Minimally Invasive Gynecologic Surgery Research Articles

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

Demographics and Characteristics of US-Based Minimally Invasive Gynecologic Surgery Fellowship Program Directors: A 2023 Descriptive Analysis

Fellowship program directors (FPDs) play an important role in the development of fellows and learners, but little is known about their demographics. This cross-sectional study aims to examine the characteristics of minimally invasive gynecologic surgery (MIGS) FPDs. A retrospective cross-sectional study. Data obtained from publicly available information on official websites of the program directors studied. MIGS fellowship program directors. All US-based MIGS programs affiliated with the AAGL in 2023 were included. Information about FPD gender, medical school attended and graduation year, residency program attended and graduation year, any additional graduate degrees earned, fellowship programs completed, and the year of their appointment as FPD was collected through publicly available sources. Scholarly activity was measured by peer-reviewed articles and the Hirsch index. Of the 54 FPDs, 28 (51.85%) were female and 26 (48.15%) were male. Male FPDs were significantly older (54.6 ± 8.7 years) than female FPDs (46.2 ± 5.0 years), p < 0.05. Average age at appointment was 43.1 ± 6.7 years, with female FPDs being appointed at significantly younger ages (39.4 ± 5.1 years) compared to male FPDs (44.5 ± 6.8 years), p < 0.05. Male FPDs had statistically significant higher Hirsch indices (14 ± 11.4) compared to female FPDs (8 ± 5.8), p < 0.05. Of the FPDs who completed a fellowship, 27 (50.00%) did so in MIGS, eight (14.81%) in Gynecologic-Oncology, six (11.11%) in Urogynecology, and four (7.41%) in Reproductive Endocrinology/Infertility. MIGS fellowships have a uniquely equal representation of male and female FPDs, as surgical subspecialties historically tend to be male dominant. Notably, there is diversity in the type of fellowship pursued by MIGS FPDs, with nearly half of FPDs completing a fellowship outside of MIGS. The reasons for differences in scholarly contributions, indicated by Hirsch index, of male versus female FPDs is unclear.

Clinical Trial Racial and Ethnic Disparities in Minimally Invasive Gynecologic Surgery

Study ObjectiveTo study racial and ethnicity disparities in randomized clinical trials (RCT) in Minimally Invasive Gynecologic Surgery (MIGS). DesignCross sectional study. SettingOnline review of all published MIGS RCTs in high-impact journals from 2012 to 2023. PatientsJournals included all Q1 Obstetrics & Gynecology journals, as well as The New England Journal of Medicine, The Lancet, The British Medical Journal, and The Journal of the American Medical Association. The National Institutes of Health's PubMed and the ClinicalTrials.gov websites were queried using the following search terms from the American Board of Obstetrics and Gynecology's certifying examination bulletin 2022 to obtain relevant trials: adenomyosis, adnexal surgery, abnormal uterine bleeding, cystectomy, endometriosis, fibroids, gynecology, hysterectomy, hysteroscopy, laparoscopy, leiomyoma, minimally invasive gynecology, myomectomy, ovarian cyst, robotic surgery InterventionsThe United States (US) Census Bureau data was used to estimate the expected number of participants. We calculated the enrollment ratio (ER) of actual to expected participants for US trials with race and ethnicity data available. Measurements and Main ResultsA total of 352 RCTs were identified. Of these, race and/or ethnicity data were available in 65 studies (18.5%). We analyzed the 46 studies that originated in the US, with a total of 4,645 participants. Of these RCTs only 8 (17.4%) reported ethnicity in addition to race. When comparing published RCT data to expected proportions of participants, White participants were overrepresented [70.8% versus 59.6%, ER 1.66, 95% confidence interval (CI) 1.52-1.81], as well as Black or African American participants (15.4% versus 13.7%, ER 1.15, 95% CI 1.03-1.29). Hispanic (6.7% versus 19.0%, ER 0.31, 95% CI 0.27-0.35), Asian (1.7% versus 6.1%, ER 0.26, 95% CI 0.20-0.34), Native Hawaiian or Other Pacific Islander (0.1% versus 0.3%, ER 0.21, 95% CI 0.06-0.74), and Indian or Alaska Native participants (0.2% versus 1.3%, ER 0.16, 95% CI 0.08-0.32) were underrepresented. When comparing race/ethnicity proportions to the 20 states where the RCTs were conducted, Black or African American participants were underrepresented. ConclusionIn MIGS RCTs conducted in the US, White and Black or African American participants are overrepresented compared to other races, and ethnicity is characterized in fewer than one fifth of trials. Efforts should be made to improve racial and ethnic recruitment equity as well as reporting in future MIGS RCTs.

