Invasive Gynecologic Surgery Research Articles

11425 Referral Patterns for Minimally Invasive Gynecologic Surgery Subspecialists Within an Urban Tertiary Care Network

11425 Referral Patterns for Minimally Invasive Gynecologic Surgery Subspecialists Within an Urban Tertiary Care Network

11680 Implementing Social Needs Screening in a Minimally Invasive Gynecology Surgery Clinic: A Quality Improvement Project

11680 Implementing Social Needs Screening in a Minimally Invasive Gynecology Surgery Clinic: A Quality Improvement Project

11371 Academic Retention and Geographic Distribution of Recent Graduates of Minimally Invasive Gynecologic Surgery Fellowships

11371 Academic Retention and Geographic Distribution of Recent Graduates of Minimally Invasive Gynecologic Surgery Fellowships

11825 Race, Ethnicity, and Sex Representation Trends Among Minimally Invasive Gynecologic Surgery Fellowship Trainees and Graduates

11825 Race, Ethnicity, and Sex Representation Trends Among Minimally Invasive Gynecologic Surgery Fellowship Trainees and Graduates

The Current State of AAGL Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS): Surgical Volume and Case Types

The Current State of AAGL Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS): Surgical Volume and Case Types

Trends in reimbursement for minimally invasive gynecologic surgery

Trends in reimbursement for minimally invasive gynecologic surgery

11766 Essentials in Minimally Invasive Gynecologic Surgery (EMIGS): Set Up and Technique for the Suprapubic Surgeon

11766 Essentials in Minimally Invasive Gynecologic Surgery (EMIGS): Set Up and Technique for the Suprapubic Surgeon

The Impact of Minimally Invasive Gynecologic Surgery Subspecialty Training on Outcomes of Benign Hysterectomy

The Impact of Minimally Invasive Gynecologic Surgery Subspecialty Training on Outcomes of Benign Hysterectomy

Surgical Management of Fibroids: A Changing Landscape.

Background: Uterine fibroids affect patients' quality of life and contribute significantly to health care costs. Studies from 2009 to 2011 demonstrated that fibroids disproportionately affect Black women, with lower odds of uterine preservation and minimally invasive approaches. Objective: This is a retrospective cohort study of data abstracted from the National Surgical Quality Improvement Program database from 2015 to 2019 examining trends in surgical management of uterine fibroids and exploring disparities in surgical approach in a modern cohort. Results: In total, 52,909 women underwent hysterectomy and 15,485 women underwent myomectomy between 2015 and 2019. Over the study period, the overall number of surgeries for fibroids increased by 44.2% with minimally invasive hysterectomy responsible for the majority of this increase. The proportion of patients who underwent myomectomy significantly increased (20.85% to 24.62%, p value <0.0001), whereas hysterectomy significantly decreased (79.15% to 75.38%, p value <0.0001). Bivariate analysis identified younger age, non-White race, and body mass index (BMI) <25 as significantly associated with performance of myomectomy. Non-Hispanic Black (adjusted odds ratio [aOR]: 3.55, 95% confidence interval [CI]: 3.23-3.89), Asian (aOR: 3.26, 95% CI: 2.80-3.80), and Hispanic Black (aOR: 5.50, 95% CI: 3.29-9.25) women were more likely to undergo myomectomy than non-Hispanic White women. Conclusion: Surgical treatment for fibroids increased over time, shifting toward uterine preservation. Myomectomy performance is associated with lower age and BMI and identifying as a racial and/or ethnic minority. These trends may represent improved access to surgical treatment of fibroids, resulting from the growth of minimally invasive gynecological surgery as a specialty and advocacy for equitable health care for all patients.

