Single-Use Energy Sources and Operating Room Time for Laparoscopic Hysterectomy: A Randomized Controlled Trial

Cost-effective minimally invasive gynecologic surgery: emphasizing surgical efficiency

PURPOSE OF REVIEW

The United States has the highest healthcare costs among developed countries. This review evaluates surgical practices and equipment choices during endoscopic hysterectomy, highlighting opportunities for the gynecologic surgeon to reduce costs and maximize surgical efficiency.

RECENT FINDINGS

There are opportunities to economize at every step of the endoscopic hysterectomy. When surgeons are provided education about instrumentation costs, the cost of hysterectomy has been shown to decrease. Colpotomy has been found to be the rate-limiting step in laparoscopic hysterectomy; use of a uterine manipulator likely saves time and money. When evaluating the economic impact of route of surgery, the cost differential between laparoscopic and robotic-assisted hysterectomy has decreased. Robotic-assisted hysterectomy may be more cost-effective in some cases, such as for larger uteri. From a systems-level perspective, dedicating a specific operating room team to the gynecology service can decrease operative time.

SUMMARY

The gynecologic surgeon is best equipped to control surgery-related costs by making choices that improve surgical efficiency and decrease operating room time. If a costlier piece of equipment leads to a more efficient case, the choice may be more cost-effective. There are multiple systems-level changes that can be implemented to decrease surgery-related costs.

Postpartum Salpingectomy Compared With Standard Tubal Ligation After Vaginal Delivery

OBJECTIVE

To compare operative outcomes of postpartum salpingectomy and tubal ligation after vaginal delivery.

METHODS

This retrospective cohort study identified patients who underwent tubal sterilization between January 1, 2009, and December 31, 2019, at a large academic hospital, using the electronic medical record. All patients who delivered vaginally and underwent tubal sterilization during their delivery admissions were included. The primary outcome was total operative time. Secondary outcomes included estimated blood loss, perioperative complications, and readmission within 6 weeks postpartum. Patients who underwent bilateral tubal ligation were compared with those who underwent bilateral salpingectomy using Pearson's χ2 test, Fisher exact, and Student's t test.

RESULTS

A total of 317 eligible patients were identified. One hundred and six (94%) salpingectomies were completed using a bipolar electrocautery device. Operative time was 3 minutes shorter in the salpingectomy group, 30 minutes (interquartile range 24-38) compared with 33.5 (26-42) minutes, P=.032. Patients who underwent salpingectomy were more likely to have estimated blood loss of 5 mL or less (our institutional shorthand for minimal blood loss) than women who underwent bilateral tubal ligation (78 [69%] vs 112 [55%], P=.015). There were no significant differences in perioperative complications between the groups.

CONCLUSION

When using electrocautery, bilateral salpingectomy can be completed in the immediate postpartum period after vaginal delivery with equivalent operative times to bilateral tubal ligation.

Surgical simulation supplements reproductive endocrinology and infertility fellowship training

Objective

To assess if a surgical boot camp improves laparoscopic skill among reproduction endocrinology and infertility (REI) fellows and increases fellow desire to incorporate surgical skills into practice and to examine whether fellowship in vitro fertilization (IVF) volume correlates with surgical efficiency.

Design

Prospective evaluation.

Setting

Simulation Center.

Patients

Forty REI fellows.

Interventions

Fellows were timed before and after training in laparoscopic suturing and knot tying and while using virtual simulators. Fellows were surveyed before boot camp on prior experience with IVF and reproductive surgery, and immediately and 1 month after boot camp on their desire to incorporate surgical skills into practice.

Main Outcome Measures

Efficiency of laparoscopic suturing and knot tying before and after boot camp; likelihood and persistence of incorporating surgical skills into practice immediately and 1 month after boot camp; and correlation between fellowship IVF volume and fellow surgical efficiency.