Gynecologic Surgical Subspecialty Training Decreases Surgical Complications in Benign Minimally Invasive Hysterectomy

Study ObjectiveTo evaluate the impact of gynecologic subspecialty training on surgical outcomes in benign minimally invasive hysterectomies (MIH) while accounting for surgeon volume. DesignRetrospective cohort study of patients who underwent a MIH between 2014 and 2017. SettingSingle community hospital system. PatientsPatients were identified via CPT (Current Procedural Terminology) codes for MIH: vaginal, laparoscopic or robotic. Exclusion criteria included a gynecologic cancer diagnosis or concomitant major procedure at the time of hysterectomy. One thousand six hundred and thirty-one patients underwent a benign MIH performed by a gynecologic generalist or a subspecialist in Minimally-Invasive Gynecologic Surgery (MIGS), Urogynecology and Pelvic Reconstructive Surgery (URPS), or Gynecologic Oncology. 125 hysterectomies were vaginal, 539 were conventional laparoscopic, and 967 were robotic. InterventionsN/A Measurements and Main ResultsSurgical outcomes including intraoperative complications, operative outcomes, and postoperative readmissions and reoperations, were compared between generalists and subspecialists and stratified by surgeon volume status, with “high-volume” defined as performing 12 or more hysterectomies annually. Odds ratios for the primary outcome, Clavien-Dindo Grade III complications (which included visceral injuries, conversions, and reoperations within 90 days), were calculated to evaluate the impact of subspecialty training while accounting for surgeon volume status. 855/1631 (52.4%) MIH were performed by generalists and 776/1631 (47.6%) by subspecialists. High-volume generalists performed 618/1631 (37.9%) of MIH, 14.5% (237/1631) were performed by low-volume generalists. All subspecialists were high-volume surgeons; 38.1% of generalists were high-volume.The odds of a Clavien-Dindo Grade III complication was 0.39 (0.25-0.62) for hysterectomies performed by subspecialists compared to high-volume generalists after adjusting for potential confounding variables (p < .001). Subspecialists and high-volume surgeons had significantly lower incidence of visceral injuries, transfusions, blood loss over 500 mL, and conversions compared to generalists and low-volume surgeons, respectively. ConclusionBoth subspecialty training and high surgeon volume status are associated with a lower risk of surgical complications in benign MIH. Subspecialty training is associated with a reduction in surgical complications even after accounting for surgeon volume.

Safely Introducing New Surgical Devices in Minimally Invasive Gynecologic Surgery: An Argument for Use of the IDEAL Framework

To review the Food and Drug Administration (FDA) premarket regulatory and postmarket surveillance processes for 2 minimally invasive gynecologic surgery case studies-the laparoscopic power morcellator and the Essure permanent birth control device-and to introduce the IDEAL (Idea, Development, Exploration, Assessment, Long-term) framework for safely introducing and monitoring minimally invasive gynecologic surgery devices. News media publications, agency websites, legal articles, and scientific papers. Articles and papers were selected that described events leading to FDA approval of these devices and subsequent complications. Based on current FDA premarket regulatory processes, 67% of devices do not currently require premarket review and only 1% are subject to clinical trial requirements. The IDEAL framework delineates 5 phases for safe introduction of medical devices: idea, development, exploration, assessment, and long-term study. The laparoscopic power morcellator and Essure cases illustrate possible shortcomings in our device approval system that could be improved upon using the IDEAL framework, which limits device use until safety and efficacy data have been established and recommends postmarket surveillance.

Innovations in Minimally Invasive Gynecologic Surgery: Improving Outcomes and Recovery Gynecology

