning to be credentialed in robotic surgery with no difference by district or practice type. The proportion did vary by subspecialty: 100%GynOnc, 79%MIGS, 77%Urogynecology, 67%ObGyn, 46%Gynecology only, 44%REI. The primary reason for not seeking privileges among Surgeons with access was: 20%Cost, 18% Increased OR time, 10%Additional training, 8%OR unavailable, 4% Training Cost, 1%Safety, 1%Possible Additional ports. These did not vary by District (p=0.764); however, there was more concern about cost and increased operating time among P (24% and 25%, respectively) than A (13% and 15%, respectively). Conclusion: Less than a decade from the introduction of the robot to gynecologic surgery an overwhelming number of Surgeons have access to a robot, and the vast majority of Residents/Fellows are being trained on this modality. Robotic surgery practices are influenced more by practice type and specialty than geography. Despite less access, P pursue credentialing as often as A. There is no single overriding barrier, and some will likely be overcome by the large number of Residents/Fellows currently training in robotic surgery.
559 Same Day Robotic Hysterectomy: Protocol and Safety and Feasibility Study Borahay MA,1 Eastham B,1 Patel PR,1 Atik MM,2 Kilic GS.1 1Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas; 2 University of Houston, Houston, Texas Study Objective: To develop an integrated program for same day robotic hysterectomy and to assess its safety and feasibility. Design: Prospective cohort study. Setting: University teaching hospital. Patients: A cohort of 29 patients who underwent robotic hysterectomy for benign conditions by same surgeon. Intervention: An integrated same day hysterectomy program was developed. This included patient eligibility criteria (patient condition deemed medically suitable, living within 30 miles radius from hospital, and has someone to stay with at home), outpatient patient education and counseling, educating day surgery and OR nurses/staff; and collaboration with anesthesiologists. Patients fulfilling eligibility criteria were counseled and those accepting were managed according to days surgery protocol. Prior to discharge, patients were educated about warning symptoms and given cell phone number of surgeon. Nurse checked on patient on first postoperative day. Patient returned to clinic within one week of surgery. Measurements and Main Results: Outcome measures included clinical outcomes and cost analysis. Three patients were excluded from analysis as they had to be admitted because of operative characteristics. There were no statistically significant differences in demographic, preoperative and operative characteristics between groups. Length of stay in hospitalized group was 1.13 (0.35)days. There was one readmission in the same day group that occurred 8 days after procedure. Average hospital cost savings in same day discharge versus hospitalized group was $4968.2 per case. Conclusion: In well-selected patient population and well-designed program, same day robotic hysterectomy seems to be safe and feasible. Further studies with more numbers are needed to confirm these findings.
Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S133–S181
Patients: 4 patients with heterotopic pregnancy, 3 of which were spontaneous conceptions. Intervention: 3 patients were treated with laparoscopic surgery and one patient underwent open surgery due to hemodynamic instability with a hemoperitoneum of 3.5 L. Measurements and Main Results: One intrauterine pregnancy ended with a first trimester miscarriage. The other 3 pregnancies resulted in live births, 2 at term and one delivered at 30 weeks due to severe pre-eclampsia. Conclusion: The presence of an intrauterine pregnancy may falsely reassure the clinician and a high degree of suspicion is essential to make the diagnosis. High beta hCG levels may give false assurance, early transvaginal scan may not diagnose all cases of ectopic gestation and a haemorrhagic corpus luteum may confuse and delay diagnosis of heterotrophic pregnancy. The detection rates of heterotopic pregnancy with transvaginal scan ranges from 41-84%. Heterotopic pregnancy remains an unusual condition, in spite of its increasing prevalence in recent decades. Most cases are associated with assisted reproductive techniques although spontaneous heterotropic pregnancy appears to be on the increase. Clinical suspicion remains the cornerstone for diagnosis, as there is a failure rate for all the diagnostic tests available. Surgical management is the preferred treatment with laparoscopic salpingectomy preferable to open surgery or conservative surgical techniques. 