Confocal Laser Endomicroscopy as a method for assessing endometriosis: A pilot study

ObjectivesTo validate probe-based Confocal Laser Endomicroscopy (pCLE) as a method in assessing endometriosis during conventional and robot-assisted laparoscopy. Study DesignPilot study, including five women in Hospital Moriah, São Paulo, Brazil. During laparoscopic procedures, pCLE was used to assess endometriosis lesions, complemented by subsequent histological evaluations. 214 optical biopsies were performed. These assessments contributed to the development of a comparative atlas, which was used by surgeons to respond to a questionnaire to identify specific cellular structures related to endometriosis in selected confocal images. ResultsThe patients had an average age of 35, exhibiting predominant symptoms like dysmenorrhea and dyspareunia. Despite varied familiarity with pCLE, surgeons demonstrated positive acceptance of the method, with 63.1% recommending its use for intraoperative diagnosis. The technique was particularly noted for its ability to provide real-time, detailed images aiding the identification of endometriosis and associated structures like adipocytes and vascularization, with average evaluation scores exceeding 8 of 10. ConclusionsThis study underscores pCLE’s potential as a transformative diagnostic tool in minimally invasive gynecological surgery. It highlights the feasibility and initial acceptance among surgeons, emphasizing the need for further improvements in device durability and cost-effectiveness. pCLE promises significant advancements in the diagnosis and management of endometriosis, suggesting a future direction for clinical applications and technological refinement.

Extraction Laparotomy for Specimen Retrieval Does Not Alter Same-day Discharge Plans

Study ObjectiveTo evaluate if extraction laparotomy (EL) for intact specimen removal adversely impacted the feasibility or safety of same-day discharge (SDD) in patients undergoing minimally invasive surgery (MIS) for confirmed or suspected gynecologic malignancies. DesignRetrospective study SettingSingle institution study PatientsPatients undergoing minimally invasive surgery for gynecologic malignancy at a single institution, who underwent extraction laparotomy (N=67) and age matched controls (N=134) InterventionsComparing same day discharge rates, complications, readmission and outpatient follow up after between patients requiring extraction laparotomy to those that did not after minimally invasive gynecologic surgery. Measurements and Main ResultsA total of 1224 patients were identified. Sixty-seven patients underwent EL for specimen extraction. From the remainder, 134 patients were selected as age matched controls. SDD rate was 83% (EL) vs. 87% (no EL) (p=.39). There was no difference in median pain scores (1.8 vs. 1.9 p=.86), length of stay (LOS) (0 days for both) (p=.41), 30-day readmission rate (6% vs. 3%) (p=.45), ED visit (13% vs. 10%) (p=.76) or any patient contact (34% vs. 39%) (p=.53), between the groups. Specimen weight was higher for EL (524g vs 142g, p<.001), as was estimated blood loss (EBL) (104ml vs. 46ml, p<.001), and surgery time was increased by 22 minutes in the EL group (121 min vs. 99 min, p<.001). Patients who underwent EL did require more narcotics in PACU 20.5 vs 12.2 OME p=.033, however this did not translate to increased number of narcotics prescribed at discharge. On logistic regression a higher specimen weight trended to increase the likelihood of admission (OR 1.04 CI 1.01-1.08), however, surgery time, time in PACU, race, BMI, surgery type or need for EL did not predict SDD or need for admission. ConclusionsMinimally invasive surgery patients who require extraction laparotomy can still achieve SDD. Same-day discharge is safe and feasible without increased risk of readmission, pain score, or unscheduled patient contact post-operatively.

The Impact of Minimally Invasive Gynecologic Surgery Subspecialty Training on Outcomes of Benign Laparoscopic Hysterectomy: A Retrospective Cohort Study