A paradigm change has occurred in minimally invasive gynecologic surgery (MIGS), which uses improved techniques and technology to improve patient care and recovery after surgery. This review paper provides a thorough analysis of current advancements in MIGS, emphasising its significant influence on surgical results and patient recovery. This research examines significant technical developments, procedural improvements, and their effects on how gynecologic surgery is evolving.&#x0D; The accuracy and effectiveness of MIGS have been redefined by technological advancements such as augmented reality, robotic-assisted surgery, sophisticated imaging modalities, and specialty equipment. By reducing invasiveness and revolutionising the surgical technique, these advancements provide improved visibility, surgical precision, and manoeuvrability. The paper goes into detail on how important these developments are for streamlining complex procedures and enhancing patient outcomes.&#x0D; The study also explores the development of improved recovery pathways in MIGS, highlighting early mobilisation, individualised care plans, multimodal pain management techniques, and psychological support. When these tactics are included into perioperative treatment, they greatly speed up patients' recuperation and enhance their general health.&#x0D; When comparing MIGS advancements to open operations, a critical examination shows that patients have less blood loss, shorter hospital stays, fewer complications, better pain management, and a speedier return to regular activities. Promising findings are also shown in long-term patient outcomes and safety profiles after MIGS treatments.

Differences in Exposure to Minimally Invasive Surgery in a Sample of United States Obstetrics and Gynecology Residents.

The objective of this study was to assess the exposure to minimally invasive gynecologic surgery (MIGS) techniques among senior (third and fourth year) Obstetrics and Gynecology residents in the United States. We conducted an online cross-sectional survey among senior residents who completed a 19-item questionnaire regarding their exposure to laparoscopic and robotic cases and techniques and their access to their simulation. We performed a comparison among these residents, grouped based on the four geographical regions of the United States. Senior residents, on average, performed 4.0 MIGS cases (standard deviation (SD) ±2.5), 1.0 two-handed laparoscopy (SD ±1.0), and 1.5 robotic cases (SD ±1.5) per week. The exposure to challenging skills such as extracorporeal and intracorporeal suturing and laparoendoscopic single site (LESS) surgery per week was minimal and did not vary across the nation (p=0.99, p=0.06, p=0.52, respectively). Access to dual consoles increased the number of robotic cases performed per week (p=0.01). While residents of all regions had equal access to laparoscopic box trainers (p=0.81) and laparoscopic simulators (p=0.22), residents of the southern region had less access to robotic simulators (p=0.04). The number of MIGS cases performed by residents did not differ nationwide. However, exposure to advanced aspects of endoscopy training was minimal. The presence of a fellowship or type of teaching environment did not alter the number of cases performed by residents. Residents performed a greater number of robotic cases with the presence of dual consoles.

Socioeconomic Factors Associated with Delay of Minimally Invasive Benign Gynecologic Surgery and Impact of the COVID-19 Pandemic

Objective: The effects of demographic and socioeconomic characteristics on delay of minimally invasive gynecologic surgery (MIGS) before and during the COVID-19 pandemic were studied. The primary outcome was interval between first MIGS appointment and date of surgery. Materials and Methods: This retrospective cohort study used electronic medical record data of a historical cohort who had benign MIGS in 2014–2016 (n = 370) and a cohort in 2020 during the COVID pandemic (n = 249). Included procedures were laparoscopic hysterectomy, myomectomy, adnexal surgery, or endometriosis excision. Patient demographics (race, ethnicity, age, marital status, language, insurance, and socioeconomic factors) were evaluated for associations with surgery delay (> 90 days from initial consultation to operating room date). Results: Median time to surgery was 21 days faster during the pandemic. In the historical cohort, 61% patients waited >90 days, and in the pandemic cohort, 47% patients waited >90 days. In the pandemic cohort, race and primary language were new factors associated with surgery delays. During the pandemic, a greater proportion of patients having surgery delays were Black or other races, compared to White, and a greater proportion did not speak English. After adjusting for referral indications, in multivariable logistic regression, patients who reported Other race had 3 times the odds of surgery delay, compared to White patients. Black patients had higher odds of surgery delay, although this estimate was less precise. Patients with a non-English primary language had >4 times the odds of surgery delay. Ethnicity, insurance and employment status, median household income, neighborhood segregation, and distance to hospital were not associated with surgery delay. Telemedicine accounted for 71% of visits in the pandemic cohort and was associated with a significant decrease in surgery delays with a median wait time of 87 days for patients seen via telemedicine, compared to 101 days for patients seen in-person. A higher proportion of patients using telemedicine were White and spoke English. Hispanic/Latino ethnicity, non-English primary language, and unemployment were associated with in-person versus telemedicine visits. Visit type was not correlated with insurance status, median household income, neighborhood segregation, and distance from the hospital. A risk score was calculated to summarize the estimated effect of intersectionality of multiple identities; multiple minority characteristics were correlated with surgery delays. Time to benign MIGS decreased from historical baselines during the pandemic, indicating improved access to surgical care. This benefit did not apply equally. Disproportionately, White patients who spoke English had no delays and used telemedicine; racial minority patients who did not speak English had greater odds of surgery delays and in-person appointments. Conclusions: Telemedicine can improve access to both MIGS care and surgical outcomes; additional strategies are needed to ensure that all patients receive care advances equitably. (J GYNECOL SURG 20XX:000)