Results

Fellows experienced significant improvement in laparoscopic suturing (44 sec), intracorporeal knot tying (82 sec), and extracorporeal knot tying (71 sec). Fellows reported being more likely to incorporate operative hysteroscopy (89%), operative laparoscopy (87%), and laparoscopic suturing (84%) into practice immediately following boot camp with no difference 1 month later. Fifty-four percent of fellows reported being more likely to perform robotic surgery after the boot camp, increasing to 70% 1 month later. There were weak correlations between IVF case volume and efficiency in laparoscopic suturing or hysteroscopic polypectomy (Spearman correlation coefficients, -0.14 and -0.03).

Conclusions

An intensive surgical boot camp enhances surgical skill among REI fellows.

Comparison of the efficacy and safety of two advanced vessel sealing technologies in total laparoscopic hysterectomy

AIM

Adequately powered, randomized controlled studies evaluating efficacy and safety of advanced bipolar energy devices in gynecologic laparoscopic surgery are very few. We aimed to compare the two most commonly used devices in total laparoscopic hysterectomy.

METHODS

This randomized controlled trial was carried out in the department of obstetrics and gynecology in an education and research hospital. One hundred thirty-two women who underwent total laparoscopic hysterectomy for benign indications were included. Women with age younger than 18 years, suspected malignancy, stage 3-4 endometriosis and cervical/intraligamentary leiomyoma were excluded. Patients were randomized preoperatively to LigaSure or Articulating Enseal. One experienced surgeon performed all operations.

RESULTS

LigaSure was used in 67 patients and Enseal was used in 65 patients. Primary outcomes of the study were operative time (time from start of sealing and transection of the round ligament until completion of colpotomy) and total operative time (time from skin incision to skin closure). Secondary outcomes were intraoperative blood loss (blood lost during operative time period) and perioperative complications. Operative time was significantly shorter in LigaSure group (P = 0.001). Total operative time, intraoperative blood loss and perioperative complications were similar. When two groups were further classified according to uterine weight taking 300 g as cut-off value, operative time was significantly shorter in LigaSure group in both subgroups (P = 0.003 and P = 0.007).

CONCLUSION

LigaSure use in total laparoscopic hysterectomy shortens operative time when compared with Enseal; without an apparent increase in intraoperative blood loss and perioperative complications. On the other side, total operative time remains unaffected.

Comparison of the Thermal Spread of Three Different Electrosurgical Generators on Rat Uterus: A Preliminary Experimental Study

BACKGROUND/AIMS

The objective of this study was to compare the depth and width of thermal spread caused on rat uterine tissue after application of 3 different electrosurgical generators.

METHODS

Alsa Excell 350 MCDSe (Unit A), Meditom DT-400P (Unit M), and ERBE Erbotom VIO 300 D (Unit E) electrosurgical units (ESUs) were used. The number of Wistar Hannover rats required to obtain valid results was 10. The primary objective of the study was to compare the 3 ESUs using the same instrument and the same waveform. The secondary objective of the study was to compare the differences between monopolar and bipolar systems of each ESU separately using the same waveform.

RESULTS

The thermal spread caused by each ESU using monopolar instruments with continuous and interrupted waveforms was significantly different. Among the 3 devices, Unit A caused the largest thermal uterine tissue spread. On the other hand, Unit E caused the most superficial thermal tissue spread, and the smallest thermal spread among all ESUs.

CONCLUSIONS

Surgeons should note that different ESUs used with the same power output might create different thermal effects especially in the monopolar configuration within the same waveform, for the same duration, and with the same instrument.

Understanding Costs of Care in the Operating Room

Importance

Increasing value requires improving quality or decreasing costs. In surgery, estimates for the cost of 1 minute of operating room (OR) time vary widely. No benchmark exists for the cost of OR time, nor has there been a comprehensive assessment of what contributes to OR cost.

Objectives

To calculate the cost of 1 minute of OR time, assess cost by setting and facility characteristics, and ascertain the proportion of costs that are direct and indirect.