Study ObjectiveTo compare surgical outcomes among patients undergoing minimally invasive hysterectomy (MIH), laparoscopic or robotic, with minimally invasive gynecologic surgery (MIGS) subspecialists, gynecologic oncologists (GO), or general obstetrician/gynecologists (OB/GYN). DesignRetrospective cohort study. SettingQuaternary care academic hospital. Patients or participantsPatients undergoing MIH for benign indications from 3/2015 to 3/2020 were included. InterventionsMIH. Measurements and Main ResultsThe primary outcome was the odds of a composite of any intra- or postoperative complications within 30 days of surgery by surgeons’ group.A total of 728 MIHs were performed during the study period and constituted the cohort, of which 368 (50.5%) were performed by MIGSs, 144 (19.8%) by GOs, and 216 (29.7%) by OB/GYNs.Intra- and postoperative complications occurred in 11.7% of the MIGS group, 22.9% of the GO group (OR 2.25, 95%CI 1.36-3.71) and 25.9% of the OB/GYN group (OR 2.65, 95%CI 1.70-4.12). Major intra- or postoperative complications were associated with surgeons’ groups (OR 7.02 95%CI 2.67-18.47, and 6.84 95%CI 2.73-17.16 for GO and OB/GYN compared with MIGS, respectively). Intraoperative complication rates were significantly lower for MIGS surgeons (1.4%) than for GOs (9.0%, OR 7.21 95%CI 2.52-20.60) and OB/GYNs (9.7%, OR 7.82 95%CI 2.90-21.06). There was a higher odd of postoperative complications for OB/GYNs compared with MIGS (18.5% vs. 10.9%, OR 1.86 95%CI 1.16-3.00). Rates of conversion to laparotomy were lowest among MIGS surgeons (0.3%) compared to GOs (7.6%) and OB/GYNs (7.9%). Estimated blood loss 90th percentile or higher and surgery time 90th percentile or higher were more common for OB/GYNs compared with MIGS surgeons (OR 2.12 95%CI 1.07-4.22; OR 2.48 95%CI 1.49-4.12, respectively). ConclusionFellowship trained MIGS subspecialists had improved surgical outcomes for benign MIH compared with GOs and OB/GYNs, with lower rates of perioperative complications and fewer conversions to laparotomy.

High-Volume Surgeons and Reducing Racial Disparities in Route of Hysterectomy

Study ObjectiveTo examine racial disparities in route of hysterectomy and perioperative outcomes before and after expansion of high-volume minimally invasive surgeons (>10 minimally invasive hysterectomies (MIH)/year) DesignRetrospective cohort study SettingMulti-center academic teaching institution PatientsAll patients who underwent a scheduled hysterectomy for benign indications during 2018 (pre-intervention) and 2022 (post-intervention) InterventionsRecruitment of Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS)- trained faculty and increased surgical training for academic specialists in obstetrics and gynecology occurred in 2020. Measurements and Main ResultsPatients in the pre-intervention cohort (n=171) were older (median age 45 years vs. 43 years, p=0.003) while patients in the post-intervention cohort (n=234) had a higher burden of comorbidities (26% ASA class III vs. 19%, p=0.03). Uterine weight was not significantly different between cohorts (p=0.328). Between the pre-intervention and post-intervention cohorts, high-volume minimally invasive surgeons increased from 27% (n=4) to 44% (n=7) of those performing hysterectomies within the division and percentage of hysterectomies performed via minimally invasive route increased (63% vs. 82%, p<0.001). In the pre-intervention cohort, Black patients had a lower percentage of hysterectomies performed via minimally invasive route compared to White patients (Black = 56% MIH vs. White = 76% MIH, p=0.014). In the post-intervention cohort, differences by race were no longer significant (Black = 78% MIH vs. White = 87% MIH, p= 0.127). There was a significant increase (22%) in MIH for Black patients between cohorts (p<0.001). After adjusting for age, BMI, ASA class, prior surgery, and uterine weight, disparities by race were no longer present in the post-intervention cohort. Perioperative outcomes including length of stay (p<0.001), infection rates (p=0.002) and blood loss (p=0.01) improved post-intervention. ConclusionIncreasing FMIGs-trained gynecologic surgeons and providing more opportunities in robotic/laparoscopic training for academic specialists may improve access to MIH for Black patients and reduce disparities.