Black Race and Racism Affect Likelihood of Undergoing Surgery After Referral to a Minimally Invasive Gynecologic Surgeon [ID: 1377814

INTRODUCTION: Significant racial and ethnic disparities persist in access and outcomes for patients with benign gynecologic disorders. The role of sociodemographic factors in surgical delays after referral to a minimally invasive gynecologic surgery (MIGS) specialist is unknown. METHODS: A retrospective cohort study of patients who completed a MIGS consultation at a single, large academic hospital between March 2015 and July 2016 (n=1,110) was performed. Logistic regression was used to assess effect of age, self-reported race and ethnicity, primary language, and insurance type on likelihood of surgical intervention within 12 months of consultation. RESULTS: Of patients undergoing surgery, the average wait time after consultation was 86 days (SD 69). Black patients had 2.6 times the odds of having surgery within 12 months of consultation (odds ratio [OR] 2.6, 95% CI 1.96–3.47) compared to White patients. Patients with Medicare had lower odds of completing surgery (OR 0.4, 95% CI 0.21–0.72) compared to those with other insurance or no insurance. Age, ethnicity, and primary language were not found to be correlated with surgical intervention. CONCLUSION: Race was found to be independently associated with likelihood of surgical intervention. Black patients in our study had more than twice the odds of having surgery compared to White patients, irrespective of age, ethnicity, primary language, or insurance. This may be due to more advanced disease at time of presentation secondary to care delays as well as surgeon bias in more readily pursuing surgery for Black patients, both of which stem from racism.

Gynecologic Surgical Training: Current and Future Perspectives

Gynecologic Surgical Training: Current and Future Perspectives

Evidence-Based Recommendations for Referral and Consultation to a Minimally Invasive Gynecologic Surgeon: A Systematic Review

Study Objective Minimally invasive gynecologic surgery (MIGS) is a subspecialty focus of obstetrics and gynecology with focused expertise on complex benign gynecologic pathology. To date, no formal recommendations have been made in defining a referral system for MIGS. This systematic review investigates the evidence regarding common pathologies and procedures including leiomyomatous uteri, endometriosis, and complex hysterectomies and their outcomes, and posits a basis for MIGS referral. Design Systematic Review. Setting University-Affiliated Community Hospital. Patients or Participants A PubMed literature search of pertinent research published within the preceding 5 years from January 2017 - Dec 2021. 1435 titles and abstracts were identified, and of these 372 full articles screened. 26 retrospective studies were eligible and included in this systematic review. Interventions The following PubMed MeSH terms were used for literature review: Leiomyomas - fibroids, myomectomy, complications, outcomes; Endometriosis - endometriosis, minimally invasive gynecologic surgery fellowship; and Complex Hysterectomy - complex MIS, Hysterectomy, obesity, outcomes, high volume, high volume gynecologic surgeon. Measurements and Main Results In instances where intraoperative and perioperative features may pose clinical challenges to the surgeon and ultimately the patient, the literature suggests the following scenarios may have adverse outcomes and therefore benefit from the skills of MIGS subspecialists: Fibroids - ≥5 myomas, myoma size ≥9cm, and suspected myoma weight ≥500g; Endometriosis - presence of endometrioma(s), suspected stage III/IV endometriosis, and requirement for advanced adjunct procedures; and Complex Hysterectomy - uteri ≥250g or 12 weeks estimated size, ≥3 prior laparotomies, obesity, and complex surgical history with suspected adhesive disease. Conclusion A referral system for MIGS subspecialists has proven benefits for both the gynecologic surgical community as well as the patients and their outcomes. This article provides evidence for collaboration with MIGS especially as it relates to leiomyomatous uteri, endometriosis, and complex hysterectomies. Minimally invasive gynecologic surgery (MIGS) is a subspecialty focus of obstetrics and gynecology with focused expertise on complex benign gynecologic pathology. To date, no formal recommendations have been made in defining a referral system for MIGS. This systematic review investigates the evidence regarding common pathologies and procedures including leiomyomatous uteri, endometriosis, and complex hysterectomies and their outcomes, and posits a basis for MIGS referral. Systematic Review. University-Affiliated Community Hospital. A PubMed literature search of pertinent research published within the preceding 5 years from January 2017 - Dec 2021. 1435 titles and abstracts were identified, and of these 372 full articles screened. 26 retrospective studies were eligible and included in this systematic review. The following PubMed MeSH terms were used for literature review: Leiomyomas - fibroids, myomectomy, complications, outcomes; Endometriosis - endometriosis, minimally invasive gynecologic surgery fellowship; and Complex Hysterectomy - complex MIS, Hysterectomy, obesity, outcomes, high volume, high volume gynecologic surgeon. In instances where intraoperative and perioperative features may pose clinical challenges to the surgeon and ultimately the patient, the literature suggests the following scenarios may have adverse outcomes and therefore benefit from the skills of MIGS subspecialists: Fibroids - ≥5 myomas, myoma size ≥9cm, and suspected myoma weight ≥500g; Endometriosis - presence of endometrioma(s), suspected stage III/IV endometriosis, and requirement for advanced adjunct procedures; and Complex Hysterectomy - uteri ≥250g or 12 weeks estimated size, ≥3 prior laparotomies, obesity, and complex surgical history with suspected adhesive disease. A referral system for MIGS subspecialists has proven benefits for both the gynecologic surgical community as well as the patients and their outcomes. This article provides evidence for collaboration with MIGS especially as it relates to leiomyomatous uteri, endometriosis, and complex hysterectomies.