Design, Setting, and Participants

This cross-sectional and longitudinal analysis examined annual financial disclosure documents from all comparable short-term general and specialty care hospitals in California from fiscal year (FY) 2005 to FY2014 (N = 3044; FY2014, n = 302). The analysis focused on 2 revenue centers: (1) surgery and recovery and (2) ambulatory surgery.

Main Outcomes and Measures

Mean cost of 1 minute of OR time, stratified by setting (inpatient vs ambulatory), teaching status, and hospital ownership. The proportion of cost attributable to indirect and direct expenses was identified; direct expenses were further divided into salary, benefits, supplies, and other direct expenses.

Results

In FY2014, a total of 175 of 302 facilities (57.9%) were not for profit, 78 (25.8%) were for profit, and 49 (16.2%) were government owned. Thirty facilities (9.9%) were teaching hospitals. The mean (SD) cost for 1 minute of OR time across California hospitals was $37.45 ($16.04) in the inpatient setting and $36.14 ($19.53) in the ambulatory setting (P = .65). There were no differences in mean expenditures when stratifying by ownership or teaching status except that teaching hospitals had lower mean (SD) expenditures than nonteaching hospitals in the inpatient setting ($29.88 [$9.06] vs $38.29 [$16.43]; P = .006). Direct expenses accounted for 54.6% of total expenses ($20.40 of $37.37) in the inpatient setting and 59.1% of total expenses ($20.90 of $35.39) in the ambulatory setting. Wages and benefits accounted for approximately two-thirds of direct expenses (inpatient, $14.00 of $20.40; ambulatory, $14.35 of $20.90), with nonbillable supplies accounting for less than 10% of total expenses (inpatient, $2.55 of $37.37; ambulatory, $3.33 of $35.39). From FY2005 to FY2014, expenses in the OR have increased faster than the consumer price index and medical consumer price index. Teaching hospitals had slower growth in costs than nonteaching hospitals. Over time, the proportion of expenses dedicated to indirect costs has increased, while the proportion attributable to salary and supplies has decreased.

Conclusions and Relevance

The mean cost of OR time is $36 to $37 per minute, using financial data from California's short-term general and specialty hospitals in FY2014. These statewide data provide a generalizable benchmark for the value of OR time. Furthermore, understanding the composition of costs will allow those interested in value improvement to identify high-yield targets.

Bipolar Energy Instruments in Laparoscopic Uterine Cancer Surgery: A Randomized Study

OBJECTIVE

To compare the perioperative outcomes of patients with uterine cancer, who were operated using advanced or conventional bipolar instruments.

MATERIALS AND METHODS

Patients with clinically early-stage endometrial cancer were randomized to advanced (LigaSure) or conventional (Robi forceps) bipolar groups. Surgeries were performed by laparoscopy. Hysterectomy and bilateral salpingo-oophorectomy with retroperitoneal lymphadenectomy were done in all cases. Primary endpoint of the study was to compare operation time for 2 groups. Other perioperative outcomes were also compared. ClinicalTrials.gov identifier number of the study was NCT02822820.

RESULTS

Sixty-eight cases with endometrial cancer were randomized to 2 groups and each group included 34 subjects. Mean age and body mass index of all cases were 56.8 ± 10.4 years and 31.1 ± 5.3 kg/m², respectively. Mean operation time was found significantly shorter in advanced bipolar group (134.2 ± 29.7 minutes versus 163.5 ± 27.7 minutes, P < .001). The other variables investigated such as intraoperative blood loss, duration of hospital stay, and postoperative pain scores did not show statistically significant difference between the groups.

CONCLUSION

Operation time was shorter in advanced bipolar group, however, advanced and conventional bipolar energy instruments were comparable for other perioperative outcomes in laparoscopic endometrial cancer surgery.