Case Report of Lipomyoma

Report: Uterine lipoleiomyoma are rare forms of leiomyomas that are often only described in literature as case reports. Lipoleiomyomas could increase in size despite menopause and most commonly occur in postmenopausal women with an incidence rate of 0.03% to 0.2% Clinical symptoms of lipoleiomyoma are very similar to leiomyoma. Radiologic imaging can aid in the diagnosis of lipoleiomyoma with smooth muscle confined to the tumor periphery. In our case, we describe a 53y/o G0P0 perimenopausal patient who complained of abnormal uterine bleeding with irregular menses, urinary retention and difficulty completely emptying her bladder due to the large mass compressing her bladder. She was diagnosed with a large 8.8 cm hyperechoic lesion with internal vascularity arising from the central uterus/ endometrium. Radiology recommended a pelvic MRI for further differentiation of mass. Office hysteroscopy with endometrial biopsy was performed. Pathology confirmed limited inactive endometrium, benign endometrial surface epithelium. The patient requested a hysterectomy through a minimally invasive gynecologic surgery approach. A pelvic MRI was performed that revealed a large, round, circumscribed mass measuring 7.3 X 7.2 X 7.5 cm favoring to represent an intramural lipoleiomyoma. The patient had a robotic assisted laparoscopic hysterectomy which was uncomplicated. Final histopathologic diagnosis was uterine lipomyoma. As benign masses, management for lipoleiomyoma are guided by symptoms, fertility preservation desires, and whether or not a patient is a candidate for surgical intervention. Given the rarity of these cases, the histogenesis is still relatively unknown although various theories exist such as differentiation of embryonic fat cells, metaplastic changes of existing cells into fat cells, and pluripotent cell migration. Although there was not evidence of malignancy in our case report, certain literature has suggested the presence of coexisting malignancies and in an even rarer occasion the presence of liposarcoma from a lipoleiomyoma. More information is needed on these rare cases in order to further lead management and any recommendations regarding cancer screening on top of age related recommendations already in place.

Evolving Referral Patterns and Management Following Implementation of a Multidisciplinary Fibroid Center: A Retrospective Cohort Study.

Background/Objectives: Our objective was to evaluate changes in the management of symptomatic fibroids after establishing a multidisciplinary fibroid center with minimally invasive gynecologic surgery (MIGS) and interventional radiology (IR). Methods: A retrospective cohort study was conducted at the fibroid center created in September 2020. Patients were offered same-day consults with both MIGS and IR providers. Data were collected for patients with initial consultations from January to June 2019 (pre-fibroid center) and from January to June 2021 (post-fibroid center). Results: Among 615 patients meeting inclusion criteria, 273 had consultations pre-center and 342 post-center. More patients seen post-center had previously attempted medical management (30.1% vs. 20.2%), with a significant proportion having no prior medical or surgical treatment (53.2% vs. 61.5%). Post-center, there were more MIGS consultations (65.5% vs. 53.1%) and a decrease in general gynecology (GYN) consultations (19.0% vs. 25.6%). More patients sought additional opinions post-center (83.6% vs. 67.0%), particularly with MIGS (58.8% vs. 37.0%). General GYNs referred to MIGS (79.3% vs. 73.1%) and IR specialists (16.0% vs. 13.0%) more often in 2021. In 2021, use of MRI increased (66.5% vs. 52.4%), and more patients underwent uterine artery embolization (UAE) within 1 year of consultation compared to the pre-center period (13.8% vs. 6.9%). Conclusions: Patients with symptomatic fibroids often seek the expertise of specialists to explore treatment options. A multidisciplinary fibroid center that integrates efforts of MIGS and IR enables thorough counseling and a rise in the utilization of minimally invasive procedures, including UAE.

Patient positioning in minimally invasive gynecologic surgery: strategies to prevent injuries and improve outcomes.