8715 Enhancing Quality of Recovery and Satisfaction in Minimally Invasive Gynecologic Surgery - Utility of Structured Perioperative Education

<h3>Study Objective</h3> Determine if additional structured perioperative education improves patient quality of recovery (QoR) and satisfaction in patients undergoing minimally invasive gynecologic surgery (MIGS). <h3>Design</h3> Two-phased quality improvement initiative. <h3>Setting</h3> Academic institution. <h3>Patients or Participants</h3> All patients undergoing MIGS with fellowship-trained surgeons. <h3>Interventions</h3> Patient educational video and informational handout. <h3>Measurements and Main Results</h3> Atotal of 126 patients received standard of care (SoC) counseling with their individual surgeon and 96 patients received standard of care plus additional education (SoC+E). Thirty SoC patients and 31 SoC+E patients met criteria. There were no significant differences in age, BMI, and duration of surgery between our two cohorts, however we observed longer duration of surgery in the SoC+E group. Approximately 75% of all cases were performed via multi-port laparoscopy. When examining our primary outcome, QoR between the cohorts was significantly different (p=0.03). Interestingly, while we hypothesized that QoR would be better in patients receiving additional education, the opposite was true in our study population. There were no significant differences when patients were asked to rate their recovery and preoperative counseling. Patient satisfaction did not differ between SoC and SoC+E groups with 80% and 74% as "very satisfied" in each cohort respectively. When patients in the SoC+E group were asked to rate the preoperative video and handout, 45% of patients and 32% of patients "strongly agreed" and "agreed" that the video was helpful, respectively. <h3>Conclusion</h3> Current literature supports the safety and feasibility of same-day-discharge in MIGS. This places the patient in a unique position to self-manage their recovery at home. There is a paucity of data suggesting ways to actually enhance peri-operative counseling beyond individual surgeon counseling (SoC). We demonstrate a significant difference between QoR scores. Interestingly, those who only received surgeon counseling demonstrated higher QoR scores. Additional studies are needed to determine effective tools that will serve as an adjunct to each surgeon's standard of care

Minimizing Repeat Surgeries for Endometrioma: Impact of Surgical Intervention by Minimally Invasive Gynecologic Surgeons