556 Successful Live Births Following Laparoscopic Repair of Symptomatic Cesarean Section Scar Pregnancy: Two Case Reports Yang G, Lee D, Jeong K. Department of Obstetrics and Gynecology, School of Medicine, Ewha Womans University, Seoul, Korea Study Objective: To assess the efficacy and safety of laparoscopic repair for symptomatic cesarean section scar pregnancy. Design: Two case reports. Setting: Department of Obstetrics and Gynecology of Ewha Womans University Mokdong Hospital. Patients: 27-year-old woman in the seven weeks and two days and 30-yearold woman in the seven weeks and three days of pregnancies with abdominal pain and vaginal bleeding. Intervention: Laparoscopic primary repair after failure of suction curettage. Measurements and Main Results: Cesarean section scar pregnancies with fetal heart beats were diagnosed by transvaginal sonography. At first, suction curettages were tried at b-hCG 105,330 and 68,500mIU/ml, respectively. The first patient underwent the laparoscopic repair of cesarean scar defect because of heavy bleeding after 26 days from suction curettage. The second patient underwent the laparoscopic repair of cesarean scar defect immediately after suction curettage. The defected uterine walls on anterior lower segments and bladder peritoneum were closed using Vicryl #2-0 and #3-0, respectively. After surgery, normal menses resumed in both patients. Two patients all conceived naturally 6 months later and underwent repeated cesarean section at term. These were successful live births although the first patient was treated with uterine artery embolization for postpartum hemorrhage on the tenth day after parturition. Conclusion: Laparoscopic approach of cesarean section scar pregnancy is a useful treatment for subsequent pregnancy to successful live birth. 557 Abstract Withdrawn VIRTUAL POSTER: ROBOTICS 558 Attitudes of Minimally Invasive Reproductive and Gynecologic Surgeons toward Robotic Surgery Bailey AP, Correia KF, Missmer SA, Gargiulo AR. Department of Obstetrics & Gynecology, Brigham and Women’s Hospital and Harvard School of Medicine, Boston, Massachusetts
Study Objective: To identify barriers to the adoption of robotic surgery and how they differ by geography (ACOG Districts) and practice type: Academic (A) versus Private (P). Design: Online survey link emailed June 2012 to all AAGL and ASRM members. Setting: Academic medical center. Patients: 561 actively-practicing post-training gynecologic laparoscopic surgeons (Surgeon) and 138 residents/fellows (response rate 15%). Intervention: Survey completion. Measurements and Main Results: Statistical differences were quantified by chi-square tests. 84%Surgeons had access to a robot with more in A (93%) than P (77%) and less in District VIII (67%) versus the mean for all districts (all p\0.05). 85%Residents/Fellows had robotic training; there was more exposure in Districts IV (96%) and VI (100%) and less in District I (72%) versus the mean for all districts (all p\0.05). 61% Surgeons were credentialed or planning to be credentialed in robotic surgery with no difference by district or practice type. The proportion did vary by subspecialty: 100%GynOnc, 79%MIGS, 77%Urogynecology, 67%ObGyn, 46%Gynecology only, 44%REI. The primary reason for not seeking privileges among Surgeons with access was: 20%Cost, 18% Increased OR time, 10%Additional training, 8%OR unavailable, 4% Training Cost, 1%Safety, 1%Possible Additional ports. These did not vary by District (p=0.764); however, there was more concern about cost and increased operating time among P (24% and 25%, respectively) than A (13% and 15%, respectively). Conclusion: Less than a decade from the introduction of the robot to gynecologic surgery an overwhelming number of Surgeons have access to a robot, and the vast majority of Residents/Fellows are being trained on this modality. Robotic surgery practices are influenced more by practice type and specialty than geography. Despite less access, P pursue credentialing as often as A. There is no single overriding barrier, and some will likely be overcome by the large number of Residents/Fellows currently training in robotic surgery.
559 Same Day Robotic Hysterectomy: Protocol and Safety and Feasibility Study Borahay MA,1 Eastham B,1 Patel PR,1 Atik MM,2 Kilic GS.1 1Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas; 2 University of Houston, Houston, Texas Study Objective: To develop an integrated program for same day robotic hysterectomy and to assess its safety and feasibility. Design: Prospective cohort study. Setting: University teaching hospital. Patients: A cohort of 29 patients who underwent robotic hysterectomy for benign conditions by same surgeon. Intervention: An integrated same day hysterectomy program was developed. This included patient eligibility criteria (patient condition deemed medically suitable, living within 30 miles radius from hospital, and has someone to stay with at home), outpatient patient education and counseling, educating day surgery and OR nurses/staff; and collaboration with anesthesiologists. Patients fulfilling eligibility criteria were counseled and those accepting were managed according to days surgery protocol. Prior to discharge, patients were educated about warning symptoms and given cell phone number of surgeon. Nurse checked on patient on first postoperative day. Patient returned to clinic within one week of surgery. Measurements and Main Results: Outcome measures included clinical outcomes and cost analysis. Three patients were excluded from analysis as they had to be admitted because of operative characteristics. There were no statistically significant differences in demographic, preoperative and operative characteristics between groups. Length of stay in hospitalized group was 1.13 (0.35)days. There was one readmission in the same day group that occurred 8 days after procedure. Average hospital cost savings in same day discharge versus hospitalized group was $4968.2 per case. Conclusion: In well-selected patient population and well-designed program, same day robotic hysterectomy seems to be safe and feasible. Further studies with more numbers are needed to confirm these findings.