Effective patient positioning is a critical factor influencing surgical outcomes, mainly in minimally invasive gynecologic surgery (MIGS) where precise positioning facilitates optimal access to the surgical field. This paper provides a comprehensive exploration of the significance of strategic patient placement in MIGS, emphasizing its role in preventing intraoperative injuries and enhancing overall surgical success. The manuscript addresses potential complications arising from suboptimal positioning and highlights the essential key points for appropriate patient positioning during MIGS, encompassing what the surgical team should or shouldn't do. In this perspective, the risk factors associated with nerve injuries, sliding, compartment syndrome, and pressure ulcers are outlined to guide clinical practice. Overall, this paper underscores the critical role of precise patient positioning in achieving successful MIGS procedures and highlights key principles for the gynecological team to ensure optimal patient outcomes.

Surgical Considerations for Minimally Invasive Gynecologic Surgery in Patient With Skeletal Dysplasia

Skeletal dysplasias are a group of heritable diseases in which the bone and cartilage are affected. Despite their impact in anatomical structures, there are many gaps in knowledge between the relationship between skeletal dysplasias and minimal invasive gynecologic surgery. Here, we present a case of a 44-year-old patient with a history of skeletal dysplasia and abnormal uterine bleeding, due to uterine fibroids. As medical treatment failed, a laparoscopic surgery was performed. As expected, normal anatomical landmarks used in laparoscopy were lost as a result of severe scoliosis.Despite anesthesic and surgical difficulties, a successful total laparoscopic hysterectomy and bilateral salpingectomy was performed. Patients with these disorders need to have an individualized and interdisciplinary approach in gynecologic laparoscopic surgery

Surgical Field Separation in Total Laparoscopic Hysterectomy.

We aimed to study whether separating the vaginal and abdominal surgical fields during total laparoscopic hysterectomy (TLH) is associated with surgical site infection rates. This was a retrospective cohort study of all patients who underwent TLH and any concomitant procedures with two minimally invasive gynecologic surgery subspecialists between January 2016 and May 2023. Among 680 included patients, the rate of infection was 0.8% with surgical field separation and 1.3% without (3/377 vs 4/303; odds ratio 0.60, 95% CI, 0.13-2.70). There was no statistical difference between groups; however, the difference in infection rates between groups was extremely small, which led to inadequate power. Our findings suggest that rates of infection after TLH are low, with or without surgical field separation. Treating the vagina, perineum, and abdomen as a single, continuous operative field during TLH may be an acceptable practice.

Sustainability of an enhanced recovery pathway after minimally invasive gynecologic oncology surgery

ObjectiveSame day discharge is safe after minimally invasive gynecology oncology surgery. Our quality improvement peri-operative program based on enhanced recovery after surgery principles led to an increase in same day...

Same-Day Discharge in Minimally Invasive Gynecologic Surgery: A Care Partner Perspective [ID 2683597

INTRODUCTION: Same-day hospital discharge after minimally invasive gynecologic surgery has gained popularity and become feasible with increased adherence to enhanced recovery after surgery protocols. Benefits include reduced hospital admissions, increased cost-effectiveness, and practicality of patient recovery at home—without any demonstrable increase in patient harm or readmissions. Although studies show patients perceive same-day discharge favorably, there are little data regarding care partner perception of this trend. METHODS: A REDCap survey was administered prospectively to care partners of patients undergoing minimally invasive hysterectomy (MIH) within a single tertiary-care department between November 2022 and September 2023. The 16-question survey included questions evaluating care-partner perspectives regarding same-day discharge and postoperative home care. Approximately 75 patients were targeted for recruitment. Responses were analyzed using descriptive statistics. RESULTS: Approximately 66.7% of care partners indicated they were “very comfortable” caring for the patient at home the night of surgery. When asked to rate the level of concern about the patient going home on the same day as surgery, 64% selected a 2 or below on a 5-point Likert scale, with 36.4% of these individuals indicating that they were “not concerned at all.” Moreover, 42.4% of the respondents reported that this was their experience with postoperative home care. CONCLUSION: This study demonstrates that despite having no prior experience, care partners are comfortable caring for MIH patients on postoperative day 0. This is additive to current literature on patient comfort in same-day discharge. Thus, not only is same-day discharge a reasonable option for many patients but also most care partners are comfortable supporting this plan.