<h3>Study Objective</h3> The objective of this study is to determine whether patients who are diagnosed with ovarian endometrioma(s) on imaging undergo fewer total surgeries for treatment of their endometrioma and endometriosis if the initial surgery is performed a minimally invasive gynecologic surgery (MIGS) specialists compared to a general obstetrician-gynecologist. <h3>Design</h3> Single center, IRB-approved retrospective chart review. <h3>Setting</h3> Academic, tertiary care institution in the United States. <h3>Patients or Participants</h3> Records of 383 females age 18 with endometrioma(s) diagnosed on pelvic imaging who underwent surgical treatment were included in this study. Patients without endometrioma on final pathology or with diagnosis of malignancy were excluded. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> Patients who underwent primary surgery by MIGS specialists were significantly less likely to undergo a second and third surgery than if initially performed by a general Ob/Gyn (second surgery n=19, 10.4% vs. n=24, 18.2%, third surgery n=2, 1.1% vs. n=9, 6.8%; p<0.01). A higher proportion of patients whose first surgery was performed by MIGS had only 1 surgery than patients whose first surgery was performed by a general Ob/Gyn (n=162, 88.5% vs. n=99, 75.0%). MIGS specialists were more likely to use a laparoscopic approach compared to general Ob/Gyn for all cases (first surgery n=183, 54.8% vs. n=106, 31.7%, second surgery n=41, 73.2% vs. n=9, 16.1%, third surgery n=11, 84.6% vs. n=1, 7.7%; p<0.01). <h3>Conclusion</h3> Patients diagnosed with endometriomas on imaging who undergo surgical management are less likely to undergo subsequent surgery if their initial surgery was performed by a MIGS specialist as compared to a general obstetrician-gynecologist. These findings have important implications for surgical referral patterns of patients with endometriomas on preoperative imaging.

8553 The Effect of Obesity on the Accuracy of Uterine Weight Estimation and Impact on Hysterectomy Outcomes

<h3>Study Objective</h3> Determine the effect of obesity on the accuracy of uterine weight estimation by bimanual exam (BME) and transvaginal ultrasonography and evaluate the impact on hysterectomy outcomes including surgical route and operative complications. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> Large academic medical center. <h3>Patients or Participants</h3> 1297 patients who underwent hysterectomy for benign indications at Parkland Hospital by generalists and Minimally Invasive Gynecologic Surgery (MIGS) fellowship-trained gynecologists between 01/2016 to 06/2018. <h3>Interventions</h3> Data was collected from electronic medical records up to 6months after hysterectomy. Surgeon type and mode of hysterectomy were compared. Resident physicians performed preoperative BME to determine estimated uterine size by gestational age, which was then converted to clinical uterine weight (grams) using mean weights for uteri between 6-26 weeks. For ultrasound weight, the equation: weight (g) = 50.0 + 0.71 x volume (cc) was used. Actual uterine weight was collected from surgical pathology data. <h3>Measurements and Main Results</h3> There was a significant correlation between both ultrasound-converted weight and pathology weight (r=0.81, p<0.001), and BME clinical weight and pathology weight (r=0.70, p<0.001). The correlation between ultrasound estimation and actual weight did not statistically differ between obese and non-obese populations (p=0.06). The correlation between BME estimation and actual weight did statistically differ between obese and non-obese populations (p<0.001). Most hysterectomies performed by MIGS surgeons were laparoscopic (59%) and generalists were open (50%). With uteri up to 22 weeks, MIGS surgeons performed significantly more laparoscopic hysterectomies than generalist surgeons regardless of obesity class (p<0.05). Complication rates did not statistically differ in obese versus non-obese populations (p>0.05). <h3>Conclusion</h3> BME estimation was affected by obesity and had a stronger correlation with actual weight in obese patients. Regardless of obesity class or uterine size, more MIGS surgeons chose a laparoscopic route while generalist surgeons chose open. Despite MIGS surgeons performing minimally invasive hysterectomies in more surgically complex cases, there were no differences in complication rates.

8519 Effects of Prior Cesarean Section on Outcomes of Laparoscopic Hysterectomies Performed by Minimally Invasive Gynecology Trained Surgeons