Comparison of Industry-Leading Energy Devices for Use in Gynecologic Laparoscopy: Articulating ENSEAL versus LigaSure Energy Devices

STUDY OBJECTIVE

To compare 2 laparoscopic bipolar electrosurgical devices used in total laparoscopic hysterectomy (TLH). An articulating advanced bipolar device (ENSEAL G2; Ethicon Endo-Surgery, Cincinnati, OH) and an electrothermal bipolar vessel sealer (LigaSure; Medtronic, Minneapolis, MN) were analyzed for differences in surgeon perception of ease of instrument use and workload using the NASA Raw Task Load Index (RTLX) scale. A second objective was to examine differences in operative time, estimated blood loss (EBL), and perioperative complication rates between the 2 devices.

DESIGN

Single-institution, single-blinded, randomized controlled trial (Canadian Task Force classification I).

SETTING

Division of Minimally Invasive Gynecologic Surgery in a university hospital.

PATIENTS

Eligibility required planned TLH, over age 18 years, and able to give informed consent; exclusions were stage III or IV endometriosis, known gynecologic malignancy, and early decision for conversion to laparotomy. One hundred seventy-eight patients screened, 142 enrolled, 2 withdrew, and 140 completed the study. Patients were followed 1 month postoperatively.

INTERVENTIONS

Preoperative randomization to articulating advanced bipolar device or electrothermal bipolar vessel sealer to be used during TLH.

MEASUREMENTS AND MAIN RESULTS

At the end of each hysterectomy the primary surgeon completed an ergonomic assessment tool, the RTLX. Results were analyzed to detect differences in workload between the 2 devices. For each case the time to ligation of the bilateral uterine arteries, EBL, and complications (including device failure, blood transfusion, or other injury) were recorded. Statistical analysis was performed using the t test for normally distributed data, χ² test for categorical data, and Mann-Whitney U-test for nonparametric data. There were no differences in age, body mass index, parity, prior surgery, uterine weight, race, indication, pathology, and comorbidities between the 2 groups. A statistically significant increase in RTLX scores (p < .0001), device failures (p = .0031), and time to ligation of bilateral uterine arteries (p = .0281) was noted in the articulating device group. No significant differences in EBL or complication rates were noted between the groups.

CONCLUSIONS

The articulating advanced bipolar device was shown to have a statistically significant increase in surgeon-perceived workload and rate of device failure when used in TLH; however, clinical and surgical outcomes were equivalent.

A network meta-analysis of updated haemostatic strategies for hysterectomy

OBJECTIVE

To determine the best haemostatic strategy for hysterectomy through a network meta-analysis.

METHODS

We conducted a systematic literature search of the PubMed, Embase, and Cochrane Library databases and extracted data from randomized controlled trials comparing haemostatic strategies for hysterectomy. Direct comparisons and network meta-analyses were conducted in RevMan and ADDIS. Consistency models were established to identify the differences among different haemostatic strategies, and cumulative probability was used to rank the included strategies. Inconsistencies were also tested using node-splitting models.

RESULTS

Twenty studies from 16 articles (2 articles contained 3 studies each) comprising 1392 patients were included. Direct meta-analysis showed that the LigaSure (SMD = -1.42 [-2.39, -0.44], P = 0.004), bipolar vessel sealing systems (BVSS) (SMD = -0.35 [-0.66, -0.03], P = 0.03), and pituitrin (SMD = -2.13 [-4.14, -0.13], P = 0.04) applications were effective haemostatic strategies. Based on the network meta-analysis and related subgroup analysis of different surgical procedures, the results showed that the application of pituitrin seemed to be the best haemostatic method for hysterectomy (Rank P = 0.64), especially for vaginal hysterectomy (Rank P = 0.72). The application of LigaSure was the best strategy for abdominal hysterectomy (Rank P = 0.54) but was not effective for laparoscopic hysterectomy (direct comparison with BVSS, MD = -31.39 [-146.61, 83.83], P = 0.59). The node-splitting models test revealed that no significant inconsistencies existed in this research.

CONCLUSIONS

Pituitrin application seemed to be the most effective haemostatic strategy for hysterectomy and was especially suitable for vaginal hysterectomy. The best method for reducing blood loss in abdominal hysterectomy was the application of LigaSure.