<h3>Study Objective</h3> To evaluate the effect of a history of cesarean section (CS) on complications and operative time of minimally invasive hysterectomies (MIH) performed by surgeons trained in minimally invasive gynecologic surgery (MIGS). <h3>Design</h3> Retrospective cross-sectional study. <h3>Setting</h3> Single institution, tertiary care center in Southeastern USA from 2016-2019 <h3>Patients or Participants</h3> Patients who underwent MIH for benign conditions, performed by a MIGS trained surgeon, and did not have a history of laparotomy other than CS. <h3>Interventions</h3> Minimally invasive hysterectomy. <h3>Measurements and Main Results</h3> A total of 484 hysterectomies met inclusion criteria. Of these, 152 patients had a history of CS and 332 did not have a history of CS. No significant demographic differences were noted between groups. In patients with a history of CS, 69 (45.4%) had one, 52 (34.2%) had two, 24 (15.8%) had three, and 7 (5.2%) had four or more prior CS. Generalized linear models controlling for body mass index (BMI) did not show a relationship between history of CS as a binary variable (CS vs no CS) and estimated blood loss (EBL) (mean 62 mL vs 57 mL, p=0.44) or operative time (mean 152 minutes vs 148 minutes, p=0.70). Similarly, there was no relationship between the number of prior CS and EBL (p=0.421) or operative time (p=0.411). The adjusted odds ratios were not significant between CS vs no CS for intraoperative complication (aOR = 0.920, CI 0.282 – 3.00) or 30-day postoperative complication (aOR = 0.946, CI 0.573 – 1.563). <h3>Conclusion</h3> While previous studies have found a relationship between history of CS and hysterectomy complications, this has not been evaluated in patients undergoing MIH with a MIGS trained surgeon. In our study, neither a history of any CS nor the number CS had an effect on EBL, operative time, or intraoperative or post-operative complications of MIH performed by MIGS trained surgeons.

Management of Hemorrhage during Dilation and Evacuation by Mid-Procedure Laparoscopic Uterine Artery Ligation

<h3>Study Objective</h3> To present a video demonstrating a multidisciplinary technique for managing hemorrhage during a dilation and evacuation (D&E) via intraoperative consult to minimally invasive gynecologic surgery (MIGS) and laparoscopic uterine artery ligation <h3>Design</h3> Case report. <h3>Setting</h3> Operating room at tertiary care center. <h3>Patients or Participants</h3> 37-year-old gravida 5 para 4 at 22 weeks gestation. <h3>Interventions</h3> A video demonstration of a laparoscopic, bilateral uterine artery ligation with pregnancy in situ to control mid-procedure hemorrhage. After initiating the D&E procedure, brisk bleeding was encountering with an estimated blood loss of 1600 mL within minutes. Options for controlling the hemorrhage were limited, as uterotonics or balloon tamponade were not possible with the pregnancy still in situ, and interventional radiology was not available for uterine artery embolization. An urgent, intraoperative consultation to MIGS was placed. A diagnostic laparoscopy was performed to evaluate for placenta accreta, uterine perforation, or other injury. No hemoperitoneum or defect was noted, however given ongoing heavy vaginal bleeding and potential need for a hysterectomy, the decision was made to proceed with uterine artery ligation prior to completion of the D&E procedure. Starting on the left side, the round ligament was incised, and the retroperitoneum was entered. The perirectal space was developed using the horizontal push-spread technique The uterine artery was skeletonized and ligated at its origin with a vascular clip. This was repeated on the contralateral side. Excellent hemostasis was noted, and the D&E was completed under laparoscopic guidance. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Mid-procedure laparoscopic uterine artery ligation is a feasible option for controlling hemorrhage during second trimester dilation and evacuation when more traditional methods are not feasible or unavailable. A multidisciplinary, subspecialty approach to management of gynecologic complications can help optimize safe gynecologic procedures.

Enhanced Recovery After Surgery (ERAS) practices in minimally invasive gynecologic surgery: A national survey

Objectives: Enhanced Recovery After Surgery (ERAS) pathways are evidence-based practices aimed at minimizing perioperative physiologic stress responses. They have been shown to reduce recovery time, postoperative complications, and hospital cost per patient. The objective of this study was to assess the Canadian application of and adherence to ERAS protocols during minimally invasive gynecologic surgery (MIGS). We also aimed to identify facilitators and barriers to ERAS uptake in our population.

The role of minimally invasive gynecologic surgeons in the era of subspecialties: when to refer and consult.

Minimally invasive gynecologic surgery (MIGS) is a subspecialty focus of obstetrics and gynecology with focused expertise on complex benign gynecologic disorders. To date, no formal recommendations have been made in defining a referral system for MIGS. This article reviews the evidence regarding common disorders and procedures and their outcomes, and posits a basis for MIGS referral. In instances where intraoperative and perioperative features may pose clinical challenges to the surgeon and ultimately the patient, the literature suggests the following scenarios may have adverse outcomes, and therefore, benefit from the skills of MIGS subspecialists: fibroids - at least five myomas, myoma size at least 9 cm, and suspected myoma weight at least 500 g; endometriosis - presence of endometrioma(s), suspected stage III/IV endometriosis, and requirement for advanced adjunct procedures; hysterectomy - uteri at least 250 g or 12 weeks estimated size, at least three prior laparotomies, obesity, and complex surgical history with suspected adhesive disease. A referral system for MIGS subspecialists has proven benefits for both the gynecologic surgical community as well as the patients and their outcomes. This article provides evidence for collaboration with MIGS especially as it relates to leiomyomatous uteri, endometriosis, and complex hysterectomies.

Patient Characteristics Associated with Access to Minimally Invasive Gynecologic Surgery: Changes during the COVID-19 Pandemic

Study ObjectiveTo evaluate patient characteristics that affect access to minimally invasive gynecologic surgery (MIGS) subspecialty care and identify changes during the coronavirus disease 2019 pandemic.DesignRetrospective cohort study of patients referred to MIGS from 2014 to 2016 (historic cohort) compared with those referred to MIGS in 2020 (pandemic cohort). Primary outcome was the interval between referral and first appointment.SettingSingle-institution academic MIGS division.PatientsHistoric cohort (n = 1082) and pandemic cohort (n = 770).InterventionsNot applicable.Measurements and Main ResultsDemographics and socioeconomic variables (race, ethnicity, language, insurance, employment, and socioeconomic factors by census tract) and distance from hospital were compared between historic and pandemic cohorts with respect to referral interval using the chi-square, Fisher exact tests, and logistic regression. After adjusting for referral indication, being unemployed and living in an area with less population density, less education, and higher percentage of poverty were associated with a referral interval >30 days in the historic cohort. In the pandemic cohort, only unemployment persisted as a covariate associated with prolonged referral interval and new associated variables were primary language other than English (odds ratio, 3.20; 95% confidence interval [CI], 1.60–6.40) and “other” race (odds ratio, 2.22; 95% CI, 1.34–3.68). The odds of waiting >30 days increased by 6% with the addition of 1 demographic risk factor (95% CI, 1.01–1.10) and by 17% for 3 risk factors (95% CI, 1.03–1.34) in the historic cohort whereas no significant intersectionality was identified in the pandemic cohort. Average referral intervals were significantly shorter during the pandemic (31 vs 50 days, p <.01). Telemedicine appointments had a significantly shorter referral interval than in-person appointments (27 vs 47 days, p <.01). Of patients using telemedicine, a greater proportion were non-Hispanic, English speaking, employed, privately insured, and lived further from the hospital (p <.05).ConclusionTime from referral to first appointment at a tertiary-care MIGS practice during the coronavirus disease 2019 pandemic was shorter than that before the pandemic, likely owing to the adoption of telemedicine. Differences in socioeconomic and demographic factors suggest that telemedicine improved access to care and decreased access disparities for many populations, but not for non–English-speaking patients.

Very Low Rates of Ureteral Injury in Laparoscopic Hysterectomy Performed by Fellowship-trained Minimally Invasive Gynecologic Surgeons

The objective of this case series is to evaluate the rates of ureteral injury at the time of laparoscopic hysterectomy among high-volume fellowship-trained surgeons. A retrospective chart review was performed, evaluating laparoscopic hysterectomy cases between 2009 and 2019 performed exclusively by fellowship-trained surgeons. Division of Minimally Invasive Gynecologic Surgery (MIGS) at the Brigham and Women's Hospital and Brigham and Women's Faulkner Hospital, a Harvard Medical School teaching hospital in Boston. All patients undergoing laparoscopic hysterectomy by one of 5 surgeons with fellowship training in MIGS. None. A total of 5160 cases were handled by MIGS surgeons between 2009 and 2019 at our institution. Of these cases, 2345 were laparoscopic hysterectomy cases with available intraoperative and postoperative documentation. Most patients had undergone previous surgeries, and the most common indications for hysterectomy included uterine myomas, pelvic pain/endometriosis, and abnormal uterine bleeding. At the time of hysterectomy, 1 ureteral injury (0.04%) was noted. No additional delayed ureteral injuries were observed. Most patients were discharged home the same day (64.9%) and did not have any postoperative complications (63.9%) as designated by the Clavien-Dindo classification. Ureteral injury, although rare, is more prevalent in gynecologic surgery than in other surgical disciplines that have some focus on the pelvis. No study to date has evaluated the effect of surgical training and volume on rates of ureteral injuries. This study retrospectively examined ureteral injury rates for one group of high-volume fellowship-trained surgeons and found their rates to be lower than the national average. Proposals are presented for optimizing training and delivery of gynecologic surgical care to minimize complications.